Diabetes

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In Process

Author / Curator:

Faculty Advisor:

GUIDELINES:
The format of each page are recommended guidelines. They should be fluid as each topic will have a unique flow.

(1) Be concise.

(2) Be evidence-based. (Everything should have a reputable citation and resource)

(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).


Top Teaching Points

  • Core components of managing diabetes are to target the "ABCs" (A1C, Blood Pressure, Cholesterol), along with other standards of diabetes care.
  • In addition to the Target ABCs, management of patients with diabetes includes lifestyle counseling regarding diet and exercise, prevention, vaccinations, and aspirin therapy for some, as well as screening for polyneuropathy and retinopathy.
  • The goal for A1C in diabetes is <7%, with individualized lower near-normal targets in younger patients with recent onset disease, hypoglycemia awareness, and no vascular complications, and higher targets in the older patient with long-standing diabetes, hypoglycemia unawareness, and/or evidence of cardiovascular disease.
  • Preprandial glucose target in non-pregnant patients is 70-130 mg/dl, though this should be individualized. In patients who have not achieved target A1C, but are at target for preprandial glucose, aim for peak postprandial glucose of <180 mg/dl.
  • Self-monitoring of blood glucose is often important in reaching glycemic targets. Monitor hemoglobin A1C every 6 months, or every 3 months if diabetes is uncontrolled, medications are being adjusted, or patients are on insulin.
  • First-line pharmacotherapy for type 2 diabetes is metformin and there are now several non-insulin options that are now available. In situations of severe hyperglycemia or presentations with significant weight loss or ketonuria, initiate therapy with insulin, not oral agents. In type 2 diabetes, insulin therapy is often started as a basal supplement with intermediate or long-acting insulin preparations, such as NPH or lantus at 10 units nightly, titrated to meet fasting glucose target.
  • Indications for referral to an endocrinologist include type 1 diabetes, frequent hypoglycemia, and inability to reach glycemic targets.

Background

This portion should be a brief background. It may include recommended sub-headers:

- Epidemiology

- Physiology / Pathophysiology

  • Type 1
  • Type 2
  • Rare, Non-Type 2 Types:
    • Flatbush DM - presents with DKA but does not always result in insulin dependence; variable presence of autoantibodies and B-cell function
    • LADA - late onset Type 1
    • Drug-Induced (e.g. corticosteroids)
    • Endocrinopathy-Induced (e.g. Cushing's, Acromegaly)
    • Pancreatic Insufficiency (e.g. chronic pancreatitis, cystic fibrosis)
    • MODY

- Progression and Complications of Disease (i.e. what we get worried about)

  • HHS/DKA
  • Macrovascular: CAD, PAD
  • Microvascular: nephropathy, retinopathy, neuropathathy (sensorimotor, autonomic), foot disease, infections (esp. psuedomonas, rhizopus, fungal), depression, anxiety
  • Co-morbidities: smoker/HTN/HLD(LDL)/obesity/FH

Diagnosis

All diagnosis information should be evidence-based only. Recommended sub-headers:

- History:

  • Duration, polyuria/polydipsia/fatigue/blurred vision/numbness/tingling/ED/gastropareses
  • Prior meds
  • History of HHNKS/hypoglycemia, DKA (more typical T1DM)
  • RF: autoimmune disease (incl. thyroid), weight history, other medications, FH, pancreatic disease

- Signs and Symptoms -

- Differential Diagnosis (i.e. what else to look for)

- Physical Exam Findings

- Recommended Work-up (Evidence-based Labs / Imaging / Diagnostics)

Management

All treatment information should include citations and evidence-based links. Recommended sub-headers:

- Non-pharmalogical treatment

- Pharmacological treatments

- Things to Avoid (e.g. dietary, medication restrictions)

Other Teaching Pearls

These should be short one-liners (with citations) of unique or interesting "pearls" that can offer teaching points for more advanced practitioners. (e.g. Losartan is the only ARB hypertensive agent that is associated with a lower incidence of gout attacks [1])

Trial Summaries

These are brief one-line summaries of relevant trials and studies. One recommendation is to like to discussion pages like WikiJournalClub for further information.

Ongoing controversies / New updates

What's the latest scuttlebutt? This is a place to include new guidelines, controversies, or other recent updates on the topic.

Teaching Resources

Blogs:

Videos:

Podcast episodes:

Core review articles / Guidelines:

Other links:

References


Diabetes

  1. Choi et al.: Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study. BMJ 2012;344:d8190.