Section 1: Diabetes Mellitus Flashcards

Question

Side effects of Glucagon-like peptide-1 (GLP-1) analogs

Answer 1

* Nausea * Vomiting * Weight loss * Hypoglycemia These agents slow-gastric emptying and so promote weight loss

Answer 2

If other agents do not sufficiently control the level of glucose, then the patient is switched to insulin. A long-acting insulin, such as insulin glargine, which is a once-a-day injection with an extremely steady-state level of insulin, is used in combination with a very short-acting insulin at mealtime. ## Footnote

Answer 3

* Regular insulin * Lispro * Aspart * Glulisine

Answer 4

* NPH (Neutral Protamine Hagedorn): twice a day * Detemir * Glargine: once a day

Answer 5

* "Fruity breath" * Kussmaul hyperpnea * Dehydration * Abdominal pain * Increase annion gap * Hyperkalemia * Hyperglycemia * Ketones in blood/urine

Answer 6

Serum bicarbonate is the best way to determine the severity of illness ## Footnote

Answer 7

* Hyperglycemia * Hyperkalemia * Decreased serum bicarbonate * Low pH, with low pCO₂ as respiratory compensation * Acetone, acetoacetate, and beta hydroxybutyrate levels are elevated * Elevated anion gap

Answer 8

By monitoring anion gap

Answer 9

* Admit ICU/ward * Fluid resuscitation (NS + IV insulin) * Monitor Na+ K+ phosphate and glucose * Change NS to D₅NS when glucose level \< 250 mg/L * Change IV insulin to an SQ insulin sliding scale once the anion gap normalizes * Continue IV insulin for at least 30 minutes following the administration of the first dose of SQ insulin

Answer 10

* HTN * Retinopathy (proliferative) * Nephropathy * Neuropathy * Erectile dysfunction * Gastroparesis

Answer 11

* Metoclopromide * Erythromycin

Answer 12

* Gabapentin * Pregabalin

Answer 13

\< 100 mg/dL

Answer 14

\< 70 mg/dL

Answer 15

Laser photocoagulation

Answer 16

* Serum glucose \> 600 mg/dL (hyperglycemia) * Serum pH \> 7.3 * Serum bicarbonate \> 15 mEq/L * Anion gap 14 mEq/L (normal) * Serum osmolality \> 310 mOsm/kg.

Answer 17

1. Offload the foot 2. Tight glycemic control 3. Aggressive wound care including proper antibiotic coverage 4. Improve macrovascular and microvascular circulation (check ABI) 5. Good nutrition

Answer 18

Hyperbaric oxygen

Answer 19

ß-hydroxybutyrate

Answer 20

Answer and Critique (Correct Answer = C) This patient has impaired fasting glucose and impaired glucose tolerance. The American Diabetes Association and World Health Organization have similar classifications of the various glycemic abnormalities that are becoming increasingly common. Diabetes mellitus is now defined by a fasting plasma glucose level of ≥126 mg/dL or by a 2-hour plasma glucose level of ≥200 mg/dL during an oral glucose tolerance test (the oral glucose tolerance test is not recommended for routine clinical use by the American Diabetes Association). Alternatively, a “casual” (without respect to meals) plasma glucose level of ≥200 mg/dL, if accompanied by classic symptoms of hyperglycemia, may also be used to make the diagnosis. Prediabetes glycemic states consist of impaired glucose tolerance, defined as a 2-hour glucose level of 140–199 mg/dL during an oral glucose tolerance test, and impaired fasting glucose, defined as a fasting glucose level of 100–125 mg/dL. This patient therefore has both impaired glucose tolerance and impaired fasting glucose. Both of these prediabetes states predispose a patient to type 2 diabetes mellitus; impaired glucose tolerance appears to be a stronger factor than impaired fasting glucose. When both are present, as in this patient, the risk is incrementally higher. **Key Point** Prediabetes glycemic states consist of impaired glucose tolerance, defined as a 2-hour glucose level of 140–199 mg/dL during an oral glucose tolerance test, and impaired fasting glucose, defined as a fasting glucose level of 100–125 mg/dL. Bibliography American Diabetes Association. Standards of medical care in diabetes--2007. Diabetes Care. 2007;30 Suppl 1:S4-S41. [PMID: 17192377] [PubMed]

