77 terms

PD 3- Test 1: cholesterol and diabetes guidelines

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what do we use LDL for
to assess whether a statin is working or not
high intensity vs moderate intensity statins
high intensity lower LDL by >50%

moderate intensity lower LDL by 30-50%
3 risk factors of taking Statins
#1: myalgias (muscle pain)

rhabdomyolysis

raises liver enzymes
need to check _____ and ____ if pt has sxs of rhabdo
CK and myoglobinuria
Muscle pain while on statin- check for
drug interactions,
Vitamin D, hypothyroid,
tx for pt who has muscle pain caused from Statins
switch to fluvastatin or pravastatin

lower dose and alternate days
____ reduces triglycerides, raises HDL and cause myopathy and rhabdo when used with statins
Fibrates
fish oil and cholesterol
reduced tris and raises HDL
what type prevention prevents a heart attack before it occurs
primary
preventing a heart attack in a person with ASCVD is an ex of ______ prevention
secondary
USPTF screening guidelines for Cholesterol
screen men > 35 and women > 45 with a lipid panel, frequency not specified.

screen at risk men and women over 20 years old
ADA lipid profile guidelines for diabetics
1 done at dx and then every 5 yrs
normal LDL
70s
4 major statin benefit groups
1.) Any clinical ASCVD (arteriosclerotic cardiovascular disease)

2.) Primary elevations of LDL-C >190 mg/dL

3.) Diabetes aged 40 to 75 years with LDL-C 70 to 189 mg/dL and without clinical ASCVD

4.) Aged 40-75 years without clinical ASCVD or diabetes with LDL-C 70 -189 mg/dL and estimated 10-year ASCVD risk > or = 7.5%
if pt has ASCVD do they need a statin
YES:

High intense statin therapy if < 75 years old

Moderate intense statin therapy if >75 y/o
if pt has LDL > or = to 190 do they need a statin?
yes- HIGH intensity
if pt is diabetic (age 40-75) with LDL 70-189 do they need a statin? if so what type?
Moderate intensity statin unless.....

High-intensity statin if estimated pt has ASCVD or if 10-y ASCVD risk >7.5%
if pt has a >7.5% Estimated *10-year ASCVD risk (age 40-75) do they need statins
must use the calculator to determine 10 yr risk

moderate to high intensity
how often do you need to check ALTs when a pt is on Statins
once

again only if hepatic sxs present
normal triglyceride levels
<150
pt with VERY high triglycerides >500 tx
check for high glucose

high intensity statin

consider fibrate & fish oil
pt with triglycerides > 500 are at risk for____
pancreatitis
xanthomas
small skin tumors seen in ppl with high triglycerides
normal HDL levels
>60 is good

<40 is bad= categorical risk factor
HDL is an element of Metabolic syndrome if <___ in a man or <___ in a woman
40 in men

50 in women
tx for metabolic syndrome
wt management/physical activity

tx htn

asprin for CHD to reduce prothrombotic state

tx elevated triglycerides and/or low HDL
what is the most cost effective tx for cholesterol
therapeutic lifestyle changes
who needs aspirin therapy
diabetic pts > 50yrs
type 2 diabetes dx criteria

a1c
FPG
OGTT
RPG
A1C >= 6.5%

Fasting plasma glucose (FPG) ≥126 mg/dL

2-h plasma glucose ≥200 mg/dL during an OGTT

A random plasma glucose (RPG) ≥200 mg/dL in person with classic diabetic sxs
β-cell destruction
Type 1 diabetes
Progressive insulin secretory defect
Type 2 diabetes
Other specific types of diabetes
Genetic defects in β-cell function, insulin action

Diseases of the exocrine pancreas

Drug- or chemical-induced
fasting def
no caloric intake for 8 hours
Testing for diabetes should start at ___ yrs unless _____
45 years

unless overweight/obese & 1 or more additional risk factors for diabetes
if diabetes tests are normal ......
repeat testing should be carried out at least at 3-year intervals
prediabetes:
FPG
2 hour OGTT
a1c
FPG: 100-125

2 hour OGTT: 140-199

a1c: 5.7%-6.4%
prediabetes def
individual's plasma glucose level is higher than normal, but not yet high enough to be diagnostic of having diabetes
Primary prevention of diabetes
wt loss programs + metformin for ppl at risk of developing type 2 diabetes
how often should glucose be monitored in prediabetics
every year
Individuals at high risk for type 2 diabetes should be encouraged to achieve:
dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains
Yale Diabetes Center Mnemonic Glucose bad
see slide 29-31
Self-monitoring of blood glucose (SMBG) should be carried out ___ x / day
3
A1C monitoring in diabetics:

pts meeting goals
pts not meeting goals
2x a year in pts meeting treatment goals

quarterly in pts whose therapy has changed or who are not meeting glycemic goals
a1c goal in pt with diabetes
A1C<7
tx for diabetes 4 steps
1.) Start with lifestyle change

