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CANADIAN DIABETES EDUCATOR EXAM QUESTIONS WITH
COMPLETE SOLUTIONS GRADED A+ PASS.
Diagnosis of Diabetes (FPG, A1C, 2hPG in a 75g OFTT, random PG) - ANSWERS-FPG
/=7mmol/ml A1c >/= 6.5% 2h PG in a 75g OGTT >/= 11mmol/L random PG >/= 11.1mmol/L Prediabetes (i.e. at high risk for developing diabetes) - A1C - ANSWERS-6-6.4% what medical conditions can cause A1C results to be misleading? - ANSWERS-- hemoglobinopathies -iron deficiencies -hemolytic anemia -severe hepatic or renal disease Impaired Fasting glucose (IFG) - ANSWERS-FPG - 6.1-6.9mmol/L Impaired glucose tolerance (IGT) - ANSWERS-OGTT (w/ 75g of glucose) 7.8- 11mmol/L Screening for T1D is .... - ANSWERS-NOT recommended Screening recommendations for T2D - ANSWERS-use FPG and/or A1c every 3 years in individuals >/=40yo or in individuals at high risk (using risk calculator) macrosomic infant - ANSWERS-infant that weighs over 8lbs at birth microvascular complications - ANSWERS-retinopathy, neuropathy, nephropathy
macrovascular complications - ANSWERS-coronary, cerebrovascular, peripheral Pharmacological therapies for PREVENTION of T2D (include by how much % it is reduced by) - ANSWERS-1. Metformin (~30%)
- Acarbose (~30%)
- Thiazolidinediones (~60%) ACCORD, ADVANCE and VADT were the three major trials that concluded what? - ANSWERS-intensive glycemic control - lowering A1C <6% resulted in higher mortality, severe episodes of hypoglycemia - therefore targets should individualized!! TARGET for A1C, FPG and RPG for MOST Diabetic (T1D and T2D) patients? - ANSWERS-A1c <7mmol/L FPG 4-7mmol/L PPG 5-10mmol/L (5-8mmol/L if A1c target not achieved) Who should have target of A1c <6.5% - ANSWERS-in T2D to further decrease risk of nephropathy and retinopathy (ensure there is a balance so as not to cause HYPOGLYCEMIA) Who should have target of 7.1-8.5% (7) - ANSWERS-1. limited life expectancy
- High level of functional dependency
- severe coronary artery disease/ increased risk for ischemic events
- multiple comorbidities
- HX of recurrent severe hypoglycemic episodes
- hypoglycemic unawareness
- Long standing diabetes that is difficult to reduce A1c<7% - despite appropriate treatments
intake saturated fats <7% of total daily what type of fats are preferred? - ANSWERS-monounsaturated fats (MUFA) polyunsaturated fats (PUFA) long chain omega 3 FA included up to 10% of total energy intake Recommendation for proteins? - ANSWERS-1-1.5g/kg body weight per day -15- 20% of total energy intake What are dAGEs? Good / bad? - ANSWERS-dietary advanved glycation endpoints BAD - increases markers for endothelial and adipocyte dysfunction and impairs vascular function Alcohol recommendations - ANSWERS-</=2 drinks per day OR <10 drinks per week for women </= 3 drinks per day OR <15 drinks per week for men main bad effect of alcohol - ANSWERS-HIDES and DELAYS hypoglycemia Name the diets that can improve glycemic control (i.e. decreases A1c) (4) - ANSWERS-1. Mediterranean diet
- vegan/vegetarian diet
- incorporation of dietary pulses (beans, peas, chickpeas, lentils)
- DASH Rapid Acting Insulin Analogues? - ANSWERS-Aspart (NovoRapid) Glulisine (Apidra) Lispro (Humalog)
Short Acting insulin - ANSWERS-Insulin regular (Humulin R and Novolin ge Toronto) Intermediate acting insulin - ANSWERS-Insulin NPH (Humulin-N, Novolin ge NPH) Long acting insulin - ANSWERS-Detemir (Levemir) Glargine (Lantus, Tuojeo (highconc), Basaglar) Ultra-long acting insulin - ANSWERS-Degludec (Tresiba) Pre-mixed regular insulin NPH - ANSWERS-insulin NPH + insulin regular Humulin 30/ Novolin ge 30/70, 40/60, 50/ Premixed insulin analogues - ANSWERS--Aspart30%/aspart protamin 70% (NovoMix 30) -Lispro25%/lispro protamine 75% (Humalog Mix 25) -Lispro50%/lisproprotamine 50% (Humalog Mix 50) What is the honeymoon period? - ANSWERS-Time when insulin therapy is just started - requirements of insulin will be low but this is a transient state and requirements will increase Hypoglycemia unawareness - ANSWERS-happens when the threshold for the development of autonomic warning symptoms is close to or lower than the threshold for neuroglycopenic symptoms = i.e. first symptoms are CONFUSION or LOSS OF CONSCIOUSNESS Neuroglycopenic symptoms (really bad) (8) - ANSWERS-Difficulty concentrating confusion weakness drowsiness
