Category: CDE

Flashcards: Type 1 Diabetes in Children and Adolescents (Chapter 34)

Post author By Michael Boivin
Post date December 25, 2025

Type 1 diabetes is the most common endocrine disease in childhood and adolescence, presenting unique challenges that evolve as the child grows. These flashcards are designed to help pharmacists and healthcare professionals memorize the 2018 Clinical Practice Guidelines regarding pediatric-specific A1C targets, the prevention of diabetic ketoacidosis (DKA) complications, and the screening schedules for associated autoimmune conditions.

Key Topics Covered:

Therapeutic Targets: Recalling the unified A1C target of <7.5% for all pediatric age groups to balance long-term complications with the risk of severe hypoglycemia.
Insulin Regimens: Identifying basal-bolus therapy (MDI) and continuous subcutaneous insulin infusion (CSII/pumps) as the standards of care for matching insulin to physiological needs.
DKA Management: Understanding the critical protocols to prevent cerebral edema, the leading cause of mortality in pediatric DKA, particularly avoiding aggressive fluid resuscitation.
Comorbidity Screening: Memorizing the screening schedule for hypothyroidism (at diagnosis and every 2 years) and celiac disease (at diagnosis and if symptomatic).
Monitoring Protocols: Reviewing the recommendation for frequent glucose monitoring (6 to 10 times daily) or the use of Continuous Glucose Monitoring (CGM) to manage glycemic variability.

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Practice Exam: Type 1 Diabetes in Children and Adolescents (Chapter 34)

Post author By Michael Boivin
Post date December 25, 2025

Tags CDE, Diabetes

CDE Diabetes

Study Guide: Type 1 Diabetes in Children and Adolescents (Chapter 34)

Post author By Michael Boivin
Post date December 25, 2025

1. Overview & Diagnosis

Type 1 diabetes (T1D) is the most common endocrine disease in children.

Presentation: Classic symptoms (polyuria, polydipsia, weight loss) are common. However, DKA is the initial presentation in 15-67% of cases.
Urgency: Suspicion of diabetes in a child is a medical emergency. Immediate referral and confirmation are required to prevent DKA.
Differentiation: While T1D is autoimmune (positive antibodies: GAD, IA-2, ZnT8), Type 2 diabetes is rising in youth.
- Type 1: Leaner, younger, autoimmune markers, insulin deficient.
- Type 2: Obesity, acanthosis nigricans, family history of T2D, insulin resistant.
- Monogenic (MODY): Strong multi-generational family history, negative antibodies.

2. Management Targets

Glycemic targets in pediatrics balance the need to prevent long-term complications with the risk of severe hypoglycemia and the developmental burden of care.

A1C Target: $\le$ 7.5% for all children and adolescents (age < 18).
- Note: This differs from the adult target of $\le$ 7.0%.
- Rationale: To minimize neurocognitive impairment from severe hypoglycemia in young brains while protecting against vascular complications.
Intensive Therapy: Basal-bolus regimens (MDI) or Insulin Pumps (CSII) are the standard of care to achieve these targets.

3. Acute Complications: Pediatric DKA

Management of DKA in children differs significantly from adults due to the risk of Cerebral Edema.

Cerebral Edema: The leading cause of diabetes-related death in children.
- Risk Factors: Younger age, new onset, severe acidosis, rapid fluid administration, rapid drop in osmolality.
Fluid Management:
- Do NOT bolus fluids aggressively unless in shock.
- Rehydrate gradually over 48 hours.
- Use isotonic fluids (0.9% NaCl) initially.
Insulin: Start IV insulin infusion (0.05–0.1 units/kg/h) only 1–2 hours AFTER starting fluid replacement. Do not give an IV insulin bolus.

4. Routine Screening & Autoimmune Comorbidities

Children with T1D are at higher risk for other autoimmune conditions.

Thyroid Disease: Screen at diagnosis and then every 2 years. (Hypothyroidism affects growth).
Celiac Disease: Screen at diagnosis and then every 1–2 years. (Symptoms: poor growth, anemia, unpredictable hypoglycemia).
Complication Screening (Retinopathy, Nephropathy, Neuropathy):
- Neuropathy and Retinopathy Start Screening: At 15 years of age, provided diabetes duration is $\ge$ 5 years.
- Nephropathy Start Screening: At 12 years of age in those with duration of type 1 diabetes >5 years

5. Psychosocial & Developmental Stages

Diabetes management must be adapted to the child’s developmental stage.

Infants/Toddlers: Parents manage all care. Risk of severe hypoglycemia affecting brain development is high.
Preschoolers: Can help pick injection sites but cannot manage tasks. Picky eating makes dosing difficult.
School Age: Can perform tasks (testing, bolusing) but require supervision. They cannot be solely responsible.
Adolescents: Transition to autonomy but high risk of rebellion, burnout, and eating disorders (insulin omission for weight loss).
Transition Care: Structured transition to adult care should begin in early adolescence and occur gradually.

6. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S244).

DKA Protocol: Management of DKA should follow pediatric-specific protocols (gradual rehydration, no insulin bolus) to avoid cerebral edema [Grade D, Consensus].
Targets: Target A1C is $\le$ 7.5% for all children/adolescents [Grade D, Consensus].
Regimens: Children should be treated with intensive insulin therapy (MDI or Pump) matched to food and activity [Grade A, Level 1].
Autoimmune Screening: Screen for Thyroid and Celiac disease at diagnosis and regularly thereafter [Grade D, Consensus].
Complication Screening: Screen for retinopathy, and neuropathy starting at 15 years of age with a duration of diabetes of 5 years. Screen for nephropathy starting at 12 years of age with diabetes duration of 5 years. [Grade D, Consensus].
Psychosocial: Screen for diabetes distress and mental health issues regularly [Grade D, Consensus].
Dyslipidemia: Screen at 12 and 17 years of age.
Hypertension: Screen all children with type 1 diabetes at least twice a year

Reference:

Wherrett DK, Ho J, Huot C, Legault L, Nakhla M, Rosolowsky E. Type 1 Diabetes in Children and Adolescents. Can J Diabetes. 2018;42 Suppl 1:S234-S246. doi:10.1016/j.jcjd.2017.10.036

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CDE Diabetes

Flashcards: Sexual Dysfunction and Hypogonadism in Men with Diabetes (Chapter 33)

Post author By Michael Boivin
Post date December 24, 2025

Erectile dysfunction (ED) affects a staggering 35% to 90% of men with diabetes and often serves as a “canary in the coal mine” for silent coronary artery disease. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines regarding screening protocols, the cardiovascular implications of ED, and the safe management of hypogonadism.

Key Topics Covered:

Vascular Warning Signs: Understanding the evidence that ED may precede the onset of coronary artery disease, serving as a critical marker for vascular health.
Screening Protocols: Memorizing the recommendation to screen all men with diabetes for ED using a sexual function history or the IIEF-5 questionnaire.
First-Line Therapy: Identifying PDE5 inhibitors as the first-line treatment and recalling the absolute contraindication for their use with nitrates.
Hypogonadism Diagnosis: Recalling the specific requirement for morning total testosterone measurement to accurately diagnose biochemical hypogonadism.
Testosterone Replacement: Understanding the indications for replacement therapy—specifically for symptomatic men with confirmed low testosterone—and its potential to improve insulin sensitivity.

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CDE Diabetes

Practice Exam: Sexual Dysfunction and Hypogonadism in Men with Diabetes (Chapter 33)

Post author By Michael Boivin
Post date December 24, 2025

Erectile dysfunction (ED) is a common and often overlooked complication that affects 35% to 90% of men with diabetes. Beyond quality of life, the 2018 Clinical Practice Guidelines identify ED as a critical marker for vascular health, potentially preceding coronary artery disease by several years.

This practice exam tests your ability to screen effectively, interpret diagnostic criteria for hypogonadism, and select safe pharmacological interventions based on cardiovascular comorbidities.

Key Concepts Covered in This Exam:

Vascular Warning Signs: Understanding that ED may be an early marker of underlying atherosclerosis and coronary artery disease, necessitating cardiovascular risk assessment.
Screening Recommendations: Identifying the requirement to screen all men with diabetes for ED using sexual function history or tools like the IIEF-5 questionnaire.
First-Line Therapy: Recognizing phosphodiesterase type 5 (PDE5) inhibitors as the first-line treatment for ED and understanding the absolute contraindication for their use in patients taking nitrates.
Hypogonadism Diagnosis: Mastering the diagnostic criteria for biochemical hypogonadism, which requires morning total testosterone measurement.
Testosterone Replacement: Knowing when testosterone replacement therapy is indicated—specifically for men with clinically significant symptoms and confirmed biochemical hypogonadism—and its potential benefits on insulin sensitivity.

Please go to Practice Exam: Sexual Dysfunction and Hypogonadism in Men with Diabetes (Chapter 33) to view this quiz

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CDE Diabetes

Study Guide: Sexual Dysfunction and Hypogonadism in Men with Diabetes (Chapter 33)

Post author By Michael Boivin
Post date December 24, 2025

1. Overview & Epidemiology

Sexual dysfunction is a common but often overlooked complication in men with diabetes. It significantly impacts quality of life and can serve as a “canary in the coal mine” for cardiovascular health.

Erectile Dysfunction (ED): Affects approximately 34% to 45% of adult men with diabetes.
- Prevalence: Increases with age and duration of diabetes. Up to 50% of men have ED within 6 years of diagnosis.
- CVD Link: ED may be an early clinical indication of cardiovascular disease (CVD). It is an independent marker for future cardiovascular events.
Hypogonadism (Low Testosterone):
- Type 2 Diabetes: Highly prevalent (up to 40% of men).
- Type 1 Diabetes: Prevalence is similar to the general population (not elevated).
- Risk: Hypogonadism in men with diabetes is associated with higher cardiovascular mortality.

2. Screening Protocols

Because these issues are common and treatable, proactive screening is required.

Who to Screen for ED: All adult men with diabetes should be regularly screened.
How to Screen: A sexual function history is the primary tool. Validated questionnaires (like the IIEF or SHIM) can also be used.
When to Screen for Hypogonadism:
- Screen men who are symptomatic (e.g., low libido, ED not responding to treatment, fatigue, muscle weakness).
- Routine biochemical screening in asymptomatic men is not indicated.

3. Diagnosis of Hypogonadism (Testosterone Deficiency Syndrome)

Diagnosis requires careful timing due to natural hormonal fluctuations.

Test Timing: Measure Total Testosterone in the morning (between 7 am and 11 am or within 3 hours of waking).
Confirmation: If levels are low or borderline, repeat the test to confirm.
Bioavailable Testosterone: If Total Testosterone is borderline low-normal but symptoms are strong, measuring bioavailable testosterone is helpful (especially since SHBG is often low in insulin-resistant states, artificially lowering Total T).

4. Management of Erectile Dysfunction

A. First-Line Therapy: PDE5 Inhibitors

Agents: Sildenafil, Tadalafil, Vardenafil.
Efficacy: They are the mainstay of therapy and should be offered first-line.
Dosing: Can be “on-demand” or “daily” (scheduled).
Contraindications:
- Nitrates: Absolute contraindication (risk of severe hypotension).
- Unstable angina or untreated cardiac ischemia.

B. Second-Line & Adjunctive Therapies

Vacuum Constriction Devices: Useful for men who fail or cannot use PDE5 inhibitors.
Intracavernosal Injections: Prostaglandin E1 alone or in combination.
Referral: Men who do not respond to PDE5 inhibitors should be referred to a specialist.

5. Management of Hypogonadism

Weight Loss: In men with Type 2 diabetes and obesity, significant weight loss can increase testosterone levels, sometimes restoring eugonadism without medication.
Testosterone Replacement Therapy (TRT):
- Considered for men who are symptomatic and biochemically hypogonadal.
- Controversy: Evidence is conflicting regarding CV safety. Some studies suggest benefit, others potential risk. It is prudent to discuss this uncertainty with the patient.
- Prostate Health: Monitor for prostate cancer before and during therapy (PSA, DRE).

6. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S231).

Screening for ED: All adult men with diabetes should be regularly screened for ED with a sexual function history [Grade D, Consensus].
First-Line ED Treatment: A PDE5 inhibitor should be offered as first-line therapy (on-demand or daily) [Grade A / Grade B].
Investigating Non-Responders: Men with diabetes and ED who do not respond to PDE5 inhibitors should be investigated for hypogonadism (measure morning Total Testosterone) [Grade D, Level 4].
Referral: Consider referral to a specialist for men who do not respond to or cannot take PDE5 inhibitors [Grade D, Consensus].
Fertility: Men with ejaculatory dysfunction interested in fertility should be referred to a specialist [Grade D, Consensus].

Reference:

Bebb R, Millar A, Brock G. Sexual Dysfunction and Hypogonadism in Men With Diabetes. Canadian Journal of Diabetes. 2018;42:S228-S233. doi:10.1016/j.jcjd.2017.10.035

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CDE Diabetes

Flashcards: Foot Care (Chapter 32)

Post author By Michael Boivin
Post date December 23, 2025

Lower extremity complications are a leading cause of hospitalization and amputation in diabetes. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines regarding risk stratification, the interprofessional approach to wound care, and the appropriate use of antimicrobials.

Key Topics Covered:

Risk Factors: Identifying peripheral neuropathy and peripheral arterial disease (PAD) as the primary drivers of foot ulceration and amputation.
Wound Management: Memorizing the core components of care: glycemic control, infection management, mechanical off-loading, and vascular assessment.
Antimicrobial Stewardship: Understanding the recommendation that antibiotics are not required for uninfected neuropathic ulcers and should be reserved for clinically infected wounds.
Dressing Selection: Recalling that there is insufficient evidence to support the routine use of expensive antimicrobial dressings over standard moist wound care.
Epidemiology: Recognizing the stark statistic that adults with diabetes are 20 times more likely to undergo nontraumatic lower limb amputation than the general population.

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CDE Diabetes

Practice Exam: Foot Care (Chapter 32)

Post author By Michael Boivin
Post date December 23, 2025

Lower extremity complications are a major cause of morbidity and mortality in people with diabetes. The 2018 Clinical Practice Guidelines emphasize that the treatment of foot ulcers requires a structured, interprofessional approach to address the underlying causes—such as neuropathy and peripheral arterial disease—and prevent the devastating outcome of amputation.

This practice exam tests your ability to apply the evidence-based recommendations for screening, wound management, and the appropriate use of antimicrobial therapy.

Key Concepts Covered in This Exam:

Risk Assessment: Recognizing that individuals with peripheral neuropathy and peripheral arterial disease are at the highest risk for developing foot ulcers and subsequent amputation.
Wound Management Principles: Understanding the interprofessional approach that includes glycemic control, infection management, mechanical off-loading of high-pressure areas, and assessment of vascular status.
Antimicrobial Stewardship: Identifying the recommendation that antibiotic therapy is not required for uninfected neuropathic foot ulcers and should be reserved for clinical infection.
Dressing Selection: Understanding the lack of sufficient evidence to support the routine use of proprietary antimicrobial dressings over standard moist wound care.
Amputation Prevention: Acknowledging that adults with diabetes are 20 times more likely to be hospitalized for nontraumatic lower limb amputation than those without diabetes, highlighting the urgency of effective care.

Please go to Practice Exam: Foot Care (Chapter 32) to view this quiz

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CDE Diabetes

Study Guide: Foot Care (Chapter 32)

Post author By Michael Boivin
Post date December 23, 2025

1. Overview & Epidemiology

Lower extremity complications are a major source of morbidity and mortality.

Amputation Risk: Adults with diabetes in Canada are 20 times more likely to undergo a non-traumatic lower limb amputation than those without diabetes.
Hospitalization: Foot ulcers are a leading cause of hospitalization for people with diabetes.
Recurrence: Individuals with a history of foot ulcers have a high rate of recurrence, making ongoing surveillance critical.

2. Risk Assessment

Every person with diabetes requires regular foot risk assessment.

Frequency: Perform a foot exam at least annually, and more frequently for high-risk individuals.
Key Risk Factors for Ulceration:
- Peripheral Neuropathy (Loss of Protective Sensation).
- Peripheral Arterial Disease (PAD).
- Structural deformity (e.g., Charcot foot, hammer toes).
- Previous ulcer or amputation.
- Elevated A1C and Onychomycosis (fungal nail infection).

3. The Physical Exam (The "3-Minute Exam")

A proper foot exam includes three main components:

A. Neurological Assessment (Protective Sensation)

Tool: 10g Semmes-Weinstein Monofilament.
Method: Test specific sites on the plantar surface. Loss of sensation to the 10g monofilament is a significant independent predictor of future ulceration and amputation.

B. Vascular Assessment (Circulation)

Inspection: Look for skin color, hair growth, and temperature.
Palpation: Check dorsalis pedis and posterior tibial pulses.
Advanced Testing: Ankle-Brachial Index (ABI) is standard but may be falsely elevated (unreliable) in diabetes due to calcified arteries (medial arterial calcification). Toe Pressures (systolic toe pressure) are often more accurate in this population.

C. Dermatological/Musculoskeletal

Skin: Assess for calluses (pre-ulcerative lesion), fissures, blisters, or tinea pedis.
Structure: Look for deformities like Charcot arthropathy (collapsed arch, warmth, redness) or claw toes which increase pressure points.

4. Classification of Ulcers

Using a validated system helps predict outcomes. The guidelines highlight two systems:

Wagner Classification: Grades 0 (intact skin) to 5 (gangrene of whole foot).
University of Texas System: Incorporates Ischemia and Infection into the grading (Stages A, B, C, D), which improves prediction of amputation risk.

5. Management of Foot Ulcers

Treatment requires an interprofessional approach focusing on VIP: Vascular status, Infection, and Pressure off-loading.

Debridement: Regular debridement of non-viable tissue (callus/slough) is recommended to promote healing.
Infection:
- Uninfected Ulcers: Do NOT use antibiotics (topical or systemic) for uninfected ulcers. It promotes resistance.
- Infected Ulcers: Classify as mild (localized), moderate, or severe. Treat with empiric antibiotics covering Staph. aureus and Strep, then tailor based on deep tissue culture (swabs are unreliable).
Off-Loading (Pressure Relief):
- Gold Standard: Total Contact Cast (TCC) or non-removable walker boot is the most effective method for healing plantar neuropathic ulcers.
- Removable Cast Walkers: Effective if worn consistently (but compliance is lower).
Dressings: No single specific dressing type is superior. The principle is to maintain a physiologically moist wound environment.
Adjunctive Therapies: Therapies like negative pressure wound therapy (NPWT) or hyperbaric oxygen are not recommended for routine treatment of simple ulcers but may be considered for complex/non-healing wounds.

6. Charcot Neuroarthropathy

Definition: A progressive degeneration of a weight-bearing joint, characterized by bony destruction and deformity.
Acute Phase Signs: Red, hot, swollen foot (often mistaken for cellulitis).
Differentiation: If a foot is red/hot but the patient is afebrile and WBC is normal, suspect Charcot. Elevating the foot may decrease redness in Charcot (dependent rubor) but not in cellulitis.
Treatment: Immediate immobilization (Total Contact Cast) and non-weight bearing until the acute phase resolves (temperature normalizes).

7. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations

Key takeaways from the “Recommendations” section (Page S226).

Screening: Perform a foot exam at least annually to identify risk factors (neuropathy, PAD, deformity) [Grade C, Level 3].
Education: High-risk individuals should receive foot care education and professionally fitted footwear [Grade D, Consensus].
Prompt Treatment: Any foot ulcer or sign of infection requires prompt treatment by an interprofessional team [Grade C, Level 3].
Wound Care:
- Debride non-viable tissue [Grade A, Level 1A].
- Use dressings that maintain a moist environment [Grade D, Consensus].
- There is insufficient evidence to recommend specific dressing types or antimicrobial dressings for routine use [Grade C, Level 3].
Adjunctive Therapy: Therapies like topical growth factors or dermal substitutes are not for routine use but may be considered for non-healing, non-ischemic wounds after standard care fails [Grade A, Level 1].

Reference:

Embil JM, Albalawi Z, Bowering K, Trepman E. Foot Care. Canadian Journal of Diabetes. 2018;42:S222-S227. doi:10.1016/j.jcjd.2017.10.020

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CDE Diabetes

Flashcards: Neuropathy (Chapter 31)

Post author By Michael Boivin
Post date December 23, 2025

Diabetic neuropathy affects up to 50% of people with diabetes within 10 years of diagnosis, significantly increasing the risk of foot ulcers, amputation, and cardiovascular mortality. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2018 Clinical Practice Guidelines regarding screening techniques, preventive strategies, and the hierarchy of pharmacologic treatments for neuropathic pain.

Key Topics Covered:

Screening Tools: Memorizing the use of the 10 g Semmes-Weinstein monofilament and 128 Hz tuning fork for detecting loss of protective sensation.
Assessment Timelines: Recalling the different screening initiation protocols: starting at diagnosis for Type 2 diabetes versus 5 years post-diagnosis for Type 1 diabetes.
Pain Management: Identifying the first-line pharmacotherapies (anticonvulsants like pregabalin/gabapentin and antidepressants like duloxetine/venlafaxine) and understanding why opioids are not recommended as primary therapy.
Autonomic Neuropathy: Recognizing the clinical signs of autonomic dysfunction, such as resting tachycardia, orthostatic hypotension, and gastroparesis.
Differential Diagnosis: Understanding the importance of excluding other causes of neuropathy, such as Vitamin B12 deficiency (especially with metformin use) or alcohol overuse.

Tags CDE, Diabetes