exam time
Which of the following would be the most appropriate blood pressure goal for a pregnant woman with chronic hypertension?
120-160/80-105 mmHg is correct. The 2019 ADA guidelines recommend a blood pressure goal of 120-160/80-105 mmHg for pregnant patients with diabetes and chronic hypertension to optimize long-term maternal health and minimize impaired fetal growth. Lower targets (Answer A and B) may improve long-term maternal health, but may be associated with impaired fetal growth. Elevated blood pressures (Answer D) increase both maternal and fetal health risk.
Which of the following best describes the onset of insulin lispro?
15 to 30 minutes is correct. Rapid acting insulin products, such as lispro, aspart and glulisine enter the bloodstream 15 to 30 minutes after subcutaneous injection. Short-acting regular insulin has an onset of 30 to 60 minutes and lasts approximately 4 to 6 hours (Answers B and C). The intermediate and long-acting insulin products have a 1 to 3 hour onset of action, with NPH reaching its peak effect at 6 hours and lasting 12 hours (Answer D).
An overweight 54-year-old man taking metformin 1g twice daily plus glimepiride 4mg daily presents for evaluation. He is 5 feet, 9 inches tall and weighs 200 pounds (BMI 29.5 kg/m^2) with an A1C of 9%. His diabetes care team decides to start basal insulin. Which of the following would be the most appropriate weight-based starting dose based on the 2019 ADA treatment algorithm? 2 units 8 units 18 units 27 units
18 units is correct. The 2019 ADA treatment algorithm recommends that basal insulin be started at a dose of 10 units or weight-based dosing of 0.1-0.2 units/kg. This patient weighs 90 kg (200 pounds), which calculates to 9-18 units (0.2 units/kg x 90 kg).
A 28-year-old woman with Type 1 diabetes for 10 years needs to re-calculate a correction bolus based on her new insulin regimen. Her current total daily dose (TDD) of insulin is 60 units. Which of the following best estimates the amount 1 unit of insulin will lower her blood glucose level?
30 mg/dL is correct. The Rule of 1800 (some providers recommend 1700 for patients on insulin pumps, or 1500 for patients injecting regular insulin) estimates the amount 1 unit of insulin will lower her blood glucose level. This patient takes a total daily dose (TDD) of 60 units (1800 divided by 60 units = 30 mg/dL). A general rule of thumb is that 1 unit of insulin will lower the blood glucose by 50 mg/dL.
A 35-year-old patient with type 2 diabetes presents for follow-up of her glycemic control. Her current medications include: metformin 1g twice daily and glargine 46 units at bedtime with a recent A1C of 7.7% (goal <7%). She eats a granola bar for breakfast, has a sandwich and water at lunch, then a large evening meal. She denies symptoms of hypoglycemia. She weighs 156 pounds (BMI 26 kg/m^2) and her average preprandial self-monitored blood glucose levels are: 152 mg/dL at 8AM, 160 mg/dL at noon, 146 mg/dL at 6 PM, and 220 mg/dL at 10 PM. Her provider decides to start glulisine before the evening meal (at 6 PM). Which of the following would be the most appropriate recommendation for this patient?
5 units is correct. Both the ADA and AACE guidelines recommend adding bolus insulin at a dose of either 10% of the current basal dose, or 0.1 units/kg, or 5 units. Subsequent dose adjustments can be made in 1 to 2 unit increments or 10% to 15% of the dose.
A 28-year-old woman with Type 1 diabetes for 10 years needs to re-calculate a mealtime (insulin to carbohydrate ratio) bolus based on her new insulin regimen. Her current total daily dose (TDD) of insulin is 60 units. Which of the following best estimates the amount of carbohydrates matched by 1 unit of insulin?
8 g is correct. The Rule of 500 estimates the amount of carbohydrates matched by 1 unit of insulin. This patient takes a total daily dose (TDD) of 60 units (500 divided by 60 units = 8 g of carbohydrate). A general rule of thumb is that 1 unit of insulin is necessary for every 15 g of carbohydrate.
A 52-year-old male with diabetes, CAD, hypertension and dyslipidemia presents to clinic to follow-up on his fasting laboratory values (see labs below). His medical history is significant for MI (2009, 2011, 2014), PTCA (2009, 2014), and CABG (2011). His current medications include rosuvastatin 20 mg daily, empagliflozin 25 mg daily, amlodipine 10 mg daily, valsartan/HCTZ 320/12.5 mg daily, isosorbide mononitrate 30 mg daily, and metoprolol XL 100 mg daily. His fasting laboratory values are as follows: total cholesterol 298 mg/dL, triglyceride 187 mg/dL, HDL-cholesterol 35 mg/dL, LDL-cholesterol 225 mg/dL. Which of the following represents the most appropriate drug therapy option for this patient?
