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IOS 9 Exam 4
MIcrovascular Complications
| Question | Answer |
|---|---|
| Prevent/Slow the progression of Microvascular complications | 1. Optimize glucose, A1C<7, preprandial glucose 90-130, peak post prandial glucose <180 (Diabetes Control and Complication Trial and UK Prospective Diabetes study |
| Shown risk reduction if intensive glycemic control in Diabetes control and complication trials | Retinopathy (65), Neuropathy (60), and Nephropathy (microalbuminuria-39) |
| Risk reductions with glycemic control in the UL Prospective Diabetes study | Rentinopathy (29), Nephropathy (27), Microvascular complications (25%) NOT NEUROPATHY!! |
| Diabetic nephropathy occurs in | 40% of patients with Type 1 DM, since more in Type 2 60% of them also see other microvascular complications |
| Stages I of Diabetic nephropathy | CKD=1, GFR>90 and onset 0-2 years (hyperfiltration) |
| Stage II of Diabetic nephropathy | CKD 1-2, GFR >90 onst 2-7 years (Glomular basement lesions-GFR normal) |
| Stage III Diabetic nephropathy | CKD 1-2, GFR 60-89 onset 7-15 years (microalbuminuria-last reversible) |
| Stage IV Diabetic nephropathy | CKD 3-4, GFR 50-29, Onset 15-25 years-macroalbuminuria, Decreased GFR and no reversal |
| Stage V Diabetic nephropathy | CKD 5, GFR<15, Onset 25years ESKD |
| Screening :type 1, Type 2 | Microalbuminuria, Calculate GFR- Type 1 5 years after Dx, Type 2 at time of Dx |
| Risk factors for Nephropathy | Modifiable (5)-Hyperglycemia, HTN, Micro/Macroalbuminuria, dyslipidemia, smoking |
| Treatment diabetic nephropathy | ID Stage, Optimiza BP <130/90if protein>1g/day 125-75, ACE, treat lipids , quit smoking, protein restriction RDA<8g/kg/day per KDOQI and NCEP guidelines |
| Microalbuminuria is | Stage III- 30-299mcg/dL albumin/creatine in urine indicated increased glomular capilary pressure |
| Macroalbuminaria is | Stage IV (no reversal/just delay) >300mcg/dL of Albumin/creatine 70% will progress to ESKD in 20 years Treat with ARB |
| When screening for albuminuria make sure no false positives | Comption of high protein meal, recent vigorus exercise, infection, very high blood pressure or blood glucose, dehydration, hematuria |
| Level A ACE or and ARC Type 2 DM microalbuminuria | ADA and KDOQI |
| Type 1 ADA Level A for Micro/macroalbuminuria | ACE- decrease in glomerular pressuremay drop GFR slightly at start (aka release pressure) |
| Type 2 ADA Macroalbinuria | ARB-decrease in glomerular pressuremay drop GFR slightly at start (aka release pressure) |
| Base line microalbuminuria evidence for ARBS in Type 2 | IRMA-2 (Irbesartan vs placebo), MARVEL (valsartan vs Amplodipine) |
| Baseline Macroalbuminuria for ARBS in Type 2 | IDNT (Irbesartan vs amlodipine- Stop decline of Scr), RENNAL (Losartan vs placebo-decrease ESKD an prevent drop in Scr) |
| ACE vs ARB name of study and result | DETAIL study and NO difference in micro/macroalbuminaria, Scr, |
| Can ACE + ARB be used in Micro or macroalbuminuria? | Few small studies say that both together> than either alone, consider in those who albuminuria continues to progress on single agent |
| Neuropathy is most commonly caused by | Diabetes (30-50% are affected-75% of all non-trauma amputations), then ETOH |
| Modifiable risk factors for Neuropathy | HTN, Hyperglycemia, Dyslipidemia, Smoking, ETOH |
| 2 common types of diabetic neuropathy | Chronic sensorimotor (DPN) or autonomic (DAN) |
| Chronic Sensorimortor Neuropathy includes | Positive symptoms=pain (burning, pricking), negative symptoms-Numbness (loss of feeling)- this is most common |
| Glove and stocking distribution of Chronic sensorimortor neuropathy | Mild( feet), moderate (mover paroximal- feet-calf and fingers) severe (feet, calf, thighs, stomach, finders , forearms) |
| Autonomic neuropathy types | Cardiovascular, GI, GU |
| Cardiovascular diabetic neuropathy presentation/treatment | Clinical manifestation is exercise intolerance, resting tachycardia, at risk for sudden cardiac death! (B-Blocker needed) |
| GI diabetic neuropathy presentation /treatment | 76% of patients have -Constipation, erratic glucose control (gastroparesis-need metoclopramide or erythromycin) |
| GU diabetic neuropathy presentation/treatment | Many have UTI, Urgency or Overflow incontinence or Erictile dysfunction, or vaginal dryness |
| Screening for neuropathy Type 1 and TYpe II | Type 1 at time of dDx for chronic sensorimotor and 5 years later for autonomic then annually Type 2 at DX |
| Management of Neuropathy (4) | TCA, Duloxetine, Prgabalin, Gabapentin |
| Side effects of TCA | anticholinergics-orthostatic hypotension (NO>65yo), confusion Cost $20 |
| Duloxetine side effects | Increase in blood glucose, dizziness, NO Not use CrCL<30, Cost $ 112/m |
| Gabapentin Side effects | Sedation and dizziness, adjust for CrCl, Cost $90-200/m |
| Pregabalin side effects | Peripheral edema, weight gain (NO TZD), D/C id CrCL<30 Cost 160/m |
| Diabetic Retinopathy is the most common cause of | New Blindness, After 20 year of DM nearly all Type 1 and >60% ot type 2 develop retinopathy= Strongest predictor for development & progression is Duration of DM |
| Screening for diabetic retinopathy | Type 1-w/in 3-5 years of Dx or once age 10 then annual, Type 2 After Dx then annual, Pregnancy-Prior to conception and during 1st trimeter then follow up throught and 1year after |
| Prevention and treatment of Retinopathy | Optimize glycemic control, BP control, Smoking cessation, annula exam, Treatwith laser photocoagulation |
| STENO-2 study of Type 2 /Microalbuminuria/BP control, AIC, Cholesterol,exercise, smoking, ASA, ACE/ARB | Decreasein retinopathy by 58% and nephropathy 61%, Autonomic neuropathy 63% (N/C in Chronic sensorimotor) |
Created by:
liza001
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