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CANADIAN DIABETES EDUCATOR
EXAM QUESTIONS AND ANSWERS
Diagnosis of Diabetes (FPG, A1C, 2hPG in a 75g OFTT, random PG) - answer 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 - answer 6-6.4% what medical conditions can cause A1C results to be misleading? - answer -hemoglobinopathies -iron deficiencies -hemolytic anemia -severe hepatic or renal disease Impaired Fasting glucose (IFG) - answer FPG - 6.1-6.9mmol/L Impaired glucose tolerance (IGT) - answer OGTT (w/ 75g of glucose) 7.8-11mmol/L Screening for T1D is .... - answer NOT recommended Screening recommendations for T2D - answer use FPG and/or A1c every 3 years in individuals
/=40yo or in individuals at high risk (using risk calculator) macrosomic infant - answer infant that weighs over 8lbs at birth microvascular complications - answer retinopathy, neuropathy, nephropathy
macrovascular complications - answer coronary, cerebrovascular, peripheral Pharmacological therapies for PREVENTION of T2D (include by how much % it is reduced by) - answer 1. Metformin (~30%)
- Acarbose (~30%)
- Thiazolidinediones (~60%) ACCORD, ADVANCE and VADT were the three major trials that concluded what? - answer 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? - answer 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% - answer 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) - answer 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
saturated fats <7% of total daily what type of fats are preferred? - answer monounsaturated fats (MUFA) polyunsaturated fats (PUFA) long chain omega 3 FA included up to 10% of total energy intake Recommendation for proteins? - answer 1-1.5g/kg body weight per day -15-20% of total energy intake What are dAGEs? Good / bad? - answer dietary advanved glycation endpoints BAD - increases markers for endothelial and adipocyte dysfunction and impairs vascular function Alcohol recommendations - answer </=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 - answer HIDES and DELAYS hypoglycemia Name the diets that can improve glycemic control (i.e. decreases A1c) (4) - answer 1. Mediterranean diet
- vegan/vegetarian diet
- incorporation of dietary pulses (beans, peas, chickpeas, lentils)
- DASH Rapid Acting Insulin Analogues? - answer Aspart (NovoRapid) Glulisine (Apidra) Lispro (Humalog)
Short Acting insulin - answer Insulin regular (Humulin R and Novolin ge Toronto) Intermediate acting insulin - answer Insulin NPH (Humulin-N, Novolin ge NPH) Long acting insulin - answer Detemir (Levemir) Glargine (Lantus, Tuojeo (highconc), Basaglar) Ultra-long acting insulin - answer Degludec (Tresiba) Pre-mixed regular insulin NPH - answer insulin NPH + insulin regular Humulin 30/ Novolin ge 30/70, 40/60, 50/ Premixed insulin analogues - answer -Aspart30%/aspart protamin 70% (NovoMix 30) -Lispro25%/lispro protamine 75% (Humalog Mix 25) -Lispro50%/lisproprotamine 50% (Humalog Mix 50) What is the honeymoon period? - answer 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 - answer 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) - answer Difficulty concentrating confusion weakness
Biguanide - answer Metformin - increases insulin sensitivity, decreases glucagon and decreases intensitinal glucose absorption Metformin contraindications - answer liver and renal failure due to lactic acidosis 2 classes of incretin agents - answer DPP-4 inhibitors GLP-1 receptor agonists DPP-4 inhibitors - answer Linagliptin (Trajenta) , Saxagliptin (Onglyza), Sitagliptin (Januvia) DPP-4 - inhibitory incretin mechanism of GLP1 = these drugs prolongs the activity of GLP incretin GLP-1 Receptor agonists - answer Exenatide (Byetta), Liraglutide (Victoza) incretins = hormones that directly stimulate insulin release and inhibit glucagon Sulfonylureas - answer 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 - answer Sulfonylureas, Incretin analogues (DPP4 antagonist and GLP1 receptor agonist) Meglitinides - answer Nateglinide (Starlix), Repaglinide (GlucoNorm) stimulate insulin release at potassium channel (diff site than sulfonylureas) - works faster than sulfonylureas Thiazolidinediones - answer Pioglitazone (Actos), Rosiglitazone (Avandia)
increases insulin sensitivity (indirectly) via transcription factor PPAR - at adipose and muscle tissue Thiazolidinediones Side effect - answer increases cardiovascular risk esp CHF Recommended time frame to reach target after diagnosis? - answer 3 TO 6 MONTHS If at diagnosis A1C </=8.5% (T2D) what is the recommended initial therapy? - answer 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? - answer START metformin AND consider adding another therapy (combo therapy) to decrease A1c by >/=1.5% possibly When is metformin + insulin indicated/recommended? - answer 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? - answer 30/70 about 30-45min BEFORE meals Insulin analogues = immediately before eating Hypoglycemia - answer <4mmol/L Severity of Hypoglycemia - answer Mild: autonomic symptoms, can still self treat Moderate: autonomic AND neuroglycopenic symptoms but individual is still able to self treat
What is the main risk difference between hyperglycemic emergency in adults vs. children? - answer Children have higher increase of cerebral edema with DKA (life-threatening) HHS treatment protocol (5) - answer 1) fluid resuscitation
- avoid hypokalemia
- avoid rapidly falling serum osmolality
- search for the cause