Answer 21

Prediabetes glycemic states consist of impaired glucose tolerance, defined as a **2-hour glucose level of 140–199 mg/dL during an oral glucose tolerance test**, and **impaired fasting glucose, defined as a fasting glucose level of 100–125 mg/dL.**

Answer 22

Answer and Critique (Correct Answer = B) The correct management step is to decrease glargine at bedtime. This patient is having significantly low blood glucose levels during the night and early morning with less severe low glucose levels throughout the day. Her highest glucose values also occur on arising each morning, possibly as a result of having low glucose levels at night. She is on basal bolus insulin therapy. The average patient with type 1 diabetes mellitus who does not have coexisting insulin resistance requires a total daily dose of about 0.4 to 0.5 units of insulin per kg of body weight. Most patients take 40% to 50% of their total daily dose as basal insulin (glargine) and 50% to 60% as meal boluses (lispro or aspart). This patient weighs 60 kg (132 lb) and would therefore have an anticipated total daily insulin dose of 24 to 30 units. However, she is currently taking 28 units of basal insulin and another 12 units as boluses. Her insulin dose may therefore be excessive and imbalanced because of excessive glargine. Therefore, her frequent hypoglycemia, which is most prominent during the night and early morning but which also occurs during the daytime, is most likely due to excessive bedtime glargine. Excessive lispro at dinner most often causes hypoglycemia 2 to 5 hours after dinner, rather than at 3 AM, and would not be expected to cause hypoglycemia during the day. Reducing her bedtime glargine is the most prudent initial adjustment to make. Once the hypoglycemia is corrected by lowering the bedtime glargine dose, preprandial and postprandial glucose monitoring will help to determine if her mealtime lispro doses should be adjusted. **Key Point** The average patient with type 1 diabetes mellitus who does not have coexisting insulin resistance requires a total daily dose of about 0.4 to 0.5 units of insulin per kg of body weight with 40% to 50% delivered as long-acting basal insulin. Bibliography Hirsch IB. Insulin analogues. N Engl J Med. 2005;352:174-83. [PMID: 15647580] [PubMed]

Answer 23

Answer and Critique (Correct Answer = D) The most appropriate change in this patient's medical program is to add short-acting insulin (lispro or aspart) with meals. This patient is having significant postprandial hyperglycemia. Postprandial glucose excursions should ideally be limited to 30 to 50 mg/dL above premeal glucose values. This patient should do more postprandial glucose testing, but the values she has obtained so far show excursions much greater than 50 mg/dL above premeal values. This can be best corrected by using a bolus of short-acting insulin (lispro or aspart) just before or with each meal. Acarbose is not effective enough to reduce postprandial glucose excursions sufficiently in this situation. Bedtime NPH insulin is used mainly to lower elevated fasting glucose levels, which are not a problem in this patient. Morning NPH insulin would provide a peak in mid-afternoon, but the NPH peak would not occur at a completely reliable time and would also not cover breakfast or dinner. Since glargine is a basal insulin, increasing the dose would still not provide the post-meal insulin peaks that are required to control postprandial hyperglycemia. **Key Point** Significant postprandial hyperglycemia can be managed by using a bolus of short-acting insulin (lispro or aspart) just before or with each meal. Bibliography Hirsch IB. Intensifying insulin therapy in patients with type 2 diabetes mellitus. Am J Med. 2005;118 Suppl 5A:21S-6S. [PMID: 15850550] [PubMed]