Add alirocumab 75 mg every 2 weeks is correct. This patient at very high ASCVD continues to have significantly elevated LDL-cholesterol and non-HDL-cholesterol, therefore would benefit most from adding a PCSK9 inhibitor. Increasing rosuvastatin to 40 mg daily (Answer A) will only lower his LDL-cholesterol by another 6% to 7%; whereas adding alirocumab will lower his LDL-cholesterol by 58% and non-HDL-cholesterol by 50%.
A 64-year-old man with type 2 diabetes, cardiovascular disease and heart failure returns to clinic on metformin 1g twice daily plus glargine 65 units at bedtime. His fasting glucose is 162 mg/dL with an A1C of 8.1% and eGFR 50 mL/min/1.73m2. Which of the following would be the most appropriate recommendation for this patient?Increase metformin Add empagliflozin Add pioglitazone Add dapagliflozin
Add empagliflozin is correct. Based on data from the EMPA-REG trial, adding empagliflozin to background therapy in patients with established cardiovascular disease decreases heart failure hospitalizations by 35%, cardiovascular death by 38% and all-cause mortality by 32%. The optimal dose of metformin is 2g per day, increasing the dose offers no additional A1C reduction but does increase side effects (Answer A). Adding pioglitazone in this patient would not be ideal considering his history of heart failure (Answer C). It is uncertain whether the beneficial effects observed in EMPA-REG are restricted to empagliflozin or represent a class effect; however, dapagliflozin (Answer D) is not recommended in patients with an eGFR <60 mL/min/1.73m2.
After taking atorvastatin 40 mg daily for 6 weeks, a 62-year-old male patient with type 2 diabetes and history of myocardial infarction returns for follow-up. His laboratory values are as follows: total cholesterol 190 mg/dL, triglyceride 175 mg/dL, HDL-cholesterol 27 mg/dL, LDL-cholesterol 128 mg/dL. Which of the following represents the most appropriate drug therapy change for this patient?
Add ezetimibe 10 mg at daily is correct. The non-HDL-cholesterol goal for this patient is <100 mg/dL. Increasing atorvastatin to 80 mg daily (Answer A) will only lower his LDL-cholesterol by another 6% to 7%; whereas adding ezetimibe will lower his LDL-cholesterol by 18%. Switching from a high-intensity statin to a moderate-intensity statin (Answer C) is not appropriate in this patient with high ASCVD risk. Adding gemfibrozil (Answer D) is also not appropriate because his triglycerides are <204 mg/dL based on the ACCORD data, and gemfibrozil is contraindicated with atorvastatin.
A 38-year-old female patient with type 2 diabetes presents for evaluation. She currently takes metformin 1g twice daily and rosuvastatin 20mg daily. In clinic today her weight is 200 pounds (90kg); laboratory values include: A1C 9.4%, serum creatinine 0.7mg/dL, total cholesterol 196mg/dL, triglycerides 350mg/dL, HDL-cholesterol 36mg/dL, LDL-cholesterol 90mg/dL. Which of the following would be the most appropriate recommendation to address the hypertriglyceridemia in this patient? Add colestipol 6 g daily Add glargine 18 units daily Switch rosuvastatin to lovastatin 20 mg daily Switch metformin to glipizide 10 mg twice daily
Add glargine 18 units daily is correct. Patients with elevated fasting triglyceride levels less than 500 mg/dL should optimize their glycemic control prior to adding medical therapy such as omega-3 fatty acids (fish oil), fibrates or niacin. Addition of bile acid sequestrants (colestipol, Answer A) will lower total and LDL-cholesterol but may raise triglyceride levels. Switching to a low intensity-statin (lovastatin, Answer C) would not be appropriate for this high risk patient already on a high-intensity agent. Switching from metformin to glipizide (Answer D) offers no therapeutic advantage in this patient who is already far from her A1C goal of <7%.
A 64-year-old man with type 2 diabetes and cardiovascular disease (myocardial infarction 5 years ago) returns to clinic on metformin 1g twice daily plus glargine 34 units at bedtime. He continues to work as an automobile mechanic and enjoys gardening. His fasting glucose is 140 mg/dL with an A1C of 8.2%. Which of the following would be the most appropriate recommendation for this patient? Make no change Add liraglutide once daily Switch glargine to NPH insulin Add regular insulin before meals
Add liraglutide once daily is correct. In the LEADER study, patients with diabetes at high risk of cardiovascular events were randomized to liraglutide or standard (non-incretin) therapy plus usual care. Patients in the liraglutide group had a 15% reduction in all-cause mortality and 22% reduction in cardiovascular related death. Liraglutide was also associated with lower A1C, body weight and hypoglycemia compared with the standard therapy group. Although less intensive A1C goals are appropriate for some older patients, this patient continues to perform vigorous work and would likely benefit from tighter glycemic control (Answer A). Switching from glargine to NPH insulin provides no improvement in glycemic control and may increase the risk of nocturnal hypoglycemia (Answer C). Adding rapid-acting insulin before meals is an option for this patient, but regular insulin (Answer D) would likely increase the risk of late hypoglycemia.