2.) Metformin

3.) Add others as needed

4.) Do not delay insulin therapy if not at goal
How often do you order UA, serum creatinine, & lipid panel for diabetic?
yearly
Perform an annual test to assess urine albumin excretion in what patients?
-Type 1 diabetic pts w/ diabetes duration of ≥5 years

-All Type 2 diabetic pts starting at diagnosis
To prevent nephropathy
-optimize glucose control

-optimize BP control

-reduce protein intake in some individuals
Treatment of nonpregnant pt w/ micro- or macroalbuminuria
ACE inhibitors or ARBs should be used to help prevent nephropathy
When ACE inhibitors, ARBs, or diuretics are used, monitor
serum creatinine & potassium levels for development of acute kidney disease & hyperkalemia
Ophthalmology eye screening: initial dilated and comprehensive eye examination for Type 1 & 2 diabetics:
Type 1 (adults & children > 10)
-within 5 yrs after onset

Type 2
-shortly after diagnosis

Subsequent exams for type 1&2 repeated annually. Every 2-3 yrs may be considered following 1 or more normal eye exams. More frequently if retinopathy is progressing.
Screen for:
*ED (vascular dz, & good reason to keep glucose at goal)
-inquire about BC, assess for GDM

*DPN (distal symmetric polyneuropathy at dx & annually thereafter)
The foot examination of a diabetic should include
inspection

assessment of foot pulses

testing for loss of protective sensation

plus testing any 1 of:
-vibration
-pinprick sensation
-ankle reflexes
-vibration perception threshold
For PD and SOAP notes, look at all diabetics'
mouth & feet & at every visit!
(and document)!
Sxs of claudication or decreased or absent pedal pulses
Refer for ankle-brachial index & further vascular assessment
What is the target BP for pts with diabetes?
systolic <140
diastolic < 90
BP tx in diabetics:
Include DASH

ACE or ARB

if needed, Thiazide diuretic if GFR ≥30

Loop diuretic if GFR < 30
Men & women with type 1 or 2 diabetes > 50 should be on
ASA as primary prevention of CV dz
What should be used in a diabetic with heart disease?
ASA, ACE, Statin

-reduces risk of CV events
Pts with A1C >9% get 3x more
periodontitis
-Tx can reduce A1C by 1%
What does the CDC rec for dental care in pts with diabetes?
Annual dental exam

Cleaning & check q 6 months
Patients with diabetes and prior MI, what should be continued for at least 2 years after the event?
B-blockers
For pts on low-carbohydrate diets to reduce insulin resistance, monitor:
lipid profiles

renal function

protein intake
(in those with nephropathy)

adjust hypoglycemic therapy prn
If a pt is on metformin, a sulfonylurea & low-carb diet. What do you do if pt becomes hypoglycemia?
lower or D/C the sulfonylurea bc it's more likely to cause hypoglycemia. Keep pt on Metformin
Is routine supplementation with antioxidants, such as vitamins E and C and carotene recommended?
NOT advised bc of lack of evidence of efficacy & concern related to long-term safety.

Benefit from chromium in people with diabetes or obesity has not been conclusively demonstrated and, therefore, cannot be recommended.
Bariatric surgery should be considered for adults with
-BMI >35 & Type 2 diabetes

Pts w/ type 2 diabetes who have bariatric surgery need life-long lifestyle support & medical monitoring.
What is the recommended physical activity for a pt with diabetes?
At least 150 min/wk of moderate-intensity aerobic activity
(50-70% of max h.r.)

resistance training 3x / week

(In absence of uncontrolled HTN, severe autonomic or peripheral neuropathy)
Psychosocial Assessment
psychological & social situation should be part of medical management of diabetes.
When self-management of diabetes is poor screen for psychosocial problems such as
depression
diabetes-related distress
anxiety
eating disorders
cognitive impairment
Tx of hypoglycemic pt:
PO Glucose (15-20 g) is preferred for conscious individual, but any form of carbohydrate that contains glucose may be used

If still hypoglycemic p 15 min, repeat tx.

Once glucose returns to normal, individual should consume meal or snack to prevent recurrence
Rx for severe hypoglycemia:
Glucagon
A 55 year old diabetic pt presents to ER confused. He's speaking OK. Accucheck shows glucose of 50. What do you do?
Give glucose 10 g PO
A 55 year old diabetic patient presents to the ER confused. He is speaking OK. Accucheck shows glucose of 400. What do you do?
give SQ insulin
If not sure what the sugar level is-Giving sugar to a diabetic with hyperglycemia is better than giving insulin to a hypoglycemic diabetic. Why?
Insulin can cause death in hypoglycemic

So when in doubt, give sugar
What are the recommended vaccines for diabetic pts?
Influenza yearly

Pneumovac "routinely"
(every 5 years?)

Hep B for all diabetics
What do you do for new onset DM?
foot & oral exam

eye exam (by eye professional)

UA, serum creatinine, Lipid panel
-yearly

Educate pt
Start Metformin
Start ASA

Vaccines up-to-date
Specialists that all diabetics need to see:
Ophthalmologist
-yearly

Nutritionist for MNT

Dentist
Q 12 months, cleaning Q 6 months

Podiatrist as needed