| Diagnosis Glucose intolerance | A1c > 5.7 - 6.4 , Fasting > 100, RBG > 140 |
| Metabolic syndrome | Obesity > 40 in men, > 35 in women, HTN > 130/80, HDL < 40 men, < 50 women, FBG > 110 |
| Dx Diabetes | A1c > 6.5, FBG > 126, RBG > 200 Asymptomatic need two test, |
| DM Goals | BP < 130/80 , A1c < 7, LDL < 100 and < 70 with CAD, HDL > 40 men, > 50 women, TG < 150 and FBG < 120, PPBG < 160, Overnight change < 100 |
| DM screen | Asymptomatic > 45 y.o even 3 years. Positive RF yearly: HTN, obesity> 25, gestational DM, Ethnic minority, Dyslipidemia, First degree relatives. Start meds at A1c > 7.5 |
| DM monitoring | Yearly: microalbumin, Creatine, Lipids, A1c Q 3 mo. Each visit:BMI, BP, smoking, feet. Referral annual: Dentist, Opthomology. Vaccinate yearly for Flu, Once Tdap, Hep B, PCV 13 (preener) 1 dose > 65, followed by PPVC 23 one dose a year later. , |
| sglt2 sodium-glucose cotransporter-2 | empagliflozin(Jardiance), canagliflozin (Invokana), dapagliflozin ( Farxiga) |
| MOA SGLT2 | Proximal tubule excrete glucose |
| Effects of SGLT2 | A1c .5-.7, Wt loss 2-3 kg, lower BP, Positive CVD outcome and with Nephropathy, No hypoglycemia |
| SGLT2 Contraindication | GFR< 30, Bladder cancer risk, Prior DKA |
| Side Effects of SGLT2 | Lactic acidosis, GU infection, foot infection, bone fx, increase LDL, bladder cancer. Monitor Cr q 3 mo. |
| Insulin - When to start? | A1c > 9, FBG> 250, RBG> 300, Ketone in urine |
| Insulin replacement | 0.6-1.0 U/kg as 50% basal (Glargine) and 50% prandial( Aspart/Lispro). Gen: Start 10 U Glargine at night and titrate up 2 U Q 3 days until FBG b/w 90-140. Can add Apart to largest meal at 2-3 U and titrate to PPG goal of < 180 |
| Insulin types | Long acting : Glargine : (Lantus, Basaglar, Toujeo up to 36 hours, Degludec, Tresiba up to 42 hours. Insulin vials 1000 Units last 1 mo, Pens ( 300 U: Box of 5 pens ( 1500 U /box) |
| Sulfunylureas | 2nd generation: glyburide and glipizide - renal , 3rd generation: glimepiride- once a day with no renal clearance and 5x potent Short acting glipizide and glimepiride reduce hypoglycemia |
| SU MOA and SE | increase insulin sensitivity SE: wt gain, hypoglycemia |
| thiazolidinediones- TZD | Pioglitazone (Actos) Rosiglitazone ( Avenida) |
| TZD MOA | Inhibit hepatic gluconeogenesis |
| TZD Side Effects | Wt gain ( caution CHF) URI, Liver injury ( Actos) bladder cancer (Actos when used > 1 year) , MI ( Amanda) |
| TZD Contraindication | Class 3 and 4 CHF, pregnancy, Elevated transaminases |
| dpp-4 inhibitors | Sitagliptin (Januvia), Saxagliptin ( Onglyza), Algogliptin, Linagliptin- Oral |
| dpp-4 inhibitors MOA | Stimulate B cell to release insulin, Inhibits glucagon, enhance incretin decrease appetite and decrease gastric emptying. |
| dpp-4 inhibitors Contranindication, Caution, SE | Concomitant use with GLP1A, Caution CHF, SE: Nausea, vomiting, pancreatitis, headache, URI, joint and muscle pain, hepatic dysfunction, inflammatory bowel |
| dpp-4 inhibitors benefit | Weight neutral, OK with CKD, no hypoglycemia, OK with Insulin, metformin, TZD, SU, SLGT2. |
| GLP1A ( glucagon like polypeptide agonist) | Semaglutide (oral and injection), Exenatide, Dulaglutide, Liraglutide( Victoza) , lixsenatide : all injectable. |
| GLP1A MOA | Decrease gastric emptying, suppress glucagon, proliferation of B cell, stimulate insuling release and decrease appetite. |
| GLP1A Contraindication | Severe kidney disease, Concomitant use with DPP4, Hx of pancreatitis, GFR < 30 |
| GLP1A SE | Wt loss 1-3 kg, nausea, vomiting, diarrhea, antibody formation in 35%, hemorrhagic pancreatitis, impared renal function ( expecially with exenatide. |
| GlP1A Benefits | No hypoglycemia, A1c .5-.7, Positive CVD outcome with Lira and Sema. OK with CKD, OK with Met, Insulin, SU and TZD. |
| Metformin MOA | Decrease hepatic gluconeogenesis |
| Metformin Contraindication | Don't start if Cr > 1.4 in women and 1.5 in men or Alcoholic. Hold for Cr > 2.5, GFR < 30, Dehydreation, Azoteic, contrast study, surgery, acute CHF, sepsis. Monitor B12 level and Cr and GFR |
| Metformin SE | GI: Change to XL and take with food. Should subside in 2 wks. Lower dose for GFR 30-50 to no more than 1000 mg/d. |
| Diabetes musculoskeletal complications | Carpel tunnel, Dupuytren's, Flexortenosynovitis (trigger finger), neuropathic arthropathy (Charcot), OA, Rotator cuff tendonitis, adhesive capsulitis, calcific periartharitis, diffuse idiopathic skeletal hyperostosis ( DISH) |
| DM Neuropathy treatment | 1st: SNRI ( duloxetine, venlafaxine), TCA ( Amitriptyline, Nortriptylene), Antileptic ( pregabalin, gabapentin), 2nd line ( capsaicin, lidocaine, TENS) |
| PAD in DM - Definition and screen | ABI < 0.9 at rest and exercise Screen: symptomatic, wounds or ulcer, DM > 50 years every 5 years, or < 50 with RF |
| PAD in DM Treatment | Risk Factor reduction: smoking cessation , antiplatelete, lipids, BP control, diet, exercise and foot care Rx: ASA ( 75-100 mg/d or Clopidrogel 75 mg, mod-high intensity statin, revascularization. |
| DM Foot Infection Osteo Risk | Osteo Risk: Wound > 2 cm, depth to bone, non healing ulcer > 2 wk, sausage toe, sed rate > 70, Xray: cortical erosion, periosteal reaction, mixedlucency, sclerosis, Definitive MRI Seveity: Mild: < 2 cm, limited to skin and sub Q |
| DM foot infection severity | mild: < 2cm erythema /cellulitis, limited to skin, no systemic sx., Mod: Cellulitis > 2 cm, lymphatic streak, access, muscle tendon and bone involvement, Severe: Systemic toxicity |
