Diabetes Care Guidelines Quiz
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Questions and Answers

What is the recommended frequency for 10-g monofilament testing in people with diabetes?

  • Annually (correct)
  • Monthly
  • Every 2 years
  • Every 6 months

    • All patients with diabetes should have an annual foot exam done by a healthcare provider.

    True

    What is the recommended age for adults with diabetes to get the Hepatitis B vaccine?

    65 years or older

    Diabetes duration greater than ____ years is a risk factor for peripheral and autonomic neuropathy.

    <p>10</p> Signup and view all the answers

    Match the following conditions or factors with their respective implications:

    <p>Low BMI = Frequent hypoglycemic events Glucocorticoid use = A1C &gt;8% Recurrent falls = Peripheral neuropathy risk Family history = Autonomic neuropathy risk</p> Signup and view all the answers

    Which of the following is NOT a manifestation of cardiovascular autonomic neuropathy?

    <p>Gastroparesis</p> Signup and view all the answers

    Antibiotherapy is typically required for diabetic foot wounds with no signs of infection.

    <p>False</p> Signup and view all the answers

    What is the frequency of vaccination recommended for COVID-19 for adults?

    <p>Current initial vaccination and boosters</p> Signup and view all the answers

    What is the A1C percentage range that indicates prediabetes?

    <p>5.7% - 6.4%</p> Signup and view all the answers

    People with normal glucose results should have their testing repeated every 2 years.

    <p>False</p> Signup and view all the answers

    What is the fasting plasma glucose (FPG) range that indicates prediabetes?

    <p>100 mg/dL to 125 mg/dL</p> Signup and view all the answers

    An A1C result of ______% or higher indicates diabetes.

    <p>6.5</p> Signup and view all the answers

    At what age should testing for diabetes start for all other people?

    <p>35 years</p> Signup and view all the answers

    What is the recommended minimum weight loss percentage to help prevent type 2 diabetes?

    <p>7%</p> Signup and view all the answers

    Match the following glucose test results with their corresponding diagnosis criteria:

    <p>A1C ≥6.5% = Diabetes FPG ≥126 mg/dL = Diabetes 2-h PG ≥200 mg/dL = Diabetes A1C 5.7–6.4% = Prediabetes</p> Signup and view all the answers

    A random plasma glucose level of ______ mg/dL or higher indicates diabetes.

    <p>200</p> Signup and view all the answers

    What percentage of limb amputations in Lebanon in 2007 were attributed to diabetes mellitus?

    <p>59%</p> Signup and view all the answers

    Lebanon ranks 1st in MENA for the highest rate of diabetes mellitus.

    <p>False</p> Signup and view all the answers

    How many deaths were linked to diabetes mellitus in Lebanon in 2013?

    <p>6,600</p> Signup and view all the answers

    A BMI of __________ kg/m2 is considered overweight for testing for diabetes.

    <p>25</p> Signup and view all the answers

    Which of the following is NOT a risk factor for diabetes screening?

    <p>High HDL cholesterol level</p> Signup and view all the answers

    Match the following BMI criteria with their corresponding categories:

    <p>≥25 kg/m2 = Overweight ≥23 kg/m2 = Overweight in Asian populations &lt;18.5 kg/m2 = Underweight 18.5 to 24.9 kg/m2 = Normal weight</p> Signup and view all the answers

    Patients with prediabetes should be tested every two years for diabetes.

    <p>False</p> Signup and view all the answers

    What is the A1C percentage that indicates prediabetes?

    <p>5.7%</p> Signup and view all the answers

    Study Notes

    Counselling a Patient with Diabetes Mellitus

    • Lebanon has the 22nd highest rate of diabetes in the world, and ranks 7th in the MENA region.
    • Diabetes Mellitus (DM) was responsible for 59% of limb amputations in Lebanon in 2007.
    • Approximately 6,600 deaths were linked to DM in 2013.
    • The cost of managing diabetes is estimated at $834-$870 per person.

    Decision Cycle for Person-Centered Glycemic Management in Type 2 Diabetes

    • Review and agree on a management plan, including mutually agreed changes to therapy, which must be implemented promptly.
    • Regularly review the plan (at least annually or bi-annually).
    • Maintain an integrated system of care.
    • Provide ongoing support and monitoring of patients' emotional well-being, lifestyle and health behaviors, and tolerability of medications.
    • Monitor and adjust lifestyle factors: blood glucose levels (BGM/CGM), weight, step count, A1C, BP, and lipids.

    Goals of Care

    • Prevent complications.
    • Optimize patients' quality of life.
    • Assess key characteristics: patient's priorities, lifestyle, comorbidities (e.g., CVD, CKD, HF), age, A1C, weight, motivation, depression, cognition and social determinants of health.
    • Agree on SMART goals (Specific, Measurable, Achievable, Realistic, Time-bound).
    • Consider factors impacting treatment choices: glycemic and weight goals, factors impacting weight, hypoglycemia, and cardiorenal protection, physiological factors, side effects of medications, regimen complexity (frequency, mode of administration), access, cost, and availability of medications, and lifestyle choices.

