Final - Diabetes

what is the 2 hour glucose level OGTT to make a diagnosis of prediabetes?

140-199 (nl <140)

USPSTF recommend how many minutes of moderate intensity exercise per week for initial diabetes management

150 minutes / week

what is the A1c for prediabetes?

5.7-6.4%

how often do T1D need to get blood sugar?

6-8 x per day, and def before EVERY meal

what is the typical A1c goal for a type 2 diabetic?

</- 7%

what is normal glucose level?

<100 - 100-125 is prediabetic, >/= 126 is diabetic

what is a normal 2 hour glucose level OGTT?

<140 - 140-199 is a diagnosis of pre-diabetes and >/= 200 for type 2 diabetes

what is the fasting glucose for a diagnosis of type 2 DM?

>/= 126 on TWO separate occasions at least 1 day apart (nl <100)

what is the 2 hour glucose level OGTT to make a diagnosis of type 2 diabetes?

>/= 200 in a patient with classic symptoms

what is the random glucose level for a diagnosis of type 2 DM?

>/= 200 in patients with classic symptoms

what is the hemoglobin A1c for a diagnosis of diabetes?

>/= 6.5%

When talking to a diabetic patient (type 1 or type 2) about routine care to monitor for complications of their disease, all of the following are standard recommendations EXCEPT: A. Colonoscopy every 5 years B. Foot care including shaving of calluses by a healthcare provider C. Lipid screening D. Urinalysis E. Yearly dilated eye exam

A. Colonoscopy every 5 years

Any time a diabetic patient develops nephropathy as evidenced by proteinuria, ______ should be started.

ACE inhibitor should be started given even if they have normal BP at a low dose. ARB would be used if the patient does not tolerate an ACE-I.

if a type 2 diabetic develops HTN - what can you prescribe?

ACEi

what is the leading cause of death in type 2 diabetes?

ASCVD - MI higher risk in type 2 than type 1

A patient who is on insulin is experiencing episodes of shaking, teeth chattering, and fogginess after exercise. They check their own blood sugar and it is 55. Which one of the following is the best management option for this patient? A. Provide insulin B. Provide 15grams of a fast-acting glucose C. Send them to the ER as they are likely in DKA D. They are likely overheating and just need to be placed in a cool room

B. Provide 15grams of a fast-acting glucose patients with T1 can go into hypoglycemia quickly so need to give fast acting carbs - soft candy, table sugar, honey maple syrup

When blood sugar goes above 100mg/dL, which one of the following physiologic responses occur to maintain glucose homeostasis? A. Decreased gluconeogenesis B. Decreased lipolysis C. Increased glucose storage in cells D. Decreased glycogenolysis E. Decreased protein anabolism

C. Increased glucose storage in cells - insulin released which promotes glucose storage in cells and promotes storage of carbs and fats

A patient with type 1 diabetes is sick with COVID. Which of the following physiologic changes do we expect to see and need attention: A. Decreased levels of cortisol resulting in increased glucose levels B. Decreased levels of cortisol resulting in decreased glucose levels C. Increased levels of cortisol resulting in increased glucose levels D. Increased levels of cortisol resulting in decreased glucose levels

C. Increased levels of cortisol resulting in increased glucose levels

A patient with type 1 diabetes is in the primary care office today for routine care. The history reveals that the patient has been experiencing blood sugars in the morning ranging from 220-300mg/dL despite healthy diet habits. The patient was instructed by the endocrinologist to check blood sugars around 2-3am if this continues. The patient brought in their logbook today. Their bedtime blood sugars range from 110-150mg/dL and the 2am blood sugar checks range from 50-65mg/dL. Which of the following is the most likely cause of these high morning blood sugars? A. The evening bedtime snack B. Dawn phenomenon C. Somogyi effect D. Recent illness

C. Somogyi effect if a patient is low in the morning hours (here it is around 2 am), hormones are release and overshoot the correction which results in high blood sugar in the morning - have patient eat snack before bed or reduce overnight basal insulin

When blood sugar drops below 70mg/dL, which one of the following physiologic responses occur to maintain glucose homeostasis? A. Decreased gluconeogenesis B. Decreased lipolysis C. Increased glycogenesis D. Increased glycogenolysis E. Increased protein anabolism

D. Increased glycogenolysis when hypoglycemic, glucagon is secreted and causes glycogenolysis and gluconeogenesis

diabetes is the leading cause of what complications?

ESRD non-traumatic lower limb amputation increased risk of CHD

SGLT 2 inhibitor

Empagliflozin (Jardiance) - best for HF / CKD, good for ASCVD, weight loss, hypoglycemia and reduces hospitalizations for HF

T/F diabetic ketoacidosis is due to hypoglycemia

FALSE - due to hyperglycemia, MC seen in T1

T/F the closer you live to the equator the higher the rate of T1D

FALSE - the further you live from the equator, the higher the rates of T1D

what medication is best for patients with ASCVD as an add-on therapy?

GLP-1 (liraglutide) or SGLT2 inhibitor (empagliflozin)

what classes of drugs minimize weight gain / promote weight loss

GLP-1 agonists and SGLT2 (empagliflozin)

SGLT2 inhibitor (emphagliflozin) 1st line is first-line treatment for what condition, in addition to diabetes?

HF or CKD

what are the presenting symptoms for metabolic syndrome?

HTN - >/= 130/85 high glucose - fasting >/= 100 high TGs - >/= 150 low HDL - <40 mg/dL in men, <50 in women abdominal obesity - waist circumference >102 cm in men or >88 cm in women

what drug has the most benefit for reducing hospitalizations for HF?

SGLT-2 inhibitor - empagliflozin (jardiance)

what medication is best as an add-on therapy for those with HF of CKD?

SGLT2 inhibitor (emphagliflozin) 1st line 2nd line if SGLT2 inhibitor is not tolerated or GFR <30 then give GLP-1 (liraglutide)

once a T1 diabetes diagnosis has been made, what additional tests do you run?

T1D antibodies - anti-pancreatic antibodies thyroid - antibodies (not TSH initially) celiac - anti-endomysial antibioties, tissue transglutaminase antibodies

T/F there is higher risk of ASCVD / MI in type 2 diabetes than type 1

TRUE

T/F the diagnosis for T1 and T2 diabetes is the same blood levels

TRUE random blood glucose >200 fasting glucose >/=126 >/= 200 on OGTT A1C >/= 6.5%

T/F proliferative diabetic retinopathy had a worse visual prognosis than non-proliferative

TRUE - more strongly associated with T1D, needs tight glucose control

Which of the below laboratory findings is consistent with a diagnosis of Type 2 DM? a. 2-hour OGTT of 210 mg/dL b. Hemoglobin A1c of 6.0% c. Fasting glucose levels on 2 occasions of 99 mg/dL and 102 mg/dL d. Random plasma glucose level of 190 mg/dL in an asymptomatic patient

a. 2-hour OGTT of 210 mg/dL

A 45-year old female with Type 2 DM and obesity presents for follow up. She currently takes metformin (biguanide) at the max dose per day which she tolerates well. Her fasting morning glucose levels are running b/w 170-200 mg/dL. Her A1c today is 7.9%, up from 7.0% 3 months ago. What would be the most appropriate next step in her care? a. Add a second agent for the treatment of her DM b. Continue current treatment plan as she is very compliant w/ her diet/exercise routine c. Add basal insulin d. Refer to endocrinologist

a. Add a second agent for the treatment of her DM Given the significant increase in the patients A1c and her fasting glucose levels, it is reasonable to add on a 2nd agent at this time. Insulin would not be recommended at this time.

75 year old patient with long standing Type 2 DM on metformin and a GLP-1 inhibitor, hypertension on hydrochlorothiazide and hyperlipidemia on a statin. BP is elevated which is consistent with home readings. Recent microalbuminuria testing is abnormal, indicating retinopathy. What would be the most appropriate treatment recommendation given this new onset nephropathy? a. Add on an ACE inhibitor b. Add on a calcium channel blocker c. Add on an angiotensin II receptor blocker d. Add on an alpha blocker

a. Add on an ACE inhibitor Any time a diabetic patient develops nephropathy as evidenced by proteinuria, ACE inhibitor should be started, even if they have normal BP at a low dose. ARB would be used if the patient does not tolerate an ACE-I.