Answer 24

Answer and Critique (Correct Answer = B) This patient has diabetes secondary to pancreatic disease. Diabetes may be the direct result of other underlying disease states, in which case it is referred to as “secondary diabetes.” Potentiating conditions include other endocrinopathies, such as Cushing's syndrome, acromegaly, pheochromocytoma, and hyperthyroidism. Rarely, islet cell neoplasms, such as glucagonoma and somatostatinoma, lead to diabetes. Medications, such as glucocorticoids, may lead to diabetes as well. Disorders of the exocrine pancreas can also manifest as hyperglycemia as a result of, among other things, direct damage to the pancreatic islet cells. These conditions include acute or chronic pancreatitis, pancreatic malignancies, and cystic fibrosis. The patient's recent hospitalization showed convincing evidence of pancreatitis. Therefore, his condition should be classified as secondary diabetes. Treatment may be challenging. Sulfonylureas may be effective, depending on the number of functioning islet cells remaining. Insulin sensitizers have no role in treating this patient's secondary diabetes. He may eventually require insulin. Unfortunately, patients with pancreatic disease and diabetes may be quite labile regarding glycemic control, since they often lack adequate glucagon secretion for counterregulation. Type 1 diabetes mellitus is the result of islet cell destruction due to autoimmunity. Type 2 diabetes mellitus culminates from the combination of both insulin resistance and relative insulin deficiency and comprises more than 90% of all cases of diabetes worldwide. Gestational diabetes is diagnosed during pregnancy and has a similar pathogenesis to that of type 2 diabetes. The form of diabetes recently called latent autoimmune diabetes of adulthood (LADA) occurs in patients with type 2 diabetes who develop insulin requirements later in life and exhibit labile glycemic tendencies and many of the autoimmune markers that occur in those with type 1 diabetes. LADA involves slowly progressive loss of β-cell function and usually occurs in lean, older patients. **Key Point** Secondary diabetes mellitus is the direct result of other underlying disease states. Bibliography American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2007;30 Suppl 1:S42-7. [PMID: 17192378] [PubMed]

Answer 25

Answer and Critique (Correct Answer = A) Therapy with a sulfonylurea such as glyburide is indicated for this patient. Drug treatment for type 2 diabetes mellitus is initiated when diet and exercise have failed or are likely to fail because of the degree of hyperglycemia, or when there are symptoms secondary to hyperglycemia. The goal of therapy is a hemoglobin A1c value less than 7%. This patient has a value of 7.3% despite 8 months of diet and exercise. Although these lifestyle interventions should be continued, they are unlikely to lead to further reduction in blood glucose levels, and pharmacologic therapy is therefore indicated. In the past decade, more than 12 new medications for type 2 diabetes have become available. Initial pharmacologic therapy for type 2 diabetes is generally an oral agent. There are few differences in outcomes with different drug classes, and patient characteristics and preferences help guide the initial choice of agent. For example, in obese patients the use of metformin as a first-line agent may reduce cardiovascular events and all-cause mortality, although these findings remain controversial. Stepped therapy with bedtime insulin is effective in achieving glycemic targets in patients for whom oral agents alone are ineffective; insulin also effectively controls the disease in a substantial proportion of patients for whom oral therapy is unsuccessful. In patients in whom insulin therapy is started, current oral therapy (metformin or the thiazolidinedione pioglitazone) should be continued. For the choice of oral therapy, it is also important to understand the relative and absolute contraindications for each medication. Metformin is contraindicated in patients with renal insufficiency, defined as a serum creatinine concentration \>1.6 mg/dL in men and \>1.5 mg/dL in women. Metformin may increase the risk of lactic acidosis in such patients. This patient has a serum creatinine concentration of 1.9 mg/dL, precluding use of metformin. A thiazolidinedione pioglitazone is also contraindicated because of the patient's heart failure. Thiazolidinediones increase fluid retention and can lead to decompensated heart failure. Metformin is also commonly avoided in patients with advanced heart failure because of the increased risk of tissue ischemia and lactic acidosis related to decreased cardiac output. **Key Points** Metformin is contraindicated in patients with type 2 diabetes mellitus and renal insufficiency. Thiazolidinediones are contraindicated in patients with type 2 diabetes mellitus and heart failure. Bibliography Nathan DM. Clinical practice. Initial management of glycemia in type 2 diabetes mellitus. N Engl J Med. 2002;347:1342-9. [PMID: 12397193] [PubMed]

Section 1: Diabetes Mellitus Flashcards

(50 cards)