Week 2 Diabetes and Endocrine Disorders Flashcards
Pituitary gland releases what hormones
TSH
Adrenocorticotropic hormone (ACTH)
prolactin
thyroid gland releases what hormone
thyroid hormone
Adrenal gland releases what hormones
cortisol
catecholamines
parathyroid gland releases what hormones
parathyroid hormone
pancreas releases what hormones
glucagon
hypothalamus releases what hormones
thyrotropin- releasing hormone (TRH)
A 20-year-old female patient with tachycardia and weight loss but no optic symptoms presents with the following laboratory values: decreased TSH, increased T3, and increased T4 and free T4. A pregnancy test is negative. What is the initial treatment for this patient?
A. Beta blocker medications
B. Radioiodine therapy
C. Surgical resection of the thyroid gland
D. Thionamide therapy
A. Beta blocker medications
Beta blockers should be initiated for patients with Graves’ disease to alleviate the alpha-adrenergic symptoms of the hyperthyroidism. Radioiodine therapy is used for patients with Graves’ ophthalmopathy. Surgical resection is performed for pregnant women who cannot be managed with thioamides or for patients who refuse radioiodine therapy. Thioamide therapy is recommended for patients younger than 20 years old, pregnant women, those with a high likelihood of remission, and those with active Graves’ Orbitopathy
A female patient with hypothyroidism for the past 5 years presents for a positive home pregnancy test. She is taking levothyroxine 75 mcg daily and her TSH was 2.5 mIU/L six months ago at her routine physical. The nurse practitioner understands which of the following?
A. She will need to stop taking her medication and switch to a natural thyroid hormone replacement
B. She should continue taking her current dose of levothyroxine and have her TSH level checked at the end of the first trimester
C. Reduce her levothyroxine dose since thyroid requirements are lower in the first trimester of pregnancy
D. Thyroid requirements increase by 20-30% in pregnancy so she should have a TSH checked today
D. Thyroid requirements increase by 20-30% in pregnancy so she should have a TSH checked today
Thyroid requirements increase by 20-30% during pregnancy. The TSH should be less than 2.5 during the first trimester. Untreated hypothyroidism during pregnancy can have detrimental effects such as miscarriage and low birth weight. Levothyroxine is safe during pregnancy. TSH should be monitored at least once during each trimester, and is recommended every 4 weeks in the first and second.
A postpartum woman develops fatigue, weight gain, and constipation. Laboratory values reveal elevated TSH and decreased T3 and T4 levels. What will the nurse practitioner tell this patient?
A. A thyroidectomy will be necessary.
B. She should be referred to an endocrinologist.
C. She will need lifelong medication.
D. This condition may be transient.
D. This condition may be transient.
Postpartum hypothyroidism may be a transient condition and does not require surgical intervention, referral to a specialist, or lifelong medication unless it proves to be long-standing or refractory to treatment.
A patient has a thyroid nodule and the nurse practitioner suspects thyroid cancer. To evaluate thyroid nodules for potential malignancy, which test is performed?
A. Radionucleotide imaging
B. Serum calcitonin
C. Serum TSH level
D. Thyroid ultrasound
D. Thyroid ultrasound
Thyroid ultrasound evaluation should be performed for all patients with known thyroid nodules; high-resolution sonography can clearly distinguish between solid and cystic components. Radionucleotide imaging is not specific; many cold nodules are benign. The routine measurement of serum calcitonin levels is not useful or cost-effective. TSH levels are not specific to malignancy
Hypothyroidism labs
elevated TSH
low free T4
hyperthyroidism labs
low TSH
elevated free T4
Subclinical hypothyroidism labs
elevated TSH
normal free T4
Hypothyroidism d/t pituitary dysfunction labs
normal TSH
low free T4
euthyroid labs
normal TSH
normal free T4
A 40-year-old patient with primary hyperparathyroidism has increased serum calcium 0.5 mg/dL above normal without signs of nephrolithiasis. What is the recommended treatment for this patient?
A. Annual monitoring of calcium, creatinine, and bone density
B. Avoidance of weight-bearing exercises
C. Decreasing calcium and vitamin D intake until values normal
D. Parathyroidectomy
A. Annual monitoring of calcium, creatinine, and bone density
Medical management of primary hyperparathyroidism involves close monitoring of serum calcium and creatinine and bone density screenings. Weight-bearing exercises should be encouraged, and vitamin D and calcium intake should be adequate, not decreased. This patient does not meet criteria for parathyroidectomy because of age less than 50 years and serum calcium less than 1 mg/dL above the upper limit of normal.
Which of the following is true regarding Cushing disease?
A. Chronic use of systemic corticosteroids is the most common form of endogenous Cushing syndrome
B. The pathophysiology involves suppression of the adrenal gland leading to decreased production of cortisol
C. Levels of corticotropin releasing hormone are increased
D. Increased production of ACTH stimulates increased production of cortisol by the adrenal glands
D. Increased production of ACTH stimulates increased production of cortisol by the adrenal glands
Cushing disease is caused by the increased production of ACTH which then stimulates cortisol production from the adrenals. This leads to development of Cushing syndrome. Cushing disease accounts for 70% of Cushing syndrome. Corticosteroid use is a cause of exogenous Cushing syndrome which is due to suppression of the HPA axis.
Which of the following are symptoms of hyperparathyroidism? (Select all that apply.)
A. Chvostek’s sign
B. Cognitive impairment
C. Left ventricular hypertrophy
D. Perioral paresthesias
E. Renal calculi
B. Cognitive impairment
C. Left ventricular hypertrophy
E. Renal calculi
Cognitive impairment, left ventricular hypertrophy, and renal calculi all occur with hyperparathyroidism. Chvostek’s sign and perioral paresthesias occur with hypoparathyroidism.
Which laboratory values representing parathyroid hormone (PTH) and serum calcium are consistent with a diagnosis of primary hyperparathyroidism?
A. Appropriately high PTH along with hypocalcemia
B. Appropriately increased PTH and low or normal serum calcium
C. Inappropriate secretion of PTH along with hypercalcemia
D. Prolonged inappropriate secretion of PTH with subsequent hypercalcemia
C. Inappropriate secretion of PTH along with hypercalcemia
Primary hyperparathyroidism is characterized by the inappropriate secretion of PTH in the setting of hypercalcemia. Appropriately high PTH with hypocalcemia characterizes hypoparathyroidism. An appropriately increased secretion of PTH with low or normal serum calcium is characteristic of secondary hyperparathyroidism. Prolonged inappropriate secretion of PTH in which hypercalcemia develops is tertiary hyperparathyroidism.
A 25-year-old female patient presents with bilateral galactorrhea and irregular menses. She has a normal breast exam. In addition to checking a prolactin level, which of the following should be included in the initial work up?
A. Breast mammography
B. Human chorionic gonadotropin (HCG)
C. MRI of the pituitary gland
D. Estradiol level
B. Human chorionic gonadotropin (HCG)
Patients with symptoms of a prolactinoma should have a TSH, T4, HCG (woman of childbearing age), BUN, Creatinine, prolactin hormone, and liver transaminase. She does not require a mammogram since her breast exam is normal and symptoms are bilateral. Pituitary MRI may be needed, but it is not part of the initial work up. Estradiol is not included in the work up.
You meet with the patient and his husband to go over the test results and explain the diagnosis of diabetes. Given his age, body habitus, and lack of exercise, you feel certain that this patient has type 2 diabetes. You provide some basic education on the nature of diabetes, its natural history, and what can be done to manage it.
What is the most important next step for this patient?
A. Initiation of insulin therapy
B. Initiation of an ACE inhibitor
C. Referral to an endocrinologist
D. Diabetic education classes
E. Initiation of glyburide or other sulfonylurea
D. Diabetic education classes
A general education program that includes information on diet, disease management, and the family’s role in successful diabetes care is the most important intervention listed. While specialist consultation may be useful in complex diabetic patients or in those who are not responding to treatment, primary care physicians provide care to the majority of patients with diabetes. Insulin therapy is not indicated at this point, and an ACE inhibitor may or may not be helpful depending on the patient’s blood pressure and urine protein. “E” is also incorrect
The pathologic factors involved in type 2 diabetes in adults include:
A. Pancreatic beta-cell destruction through a yet undetermined infectious process
B. The production of anti-insulin antibodies that cause precipitation of , insulin, /antibody complexes
C. Resistance to the effects of , insulin, at peripheral tissues and , a, relative , insulin, deficiency that is progressive over time
D. An autosomal-dominant process, with the diabetes gene located on the long arm of chromosome 18
E. Too much exercise and a complete lack of a “beer gut”
C. Resistance to the effects of , insulin, at peripheral tissues and , a, relative , insulin, deficiency that is progressive over time
DM2 is the result of the development of insulin resistance at the peripheral tissues (e.g., fat and muscle cells) and a relative lack of insulin compared to the increasing amount that the body requires. “A” is incorrect. Autoimmune destruction of beta-cells in the pancreas is responsible for causing DM1. “B” is incorrect, although there are anti-insulin antibodies found in DM1. “D” is incorrect as well, but there is a strong genetic component to DM2. The exact genetic factors that cause DM2 in adults have not been completely elucidated, but no single responsible gene is transmitted in an autosomal dominant fashion. “E” is incorrect because lack of exercise, weight gain, dietary factors, and truncal obesity (the “beer gut”) predispose persons to the development of DM2.
At the next visit, you review the patient’s medical record and try to assure that he is up to date on his preventive health care.
Which of the following is NOT true regarding preventive services in diabetics?
A. Patients diagnosed with type 2 diabetes should have a dilated eye examination at the time of diagnosis
B. Patients with type 1 diabetes should have a dilated eye examination at the time of diagnosis if they are over age 12
C. A urine microalbumin should be checked at least yearly in all type 2 diabetics
D. A foot examination using a 10-g nylon microfilament should be done annually for all diabetics
B. Patients with type 1 diabetes should have a dilated eye examination at the time of diagnosis if they are over age 12
Patients with diabetes type 1 should have an eye examination 3 to 5 years after the diagnosis and then yearly. Age at the time of diagnosis is not a factor in determining when an eye examination should be done. See Table 10-2 for components of recommended diabetes follow-up.
You are seeing a new patient in your office. He is a 47-year-old man with a presenting complaint of fatigue for several months. He denies fever, rigors, cough, nausea, or diarrhea. He has lost about 10 lb. Upon questioning him you discover that he is also having nocturia and is thirsty all the time. He has asthma, for which he uses an albuterol-metered dose inhaler occasionally. He has no other chronic medical problems and takes no other medications on a regular basis. He has a family history of diabetes, hypertension, and heart disease. He smokes about one pack per day, and he works as a teacher at the local high school. He is aware of no occupational exposure to toxins.
Physical examination reveals the following: T 37°C, BP 135/83 mm Hg, P 72 bpm, BMI 38 kg/m2. Aside from obesity, the remainder of the examination is normal.
Laboratory test results reveal the following: normal CBC, BUN/creatinine, and electrolytes. You ask him to return to the office the next day for fasting laboratory tests, which reveal a fasting glucose of 123 mg/dL and an HbA1c of 7.5%.
Does this patient have diabetes?
A. Yes; he has an elevated fasting glucose
B. Probably; he needs a second fasting glucose to confirm the diagnosis
C. Probably; he needs a second HbA1c to confirm the diagnosis
D. Yes; he has the classic symptoms of diabetes: fatigue, weight loss, and thirst, associated with an elevated glucose
E. Probably not; his HbA1c is not >8%
C. Probably; he needs a second HbA1c to confirm the diagnosis
If results of two different diagnostic tests for DM are discordant, the test that is diagnostic of diabetes should be repeated. “A” and “B” are incorrect because the fasting glucose is <126 mg/dL (the threshold for diabetes). “D” is incorrect because we do not have his random glucose value that is ≥200 mg/dL. “E” is incorrect because the A1c cutoff for diabetes diagnosis is ≥6.5%.
You are seeing a new patient in your office. He is a 47-year-old man with a presenting complaint of fatigue for several months. He denies fever, rigors, cough, nausea, or diarrhea. He has lost about 10 lb. Upon questioning him you discover that he is also having nocturia and is thirsty all the time. He has asthma, for which he uses an albuterol-metered dose inhaler occasionally. He has no other chronic medical problems and takes no other medications on a regular basis. He has a family history of diabetes, hypertension, and heart disease. He smokes about one pack per day, and he works as a teacher at the local high school. He is aware of no occupational exposure to toxins.
Physical examination reveals the following: T 37°C, BP 135/83 mm Hg, P 72 bpm, BMI 38 kg/m2. Aside from obesity, the remainder of the examination is normal.
What further study must be done to complete the diagnosis of diabetes and determine whether the patient has type 1 or type 2 diabetes?
A. C-peptide level
B. Anti-islet cell antibodies
C. Anti-insulin antibodies
D. None of the above
D. None of the above
This patient’s age, history, examination (BMI 38), and laboratory findings are consistent with the diagnosis of DM2. None of the other studies listed needs to be performed. However, if questions remain regarding the type of diabetes (which will then affect therapy, prognosis, follow-up, etc.), you may choose to perform further studies. In DM1, the C-peptide level (a marker of endogenous insulin production) is low. If it is equivocal, give a glucose load (e.g., large meal) and see if it goes up. If it goes up, the diagnosis is likely DM2. Anti-islet cell antibodies are present in 80% of type 1 diabetics and, if found in the patient with criteria for diabetes, are essentially diagnostic of type 1 diabetes. “C” is incorrect because anti-insulin antibodies have a low sensitivity for DM1 and may be elevated secondary to the use of exogenous insulin.
Which of the following is NOT a side effect of GLP-1 receptor agonists (exenatide, liraglutide, albigutide)?
A. weight gain
B. pancreatitis
C. Hypoglycemia
D. GI upset
E. Thyroid tumor
A. weight gain
GLP-1 agonists can cause weight loss of 1.5 to 2.5kg over 30 weeks. These drugs are associated with pancreatitis although rarely, and the association is tenuous. Due to an association with thyroid cancer, their use is contraindicated in patients with a personal or family hx of medullary thyroid carcinoma or MEN 2A or 2B. The risk of hypoglycemia is small - but not zero. Somewhere between 10%- 50% of patients may develop GI symptoms.
Which class of medications is the best choice for initial therapy of HTN in diabetics?
A. ACE inhibitors
B. Calcium-channel blockers
C. Loop diuretics
D. Vasodilators
E. Beta-blockers
A. ACE Inhibitors
ACE inhibitors have been shown to provide renal protection in patients with diabetes (types 1 & 2). Patients with albuminuria and HTN will certainly benefit from an ACE inhibitor. Loop diuretics (ex. furosemide) are not indicated for the PRIMARY tx of HTN in diabetics (or, really, anyone else). ARBs are a reasonable alternative in the hypertensive pt with albuminuria if an ACE inhibitor is not tolerated. Vasodilators and calcium-channel blockers (verapamil, diltiazem) are an option for renal protection in patients with worsening albuminuria especially in those who cannot tolerate an ACE inhibitor or ARB. Beta-blockers should not be used first line for treating HTN in patients without cardiac dx.
Which medication is the most appropriate first-line therapy for an obese patient with type-2 diabetes?
A. A thiazolidinedione (glitazone aka Actos)
B. A sulfonylurea (glipizide)
C. insulin
D. Metformin
E. DPP-4 or “gliptin” aka Januvia
D. Metformin
Metformin does not cause weight gain (unlike many other treatments for diabetes), has evidence for reducing the complications of diabetes, and is generally well-tolerated and inexpensive. Thus, it is the drug of choice in most DM2 patients. In addition, it carries very little risk of hypoglycemia. GI side effects are common, however (nausea, diarrhea). Some patients will lose weight from use os metformin. Thiazilidinediones known as “glitazones” are not 1st line for several reasons, chief among these being the possibility of increased CV events (rosiglitazone and pioglitazone can exacerbate CHF). The track record of rosiglitazone is somewhat spotty; it was removed from market due to an increase in CV events and then reintroduced even though there was not additional safety data. Sulfonylureas are also effective and well-tolerated but have a significant risk for hypoglycemia and are associated with weight gain. Studies comparing effects on end-organ dx show better outcomes with metformin than with sulfonylureas. All other oral drugs are best considered second-line agents. Dpp-4 inhibitors aka “gliptins” block the degradation of the body’s endogenous incretin, which helps to lower blood sugar. DPP-4 acts as a “glucagon-like peptide-1 (GLP-1)”. DPP-4 inhibitors (sitagliptin, saxagliptin, alogliptin) can be used as an “add-on” tx if traditional hypoglycemic agents are not effective and have the benefit of some weight loss. In a patient with very poor control (A1c > 9%) at diagnosis, insulin would be a potential first line agent, but not in this patient whose partially controlled.
Metformin should NOT be used in which class of patients?
A. pt w/ COPD
B. Pt w/ GFR < 30 mL/min
C. Leukemia or lymphomas
D. Post MI w/ normal systolic function
E. insufficient fat stores
B. GFR < 30 mL/min
Patients with renal dx are at a higher risk of lactic acidosis, the most severe complication of metformin therapy, although it is exceedingly rare. Current manufactor reccomendations state that metformin should be avoided if serum Cr >/= 1.5 mg/dL in M and >/= 1.4 mg/dL in F. However, metformin is safe to start as long as the GFR is > 45 mL/min and can be used until the GFR is 30 mL/min (max dose 1,000mg/day for those w/ GFR between 30 and 60 mL/min). Outcomes in patients with mild CHF and renal failure (GFR > 30mL/min) are actually better with metformin than without. Patients with pulmonary or neoplastic dx may take metformin unless they also have severe hepatic or renal failure. Metformin should be held for 48 hours after contrast studies.
Which of the following drugs (by itself - not in combination with other drugs) is the most likely to cause the patient’s edema, SOB, and possible HF?
A. Metformin
B. Glyburide
C. Pioglitazone
D. Lisinopril
E. Insulin
C. Pioglitazone
The thiazolidinediones (“glitazones”) tend to cause fluid retention as one of their major side effects. Thus, they are contraindicated in patients with hx of HF. Some drug combinations can cause edema, including the combination of glimepiride and metformin.
A patient with diabetes complains of parasthesias. Which of the following medications can cause sensory changes?
a. Glipizide
b. Sitagliptin (Januvia)
c. Metformin
d. Exenatide (Byetta)
c. Metformin
The major risk factor for development of thyroid cancer is
a. Inadequate iodine uptake
b. Presence of a goiter
c. Exposure to radiation
d. Smoking
c. Exposure to radiation
Your 62 yo patient has type 1 diabetes that has historically been well controlled by insulin. Recently, however, the patient has been experiencing marital difficulties that have caused the patient to have some emotional upset. What do you expect? The patient will:
a. Have an insulin reaction more readily than usual
b. Have an increased blood sugar level
c. Need less daily insulin
d. Need more carbohydrates
b. Have an increased blood sugar level
Which of the following steps will not slow or stop the progression of diabetic nephropathy?
