sohil rangwala mdcm, ccfp primrose family medicine centre diabetes in a nutshell
TRANSCRIPT
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SOHIL RANGWALAMDCM, CCFP
PRIMROSE FAMILY MEDICINE CENTRE
Diabetes in a nutshell
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Objectives
Review screening and diagnostic criteria for DM2
Review management of DM2
Review the use of Diabetic Flow sheets
Review of CDA interactive website
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Who do you screen for diabetes?
A) EveryoneB) Men and women over 50C) Men and women over 40D) It doesn’t really matterE) Someone who scores moderate risk on the
FINRISK or CANRISK calculator
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How frequently do you screen?
A) yearlyB) every 2 yearsC) Every 3 yearsD) After the holiday seasonE) Every 5 years
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When do you screen earlier than 40 for DM2?
A) If they have metabolic syndromeB) If they are very high risk using the
FINRISK/CANRISK calculatorC)Family History of DMD) history of GDME) all of the above
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When do you screen more frequently than every 3 years?
A) If they request itB) If they have additional risk factors for DM2C) If they are high risk on FINRISK or
CANRISKD) If they are very high risk on FINRISK or
CANRISKE) B and D
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How do you screen for DM2?
A) Ask the patientB) using HBA1cC) using Fasting Blood sugarD) using HsCRPE) B or C
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How do you diagnose DM2?
A )HbA1c > 7%B) FBS > 7C) HbA1c> 6.5%D) RBS > 11.1 with symptomsE) Always need second confirmatory testF) B, C, D, E
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When do you do a 2 hour OgTT?
A) All of the belowB) if HbA1c is between 6.0-6.4%C) if HbA1c is between 5.6- 5.9% and have
a risk factorD) if FBS is between 5.6-6.0 and have a risk
factorE) if FBS is between 6.1-6.9
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Screening and Diagnosis review
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Type 2 DM risk factors
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CANRISK calculator
http://www.healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/diabetes-diabete/canrisk/index-eng.php
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Management
1. Lowering Blood sugar
2. Lowering Vascular risk
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What are the complications?
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What is the target HbA1c?
A) less than 6.5%B) less than 7 %C) it depends on the dayD) less than 6%E) if I’m on metformin who cares!
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When should Hba1c less than 6.5%
A) to help reduce complications from retinopathy
B) to help reduce complications from neuropathy
C) to help reduce complications from nephropathy
D) A + CE) A+ B
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How much physical activity is recommended in diabetes?
A) as toleratedB) 150 minutes of aerobic exerciseC) Resistance exercise 2-3 times a weekD) Daily weights at the gymE) B and C
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Physical Activity ChecklistDO a minimum of 150 minutes of moderate-to
vigorous-intensity aerobic exercise per week
INCLUDE resistance exercise ≥ 2 times a week
SET physical activity goals and INVOLVE a
multi-disciplinary team
ASSESS patient’s health before prescribing an
exercise regimen
www.guidelines.diabetes.ca
2013
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What dietary advice should be given in diabetes?
A) Patients should see a registered dieticianB)Dietary advice should emphasize low
glycemic index foodsC) Canada Food guide should be followedD) All of the above
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By how much can dietary changes lower HbA1c?
A) 1%B) 3%C) it’ s a rumorD) 2%E) 1-2%
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Nutrition Checklist
REFER for nutrition counseling by a registered dietitian
FOLLOW Eating Well with Canada’s Food Guide
INDIVIDUALIZE dietary advice based on preferences and treatment goals
CHOOSE low glycemic index carbohydrate food sources
www.guidelines.diabetes.ca
2013
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Choose low glycemic index carbohydrates
www.guidelines.diabetes.ca
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At diagnosis of Diabetes, I should:
A) Always start MetforminB) Consider MetforminC) Always recommend lifestyle changesD) A +CE) B + C
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If the A1C is > 8.5 %, I should:
A) Refer to endocrinologyB) Start Metformin ImmediatelyC) Consider combination therapyD) Start Glicazide ImmediatelyE) B and C
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If HbA1c is < 8.5% but not at target, I should:
A) Make no changesB) Start/Increase MetforminC) Start InsulinD) Run(away)
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After diagnosis, how long should it take me to reach target HbA1c?
A) one yearB) 9 monthsC) 3-6 monthsD) one monthE) 2 years
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Which of the following has the greatest effect in lowering HbA1c?
A) diet and exerciseB) insulinC) DPP4 inhibitorsD) GlicazideE) Metformin
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What is the most common side effect of metformin?
A) HeadachesB) HypoglycemiaC) VomitingD) Kidney FailureE) Diarrhea
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What is Sitagliptin?
A) DPP-4 inhibitorB) SulfonylureaC) GLP-1 receptor agonistD) Meglitinide
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Which sulfonylurea causes less hypoglycemia?