A 35-year-old patient with type 2 diabetes presents for follow-up of her glycemic control. Her current medications include: metformin 1g twice daily and glargine 26 units at bedtime with a recent A1C of 7.7% (goal <7%). She eats a granola bar for breakfast, has a sandwich and water at lunch, then a large evening meal. She denies symptoms of hypoglycemia. Her average preprandial self-monitored blood glucose levels are: 152 mg/dL at 8AM, 160 mg/dL at noon, 146 mg/dL at 6 PM, and 220 mg/dL at 10 PM. Which of the following would be the most appropriate recommendation for this patient? -Move glargine to 8 AM -Increase metformin -Add aspart at bedtime -Add lispro at 6 PM
Add lispro at 6 PM is correct. This patient is well controlled throughout the day but experiences a spike in blood glucose after her large evening meal. Based on her current A1C of 7.7%, this patient needs additional insulin so moving glargine to morning (Answer A) is unlikely to resolve her bedtime hyperglycemia. Adding rapid-acting insulin (aspart, Answer C) at bedtime will correct the hyperglycemia, but the goal of therapy is to prevent such excursions. The dose of metformin (Answer B) is already optimized and increasing will only cause more gastrointestinal disturbance without improving glycemic control.
A 57-year-old woman with type 2 diabetes returns to clinic on metformin 1g twice daily. She exercises daily and has maintained a normal weight for the last 5-years. She recently finished a course of antibiotics for a urinary tract infection (the third in the last 18 months) and denies any symptoms today. She is tolerating the metformin well with an A1C of 7.8%. Which of the following would be the most appropriate recommendation for this patient?
Add sitagliptin is correct. Addition of a DPP-4 inhibitor (sitagliptin) would be a good choice for this patient because of the low risk of hypoglycemia, weight gain and ability to reach the A1C goal of <7%. Canagliflozin (an SGLT2 inhibitor, Answer A) also has a low risk of hypoglycemia but would not be the best choice given her history of frequent urinary tract infections. Glyburide (Answer B) and other sulfonylureas would help her achieve her A1C goal but may increase the risk of hypoglycemia during her daily exercise. Bromocriptine (Answer D) has a low risk of hypoglycemia, but is not considered a favorable second agent due to the dizziness, nausea and fatigue associated with the dopaminergic agent.
Which of the following would be the most appropriate initial lipid-lowering therapy for a 46-year-old patient with clinical atherosclerotic cardiovascular disease (ASCVD)? Simvastatin 40mg Atorvastatin 40mg Rosumvastatin 5mg Atorvastatin 20mg + Ezetimibe 10mg
Atorvastatin 40mg is correct. The 2019 ADA guidelines recommend a high-intensity statin for adults ages 40 to 75 with clinical ASCVD (atorvastatin 40mg to 80mg or rosuvastatin 20mg to 40mg). Moderate-intensity statins (simvastatin 40mg, Answer A; rosuvastatin 5mg, Answer C) are suggested for patients between ages 40 to 75 without risk factors or clinical ASCVD. For patients who do tolerate a high-intensity statin, the guidelines recommend a moderate-intensity statin plus ezetimibe (Answer D).
A 45-year-old patient presents to clinic complaining of fatigue, frequent urination and a skin infection on his lower leg that is slow to heal. Laboratory values at the visit are as follows: A1C 12.8%, fasting plasma glucose 256mg/dL, serum creatinine 0.7mg/dL. The patient is currently taking metformin. Which of the following would be the most appropriate addition to metformin therapy based on the 2019 ADA guidelines?
B - Glargine is correct. the 2019 ADA guidelines recommend basal insulin if A1C level >11% especially in the setting of hyperglycemia symptoms. SGLT-2 inhibitors (empagliflozin), Answer A), DPP-IV inhibitors (sitagliptin, Answer C) and GLP-1 RA's (liraglutide, Answer D) are reserved as second line options for patients with A1C levels <11%.
Which of the following should be used with caution in patients with hypoglycemia unawareness? Beta-blockers Angiotensin converting enzyme inhibitors Statins Aspirin
Beta-blockers is correct. Patients with hypoglycemia unawareness may experience a blunted response to epinephrine in response to falling blood glucose levels. Normally, epinephrine causes tachycardia and stimulates glucagon release; however, concurrent therapy with beta-blockers may further blunt these compensatory responses. Of note, sweating is a sympathetic response that is not blunted by beta-blockers. Other common cardiovascular agents: angiotensin converting enzyme inhibitors (Answer B), statins (Answer C) and aspirin (Answer D) do not affect sympathetic response to hypoglycemia.
Which of the following is most likely to increase the risk of diabetic kidney disease? A1C 6.2% Blood pressure 156/104 mm HgLDL-cholesterol 160 mg/dL Urine albumin to creatinine ratio 24 mg/g
Blood pressure 156/104 mmHg is correct. Diabetic kidney disease is a microvascular complication caused by elevated blood pressure and blood glucose levels. Diabetes is diagnosed at an A1C level above 6.5% (Answer A) which also corresponds to increased risk of microvascular complications. LDL-cholesterol (Answer C) is a risk factor for macrovascular disease and not associated with increased kidney disease. A urine albumin to creatinine ratio above 30 mg/g is a marker of nephropathy (Answer D).
A 56-year-old overweight African-American patient with diabetes, heart failure and hypertension presents for follow-up. He currently takes all of his medications in the morning. His provider recently read in the ADA guidelines that taking at least one antihypertensive at bedtime has been shown to reduce cardiovascular events and mortality. Which of the following antihypertensives should be moved to bedtime? Furosemide Candesartan Spironolactone Hydrochlorothiazide
Candesartan is correct. Patients who maintain elevated blood pressure readings at night during sleep, called non-dippers, are at increased risk of cardiovascular events and mortality. Moving one or more antihypertensives to bedtime has been found to restore a normal blood pressure dipping pattern. Furosemide (Answer A), spironolactone (Answer C) and hydrochlorothiazide (Answer D) are diuretics which may disrupt sleep patterns due to urinary frequency.
A 64-year-old patient with type 2 diabetes and history of myocardial infarction 3-years ago returns to clinic. He complains of muscle pain in his thighs and calves that occurs during exercise. He previously tolerated atorvastatin but noticed the pain after the dose was increased from 20mg to 40mg daily 2-weeks ago. Which of the following would be the most appropriate recommendation for this patient?
Change to atorvastatin 20mg plus ezetimibe is correct. The IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) randomized patients who were >50-years-old and experienced acute coronary syndrome (ACS) within the preceding 10 days to simvastatin plus ezetimibe or simvastatin alone. Patients in the combination therapy group showed a significant reduction in major adverse cardiovascular events. Consequently, the 2019 ADA guidelines suggest adding ezetimibe to moderate-intensity statins for those patients with ACS who cannot tolerate high-intensity statin therapy. The PCSK9 inhibitors (alirocumab, Answer A) are indicated for patients with ASCVD on maximally tolerated statin therapy. Switching to a low intensity-statin (pravastatin, Answer C) would not be appropriate for this high risk patient. Adding gemfibrozil (Answer D) to atorvastatin would not be appropriate due to the increased risk of myopathy of combination therapy, especially in this patient with a history of statin-induced myositis.
On average, a child/adolescent would be expected to adjust his or her own insulin dose, to anticipate and prevent hypoglycemia, and alter their food intake in relation to blood glucose level by what age?
Children between the ages of 14 and 16 can anticipate/prevent hypoglycemia, are able to adjust insulin doses, state role of meal planning in the management of diabetes and alter food intake in relation to blood glucose levels. Children between the ages of 8 and 10 years (choice A) can recognize hypoglycemia and self-administer insulin, at least sometimes. By ages 10-12 years, children (choice B) are able to self-treat hypoglycemia and identify appropriate pre-exercise snacks.
A 55-year-old woman with diabetes asks whether she should start taking an aspirin 81mg daily as primary prevention for ASCVD. Which of the following criteria would be necessary for the benefits of aspirin therapy to outweigh the risks?
Cigarette smoking is correct. Aspirin therapy with 75mg to 162mg daily should be considered for patients with type 1 or type 2 diabetes at increased risk of cardiovascular disease. Patients at increased risk include those with a calculated 10-year risk >10%, or those >50-years-old with at least one additional major ASCVD risk factor (family history of premature atherosclerotic cardiovascular disease (Answer D), hypertension, smoking, dyslipidemia, or albuminuria (>30mg/g, Answer C)). While peptic ulcer disease might prohibit initiation of aspirin therapy, gastrointestinal reflux is considered safe (Answer B).
A pregnant woman with past medical history of type 2 diabetes, ASCVD and hypercholesterolemia uncontrolled by TLC presents for evaluation. Which of the following drug therapy options would be the best choice for this patient? Niacin Rosuvastatin Fenofibrate Colesevelam
Colesevelam is correct. Treatment of dyslipidemia in pregnant patients should consider the welfare of the woman and the fetus. Bile acid sequestrants (colesevelam, colestipol, etc.) remain in the gastrointestinal tract and are not systemically absorbed. Statins (Answer B) are classified as FDA Pregnancy Category X which signifies that studies have shown they may cause birth defects and that the risks clearly outweigh any benefit. Niacin and fibrates (Answers A and C) are Pregnancy Category C.
A 25-year-old pregnant woman with gestational diabetes inadequately controlled with diet, exercise and metformin presents for follow-up. Which of the following would be the most appropriate addition to her regimen?
Detemir is correct. All insulin products are FDA Pregnancy Category B except for glulisine, glargine and degludec which are labeled category C.
Most children with type 1 diabetes require approximately the following units of insulin per kilogram of body weight:
Most children require approximately 0.5 units of insulin per kilogram of body weight.
A 46-year-old patient with type 2 diabetes presents for evaluation of his dyslipidemia. He reports two episodes of gout in the past but no history of ASCVD. He currently takes metformin ER 500mg daily and rosuvastatin 20mg daily. Laboratory values include: A1C 6.1%, serum creatinine 0.8mg/dL, total cholesterol 232mg/dL, triglycerides 550mg/dL, HDL-cholesterol 34mg/dL, LDL-cholesterol 88mg/dL. Which of the following would be the most appropriate addition to this patient's regimen?
Fenofibrate is correct. This patient has significantly elevated triglyceride levels despite excellent glycemic control. Although the combination of simvastatin plus fenofibrate in the ACCORD trial did not improve ASCVD risk in the general population, patients with triglycerides >204mg/dL and HDL-cholesterol <34mg/dL did benefit. Likewise, cardiovascular data supporting combination therapy with statins plus niacin (Answer A) is also weak. Adding niacin might be an option considering the pancreatitis risk imparted by this patient's elevated triglycerides, but his history of gout makes niacin a less favorable choice. The PCSK9 inhibitors (evolocumab, Answer D) and ezetimibe (Answer B) primarily lower LDL-cholesterol and would not be appropriate in this patient with hypertriglyceridemia.
A 38-year-old man with type 2 diabetes and an A1C of 8.7% stopped taking metformin 500mg twice daily due to persistent diarrhea. Which of the following is most likely to achieve his A1C goal of less than 7%?
Glimepiride is correct. Biguanides and sulfonylureas lower A1C up to 2%, while other agents only lower A1C by 0.5% to 1%, including: GLP-1 receptor agonists like liraglutide (Answer A); SGLT2 inhibitors like canagliflozin (Answer B); DPP-4 inhibitors like saxagliptin (Answer C).
Which of the following is most associated with an increased risk of diabetic retinopathy?
Hypertension uncontrolled on two medications is correct. Diabetic retinopathy results from a combination of uncontrolled hypertension (blood pressure >140/90 mmHg) and poor glycemic control (A1C >7%) over time. Hypercholesterolemia increases the risk of macrovascular complications and should be treated with a statin of appropriate intensity (Answer B), either moderate or high-intensity. The occurrence of microvascular disease in one part of the body increases the likelihood of other organ involvement; however, there is no data that associates increased risk with thiazide diuretics or other agents (Answer C). The age of diabetes onset does not directly predict the occurrence of microvascular complications (Answer D), especially with contemporary aggressive management of glycemic control.
Which of the following should be avoided in a patient with a history of severe angioedema with enalapril requiring hospitalization
Irbesartan is correct. Angioedema with angiotensin converting enzyme (ACE) inhibitors is idiosyncratic and can occur at any time during therapy. African-American patients tend to be higher risk of angioedema. For patients with severe reactions, angiotensin receptor blockers (ARB) should also be avoided if other options are available
A 62-year-old man with type 2 diabetes and chronic kidney disease presents for management of his diabetes. Recent laboratory values include the following: A1C 7.8%, serum creatinine 2.3 mg/dL. Which of the following DPP-4 inhibitors most appropriate for this patient?
Linagliptin is correct. Linagliptin is the only agent in the DPP-4 inhibitor class that does not require dose reduction in patients with renal impairment. Sitagliptin (Answer A) and Saxagliptin (Answer B) require dose reductions with CrCl <50mL/min. Alogliptin (Answer D) requires dose reduction with CrCl <60mL/min.
Which of the following GLP-1 receptor agonists is administered once daily?
Liraglutide is correct. Dulaglutide, Semaglutide, and Exenatide ER are all administered once weekly as subcutaneous injections.
A 29-year-old Caucasian male patient with type 1 diabetes and newly diagnosed hypertension presents for evaluation. Which of the following would be the most appropriate as initial therapy for this patient?
Lisinopril is correct. The 2019 ADA guidelines recommend that angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB), but not both are preferred for patients with diabetes and hypertension. Loop diuretics (furosemide, Answer B) is useful for patients with heart failure to maintain fluid balance, but has less effect on systemic blood pressure control. Beta blockers (metoprolol, Answer C) are reserved for patients with history of CAD. Alpha blockers (doxazosin, Answer D) are reserved for patients with resistant hypertension already on recommended first line agents.
With the diagnosis of gestational diabetes there are associated possible neonatal complications. which are?
Macrosomia,hypoglycemia, Shoulder dystocia, polycythemia, Hyperbilirubinemia, macrosomia
Which of the following drug therapies has been shown to decrease diabetes-related deaths in patients who are overweight?
Metformin is correct. A subgroup analysis of the UK Prospective Diabetes Study (UKPDS) showed that metformin was associated with a decrease in diabetes-related deaths in overweight patients. Sulfonylureas, DPP-4 inhibitors and amylin mimetics do not decrease cardiovascular risk.
A 32-year-old pregnant female patient with type 1 diabetes and newly diagnosed hypertension presents for evaluation. Which of the following would be the most appropriate as initial therapy for this patient? Lisinopril Irbesartan Methyldopa Chlorthalidone
Methyldopa is correct. Angiotensin converting enzyme inhibitors (lisinopril, Answer A) and angiotensin receptor blockers (irbesartan, Answer B) may cause fetal damage and are contraindicated during pregnancy. Chronic use of diuretics (Answer D) during pregnancy may reduce plasma volume and also be harmful to the fetus. Drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin.
A 42-year-old male patient with type 2 diabetes presents for evaluation of his dyslipidemia. Other than diabetes, he does not have any ASCVD risk factors. Which of the following would be the most appropriate recommendation in addition to lifestyle therapy for this patient based on the 2019 ADA guidelines?
Moderate-intensity statin therapy is correct. Patients with diabetes between age 40 and 75-years-old without atherosclerotic cardiovascular disease (ASCVD) risk factors should consider therapy with a moderate-intensity statin in addition to lifestyle therapy. Adult patients with diabetes are twice as likely to experience an ASCVD event as their age-matched peers without diabetes. Patients in this age group with ASCVD risk factors or overt disease should be treated with a high-intensity statin.
A 36-year-old pregnant woman with gestational diabetes inadequately controlled with diet and exercise presents for follow-up. She and her husband have tried to become pregnant several times without success, and they are very concerned about the effects of drugs on the fetus. Which of the following would be the most appropriate addition to her regimen? Glyburide Metformin Liraglutide NPH insulin
NPH insulin is correct. Recombinant human NPH insulin is preferred during pregnancy due to its amino acid structure and long history. Several meta-analyses suggest that glyburide (Answer A) is inferior to metformin and insulin due to increased risk of neonatal hypoglycemia and macrosomia. About 50% of the metformin dose crosses the placenta but is not associated with adverse effects on the fetus; however, metformin may slightly increase the risk of prematurity (Answer B). The GLP-1 receptor agonists (liraglutide, Answer D) are all FDA Pregnancy Category C.
A 72-year-old patient with irregular eating patterns is concerned about hypoglycemia in between meals. Which of the following would be most appropriate for this patient? Glyburide Sliding scale insulin Chlorpropramide Nateglinide
Nateglinide is correct. The 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults advises against the use of long-acting sulfonylureas (glyburide, Answer A; chlorpropamide Answer C) in patients > 65 year of age because of prolonged half-life in older adults and subsequent increased risk of hypoglycemia. Glyburide is metabolized to two active metabolites which exponentially increase the potential for hypoglycemia. Sliding scale insulin (Answer B) refers to administration of short- or rapid-acting insulin as the only insulin product in response to elevated blood glucose levels. Sliding scale insulin is associated with increased risk of hypoglycemia without improvement in glycemic control regardless of the care setting. Nateglinide (Answer D) stimulates insulin release from the beta-cells; however, its short half-life and mealtime administration limits the risk of hypoglycemia.
A 62-year-old overweight woman is referred to your clinic as a new patient. Her PMH includes hypertension (5 year history), type 2 diabetes (2 year history), chronic kidney disease (Stage 4) and osteoporosis (4 years). She reports walking 2 miles daily without chest pain or shortness of breath. "I just cannot seem to lose weight." Which of the following conditions is the most compelling reason to avoid pioglitazone in this patient?
Osteoporosis is correct. Increased risk fracture in women and macular edema have also been observed with thiazolidinedione therapy. Both adipocytes and osteoblasts arise from mesenchymal stem cells. Activation of PPAR-gamma by thiazolidinediones may shift cell differentiation away from osteoblast formation in favor of new adipocytes. This patient is very active as evidenced by her daily exercise program so heart failure (Answer A) and age (Answer D) are not appropriate. Also kidney function does not affect therapy with pioglitazone.
