Diabetes Mellitus Flashcards
1
Q
- P.A. is a 55-year-old woman with a history of type
2 diabetes mellitus (T2DM), hypertension (HTN),
hyperlipidemia, and chronic urinary tract infections.
She has tolerated metformin well but has noticed an
increase in hemoglobin A1C values during the past
6–9 months. A review of blood glucose (BG) readings
reveals a record of fasting blood glucose (FBG) values
at 140–190 mg/dL and premeal BG values at 180–260
mg/dL. In addition, today’s laboratory values include
the following: A1C 8.4%; aspartate aminotransferase
(AST) 28 U/L; alanine aminotransferase (ALT) 35
U/L; serum creatinine concentration 1.4 mg/dL, and
estimated glomerular filtration rate (eGFR) 52 mL/
minute/1.73 m2
. The patient has a current body mass
index (BMI) of 31 kg/m2
, and she is concerned about
weight gain with changes in her regimen. Which is the
most appropriate therapeutic change for this patient?
A. Discontinue metformin (Glucophage) because of
poor renal function and start basal/bolus insulin.
B. Add glargine (Lantus) insulin 10 units subcutaneously at bedtime to her current regimen.
C. Add liraglutide 0.6 mg subcutaneously every day,
with a goal of titrating to a dose of 1.8 mg every
day, to her current regimen.
D. Add empagliflozin 10 mg in the morning, with a
goal of titrating to a dose of 25 mg, to her current
regimen
A
- Answer: C
This patient’s fasting, premeal BG, and A1C values are high,
representing poor glucose control. Empagliflozin could
potentially be synergistic with metformin, but this patient’s
history of recurrent urinary tract infections does not make
her a good candidate for this therapy (Answer D is incorrect). Both glargine and liraglutide would be appropriate
options in such a patient, with similar initial A1C reduction potential. However, glargine has the potential to cause
weight gain, which is of concern to the patient, whereas
liraglutide has the potential for weight loss (Answer B is
incorrect; Answer C is correct). Plus guidelines clearly
advocate that the first injectable should be a GLP-1 RA
over insulin in people with T2DM. This patient’s estimated
creatinine clearance is greater than 30 mL/minute/1.73 m2
;
therefore, discontinuing metformin would not be necessary
(Answer A is incorrect).
2
Q
- Which is the best recommendation for preventive
measures and screening assessments for patients with
diabetes mellitus (DM).
A. Annual: fasting lipid panel, influenza vaccine,
dilated eye examination, A1C assessment
B. Each visit: blood pressure assessment, urinary
albumin, comprehensive foot examination
C. Annual: urinary albumin, comprehensive foot
examination, dilated eye examination, influenza
vaccine
D. Each visit: fasting lipid panel, blood pressure
assessment, urinary albumin, A1C assessment
A
- Answer: C
The following measures should be done at least annually
for assessment and prevention in patients with diabetes:
influenza vaccine, urinary albumin assessment (e.g., spot
urinary albumin/creatinine ratio), comprehensive foot
examination, dilated eye examination, and fasting lipid
panel. Other preventive measures with varying recommendations regarding frequency are vaccines (pneumococcal,
hepatitis B), dental examinations, blood pressure assessment, A1C assessment, use of aspirin, smoking cessation
counseling, and exercise/weight loss counseling (Answer
C is correct). The A1C should be assessed every 3–6
months (Answer A is incorrect). Urinary albumin should
be assessed annually (Answer B is incorrect). For adults
not taking statins, it is reasonable to obtain a lipid profile
at the time of diabetes diagnosis, then every 5 years thereafter, or more often if indicated, but not every visit. A lipid
profile should be obtained at initiation of statin therapy
and periodically thereafter because it may help monitor the
response to therapy and inform adherence (Answer D is
incorrect).
3
Q
- Which option most appropriately lists the insulins in
order from fastest acting to the longest acting?
A. Degludec (Tresiba), glargine (Lantus), regular
insulin, aspart (NovoLog)
B. Lispro (Humalog), regular insulin, neutral protamine Hagedorn (NPH), degludec (Tresiba)
C. Glargine (Lantus), detemir (Levemir), regular
insulin, glulisine (Apidra)
D. Regular insulin, NPH, glulisine (Apidra), glargine
(Lantus)
A
- Answer: B
The fastest-acting insulins consist of the rapid-acting
insulin analogs lispro (Humalog), aspart (NovoLog), and
glulisine (Apidra). Regular insulin is next choice because
it is a short-acting insulin. Neutral protamine Hagedorn
insulin has an intermediate duration of action, followed
by the long-acting insulin analog detemir (Levemir), the
long-acting glargine (Lantus and Toujeo), and finally
degludec (Tresiba) (Answer B is correct). The other
options list the agents incorrectly from rapid to long-acting
(Answers A, C, and D are incorrect)
4
Q
- G.D. is a 76-year-old woman who lives alone. She was
given a diagnosis of T2DM 2 years ago. Yesterday her
A1C reading was 8.5%, and her most recent eGFR
value was 28 mL/minute/1.73 m2
. She has a history
of osteoporosis and had a hip fracture 3 years ago;
she still often uses a walker for stability. Her family is
concerned about hypoglycemia in anticipation of her
starting DM medication. Which medication is best for
this patient?
A. Glipizide
B. Metformin
C. Pioglitazone
D. Alogliptin
A
- Answer: D
Glipizide and alogliptin are insulin secretion stimulators;
however, only alogliptin causes an increase in insulin secretion in a glucose-dependent manner, thereby minimizing
the risk of hypoglycemia (Answer D is correct). Although
metformin is typically a first-line choice for most people
with T2DM, it is contraindicated in patients with poor
renal function. This patient’s renal function and her age
(76 years) would preclude her from receiving metformin
because she would have an increased risk of developing
lactic acidosis (Answer B is incorrect). She would not be a
good candidate for pioglitazone because of her history of
osteoporosis (Answers A and C are incorrect).
5
Q
- E.C. is a 38-year-old patient with no history of HTN
but a 2-year history of T2DM. Results of the previous two urine analyses have shown results with urine
albumin/creatinine ratio values greater than 30 mg/dL.
Which intervention is best to slow the progression of
this patient’s diabetic nephropathy?
A. Low-sodium diet
B. Angiotensin-converting enzyme inhibitor (ACEI)
C. Dihydropyridine calcium channel blocker
(DHP-CCB)
D. Aspirin
A
- Answer: B
The ACEIs decrease proteinuria, increase the time to
doubling of serum creatinine, and delay the need for
kidney transplantation and dialysis (Answer B is correct). Although aspirin reduces CV risk, it has no effect
on the progression of renal disease (Answer D is incorrect). Blood pressure reduction can delay the progression
of renal disease in patients with HTN (Answer A is incorrect). Although non-DHP-CCBs (diltiazem and verapamil)
decrease proteinuria independently of the blood pressure
effect, DHP-CCBs can exacerbate proteinuria in patients
with well-controlled blood pressure who are not receiving
renin-angiotensin-aldosterone system suppression (Answer
C is incorrect).
6
Q
- Which statement is the most accurate regarding the
use of antiplatelet therapy in patients with DM?
A. Aspirin 325 mg once daily should be used as a
secondary-prevention strategy in patients with
DM and atherosclerotic cardiovascular (CV)
disease.
B. Dual antiplatelet therapy is recommended for
patients with DM with a 10-year CV risk of
greater than 10%.
C. Aspirin 75–162 mg once daily should be used for
primary prevention in patients older than 65 years
with a history of renal disease.