You are evaluating a patient with new onset Type II diabetes Mellitus who also has a history of an acute Myocardial infarction. The patient has normal renal function. What is the first line treatment medication for this patient? a. Biguanide b. Sulfonylurea c. Thiazolidinediones d. DPP-4 inhibitors e. SGLT-2

a. Biguanide ADA guidelines recommend glucophage (Metformin) which is the only biguanide as the 1st line therapy for all patients. If add-on therapy is required, then in this case, the best option given the patients ASCVD would be a GLP-1 RA due to it's proven CVD benefit or a SGLT2i.

Which of the following is the most common complication of longstanding Type 2 DM? a. Diabetic neuropathy b. Diabetic nephropathy c. Diabetic retinopathy d. Cerebrovascular disease

a. Diabetic neuropathy

A 45-year old patients comes to the office for counseling following recent blood work from his annual physical. On two separate occasions, the result of his fasting plasma glucose has been 115 mg/dl and 120 mg/dl. Which of the following is the most appropriate next step in the management of this patient? a. Encourage following an ADA diet, exercise and weight loss b. Reassure the patient that these are normal fasting glucose levels c. Start on Metformin for Type 2 DM d. Order additional blood work with either a hemoglobin A1c or a 2-hour oral glucose tolerance test

a. Encourage following an ADA diet, exercise and weight loss 2 fasting blood glucose levels on 2 separate occasions that are >100 but <126 is consistent w/ insulin resistance/pre-diabetes. This is enough to make that diagnosis. There is no need to perform additional glucose testing at this time.

If your patient is nervous about weight gain and would prefer a medication that would promote weight loss, which of the below classes should you recommend recommended? a. GLP-1 b. Sulfonylurea c. Thiazolinedione d. DPP-4 inhibitor

a. GLP-1

A 38-year old female presents for her annual physical examination. She identifies as Asian American. History reveals the patient has a history of gestational diabetes w/ her last pregnancy 8 years ago, 10 pack year smoking history, alcohol use of an average of 10 drinks/week and she exercises 3 days/week (biking x 45 minutes). Vitals today reveal a BP of 128/78 mmgHg, HR 70 bpm, and a BMI of 27. What aspect of her history puts her at most risk of developing Type 2 DM in the future? a. History of Gestational DM b. Smoking history c. Excess ETOH intake d. Age

a. History of Gestational DM

52 year old female patient presents to the office with polyuria, fatigue and chronic white vaginal discharge w/ associated vaginal pruritis. The discharge has been on and off for the past 6 months with short term improvement in her symptoms with OTC antifungal treatment. What is the most likely diagnosis? a. Type 2 diabetes mellitus b. Hypothyroidism c. Hyperthyroidism d. Bacterial vaginosis

a. Type 2 diabetes mellitus

How often should urine be obtained to screen for microalbuminuria in the management of Type 2 Diabetes Mellitus? a. annually b. every 3 months c. every 6 months d. Every 2 years

a. annually A1c every 3 months - screening for complications of DM should take place annually (retinopathy- dilated fundoscopic exam, nephropathy- microalbuminuria, neuropathy- diabetic monofilament exam

what are you at increased risk for developing when a patient has metabolic syndrome? (multiple) a. diabetes b. pancreatitis c. coronary artery disease d. polynephritis

a. diabetes c. coronary artery disease MC ^^ also can develop ischemic stroke, fatty liver and cancer

if a patient is in DKA and has a potassium between <3.3, what do you administer? a. potassium b. insulin c. both insulin and potassium

a. potassium FIRST - hold insulin until potassium levels get above >3.3

a patient with metabolic syndrome and elevated LDL - what is the recommended medication? a. statin b. niacin c. niacin, fibrates, omega 3 FA's d. metformin e. ACEI / ARB

a. statin

what is the somogyi effect?

aka nocturnal hypoglycemia followed by rebound morning hyperglycemia presentation - super high blood sugar in the AM cause - if a patient gets low sugar in early am (like 2-3 am ish) the hormones will try to compensate and overshoot the correction = hyperglycemia when you wake up if 3 am dose is lOw (hypOglycemia) then it is the sOmOgyi effect

what is the diagnostic criteria for type 2 DM?

any of the 4: - fasting glucose ≥ 126 on 2 separate occasions (nl <100) - random glucose ≥200 in patient w/ classic symptoms - 2-hr glucose level ≥200 during OGTT - Hemoglobin A1c ≥6.5%

who should be screened for diabetes, according to the ADA?

