33 DIABETES

Question 1

1. Type 1 diabetes results from autoimmune destruction of the beta cells. Eighty-five to 90% of type 1 diabetics have:
2. Autoantibodies to two tyrosine phosphatases
3. Mutation of the hepatic transcription factor on chromosome 12
4. A defective glucokinase molecule due to a defective gene on chromosome 7p
5. Mutation of the insulin promoter factor

Answer 1

1. Autoantibodies to two tyrosine phosphatases

Question 2

Type 2 diabetes is a complex disorder involving:

1. Absence of insulin production by the beta cells
2. A suboptimal response of insulin-sensitive tissues in the liver
3. Increased levels of glucagon-like peptide in the postprandial period
4. Too much fat uptake in the intestine

Answer 2

2. A suboptimal response of insulin-sensitive tissues in the liver

Question 3

3. Diagnostic criteria for diabetes include:
4. Fasting blood glucose greater than 140 mg/dl on two occasions
5. Postprandial blood glucose greater than 140 mg/dl
6. Fasting blood glucose 100 to 125 mg/dl on two occasions
7. Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl

