Diabetes

Question 1

A 5 yo boy is brought in by his mother. Recently he has been drinking a lot of juice and has had excessive urination. His mother also says he’s been eating more recently but hasn’t been gaining any weight. She also reports that he’s been tired a lot recently. What lab tests should you order? What diagnosis might you suspect?

Answer 1

Type 1 Diabetes Mellitus
Labs: A1c, fasting glucose, postprandial blood glucose, random blood glucose (b/c he has symptoms), GTT
Also do urine dip stick test to look for high sugar levels in the urine

Question 2

An 11 yo girl presents with polyuria, polydipsia, fatigue, nausea, and blurred vision. You suspect she has T1DM, what lab/test findings would you expect to see?

Answer 2

A1c: > 6.5
Fasting blood glucose: > 126 mg/dL
Postparndial blood glucose: > 200 mg/dL
Random blood glucose: > 200 mg/d:
GTT: > 200 mg/dL
Urine dipstick test: Positive for glucose and ketones

Question 3

A 19 yo female came in previously complaining of polyuria, polydipsia, polyphagia, weight loss, fatigue, and feeling dizzy when she sat up. You receive the results of her lab work, below. What disease does this pt have? What classification?
A1c: 5.9%
Fasting blood glucose: 115 mg/dL
Postprandial blood glucose: 187 mg/dL

Answer 3

Pre-Diabetes

Question 4

A pt presents with signs of Type 1 DM. What is the most likely cause of this pt’s disease? What classification does this make it?

Answer 4

Immune-mediated (90%)

Type 1a DM

Question 5

What are the two types of T1DM? What is different between the two?

Answer 5

Type 1a DM is autoimmune

Type 1b is idiopathic

Question 6

Describe the mechanism of action in Type 1b DM.

Answer 6

Lymphocytic infiltration & B-cell destruction –> Islets of Langerhans don’t produce insulin –> insulin deficiency
DM occurs when 80-90% of B-cells have been destroyed

Question 7

What is one type of medication that can be dangerous for diabetic pts. Why is this medication dangerous?

Answer 7

Catecholamines can result in hypoglycemia unawareness

Question 8

What lifestyle changes are important for a newly diagnosed Type 1 diabetic to make?

Answer 8

Eat snacks and meals at regular intervals
Avoid dehydration
Lipid control
Exercise

Question 9

A 34 yo woman with a history of Grave’s Disease presents to your clinic complaining of polyuria, polydipsia, fatigue, blurry vision, and numbness in her hands and feet. What are your main goals when treating this pt?

Answer 9

Type 1 DM

Goals of Tx are (1) to prevent hyper-/hypoglycemia, and (2) to prevent long-term complications

Question 10

What is the preferred treatment for a newly diagnosed Type 1 diabetic?

Answer 10

Rapid & Long acting insulin
Rapid: Lispro, Humalog, NovoLog, Aspart
Long: Glargine, Lantus, Determir, Levemir

Question 11

What risks are associated with rapid-acting insulin? With short-acting?

Answer 11

Rapid-acting has a risk of hypoglycemia

Short-acting has a risk of diabetic ketoacidosis

Question 12

What are the types of intermediate-acting insulin?

Answer 12

NPH, Humilin N or L, Novolin N or L

Question 13

When is rapid-acting insulin dosed?

Answer 13

5-10 minutes before meals

Immediately after meals in children or elderly

Question 14

How frequently is intermediate-acting insulin dosed?

Answer 14

Twice a day

Question 15

When is short-acting insulin dosed?

Answer 15

30 minutes prior to a meal

Question 16

How frequently is long-acting insulin dosed?

Answer 16

Once a day

Question 17

How is insulin delivered?

Answer 17

Subcutaneous injection at a rotating site (to avoid lipid-buildup at the injection site)
Inject via a syringe, insulin pen, or a pump

Question 18

What are two very important non-pharmaceutical ways to manage T1DM?

Answer 18

Self-monitoring

Family education

Question 19

A diabetic patient comes to the ER for nausea, vomiting, abdominal pain, polyuria, and respiratory distress. What diabetic complication does this pt have?

Answer 19

Diabetic ketoacidosis

Question 20

A 9 yo pt is brought to the ER by his parents. He is vomiting, complaining of abdominal pain, shortness of breath, constantly peeing, and drinking excessive amounts of water. On exam, he is tachcardic, hypotensive, tachypneic, lethargic, and has Kussmaul’s breathing. His parents tell you he has Type 1 DM. What is causing his symptoms?

Answer 20

Diabetic ketoacidosis
A lack of insulin led to elevated glucagon
High blood sugar has caused osmotic diuresis (polyuria, polydipsia, dehydration) and lipolysis (ketone bodies and metabolic acidosis)

Question 21

What events can cause diabetic ketoacidosis?

Answer 21

Inadequate insulin
Infection
Infarction
Drugs
Pregnancy

Question 22

A 6 yo pt is brought to the ER by her parents. She is confused, lethargic, and on the way to the hospital she had a seizure. What is your diagnosis? What would you expect this pt’s blood sugar to be?

Answer 22

Hypoglycemia

Blood sugar

Question 23

How will you treat a pt who presents with lethargy, seizures, focal neurological symptoms, and autonomic hyperactivity?