D. Aspirin 75–162 mg once daily may be considered as a primary prevention strategy in patients
with DM who are at increased CV risk, after a
discussion with the patient on the benefits versus
increased risk of bleeding
A
- Answer: D
Aspirin therapy (75–162 mg/day) should be used for
secondary prevention in patients with diabetes unless a
contraindication exists (Answer A is incorrect). Aspirin
therapy (75–162 mg/day) may be recommended as a primary prevention strategy in those with diabetes who are
at increased risk of CV (10-year risk of 10% or greater),
including men or women age 50 years with one additional
risk factor, such as family history of CVD, HTN, smoking, dyslipidemia, or albuminuria after considering risk of
bleeding (Answer D is correct). Aspirin therapy is not recommended as a primary prevention strategy in those with
diabetes and at low risk of CV (10-year risk of less than
5%), such as men or women younger than age 50 years with
no additional risk factors or in patients at increased risk of
bleeding such as older age, anemia, renal disease (Answer
C is incorrect). Dual antiplatelet therapy is reasonable for
up to 1 year after an acute coronary syndrome (Answer B
is incorrect)
7
Q
- Which activity best differentiates the mechanisms of
action of semaglutide compared with linagliptin?
A. Semaglutide causes a glucose-dependent increase
in insulin secretion.
B. Semaglutide causes a glucose-dependent decrease
in glucagon secretion.
C. Semaglutide increases satiety.
D. Semaglutide reduces the extent of postmeal carbohydrate absorption.
A
- Answer: C
Linagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor,
and, similar to semaglutide, affects actions of incretin hormones. By definition, incretins increase insulin secretion
and decrease glucagon production in a glucose-dependent
mechanism (Answers A and B are incorrect). However,
unlike GLP-1 receptor agonists, DPP-4 inhibitors do not
have activity in the central nervous system and therefore
do not affect satiety (Answer C is correct). Neither class of
medications changes the extent of carbohydrate absorption
(Answer D is incorrect)
8
Q
- J.C. is a 62-year-old man with a BMI of 32.5 kg/m2
who was given a diagnosis of T2DM about 5 years
ago and is concerned about weight gain. He has taken
oral antihyperglycemic agents since the time of diagnosis. J.C. was prescribed insulin protamine/lispro
(Humalog 75/25) 40 units twice daily 5 months ago
because of an increased A1C of 9.4%. Since starting
therapy with Humalog 75/25, his A1C has decreased
to 7.2%. However, J.C. notes that he has hypoglycemic episodes midmorning most days of the week. His
BG logs show FBG values in the near-normal range.
Which is the most appropriate adjustment to this
patient’s therapy?
A. Decrease the morning dose of Humalog 75/25 to
30 units, and keep the evening dose at 40 units.
B. Increase the amount of carbohydrates eaten during breakfast.
C. Stop Humalog 75/25 and start 48 units of insulin
glargine daily and 6-7-7 units of insulin aspart at
meals.
D. Stop Humalog 75/25 and start 60 units of insulin glargine daily and 8 units of insulin aspart at
meals
A
- Answer: C
Mixed insulin can be more convenient for patients to use;
however, it is not as easily titrated as two single insulins.
For many patients, insulin needs do not match the ratio of
the commercially available combination insulin products.
As a result, titrating insulin doses to correct one problem
often results in BG readings that are too high or too low
at another time. In this case, the patient is receiving the
equivalent of 60 units of intermediate-acting insulin and
20 units of rapid-acting insulin each day. The almostdaily midmorning hypoglycemic reactions are caused by
too much (10 units) rapid-acting insulin in the morning
(Humalog 75/25 dose). Reducing the morning dose will
alleviate the midmorning low glucose concentration but
will also likely cause a rise in the predinner (post lunch) BG
(Answer A is incorrect). Consuming more calories as carbohydrates at breakfast will help prevent the midmorning
hypoglycemia but at the expense of weight gain (Answer
B is incorrect). Humalog 75/25 contains 75% insulin lispro protamine suspension (which acts similarly to NPH
insulin) and 25% insulin lispro. The recommendations for
converting intermediate-acting insulin to long-acting insulin call for using 80% of the original NPH dose (0.8 × 60
= 48 units). To prevent further midmorning hypoglycemia,
the morning quick-acting insulin dose should be less than
10 units (Answer C is correct; Answer D is incorrect)