Metformin contraindications - ANSWERS-liver and renal failure due to lactic acidosis 2 classes of incretin agents - ANSWERS-DPP-4 inhibitors GLP-1 receptor agonists DPP-4 inhibitors - ANSWERS-Linagliptin (Trajenta) , Saxagliptin (Onglyza), Sitagliptin (Januvia) DPP-4 - inhibitory incretin mechanism of GLP1 = these drugs prolongs the activity of GLP1 incretin GLP-1 Receptor agonists - ANSWERS-Exenatide (Byetta), Liraglutide (Victoza) incretins = hormones that directly stimulate insulin release and inhibit glucagon Sulfonylureas - ANSWERS-gliclazide (diamicron), glyburide (diabeta), Glimepiride (Amaryl) inhibit potassium channels causing depolarization f cell membrane = calcium release and therefore insulin release Which T2D antihyperglycemics can cause HYPOglycemia - ANSWERS- Sulfonylureas, Incretin analogues (DPP4 antagonist and GLP1 receptor agonist) Meglitinides - ANSWERS-Nateglinide (Starlix), Repaglinide (GlucoNorm) stimulate insulin release at potassium channel (diff site than sulfonylureas) - works faster than sulfonylureas Thiazolidinediones - ANSWERS-Pioglitazone (Actos), Rosiglitazone (Avandia) increases insulin sensitivity (indirectly) via transcription factor PPAR - at adipose and muscle tissue Thiazolidinediones Side effect - ANSWERS-increases cardiovascular risk esp CHF Recommended time frame to reach target after diagnosis? - ANSWERS-3 TO 6 MONTHS
If at diagnosis A1C </=8.5% (T2D) what is the recommended initial therapy? - ANSWERS-Lifestyle changes and then see after 2-3 mo if there are any changes and maybe start metformin? OR start metformin If at diagnosis A1C >/= 8.5% (T2D) what is the recommended initial therapy? - ANSWERS-START metformin AND consider adding another therapy (combo therapy) to decrease A1c by >/=1.5% possibly When is metformin + insulin indicated/recommended? - ANSWERS-symptomatic hyperglycemia (polyuria, polydypsia, weight loss, volume depletion) metabolic decompensation When should 30/70 insulin (pre mixed with regular insulin) be given? When should Humalog 25 or Novomix 30 (premixed with insulin analogues) be given? - ANSWERS-30/70 about 30-45min BEFORE meals Insulin analogues = immediately before eating Hypoglycemia - ANSWERS-<4mmol/L Severity of Hypoglycemia - ANSWERS-Mild: autonomic symptoms, can still self treat Moderate: autonomic AND neuroglycopenic symptoms but individual is still able to self treat Severe: unconscious or requires help from another person - PG<2.8mmol/L Treatment of mild/moderate hypoglycemia - ANSWERS-fast / simple carbohydrate 15g -glucose tablets -3 tsp or 3 packets of sugar dissolved in water
- search for the cause
- Insulin (prn) DKA treatment protocol (5) - ANSWERS-1) fluid resuscitation
- avoid hypokalemia
- insulin
- avoid rapidly falling serum osmolality
- search for the cause In-hospital Glucose targets and therapy of choice (non-critically ill) - ANSWERS- FBG 5-8mmol/L RBG <10mmol/L pre-hospital regimen OR basal-bolus-correction In-hospital glucose targets and therapy of choice (critically ill) - ANSWERS-BG 8- 10mmol/L IV insulin infusion In -hospital glucose targets and therapy of choice (CABG intraop) - ANSWERS-BG 5.5-10mmol/L IV insulin infusion In-hospital glucose targets and therapy of choice (Other periop) - ANSWERS-BG 5- 10mmol/L As appropriate Hypoglycemia protocols (in hospital) - describe in 3 words and who should it be initiated by? - ANSWERS-avoidance, recognition and management nurse led initiative
How much weight must be lost in order to have beneficial effects on metabolic parameters? What are the benefits? - ANSWERS-5-10% weight loss Benefits: insulin sensitivity, glycemic control, blood pressure, lipids Waist circumference thresholds (men and women) - ANSWERS-men (caucasian/african): >/=94cm men (Asian, south or central american): >/=90cm women: >/=80cm What is the rate of weight loss that is reasonable? - ANSWERS-1-2 lbs per week Which antihyperglycemic drugs can cause WEIGHT GAIN? - ANSWERS-insulin, TZDs, Sulfonylureas, meglitinides Which antihyperglycemic drugs are WEIGHT NEUTRAL or help with WEIGHT LOSS?