Answer 23

Glucagon

Sugar or candy are alternates but glucagon is the best option

Question 24

How will you treat a hypoglycemia diabetic pt who has just slipped into a coma?

Answer 24

IV bolus of 50% Dextrose

1mg glucagon IM

Question 25

What 2 events can cause early morning hyperglycemia?

Answer 25

The Dawn Effect and the Symogi Effect

Question 26

What is the pathology behind the Dawn Effect?

Answer 26

The Dawn Effect is caused by natural body changes in the early morning. Between 3-8AM there is a surge in hormones that act against insulin to raise blood sugar. This combined with the fact that nighttime insulin is wearing off in the early morning leads to early morning hyperglycemia

Question 27

What is the pathology behind the Symogi effect?

Answer 27

Late night hypoglycemia causes the body to release various hormones that increase blood sugar, leading to early morning hyperglycemia.

Question 28

An overweight 50 yo Latino female presents complaining of constant urination, extreme thirst, fatigue, blurry vision, and a cut on her foot that hasn't healed in several months. What lab values would you expect to find for this pt? What disease does this pt have? What risk factors does she have for this disease?

Answer 28

``` Type 2 Diabetes Mellitus A1c > 6.5% Fasting glucose > 126 mg/dL OGTT > 200 mg/dL Random glucose > 200 mg/dL Positive urine dip stick Risk factors: Age (>45), ethnicity (Latino), obese ```

Question 29

A 58 yo man with a history of hypertension presents to your office complaining of excessive thirst, excessive urination, and a thick velvety purple rash on the back of his neck. What is the pathophysiological cause of this pt's disease?

Answer 29

Type 2 DM w/ acanthosis nigricans T2DM is caused by chronic hyperglycemia due to insulin resistance and a relative lack of insulin. Islet paracrinopathy (a disrupted relationship between a- and b-cells) led to hyperglucagonemia.

Question 30

What are the 3 most common types of causes of T2DM?

Answer 30

Lifestyle: Obese/overweight, sedentary, poor diet, stress Genetics: TCF7L2 gene, MODY Secondary causes: Glucocorticoids, Cushing's syndrome, acromegaly, pheochromocytoma

Question 31

A 62 yo female pt presents complaining of blurry vision, a yeast infection, and excessive urination. What complications are you worried this pt might develop?

Answer 31

Type 2 Diabetes Mellitus Microvascular complications: diabetic retinopathy, diabetic neuropathy, diabetic nephropathy, diabetic HTN Macrovascular complications: CAD/PVD/cerebrovascular disease, HHS, diabetic foot ulcer, gangrene

Question 32

A pt came in to the ER with signs of severe hyperglycemia. The pt had excessive urination, and his blood sugar was 650 mg/dL when it was tested. What other lab finding would you expect to see? How will you treat this pt?

Answer 32

Hyperosmolar hyperglycemia state (HHS) Serum osmolarity > 320 mOsm Tx with IV fluids, insulin, and management of any underlying conditions

Question 33

A 65 yo female presents with polyuria, polydipsia, polyphagia, fatigue, and blurry vision. Her serum glucose was 228 mg/dL and her urine dipstick was positive for glucose, ketones, and albumin. What is the first recommendation you make for this pt?

Answer 33

Type 2 Diabetes Mellitus 1st line Tx is diet and exercise Diet should be low carb, low fat, and the pt should count carbs

Question 34

A 54 yo male comes to your practice for a follow-up. Last month you diagnosed him with Type 2 DM and recommended he diet and exercise in an attempt to control his diabetes. At today's visit you perform a fasting glucose test followed by an oral glucose tolerance test, with the results below. What treatment do you recommend? Fasting blood glucose: 134 mg/dL Oral glucose tolerance test: 225 mg/dL

Answer 34

Recommend he start Metformin (a biguanide) and return in another month to see if his T2DM is better controlled.

Question 35

A Type 2 Diabetic is currently taking Metformin but her blood sugars have been high recently. What would you add to her treatment regimen to help control her hyperglycemia?

Answer 35

Either a Sulfonylurea or a Meglitinide

Question 36

What do you have to educate your pt about if you start them on a sulfonylurea? On a meglitinide?

Answer 36

Sulfonylureas have a risk of hypoglycemia | Meglitinides cause weight gain

Question 37

When would it be appropriate to start your T2DM pt on a TZD? What risks are associated with TZDs?

Answer 37

If they are on two other oral diabetes medications but their blood sugars are not well controlled Risks are weight gain, fluid retention, increased risk of bladder CA (long-term risk), and increased risk of fractures (long-term risk)

Question 38

What recommendations should you make to a diabetic pt regarding complications of DM?

Answer 38

See an ophthalmologist every 6-12 months to check for diabetic retinopathy Protect their feet to avoid diabetic neuropathy ACEI/ARB Tx to prevent diabetic nephropathy and diabetic HTN Controol HTN, lower their LDL levels, raise their HDL levels, and start aspirin therapy to avoid CAD/PVD

Question 39

When should you start a Type 2 diabetic on insulin therapy?

Answer 39

If they are not well controlled on diet, exercise, and up to 3 oral diabetic meds