    Diagnosis of Prediabetes

    • A1C 5.7-6.4% (39–47 mmol/mol).
    • Fasting plasma glucose (FPG) 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L).
    • Two-hour postprandial glucose (2-h PG) during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L).

    Preventing Diabetes

    • Achieve and maintain at least 7% weight loss and 150 minutes of moderate-intensity physical activity per week (e.g., brisk walking).
    • Recommended pace of weight loss: 1-2 pounds per week.
    • Evidence suggests no optimal percentage of calories from carbohydrate, protein, and fat for everyone.
    • Metformin is considered for adults at high risk of type 2 diabetes, especially those aged 25-59 years old with a BMI ≥35 kg/m², higher fasting plasma glucose (e.g., ≥110 mg/dL [≥6 mmol/L]), and higher A1C (e.g., ≥6.0% [≥42 mmol/mol]), and in individuals with prior gestational diabetes mellitus.

    Diagnosing Diabetes

    • HbA1c ≥6.5% (≥48 mmol/mol).
    • Fasting plasma glucose (FPG) ≥126 mg/dL (≥7.0 mmol/L).
    • Two-hour postprandial glucose (2-h PG) ≥200 mg/dL (≥11.1 mmol/L) during OGTT.
    • Random plasma glucose ≥200 mg/dL (≥11.1 mmol/L) in individuals with classic symptoms of hyperglycemia or hyperglycemic crisis.
    • Diagnosis requires two abnormal screening test results, either taken at the same time or at different times.

    Glycemic Targets

    • HbA1c <7% is associated with reduced microvascular complications when instituted early in the course of disease.
    • A 1% reduction in HbA1c in patients with T2D was associated with a 25%-37% reduction in macrovascular and microvascular complications.
    • A 0.4% reduction in HbA1c may warrant additional non-pharmacological intervention in patients with polypharmacy.
    • Glycemic control is generally assessed through HbA1c and self-monitoring of blood glucose (SMBG).
    • Pre-prandial blood glucose level: 80-130 mg/dL.
    • Postprandial blood glucose level: <180 mg/dL (1–2 hours after a meal).
    • SMBG should be individualized (8–14 times weekly).
    • The Society of General Internal Medicine does not typically recommend daily home finger glucose testing for patients with type 2 diabetes who are not receiving insulin.
    • The Endocrine Society recommends avoiding routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on medications that do not cause hypoglycemia.

    Target HbA1c

    • Lower Target <6.5% for recently diagnosed, lifestyle changes or metformin, long life expectancy patients with no CV complications.
    • Higher Target <8% for long-standing DM, frequent hypoglycemia, short life expectancy, or comorbid conditions (e.g., CV complications).

    Frequency of HbA1c Testing

    • HbA1c should be tested every 6 months in patients with controlled DM, and every 3 months in those not achieving glycemic targets.
    • Hemoglobinopathies and hemolysis can lead to false HbA1c results.
    • Moderate to severe anemia can increase HbA1c levels.
    • HbA1c target <7%.

    Medical Management of DM

    • Optimal diabetes care encompasses behavioral, dietary, lifestyle, and pharmaceutical interventions.
    • All patients should participate in DM self-management education and support (DSMES).
    • Patient-centered approach to guide the choice of pharmacologic agents, considering efficacy, cost, side effects (including effects on weight, comorbidities, and risk of hypoglycemia) and patient preferences.
    • Metformin is the preferred first-line therapy and effective in reducing cardiovascular events and mortality; in patients with heart failure, chronic kidney disease, or history of atherosclerosis, GLP-1 or SGLT2 inhibitors are also useful.

    Question 6: Metformin failure after 3 months

    • Add sulfonylureas, thiazolidinediones, dipeptidylpeptidase-4 inhibitors, sodium-glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, or basal insulin as additional treatment options.

    Medical Management of DM: Insulins

    • Prandial insulins (e.g., Novorapid, Humalog, Apidra) are rapid-acting and injected 15-30 minutes before a meal.
    • Short-acting insulins (e.g., Humulin R, Novolin R, Actrapid) are also injected 30 minutes before a meal.
    • Intermediate insulins (e.g., Humulin N, NPH) are taken consistently twice daily and can be cloudy; they start in 1-3 hours, peak in 8 hours and last for 12-15 hours.
    • Long-acting insulins (e.g., Ultralente, Lantus) are taken once or twice daily and may last up to 36 hours.
    • Premixed insulins (e.g., Humulin Mix) are commonly used twice daily with meals and long acting parts are more effective when taken late in the evening.