a. Control of blood pressure
b. Use of ACE inhibitors
c. Restriction of protein intake
d. Use of calcium channel blockers
d. Use of calcium channel blockers
A patient with Type 2 diabetes mellitus is on the maximum dosage of three oral antidiabetic agents. The HgbA1C remains at 8.5% despite these interventions, and the patient is compliant with medication. Which of the following would be an appropriate basal insulin initiation order?
a. Insulin glargine (Lantus) 10 units nightly
b. Insulin detemir (Levemir) 10 units before each meal
c. Insulin aspart (NovoLog) 10 units before each meal
d. Regular insulin before each meal
a. Insulin glargine (Lantus) 10 units nightly
After achieving a euthyroid state after thyroidectomy, the provider should do a laboratory analysis of TSH level every
a. 3 months
b. 6 months
c. 1 year
d. 2 years
c. 1 year
DM dx criteria
fasting plasma glucose (FPG) >/= 126
OGTT 75-g w/ measured plasma glucose >/= 200 @ 2 hrs
A1c >/= 6.5 (National Glycohemoglobin Standardization Program)
random glucose >/= 200 AND classic symptoms of hyperglycemia (polyuria, polydipsia, or unexplained weight loss)
Per ADA, unless clear clinical dx, 2nd test required to confirm
DM screening tests
A1c
FPG
2-h OGTT
no one test preferred
What can make the A1c less accurate?
anemia or hemoglobinpathies (r/t rapid RBC turnover)
2nd/3rd trimester of pregnancy
recent blood loss, transfusion, erythropoietin therapy, hemolysis
DM screening asymptomatic adults
Test ALL adults beginning at age 45 regardless of weight
Recc for adults of any age that are overweight (BMI > 25 or >23 Asians) and additional RF:
- member of high-risk ethnic group (AA, hispanic, American Indian, Alaskan, Asian, Pacific islander
- 1st degree relative w/DM
- hx gestational DM or giving birth to baby > 9 lbs
- physical inactivity
- HTN >/= 140/90 or tx
- HDL-C < 35
- fasting triglycerides > 250
- PCOS
- previously noted A1c >/= 5.7% (impaired glucose tolerance ot impaired fasting glucose)
- other clinical conditions w/ insulin resistance (acanthosis nigricans, gestational age birth weight)
- hx CVD
- tx w/ atypical antipsychotics or glucocorticoids
if results are normal, reasonable to retest again at 3-y intervals, consider more frequent testing depending on initial results and risk status
DM screening asymptomatic children
ADA reccs screening for T2DM or prediabetes in children who meet following:
- overweight (BMI > 85th percentile for age/sex)
AND:
- maternal hx GDM during gestation
- fma hx of T2DM in 1st or 2nd degree relatives
- high risk ethnicity
- signs on insulin resistance or conditions associated w/ insulin resistance (acanthosis nigricans, HTN, dyslipidemia, PCOS, small for gestational age birth weight)
T1DM
immune-mediated diabetes with evidence of autoimmune B-cell destruction, typically leading to absolute insulin deficiency
T2DM
multifactoral process, including relative insulin insufficiency, insulin resistance and often unregulated gluconeogensis in liver
gestational DM
dx during 2nd or 3rd trimester of pregnancy that was NOT clear prior to gestation
Dx tests for T1DM
C-peptide level
antibody tests:
- islet cell autoantibodies (ICAs)
- insulin autoantibodies (IAAs)
- autoantibodies to glutamic acid decarbocylase 65
- tyrosine phosphatase IA-2 transmembrane proteins
- zinc transporter (ZnT8)
IAA (insulin autoantibodies) more likely to be seen in
IAA present in mostly all young patients with T1DM but may be absent in older patients w/ dx
anti-GAD antibodies more likely to be seen in
more likely present in young adults with T1DM than in children with dx
T1DM pt, screen for what other autoimmune dx?