A) GlyburideB) Glicazide
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Initial Choice of Therapy Depends on Glycemia
www.guidelines.diabetes.ca
Initial A1C ≥8.5%
Start metformin
AND
Consider combo therapy to achieve ≥1.5% A1C reduction
Initial A1C <8.5%
Start metformin
OR
Reassess in 2-3 months then decide on starting metformin
2013
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When starting insulin, should I use basal or bolus?
A) Basal insulinB) Bolus Insulin
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Generally, how many units of basal insulin should be started?
A) 5 unitsB) 15 unitsC) 10 unitsD) pick out of a hatE) 20 units
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When bolus insulin is added to basal, should oral secretagogues be stopped?
A) YesB) No
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Insulin pen
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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What is the definition of hypoglycemia?
A) Blood sugar < 6B) Blood sugar < 4C) Autonomic symptomsD) Response to carbohydrate loadE) B, C, D
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How do we treat mild-moderate hypoglycemia?
A) Equivalent of 15 g carbohydrate loadB) Equivalent of 30 g carbohydrate loadC) InsulinD) Equivalent of 10 g carbohydrate load
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1. Development of neurogenic or neuroglycopenic symptoms
2. Low blood glucose (<4 mmol/L if on insulin or secretagogue)
3. Response to carbohydrate load
Neurogenic (autonomic)
Neuroglycopenic
Trembling Difficulty Concentrating
Palpitations Confusion
Sweating Weakness
Anxiety Drowsiness
Hunger Vision Changes
Nausea Difficulty Speaking
Dizziness
Definition of Hypoglycemia
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Steps to Address Hypoglycemia
1. Recognize autonomic or neuroglycopenic symptoms
2. Confirm if possible (blood glucose <4.0 mmol/L)
3. Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve symptoms
4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and retreat (see above) if needed
5. Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein
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15 g of glucose in the form of glucose tablets
15 mL (3 teaspoons) or 3 packets of sugar dissolved in water
175 mL (3/4 cup) of juice or regular soft drink
6 Lifesavers (1=2.5 g of carbohydrate)
15 mL (1 tablespoon) of honey
Examples of 15 g Simple Carbohydrate
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Vascular protection
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Which of the following people with DM 2 should receive a statin?
A) 28 year old male recently diagnosed with diabetes
B)EveryoneC) 38 year old male with recent diagnosis of
diabetes and ACR of 7 mmol/LD) 45 year old female with diabetesE) C and D
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Which of the following people with DM2 should receive an ACE/ARB?
A) 48 year old male with Dm2B) 52 year old female with DM2 and hx of
retinopathyC) 68 year old maleD) EveryoneE) B and C
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Which of the following patients with Diabetes should receive ASA?
A) EveryoneB) All patients over 50 with diabetesC) all patient over 40 with diabetesD) all patients with diabetes who have had a
vascular eventE) Nobody
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Vascular Protection Checklist2013
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Who Should Receive Statins? (regardless of baseline LDL-C)
≥40 yrs old or Macrovascular disease orMicrovascular disease orDM >15 yrs duration and age >30 years orWarrants therapy based on the 2012 Canadian
Cardiovascular Society lipid guidelines
www.guidelines.diabetes.ca
Among women with childbearing potential, statins should only be used in the presence of proper preconception counseling & reliable contraception. Stop statins prior to conception.
2013
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Who Should Receive ACEi or ARB Therapy?(regardless of baseline blood pressure)
≥55 years of age or Macrovascular disease or Microvascular disease
At doses that have shown vascular protection [perindopril 8 mg daily (EUROPA), ramipril 10 mg daily
(HOPE), telmisartan 80 mg daily (ONTARGET)]
Among women with childbearing potential, ACEi or ARB should only be used in the presence of proper preconception
counseling & reliable contraception. Stop ACEi or ARB either prior to conception or immediately upon detection of pregnancy
2013
EUROPA Investigators, Lancet 2003;362(9386):782-788.HOPE study investigators. Lancet. 2000;355:253-59.
ONTARGET study investigators. NEJM. 2008:358:1547-59
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Insufficient evidence to support use of ASA for primary prevention
Risk of bleeding CVD protection
www.guidelines.diabetes.ca
2013
ASA Not Routinely Recommended for 1 ⁰Prevention for CVD Among Patients with DM
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How often should my patients with DM2 receive the pneumococcal vaccination?
A) Once over the age 50B) Every 5 yearsC) Over the age of 18D)One time revaccination if > 65 and> 5
years between administrationE) C+ D
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Immunization Checklist
GIVE annual influenza immunization
OFFER pneumococcal immunization if >18 years of age
RE-VACCINATE for pneumococcal for those >65 years of age; ensure ≥5 years between administrations
2013
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What to do when?
A1c check- every 3 months ( less than 7%)ACR check- Yearly( target less than 2.0)Retinopathy check- YearlyLDL check- yearly( LDL less than 2.0)BP check- every visit( less than 130/80)Neuropathy check- Yearly
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Conclusions
Diabetes is very prevalent and having a grasp on diagnosis and management is key!
CDA guidelines are interactive and a great tool for health care providers and patients!
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References
http://guidelines.diabetes.ca/fullguidelines