Which of the following immunizations would be most appropriate for a 42-year-old patient with type 2 diabetes who received the "pneumonia vaccine" 20 years ago? Zostavax (zoster) Prevnar 13 (pneumococcal 13-valent conjugate) Pneumovax 23 (pneumococcal polysaccharide) MenB (meningococcal B)
Pneumovax 23 (pneumococcal polysaccharide) is correct. Patients with diabetes are at increased risk for pneumococcal infection with a mortality rate as high as 50%. All patients with diabetes older than 2 years of age should initially receive Prevnar 13 prior to pneumococcal polysaccharide vaccine 23 (PPSV23). Patients with diabetes older than 19 years and those at high risk of infection should receive follow-up vaccination with PPSV23. Immunocompromised patients (including people over age 65 with a "naturally" declining immune system) mount a better response with Prevnar 13 followed by PPSV23 one year later. Zostavax (Answer A) is indicated for patients over age 50 to prevent herpes zoster (shingles). Vaccination against meningococcal B (Answer D) is indicated for adults less than age 25 as a 2-dose series at least one month apart.
Which of the following would be the most appropriate reason to avoid therapy with canagliflozin?
Recurrent genitourinary infections is correct. Genitourinary infections are a common adverse effect associated with SGLT2 inhibitors due to the presence of glucose-rich urine. Canagliflozin and other SGLT2 inhibitors may be affected by decreased renal function, but not hepatic function (Answer A). Increased risk of thyroid cancer (Answer C) is a concern associated with incretin mimetics but not SGLT2 inhibitors. Based on data from the EMPA-REG trial, SGLT2 inhibitors may be beneficial for patients with heart failure; however, it is unknown if these results are a class effect or restricted to empagliflozin.
A 62-year-old overweight woman is referred to your clinic as a new patient. Her PMH includes hypertension (5 year history), type 2 diabetes (2 year history), chronic kidney disease (Stage 4) and osteoporosis (4 years). She reports walking 2 miles daily without chest pain or shortness of breath. "I just cannot seem to lose weight." Which of the following conditions is the most compelling reason to avoid metformin in this patient?
Renal dysfunction is correct. Patients with Stage 4 kidney disease have severely reduced kidney function with glomerular filtration rates (GFR) <30 mL/min/1.73m2. Specific serum creatinine levels to determine appropriateness of metformin therapy (<1.4 mg/dL for women; <1.5 mg/dL for men) have been replaced with estimates of GFR. The metformin dose should be limited to 1g in patients with a GFR of 30 to 45 mL/min/1.73m2 but should be discontinued in patients with a GFR <30 mL/min/1.73m2. This patient is very active as evidenced by her daily exercise program so heart failure (Answer A) and age (Answer D) are not appropriate. Thiazolidinediones but not metformin may worsen osteoporosis symptoms (Answer C).
An active 54-year-old patient with type 2 diabetes, hypertension and dyslipidemia returns to follow-up on atorvastatin 40mg daily. He complains of muscle pain in his thighs and calves that occurs during exercise. The decision is made to stop atorvastatin for 2 weeks then begin a new therapy. Which of the following would be the most appropriate for this patient?
Rosuvastatin is correct. Statin myositis is caused by inhibition of cholesterol synthesis within muscle cells. Without sufficient endogenous cholesterol, working muscle cells are unable to repair damage cell walls resulting in lysis and pain. The lipophilic statins (atorvastatin, lovastatin and simvastatin, Answers B and C) are most commonly associated with myositis because they easily penetrate cells and become trapped. Patients who experience statin-myositis may be rechallenged with other statins, especially hydrophilic compounds (rosuvastatin, Answer D; or pravastatin). Monotherapy niaspan would not be an appropriate substitute for statin therapy (Answer A).
Which of the following is LEAST associated with nausea? Semaglutide Sitagliptin Metformin Exenatide
Sitagliptin is correct. The DPP-4 inhibitors, including sitagliptin, are very well tolerated and have a low incidence of gastrointestinal upset (1.4% with sitagliptin). Up to 20% of patients with type 2 diabetes report nausea with Semaglutide (Answer A). One study reported rates of gastrointestinal upset of 26% with immediate release metformin that dropped to 11% with extended release metformin (Answer C). Nausea with exenatide occurs in 23% of patients (Answer D).
A 78-year-old woman with type 2 diabetes and heart failure presents for evaluation. She reports frequently skipping meals because it is "too far to walk to the dining room" before getting short of breath. Her recent laboratory values include: A1C 7.8%, serum creatinine 1.2 mg/dL. Her vital signs today are as follows: weight 160 pounds (BMI 25 kg/m^2), blood pressure 118/68 mmHg, pulse 66 BPM. Which of the following would be the most appropriate recommendation?