anyone asymptomatic over age of 45 yo any age is over weight or obese with a RF (inactivity, FH, high risk, PCOS< HTN, CVD, evidence of insulin resistance)

according to USPSTF, who should be screened for diabetes?

asymptomatic 35-70 who are overweight or obese prediabetes --> annual normal --> every 3 years

If your patient has issues with hypoglycemia with their type 2 DM, which of the below classes would NOT be recommended? a. GLP-1 b. Sulfonylurea c. Thiazolinedione d. DPP-4 inhibitor

b. Sulfonylurea - Glipizide causes hypoglycemia, weight gain, rash, photosensitivity

if a patient is in DKA and has a potassium >5.3, what can you administer? a. potassium b. insulin c. both insulin and potassium

b. insulin only - high enough potassium that you need supplementation

a patient with metabolic syndrome and low HDL alone (<40) what is the recommended medication? a. statin b. niacin c. niacin, fibrates, omega 3 FA's d. metformin e. ACEI / ARB

b. niacin

proliferative retinopathy is seen with which of the following a. gestational DM b. type 1 c. type 2

b. type 1

which of the following is due to an autoimmune cause? a. gestational DM b. type 1 c. type 2

b. type 1

A 45-year old female with Type 2 DM and obesity presents for follow up. She currently takes metformin (biguanide) at the max dose per day which she tolerates well. Her fasting morning glucose levels are running b/w 170-200 mg/dL. Her A1c today is 12.1%, up from 8.0% 3 months ago. What would be the most appropriate next step in her care? a. Add a second agent for the treatment of her DM b. Continue current treatment plan as she is very compliant w/ her diet/exercise routine c. Add basal insulin d. Refer to endocrinologist

c. Add basal insulin A1c was >10% - insulin recommended. If it was <10% then add on 2nd agent. There is no reason to stop metformin at this time. She is tolerating the medication well, but her DM is now advancing and she needs add on therapy to the metformin.

if a patient is in DKA and has a potassium between 3.3 - 5.3, what can you administer? a. potassium b. insulin c. both insulin and potassium

c. both insulin and potassium - IV potassium supplementation to keep serum potassium between 4-5

a patient with metabolic syndrome and high triglycerides (>/= 150), what is the recommended medication? a. statin b. niacin c. niacin, fibrates, omega 3 FA's d. metformin e. ACEI / ARB

c. niacin, fibrates, omega 3 FA's

A patient presents to your office with a blood glucose of 275, pH of 3.2 and ketones in urine. He is tachypnea and has severe abdominal pain. What is the next step? a. give 15 g fast acting glucose b. repeat labs c. send patient to ED d. patients labs are normal

c. send patient to ED !!!!! DKA hyperglycemia glucose >250 metabolic acidosis - pH <7.3 or bicarb <18 moderate ketones in urine

non-proliferative retinopathy is seen with which of the following a. gestational DM b. type 1 c. type 2

c. type 2

which of the following is due insulin resistance and beta cell dysfunction? a. gestational DM b. type 1 c. type 2

c. type 2

a patient with metabolic syndrome and high fasting glucose (>100) what is the recommended medication? a. statin b. niacin c. niacin, fibrates, omega 3 FA's d. metformin e. ACEI / ARB

d. metformin

hyperglycemia at 4-5 am

dawn phenomenon

what happens to the beta cells in type 2 DM?

decrease in size and number and they are deficient in insulin secretion

what is the MOA for metformin?

decreases hepatic glucose production and increases insulin sensitivity to peripheral tissues and decreases glucose absorption high efficacy, no hypoglycemia, weight neutral/loss, low cost

"stocking" or "glove" pattern of sensory loss

diabetic neuropathy - MC complication with diabetes sensory loss by mid-calf (stocking) and hands (glove) and ascends up limb (distal --> proximal)

what is the main side effect seen with metformin?

diarrhea - start with a slow titration to prevent severe side effects

what do you want to be sure to monitor and discuss with diabetic patients when coming in for a PCP appointment?

discuss hypoglycemic events eye checks yearly foot care - shave calluses renal bloodwork lipids A1c every 3 months (same as T2) dental psych prn

what is the definition of metabolic syndrome?

disease with multiple risk factors that come from insulin resistance with abnormal adipose deposition and function

GLP1 agonist

dulaglutide / trulicity - good for weight loss, ASCVD, second line for HF and CKD, doesn't cause hypoglycemia, best for weight loss

a patient with metabolic syndrome and elevated BP what is the recommended medication? a. statin b. niacin c. niacin, fibrates, omega 3 FA's d. metformin e. ACEI / ARB

e. ACEI / ARB - helps with HTN and diabetes

how often do you need to change the insulin pump on the arm?

every 2 days

how frequently to you screen A1c in a diabetic patient?

every 3 months

what increases your risk for developing metabolic syndrome?

family history of MS poor diet inadequate exercise likely adipose dysfunction and insulin resistance too

what the basic cause of T1D

genetic predisposition (parent or sibling with T1D) + environmental trigger (like vital infection - enterovirus)

shaky, teeth chattering, dizzy, tired, anxious, sweating are signs of what?

hypoglycemia - need fast acting carb ASAP (soft candy, table sugar, honey, maple syrup)

How long after starting metformin can you add a 2nd agent? why would you do this?

if A1c isn't at target with being on the max dose x 3 months then add 2nd agent

when do you prescribe metformin to someone who is prediabetic (A1c 5.7-6.4%)

if BMI >35, age <60, prior gDM, high risk patients or those with A1c is high despite modifying lifestyle

when hypoglycemic, glucagon is secreted and causes what?

increased glucogenolysis and gluconeogenesis to increase blood glucose to normal resting state

do you want T1D to eat foods with a high or low glycemic index?

low GI (0-54) like apples because they are digested slower --> slower rise in blood glucose

A patient presents with BP 140/95, fasting glucose is 125 mg/dL (high), triglycerides are 175 (high) and HDL is 25. Patient also male with a waist circumference of 105 cm. What is the likely diagnosis?

metabolic syndrome glucose nl <100 TG nl <150 HDL nl >40 in men >50 in women

what is the first line treatment for ALL diabetes patients?

metformin

"cotton wool spots" on fundoscopic exam

non-proliferative retinopathy - strongly associated with T2D

what is the diagnostic criteria for DKA?

patients needs to have ALL 3: hyperglycemia glucose >250 metabolic acidosis - pH <7.3 or bicarb <18 moderate ketones in urine

what are the classic signs of T1D?

polyuria (increase glucose and water excretion - commonly see urinary yeast infections) polydipsia (high plasma osmolality = thirsty) weight loss (cells break down fat and once fat is gone it breaks down muscle for energy) fatigue from not enough energy

how often do you check A1c in a diabetic?

q3 months

if 3 am dose is lOw (hypOglycemia) then it is the ______

sOmOgyi effect

what does a T1D need to do before exercising?

since glucose can drop very quickly in T1D who are exercising, they need to hold insulin or give lower dose (you want more glucose to be released into blood, insulin decreases glucose in blood stream remember)

what is the treatment for the somgyi effect?

snack before bed or reduce overnight basal insulin so the body doesn't try to overshoot the correction

hypoglycemia at 2-3 am

somongyi effect

aka nocturnal hypoglycemia followed by rebound morning hyperglycemia

somongyi effect if 3 am dose is lOw (hypOglycemia) then it is the sOmOgyi effect

which 2 classes of drugs causes hypoglycemia?

sulfonylureas (glipizide and meglitinide)

what diabetic medication is cheapest? (2 of them)

sulfonyurea (glipizide) and thiazolidinediones (pioglitozone)

what is the dawn phenomenon?

surge of hormones around 4-5 am resulting in morning hyperglycemia so increase dose of overnight basal insulin to prevent this surge

how will dehydration appear with T1D on PE?

tenting of skin, dry mucosa

what is the proposed environmental trigger of T1D?

viral infection with enterovirus

what are the symptoms of DKA?

vomiting tachypnea abdominal pain SOB metal status change hyperglycemia, metabolic acidosis, moderate ketosis

when you are sick, how does this affect cortisol and blood glucose?

when ill, you release more cortisol which increases blood sugar so when diabetic are sick their blood sugars get higher increased cortisol = increased glucose

at what pH do you give bicarb to a patient who is likely in DKA?

when pH <6.9 - very acidotic and is in metabolic acidosis