Retinopathy treatments
no specific drugs
photocoagulation procedure may slow-but not really reverse
retinopathy prevention
Fundoscopic exams
BP control <140/80
smoking cessation
glycemic control
Fundoscopic exam & nephropathy screening in TYPE 1 for retinopathy prevention
within 5 years post-diagnosis then yearly
Fundoscopic exam & nephropathy screening in TYPE 2 for retinopathy prevention
at diagnosis (once stable) then yearly
______ is a predictor/risk factor for subsequent renal insuffiecienies
microalbuminuria
Nephropathy screening
yearly if microalbuminuria not already diagnosed
urine albumin excretion
Gold standard. Random spot urine albumin/creatinine ratio
if positive, repeat test 2-3X in 6 months-> if 2/3 are abnormal= diagnosis
Spot creatinine values (microg/mg)
normal: 300
Nephropathy treatment
no real treatment can reverse (some regression)
- ACE-inhibitors/ARBs
Prevention!- control HTN/lipids/GLU, smoking cessation, annual assessment for microalbuminuria
ACE-inhibitors & ARBs in nephropathy treatment
slows progression (may slightly reverse) treat even if normotensive
protein restriction in nephropathy
once proteinuria occurs
- 8-1g/kg/day in early stages (GFR>60)
- 8g/kg/day in later stages (GFR<60)
Diabetic neuropathy include
periphery neuropathy
GI/GU abnormalities
Peripheral neuropathy
reduced/loss sensation
painful neuropathies
ranges from numbing/tingling/burning/lancinating pain
major risk factor for foot ulcers/amputations
Neuropathic pain treatment
focused primarily on symptomatic relief anticonvulsants/AEDs antidepressants (lower doses) capsaicin cream NSAIDs/pain meds
Anticonvulsants/Antiepileptic drugs for neuropathic pain
Gabapentin: most commonly used
pregabalin (Lyrica): only one FDA approved for neuropathic pain/tid dosing
phenytoin
carbamazepine
Antidepressents for neuropathic pain
tricyclinc antidepressants (TCAs): cheap/anticholinergic side effects Duloxetine (Cymbalta): only FDA approved antidepressant; expensive; GI side effects
prevention of diabetic foot ulcers
glycemic & HTN control
smoking cessation
proper foot care & inspections
diabetic foot ulcers can turn into:
osteomyelitis or gangrene
duration of treatment is ____ & healing is_____ in diabetics
increased; slower
Diabetic foot ulcer treatment
wound debridement
pressure relief
oxygen therapy
regranex gel (topical GH): inc tisue granulation & healing
dyslipidemia in DM
High TG & low HDL
LDL- may have ok #, but density may be different
Lipid ADA goals in DM
LDL40(men); >50 (women)
____ are the best at LDL reduction & are the preferred agent
statins
use regardless of baseline LDL in: patients w/ CHD or 40+ w/ >1 CVD risk (HTN/proteinuria/smoke)
Dyslipidemia in DM treatment
> TGs: fibric acid derivative (gemfibrozil/fenofibrate) or niacin
<HDL: Niacin
limit use of niacin- lots of ADRs & do not use if significant hyperglycemia exists
hypertension in DM
comorbidity in ~20-60% of DM
significantly increases complications with DM +HTN
aggressive control
likely will need multiple meds
goal BP for diabetics
<140/80
most advantages med for HTN in DM
ACE-inhibitors: kills 2 birds with one stone (also nephropathy)
Other treatment options for HTN in DM
thiazides: may increase GLU; ok at low levels
CCBs
Beta-blockers: can mask hypoglycemia; reduces complications
HTN treatment in DM ADA guidelines
Should contain either ACE-I or ARB
Add thiazide/amlodipine (w/ GFR<30)
antiplatelet therapy in DM
Aspirin
secondary CHD prevention: everyone
primary CHD prevention: >50 (men), >60 (women) AND >1 CHD risk factor (family history, smoke, proteinuria, dyslipidemia, HTN)
Aspirin dose in DM
75-162mg/daily
therapeutic glycemic goals in DM
fasting glucose: 70-130
postprandial glucose: <7%
corner stone of therapy for DMT2
diet & exercise
if initial presentation is hyperglycemia PLUS weight loss, use ____ as initial therapy
insulin
Usually first line therapy for DMT2
oral agents
non-insulin agents contraindications/precautions & drug interactions
- DMT1, diabetic ketoacidosis, pregnancy
- beta blockers: masks hypoglycemia
sulfonylureas & metaglinides can cause ____ & ____ and reguire ____
weight can and hypoglycemia
require functioning beta cells
sulfonylureas work on
mainly fasting blood sugar, some postprandial
metaglinides work on
postprandial blood sugar
biguanide
metformin
metformin MOA
decreases gluconeogenesis, decreasing endogenous GLU; first line therapy
Black box warning for metformin in:
renal impairment: SCr >1.5 (men) & >1.4 (women)
can lead to lactic acidosis
metformin side effects
weight loss
diarrhea
lactic acidosis- renal impairment
characteristics of a best response with Metformin
central obesity (weight loss/weight neutral) mild-moderate hyperglycemia insulin resistance strongly suspected 1st line therapy trends toward reducing CV risk
Thiazolininediones (TZDs) MOA
increase peripheral sensitivity to insulin-> increase GLU uptake
avoid TZDs in___
active liver disease or increased AST/ALT >2.5X normal
contraindicated in CHF 3 & 4
Rosiglitazone (Avandia) controversies
suggested increased risk of CV events
2013 FDA lifted restrictions
Pioglitazine (Actos) controversies
increase bladder cancer?