- ANSWERS-metformin, acarbose, DPP-4 inhibitors, glucagon-like peptide- receptor agonist (GLP-1), SGLT2 inhibitors Bariatric Surgery(s) is only recommended for? - ANSWERS-Class II obesity - BMI 35-39.9 kg/m Class III >/=40 kg/m who are having tough time to decrease weight How likely is it that someone with mental health issues develops diabetes? - ANSWERS-60% How likely is it someone with diabetes develops depressive symptoms? MDD? - ANSWERS-30% MDD 10% Risk factors for developing depression in diabetic patients? (8) - ANSWERS-o Female o Teens/YA or OA
What is recommended if a person is taking antipsychotics (esp 2nd generation)? - ANSWERS-regular metabolic monitoring as they cause adverse metabolic changes Need for Antiplatelet therapy in diabetes? Medications? - ANSWERS-yes, as diabetes causes increased platelet reactivity and aggregation Meds: ASA (Secondary prevention), clopidogrel Recommended antihypertensive for diabetes? - ANSWERS-ACEI/ARBs->/=55yo OR macrovascular disease OR microcvascular disease Statin therapy recommendation in diabetes - ANSWERS->40yo OR macrovascular disease OR microvascular disease OR DM >15y and >30yo OR warrants therapy based on 2012 canadian cardiovascular society lipid guidelines ABCDES of Vascular protection in Diabetes - ANSWERS-A - A1C (usually </=7%) B- BP (<130/80) C-cholesterol (</=2mmol/L IF deciding to treat) D - Drugs (ACEI/ARB, Statins, ASA (if indicated)) E- Exercise / Eating healhy S-smoking cessation How does Diabetes affect CV risk? - ANSWERS-increases the CV age by 10-15y which worsens prognosis and can reduce life expectancy by 12y Multifaceted treatment strategy includes? the study that determined this? - ANSWERS-1. glucose, lipid and BP control
- health behaviour optimization
- vascular protective meds Study: STENO- Vascular protective meds - ANSWERS-statins
ACE/ARB
ASA (selective use/secondary prevention) Vascular protective drugs AND pregnancy - ANSWERS-STOP using prior to conception (statins and ACEI/ARB) - should only be used in proper preconception ACEI/ARBs shown to have vascular protection (strength too pls) - ANSWERS- perindopril 8mg (EUROPA), ramipril 10mg (HOPE), telmisartan 80mg (ONTARGET) Screening for CAD in diabetes checklist (3) - ANSWERS-1. Screen with baseline ECG (select patients)
- Stress testing for patients with symptoms or other associated diseases
- Refer patients with inducible ischemia to specialist Criteria for screening with ECG for CAD? How often to repeat? - ANSWERS->40yo DM >15y AND >30yo end organ damage (macro/microvascular) cardiac risk factors Repeat every 2 years Who should have stress testing and/or functional imaging to screen for CAD? - ANSWERS-stress test IF: typical/atypical cardiac symptoms (SOB, chest discomfort), associated diseases (PAD, carotid bruits, TIA, stroke), resting ECG abnormalities imagning screen if CANNOT phyically exercise or ECG abnormality present Typical presentation of dyslipidemia in Diabetics? - ANSWERS-high TGs low HDL normal LDL (but atherogenecity may be increased b/c hyperglycemia can glycate and oxidate LDL)