Sitagliptin is correct. This patient with symptomatic heart failure requires an agent with a low risk of hypoglycemia that will not worsen her heart failure symptoms. Saxagliptin and pioglitazone (Answers B and D) are contraindicated in patients with symptomatic heart failure. Metformin (Answer A) may be used with caution in patients at risk of decompensating, but sitagliptin would be a better choice.
Which of the following interventions is most effective in preventing peripheral vascular disease in patients with diabetes?
Smoking cessation is correct. Smoking cessation is the most effective intervention to prevent peripheral vascular disease. Management of existing peripheral vascular disease includes routine ambulation (Answer C) to promote corollary artery blood flow, pentoxifylline (Answer B) to reduce pain, and aspirin therapy (Answer A) to decrease associated cardiovascular risk.
Studies have demonstrated cognitive impairment occurs at blood glucose concentrations of less than ____ mg/dL.
Studies have shown cognitive impairment at blood glucose concentrations less than 60 mg/dL.
Which of the following best describes the short-term and long-term effects of improved glycemic control in patients with painful peripheral neuropathy?
Temporary increased discomfort but improved long-term prognosis is correct. Peripheral diabetic neuropathy results from vascular damage and impaired blood flow to nerves leading to erratic nerve firing and signal conduction that the patient interprets as pain. Elevated glucose levels contribute to cellular damage by formation of advanced glycosylation end products. Improved glycemic control is essential to restore normal blood flow and mitigate long-term nerve damage; however, it also tends to initially increase pain signals from damaged nerves.
A 62-year-old male patient with type 2 diabetes returns to clinic after being discharged from the hospital following a myocardial infarction. He is overweight, continues to smoke and has elevated blood pressure. Which of the following represents the most appropriate LDL cholesterol goal of therapy for this patient?
The 2018 ACC/AHA Guidelines on the Management of Blood Cholesterol recommends an LDL goal <70 mg/dL for patients with a history of ASCVD.
One of the most serious complications of type 2 diabetes in the older adult is:
The correct answer is A. Because HHS develops slowly and does not cause gastrointestinal pain, it can be overlooked or misdiagnosed. Delayed treatment and co-morbidities more common in the older adults result in a mortality rate of approximately 15%.
In the contemplation stage of readiness, the patient is: Seriously considering change in the near future Choosing among various behaviors to change Contemplating whether or not to change Considering change in the foreseeable future
The correct answer is D. In the contemplation stage the individual is aware of the problem and intends to change his/her behavior.
Which of the following was a significant benefit (occurred less often in intensive blood pressure treatment group) in the ACCORD trial?Nonfatal myocardial infarction Total and nonfatal stroke Cardiovascular death Hyperkalemia
Total and nonfatal stroke is correct. The ACCORD trial compared the effect of intensive systolic blood pressure goals (<120 mmHg) with standard care (130 to 140 mmHg) on cardiovascular events. The composite primary endpoint, nonfatal myocardial infarction (Answer A), cardiovascular death (Answer C) and all-cause mortality were not statistically different between the groups. Total and nonfatal stroke were lower in the intensive group but did not alter the primary composite endpoint. Patients in the intensive control group also experienced more orthostasis and hyperkalemia (Answer D).
Which of the following may not be a concern in the postpartum care of women with previous gestational diabetes? -Achieving a normal body mass index (BMI) -Remaining lean and fit throughout life -Staying on insulin postpartum if insulin was required during pregnancy -Having a follow-up oral glucose tolerance test 6 to 12 weeks postpartum
Women with a history of GDM are at increased risk of developing type 2 diabetes later in life. Insulin is not required for the vast majority of women in the post-partum period, as 95% of women will revert to normal glucose tolerance upon delivery. However, women with a history of GDM remain at increased risk for developing type 2 diabetes later in life. Achieving and maintaining normal BMI (choice A and B) and staying active (choice B) are two successful strategies for reducing that risk. It is also recommended and important for women to be retested for diabetes (choice D) in the postpartum period to ensure that their glucose tolerance has reverted to normal.
what do Fibrates/Gemfibrozil do?
lower LDL, raise HDL. If TG >500, lowder TF first, then LDL.
what do "STATINS" do?
lower TG, raise HDL
Which of the following lab values is most consistent with the presentation of diabetic ketoacidosis?
pH 7.0 is correct. Patients with diabetic ketoacidosis present with blood pH <7.30, serum bicarbonate <18 meq/L (Answer B), glucose >250 mg/dL (Answer C), and anion gap >12 (Answer D) with moderate or severe ketoacidosis.