Alpha-glucosidase inhibitors (AGI)
acarabose (precose) Miglitol (Glyset) blocks carb absorption/breakdown in the gut effects postprandial BS only only works when taken with food
Alpha-glucosidase inhibitor main complaint & contraindication
gas
contraindicated in GI disorders
GLP-1 agonist efficacy
shorter acting: reduce postprandial glucose
longer acting: reduce fasting & postprandial glucose
GLP-1 agonist side effects
Nausea, hypoglycemia, weight loss (pro)
DPP_4 inhibitors reduce
postprandial sugars; often used in combo with other agents
SGLT-2 inhibitors MOA
prevent reabsorption of sugar from the urine (pee out more sugar)
SGLT-2 inhibitors side effects
weight loss (pro) genitourinary infections (women>men), >K, <kidney function dont use in renal impairment
Bromocriptine (cycloset)
DA agonist
may reset circadian rhythms
dose in AM w/in 2 hours of waking
Colsevelam (WelChol)
Bile acid sequestrant that reduces fasting blood sugars; may <intestinal glucose absorption
6-8 pills/day
Weight: obese pts, use:
Metformin or GLP-1
Renal insufficiency, do NOT use
metformin or glyburide
hepatic insufficiency, do NOT use
TZD, glipizide
Heart failure, do NOT use
TZD or metformin
if monotherapy fails:
add second oral agent (or possibly insulin)
If dual oral combo fails:
add third oral agent or begin insulin
insulin should be considered if:
failing combo therapy (keep sensitizers)
initial presentation is hyperglycemia + weight loss
Basal-bolus goal
to replicates physiologic release to match body’s needs
basal component
homeostatic glucose release by liver
increases nocturnal glucose release
bolus (prandial) component
elevated glucose- postprandial, excursions
slow acting insulin products
lispro, aspart, glulisine, regular
longer acting insulin
NPH, detemir, glargine
Route of insulin administration
SQ
if given IV- would be used up in 5-10 minutes; regular insulin is the only one approved for IV admin
rarely use once daily insulin in DMT2 alone without:
oral meds
Insulin indicated in DMT2:
oral failure
once daily: A1C8.5% (TDC) or >9% (ADA)
cannot use once daily insulin in:
type 1 diabetes
once daily insulin starting dose
0.1-0.25u/kg
short-acting insulin pearls
role is to lower postprandial hyperglycemia
aka bolus insulin
NPH pearls
AKA intermittent acting
cloudy
can be mixed with R or rapid acting
variability
Glargine pearls
peakless
cannot be mixed (acid)
may burn
decrease hypoglycemic events
detemir pearls
dose dependent duration
cannot mix with other insulins
two daily injections
require meals to be at certain times requires constant carb intake-snacks needed risk for overnight hypoglycemia difficult to achieve treatment goals Breakfast-Rapid & NPH Supper-Rapid & NPH
three daily injections
decreases risk for overnight hypoglycemia
still requires constant carbs & meals at certain times
breakfast-rapid & NPH
supper- rapid
bedtime snack-NPH
true basal-bolus injection regimen
4+ injections
Breakfast, lunch, supper-rapid acting & bedtime snack- glargine
single insulin given
in the evening (supper or PM snack)
Type 1 and 2 initial daily dose of insulin (u/kg/day)
0.5 for both initially
T1: 0.3-0.5
T2 :0.2-0.6