ADA recommends screening for thyroid dx and celiac dx soon after T1DM dx
specific autoimmune dx have been reported in those w/ T1DM: Hashimoto thyroiditis, Graves dx, Addison dx, autoimmune hepatitis, dermatomyositis, myasthenia gravis, vitiligo, pernicious anemia
Metformin and renal function
considered safe whose eGFR >/= 30 mL/min
nonpharm management DM/ prediabetes
- healthy eating
- weight control
- increased physical activity (1h/day)
Impaired fasting glucose weight management
refer to effective ongoing support program for a weight loss of > 5% body weight and to increase physical activity to 30 mins a day on most days
DM preventative care
A1c < 7% (generally) ASA/antiplatelet agents BP management Cholesterol management screen neuropathy screen retinopathy screen nephropathy immunizations tobacco use assessment
How often do you check A1c in diabetic pt
every 6 months w/ stable glycemic control
every 3 months if NOT at goal or tx changes
recommended A1c nonpregnant adults after tx
< 7%
recommended A1c for children on tx
< 7.5%, individualization encouraged
ASA/antiplatelet agents DM
ASA 75- 162mg/day
secondary prevention w/ hx of CVD
primary prevention in M&F >/= 50 y.o. w/ DM
NO benefit < 30 y.o.
Clopidogrel 75mg/day if allergy to ASA
BP screening in DM
measure EVERY visit
goals:
Adults < 140/90 or <130/80 if younger and no burden
Children < 130/80 OR < 90th percentile
BP management in DM
lifestyle changes: DASH diet, weight loss, exercise
Start meds if do not lower BP to target
ACEI, ARBs, CCB, diuretics recc
Cholesterol management in DM
Per ADA, obtain lipid profile at dx and at least every 5 years in pts < 60 y.o.
ASCVD risk of > 20% and age drives decision for statin tx
neuropathy screening
diabetic foot exam at least annually w/ T2DM and started within 5 years of dx w/ T1DM
How often do you examine feet if pt has deformities or ulcers?
every visit
diabetic foot exam
inspection, foot pulses, loss of protective sensation – light-touch perception w/ 10-g monofilament and at least one of the following: temperature, vibration, pinprick, ankle reflexes
cardiovascular neuropathy
manifests as resting tachycardia and/or orthostatic hypotension
GI neuropathy
gastroparesis
screen if suspicious, gastric emptying study
retiniopathy screening
dilated retinal exam @ dx w/ T2DM
> 10 y.o. w/ T1DM for >/= 5 y
if no retinopathy after serial annual exams, may screen every 2 years
nephropathy screening
leading cause of ESRD
serum Cr annually and calculate GFR
Urine albumin annually in ALL T2DM & T1DM for >/= 5 y
w/ spot urine to Cr ration annually
albuminuria normal value
normal amount < 30mg/24 h
persistent albuminuria marker for CVD
DM & immunizations
pneumococcal vaccine given ages 2- 64 w/ DM PPSV23, repeat after 65 y.o. w/ at least 5 years between doses
flu vaccine - annually > 6 months old
Hep B vaccine given to unvaccinated adults 19- 59 y.o., consider in adults > 60 y.o.
Which hypoglycemic agent should be avoided in patients with a glomerular filtration rate (GFR) less than 25 mL/min/1.73 m2?
A Metformin
B Glyburide
C Insulin
D Acarbose
A Metformin
In general, metformin should be avoided in patients with chronic kidney disease (CKD), although observational data suggests that it may be safe to use in patient with GFR less than 30 mL/min/1.73 m2. If it is used at lower GFRs, the dose should be decreased and patients should be counseled to stop metformin when they have a high likelihood of volume depletion, such as if they are vomiting or have diarrhea. Glyburide is a sulfonylurea and may be used in CKD, as can insulin. Acarbose is an alpha-glucosidase inhibitor and can be used in patients with CKD.
