CCFP Review 2025 PART 2 (largest)
When target not met w/ lifestyle change, metformin and other orals OR if in HHS/DKA or very
symptomatic hyperglycemia (remain on metformin, not combined w/ most other orals)
often start long acting at hs, ~10u of glargine (or detemir)
go until am FBG <7
can add rapid acting (aspart or lispro) to 10 mins prior to meals (decr hypo compared to short acting)
✔️When to use insulin in DM2
How to add to DM2 regimen
BS >14mmol/L, presence of urinary or plasma ketones, pH <7.3 and serum bicarbonate <18mmol/L
Absence of insulin = decr glucose utilization = incr'd triglyceride breakdown to free FAs = ketone
production ✔️DKA dx criteria and mechanism
T1DM
T2DM w/ african american/latino, male, middle aged, overweight/obese, FHx DN, new Dx
Poor adherence, depression, wt control, money issues
Not monitoring BS ✔️RF for DKA
Infection (UTI, PNA, sepsis) ~30%, EtOH, psych stress, pregnancy, CV events (CVA.MI), trauma, Rx
(steroids, thiazide), Cushing's, acute GI illness, idiopathic in ~40% ✔️Precipitants of DKA
polyuria or polydipsia, fatigue, lethargy, decr appetite, h/a, n/v, abdo pain
decr skin turgor, decr sweat, postural hypoTN, kussmaul breathing, fruity smelling breathing
ALWAYS LOOK FOR PRECIPITANT ✔️Sx/signs of DKA
Ketosis -
,starvation ketosis - G close to n
EtOH ketoacidosis - N/decr gluc, osmolar gap
pseudo ketosis - N gluc, N gap
rhabdomyolysis - N gluc, ketones
Acidosis -
lactic
salicylate - N/decr gluc
methanol - low ket, blurry vision, osmolar gap
ethylene glycol - N ket, osmolar gap
CKD - icnr Cr, hx ✔️Ddx of ketosis/acidosis
glucose (incr, 1-7% N esp w/ SGLT2)
Na, K, HCO3 (anion gap)
ABG/VBG - pH <7.3, bicarb <18mmol/L
Serum/urine for ketones/hydroxybutyrate
Look for secondary
WBC, hgb, Cr, urea, lipase, U/A, UCx, BCx, CXR if suspicious, ECG (MI and hyperkalemia)
✔️Investigations of DKA
Monitor electrolytes, AG, Cr, plasma osmolality, fluid balance, LOC q2-4 hrs
Tx precipitating factors
Fluid replacement
- if in shock: 1-2L of 0.9% NaCl
- mild to mod 500ml x4H then 250ml x4H
- once euvolemic: if hypernatremic switch to 0.45% NaCl
,- once BG <14 mmol/L, add D5W to fluids to maintain BG 12-14
Serum potassium
- if <3.3 mmol/L --> give 40 mmol/L of KCl and hold insulin
- if 3.3 -5.5 mmol/L --> give 10-40 mmol/L and continue insulin, less w/ CKD
Acidosis
- if potassium >3.3 start short acting insulin 0.1u/kg/h IV and adjust so control glucose and close AG
- when glucose <11.1, titrate insulin down to 0.02-0.05u/kg/h, can switch to sc insulin once eating
- if pH <7, give 1amp bicarbonate
- AVOID HYPOKALEMIA IN INSULIN AND BICARBONATE TX ✔️Mgmt of DKA
glucose <11.1, bicarb >15, pH >7.3, AG <12
Cerebral edema, hypoglycemia, hypokalemia/hypophosphatemia ✔️When is the resolution of DKA?
complications of tx?
HHS glucose >33, DKA >13.9
pH >7.3 in HHS, dka <7.3
HHS bicarb >/=18, dka <18
Urine Ketones low in HHS, higher in DKA
Serum ketones normal or low in HHS, high in DKA
AG variable in HHS, DKA >10
Mental status can be variable for DKA, HHS usually is stuporous ✔️Difference b/w HHS and DKA
Very similar mgmt, more focused on insulin in DKA than HHS
Vascular occlusions (mesenteric artery occlusion, MI) or rhabdomyolysis
, Overhydration risk: ARDS, cerebral edema, lyte disturbance ✔️Mgmt of DKA vs HHS
Complications of HHS?
Sick day protocols
- once feeling sick/fever or having vomiting/diarrhea >6hrs
- check sugars q4H or more if increasing more quickly
- check urine or blood for ketones when sick
- modify insulin regimen, maintain adequate food and fluids
- call physician if gluc >13.3 on insulin or FBG on orals, or if pregnant and >11
- if have s + s ✔️How to avoid DKA/HHS?
acute is <14d of >3stools/d or >200g of stool/d
chronic >4wks ✔️Acute vs chronic diarrhea
fever
unintentional wt loss
hematochezia/melena, positive FOB
anemia
pus in stool
nocturnal defecation
sx refractory to tx
FHx colon ca or IBD ✔️Red flags of acute diarrhea
Viral studies - rarely done
Stool gram stain, culture & sens - if immunocompromised, IBD, bloody diarrhea or persistent diarrhea
Ova, cyst and parasites - travel hx, persistent diarrhea
C diff toxin - recent Abx or persistent diarrhea ✔️Investigations for acute diarrhea