creatinine >150micromol/L or creatinine clearance <30mL/min for control of volume Diabetic undergoing PCI (percutaneous coronary intervention) what is/are the antiplatelet(s) of choice? - ANSWERS-prasugrel or ticagrelor Choose prasugrel if... (5)-reversible? - ANSWERS--about to go into PCI -clopidogrel naiive -<75yo ->65kg -no history of stroke not reversible Choose ticagrelor if.. (2) - reversible? - ANSWERS--no history of hemorrhagic stroke -no extreme bradycardia yes, reversible BG target for a patient coming in with MI and BG levels of >11mmol/L - ANSWERS- target to 7-10mmol/L Risk factors for stroke in diabetics (4) - ANSWERS-o Insulin resistance o Central obesity o Impaired glucose tolerance o Hyperinsulinemia Three typical signs of Heart failure - ANSWERS-peripheral edema, SOB, and fatigue in CHF and eGFR <60mL/min - ANSWERS-start dosing ACEi/ARB should be 1/2 with gradual up titration
Monitor electrolytes, creatinine, BP, weight (within 7-10days of starting) Systolic heart failure - drug class of choice - ANSWERS-beta blockers Treatment for mild to moderate hyperkalemia (3) - ANSWERS-1. low potassium diet
- if persistent consider: non-potassium sparing diuretic (furosemide) OR sodium bicarbonate (metabolic acidosis)
- consider holding RAAS blockade medication (ACEI/ARB/DRI) Treatment for severe hyperkalemia (2) - ANSWERS-emergency management strategies RAAS blockade medication = discontinued Signs and symptoms that kidney problem is due to Diabetic nephropathy (and not an alternate renal diagnosis) (6) - ANSWERS-persistent albuminuria bland urine sediment slow progression of disease low eGFR associated with overt proteinuria other diabetic complications present DM >5y potential causes for Transient albuminuria (7) - ANSWERS-Recent major exercise acute severe rise in BP acute severe rise in blood glucose menstruation UTI febrile illness
2 main screening tests for CKD? - ANSWERS-ACR and eGFR Prevention of CKD - ANSWERS-1. proper glycemic control
- optimal blood pressure control
- initiation of ACEI/ARB When to refer diabetics to nephrologist or CKD expert? (5) - ANSWERS-1. chronic and progressive loss of kidney function
- repeated ACRs >60mg/mmol
- eGFR <30ml/min
- cannot stay on ACEI/ARB due to side effects
- unable to reach target BP When to screen for retinopathy? T1D vs. T2D - ANSWERS-T1D: >/=15y after 5 years of DM diagnosis and annually T2D: at diagnosis and every 1-2years after that How to treat sight threatening retinopathy (3) - ANSWERS-Laser photocoagulation intraocular injection of meds vitreoretinal surgery Risk factors for retinopathy (8) - ANSWERS-o Longer duration of diabetes o Elevated A1C o Increased blood pressure o Dyslipidemia o Low hemoglobin level o Pregnancy (w/ T1D)
o Proteinuria o Severe retinopathy What is the pharmacological option for delaying onset of retinopathy? - ANSWERS-adding a fibrate to statin therapy (specifically fenofibrate to simvastatin- reduced by 40% as per ACCORD eye study) Retinopathy increases morbidity and mortality via... (4) - ANSWERS-falling hip fractures 4-fold increase in mortality early death in T1D Name the 3 types of retinopathy - ANSWERS-1. Macular edema
- Nonproliferative and proliferative
- retinal capillary closure Macular edema - ANSWERS-diffuse or focal vascular leakage the macula Nonproliferative vs proliferative retinopathy - ANSWERS-blood vessel changes non-proliferative - microaneurysms, intraretinal hemorrhaging, vascular toruosity and malformation proliferative abnormal vessel growth Retinal capillary closure diagnosis, complication and treatment - ANSWERS- diagnosis via fluoroscein angiograpjy complication is blinding treatment = none at the moment pharmacological intraocular treatments for retinopathy? - ANSWERS-ranibizumab and bevacizumab