According to the American Diabetes Association (ADA), which of the following criteria can be used in the diagnosis of diabetes in nonpregnant adults?
A A1c greater than or equal to 7.0
B Fasting plasma glucose (FPG) of greater than or equal to 126
C Oral glucose tolerance test (OGTT) with 2-hour plasma glucose greater than or equal to 180
D Classic symptoms of hyperglycemia and random glucose of greater than or equal to 180
B Fasting plasma glucose (FPG) of greater than or equal to 126
According to the ADA guidelines, the diagnosis of diabetes in nonpregnant adults can be made by any of the following:
• A1c greater than or equal to 6.5%
• Fasting plasma glucose (FPG) greater than or equal to 126 mg/dL (7.0 mmol/L); fasting is defined as no caloric intake for at least 8 hours.
• Oral glucose tolerance test (OGTT, 75-gram anhydrous glucose) with measured plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L) at 2 hours (after the glucose load)
• Classic symptoms of hyperglycemia (polyuria, polydipsia, and unexplained weight loss) and random glucose greater than or equal to 200 mg/dL (11.1 mmol/L)
With what condition is prediabetes most commonly associated?
A. chronic pancreatitis
B. HLD
C. Obesity
D. Chronic steroid use
C. Obesity
• Prediabetes is diagnosed in patients with impaired glucose tolerance (blood glucose 140-199 mg/dL), impaired fasting glucose (blood sugar 100-125 mg/dL), or signs of insulin resistance (metabolic syndrome). This condition reflects worsening pancreatic beta cell function, and the most common cause of prediabetes is obesity. While patients with chronic pancreatitis and chronic steroid use may have impaired glucose metabolism, obesity is a more common cause. Hyperlipidemia is associated with the metabolic syndrome and obesity but does not cause prediabetes.
lifestyle modification and glycemic control
Lifestyle modifications which target weight loss and promote activity have been shown to improve glycemic control.
Even modest weight loss (as little as 4 kg) has been shown to improve glucose control.
Some of the most compelling data come from following patients with diabetes who undergo bariatric surgery. These procedures, which can result in sustained weight loss of greater than 20 kg may eliminate the need to take medications for diabetes. However, apart from surgery, the rate of observed eventual weight regain has blunted the impact for more modest lifestyle interventions.
DM medications that are weight neutral or cause weight loss
biguanides - metformin
GLP-1 receptor agonists - “tide”
Amylin agonist - pramlintide
DPP-4 inhibitors -“gliptin”
SGLT2 inhibitors - “gliflozin”
monotherapy tx
T2DM w/ initial A1c < 7.5%
Metformin
GLP-1 agonists (injection)
SGLT-2 inhibitors
(strongest evidence for monotherapy)
DPP-4 inhibitors TZDs alpha glucosidase inhibitors Sulfonylurieas (use w/ caution)
A1c goal not met in 3 months = dual tx
monotherapy tx for DM with high risk for ASCVD or CKD 3 or HF
long-acting GLP-1 receptor agonist
SGLT-2 inhibitor
Metformin contraindications
lactic acidosis - fatal decompensated CHF severely impaired renal function (eGFR < 30) liver failure heavy alcohol use patients undergoing major surgery
Stop w/ iodine contrast and restart in 48 hrs
Tx options w/ Metformin
GLP-1 receptor agonists
SGLT2 inhibitors (jardiance)
DPP-4 inhibitors (Januvia)
TZDs
colesevelam (bile acid sequestrant lowers LDL and improves glycemic control)
bromocriptine-QR (cycloset)
alpha-glucosidase inhibitors
sulfonylureas
non-sulfonylureas secretagogues (“glinides”
amylinomimetic agents
insulin