    Medical Management of DM: Insulin Injection

    • Abdomen is the fastest absorption site.
    • Arms and legs have slightly slower absorption.
    • Buttocks have the slowest absorption.
    • Change injection sites regularly (weekly or bi-weekly) to avoid lipohypertrophy.
    • Insulin should be stored in a cool place, preferably at room temperature when in use. Avoid freezing and keeping at high temperatures.
    • Administer using insulin pens, syringes, or an insulin pump.

    Medical Management of DM: Insulin Inhaled

    • Quickly working inhaled insulin is contraindicated in persons with chronic lung disease or who smoke/recently quit.
    • Spirometry must be done before and after starting inhaled insulin therapy.

    Medical Management: Cardiovascular Prevention

    • Atherosclerotic cardiovascular disease (ASCVD) is the primary cause of morbidity and mortality in patients with DM.
    • Physicians should assess cardiovascular risk factors at least annually.
    • Use an online ASCVD risk calculator.

    Medical Management: Heart Failure

    • Rates of incident heart failure hospitalizations are two times higher in persons with diabetes compared to persons without.
    • Using sodium-glucose cotransporter-2 (SGLT2) inhibitors may decrease the risk of heart failure hospitalizations.
    • Hypertension is a risk factor for heart failure.

    Medical Management: Blood Pressure

    • Blood pressure (BP) should be monitored routinely.
    • Target BP for patients with HTN and DM is <130/80 mmHg if safely attainable.
    • Administer a single or double drug therapy to manage blood pressure in patients with BP between 130/80 and 150/90 mmHg depending on BP above 150/90.
    • Use ACE inhibitors or ARBs, and monitor creatinine and potassium levels.

    Microvascular Disease Management: Nephropathy

    • Screen annually for GFR and urine albumin/creatinine ratio.
    • Albuminuria present if ≥2 abnormal albumin/creatinine ratio over 3–6 months.

    • 300 mg/g albuminuria may indicate ESRD diagnosis risk.

    • Nephro referall if cause of kidney disease is uncertain.
    • ACEIs or ARBS can delay progression of kidney disease in persons with HTN and diabetic kidney disease.

    Microvascular Disease Management: Retinopathy

    • Optimal management for glycemia, blood pressure and lipid profile will decrease risk and progression of diabetic retinopathy.
    • Yearly comprehensive eye exams are essential with referral to ophthalmologists.

    Microvascular Disease Management: Neuropathy

    • Assess diabetic peripheral neuropathy at diagnosis of type 2 diabetes and annually thereafter.
    • Assess for hypoglycemia unawareness, gastroparesis, constipation, diarrhea, fecal incontinence, erectile dysfunction, neurogenic bladder, and pseudomotor dysfunction.
    • Orthostatic hypotension and resting tachycardia are manifestations of cardiovascular autonomic neuropathy and increase risk of mortality.
    • Other potentially causative factors in neuropathy may include toxins (e.g., alcohol), neurotoxic medications, vitamin B12 deficiency, hypothyroidism, renal disease, malignancies (e.g., multiple myeloma and lymphoma), and chronic inflammatory demyelinating neuropathy, inherited neuropathies, and vasculitis.
    • Assess for peripheral, autonomic and proximal and small/large nerve function.
    • Ipswich Touch Test to identify sensory dysfunction (i.e., dysesthesia or numbness).

    Microvascular Disease Management: Foot Care

    • Yearly foot exams are necessary, including skin inspection, deformity evaluations, pedal pulse assessments, monofilament testing and pinprick, vibrational and ankle reflexes.
    • Educating patients and providing instructions on daily foot care.
    • Antibiotic therapy is not routinely indicated for diabetic foot wounds unless evidence shows soft tissue or bone infections.
    • COVID-19, Hepatitis B, Influenza, RSV, Tetanus-Diphtheria-Pertussis (Tdap), Zoster, and Pneumonia (PPSV23 and PCV15/20 need to be discussed dependent on pre-existing vaccination history; check current guidelines).

    General and Diabetes-Specific Risk Factors for Fracture

    • General risk factors include prior osteoporotic fracture, age >65 years, low BMI, sex, malabsorption, recurrent falls, glucocorticoid use, family history, alcohol/tobacco abuse, and rheumatoid arthritis.
    • Diabetes-specific risk factors include lumbar spine or hip T-score ≤ -2.0, frequent hypoglycemic events, diabetes duration >10 years, A1C >8%, and peripheral/autonomic neuropathy, retinopathy and nephropathy.

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    Description

    Test your knowledge on the essential care guidelines for diabetes management. This quiz covers topics such as foot exams, vaccinations, A1C levels, and neuropathy implications. Learn about the recommended practices to ensure optimal health for individuals with diabetes.

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