Week 2 RAT 1

1. Recognize the recommendations for glucose and A1C monitoring in diabetic

patients
a. Monitor glucose 6-10 times daily in type 1
b. A1c at least 2 times per year in patients at goal. Quarterly in patients
with change in therapy or not at goal
c. SMBG may be helpful in patients with less frequent insulin injections.
Definite in patients with many insulin injections a day
d. Continuous glucose monitoring is good in intensive insulin regimens in
patients over 25 with type 1. May be useful in younger populations,
success correlates with adherence
2. Determine the appropriate glycemic goals for DM and the differences
between the ADA and the AACE guidelines
a. ADA
i. A1C under 7% to reduce microvascular complications for nonpregnant adults
1. A1C under 6.5% if no adverse outcomes, short duration of
therapy, type 2 with metformin or lifestyle monotherapy,
long life expectancy, and no cardiovascular disease.
ii. Pre-prandial 80-130
iii. Post-prandial less than 180
b. ACEE
i. A1C under 6.5% if lower target can be achieved without adverse
outcomes
3. Identify the blood pressure monitoring parameters and goals for patients with
DM
a. BP should be monitored every visit and elevated BP should be
confirmed on a separate visit
b. Treat to systolic < 140 mmHg and diastolic < 90 mmHg
c. Lower targets < 130 mmHg and < 80 mmHg can be used in younger
patients if can be done with undue burden
d. Monitor SCr, Albuminuria, and potassium annually
4. Identify the monitoring parameters and goals of dyslipidemia for patients
with DM
a. Screen lipids on diagnosis, at initial medical evaluation, at age 40 and
periodically thereafter
b. Lifestyle modification
c. Triglyceride > 150, HDL < 40, LDL > 190
d. For patients with diabetes and overt CVD, add high-intensity statin
e. For patients with UNDER 40 diabetes and CVD risk factors, consider
moderate- or high-intensity statin
f. For patients with OVER 40 diabetes and WITHOUT CVD risk factors,
consider moderate-intensity statin. High
g. ..
5. Review evidence for glycemic controls impact on cardiovascular disease
a. None
6. Describe the long-term complications that can result from DM as it relates to
micro-vascular and macro-vascular complications
a. Retinopathy

i. More common in type 1

ii. Non-perfusion, increased vascular permeability, and the
proliferation of new pathologic vessels
iii. PDR and NPDR
b. Nephropathy
i. Leading cause of ESRD
ii. More common in type 1
iii. Often also have retinopathy
iv. First albuminuria, then decreased GFR
v. Do annual SCr:Albumin ratio in type 1 of 5 years duration, and in
all type 2. SCr at least annually
c. Neuropathy
i. Most common is distal symmetrical polyneuropathy
d. Cerebrovascular, coronary heart disease, peripheral arterial disease
7. Describe treatment of diabetic peripheral neuropathic pain
a. Gabapentin
Pregabalin
i. Weight gain
ii. Helps sleep
b. Duloxetine
i. Helps depression, comorbid musculoskeletal pain, body weight
concerns
ii. Caution in liver, renal, poorly controlled glucose
c. TCAs
i. Caution in liver, renal, poor glucose, weight gain, CV
ii. Help depression
d. Second-line
i. Tramadol
ii. Oxycodone
iii. OTC pain meds
iv. Venlafaxine
8. Recognize the important life-style modifications and preventative measures
that are important for patients with DM
a. Pneumovax (pneumococcal polysaccharide) for every diabetic patient.
Then repeat dose after 65, with at least 5 years between first and
second dose
b. Antiplatelets recommended in patients with 10-year CVD risk over
10%, and in men > 50 and women > 60 with one additional risk factor
9. Identify key elements to the success of non-pharmacologic interventions for
the treatment of type 1 and type 2 diabetes mellitus
10.Outline the specialized needs for the treatment of diabetes mellitus in special
populations. (adolescents, elderly, gestational diabetes, having diabetes
while pregnant).
a. Adolescents
i. A1C of 7.5% is recommended across all pediatric age-groups
b. Elderly
i. Relaxed treatment
c. GDM
i. Treat with diet and exercise, then try other stuff
ii. Avoid ACEIs and statins

iii. Should be monitored for retinopathy

iv. <6% if can be achieved
v. Metformin, insulin, glyburide
11.Apply evidence-based recommendations to non-pharmacologic and
pharmacologic treatment interventions and goals for diabetes mellitus.