- Insulin (prn) DKA treatment protocol (5) - answer 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) - answer FBG 5-8mmol/L RBG <10mmol/L pre-hospital regimen OR basal-bolus-correction In-hospital glucose targets and therapy of choice (critically ill) - answer BG 8-10mmol/L IV insulin infusion In -hospital glucose targets and therapy of choice (CABG intraop) - answer BG 5.5-10mmol/L IV insulin infusion In-hospital glucose targets and therapy of choice (Other periop) - answer BG 5-10mmol/L
As appropriate Hypoglycemia protocols (in hospital) - describe in 3 words and who should it be initiated by? - answer 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? - answer 5-10% weight loss Benefits: insulin sensitivity, glycemic control, blood pressure, lipids Waist circumference thresholds (men and women) - answer men (caucasian/african): >/=94cm men (Asian, south or central american): >/=90cm women: >/=80cm What is the rate of weight loss that is reasonable? - answer 1-2 lbs per week Which antihyperglycemic drugs can cause WEIGHT GAIN? - answer insulin, TZDs, Sulfonylureas, meglitinides Which antihyperglycemic drugs are WEIGHT NEUTRAL or help with WEIGHT LOSS? - answer metformin, acarbose, DPP-4 inhibitors, glucagon-like peptide-1 receptor agonist (GLP-1), SGLT inhibitors Bariatric Surgery(s) is only recommended for? - answer 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? - answer 60%
- coping skills training
- family therapy
- case management What is recommended if a person is taking antipsychotics (esp 2nd generation)? - answer regular metabolic monitoring as they cause adverse metabolic changes Need for Antiplatelet therapy in diabetes? Medications? - answer yes, as diabetes causes increased platelet reactivity and aggregation Meds: ASA (Secondary prevention), clopidogrel Recommended antihypertensive for diabetes? - answer ACEI/ARBs->/=55yo OR macrovascular disease OR microcvascular disease Statin therapy recommendation in diabetes - answer >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 - answer 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? - answer 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? - answer 1. glucose, lipid and BP control
- health behaviour optimization
- vascular protective meds Study: STENO- Vascular protective meds - answer statins ACE/ARB ASA (selective use/secondary prevention) Vascular protective drugs AND pregnancy - answer 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) - answer perindopril 8mg (EUROPA), ramipril 10mg (HOPE), telmisartan 80mg (ONTARGET) Screening for CAD in diabetes checklist (3) - answer 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? - answer >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? - answer stress test IF: typical/atypical cardiac symptoms (SOB, chest discomfort), associated diseases (PAD, carotid bruits, TIA, stroke), resting ECG abnormalities
3rd line combo antihypertensives - answer cardioselective BB long active CCB (verapamil, diltiazem) If patient has diabetes AND CKD and is taking ACEI/ARB what should be monitored? and when?
- answer potassium and creatinine levels at baseline, within 1-2 weeks after initiation or titration, and at times of acute illness When is a loop diuretic recommended over thiazide diuretic? - answer 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? - answer prasugrel or ticagrelor Choose prasugrel if... (5)-reversible? - answer -about to go into PCI -clopidogrel naiive -<75yo ->65kg -no history of stroke not reversible Choose ticagrelor if.. (2) - reversible? - answer -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 - answer target to 7- 10mmol/L Risk factors for stroke in diabetics (4) - answer o Insulin resistance
o Central obesity o Impaired glucose tolerance o Hyperinsulinemia Three typical signs of Heart failure - answer peripheral edema, SOB, and fatigue in CHF and eGFR <60mL/min - answer 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 - answer beta blockers Treatment for mild to moderate hyperkalemia (3) - answer 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) - answer 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) - answer persistent albuminuria bland urine sediment slow progression of disease low eGFR associated with overt proteinuria other diabetic complications present DM >5y
Stage 5 kidney disease - answer end stage renal disease - eGFR <15ml/min when to screen for CKD in T1D? - answer annually in post-pubertal age with DM >/=5years When to screen for CKD in T2D? - answer at diagnosis and annually 2 main screening tests for CKD? - answer ACR and eGFR Prevention of CKD - answer 1. proper glycemic control
- optimal blood pressure control
- initiation of ACEI/ARB When to refer diabetics to nephrologist or CKD expert? (5) - answer 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 - answer 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) - answer Laser photocoagulation intraocular injection of meds vitreoretinal surgery
Risk factors for retinopathy (8) - answer 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? - answer 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) - answer falling hip fractures 4-fold increase in mortality early death in T1D Name the 3 types of retinopathy - answer 1. Macular edema
- Nonproliferative and proliferative
- retinal capillary closure Macular edema - answer diffuse or focal vascular leakage the macula Nonproliferative vs proliferative retinopathy - answer blood vessel changes non-proliferative - microaneurysms, intraretinal hemorrhaging, vascular toruosity and malformation
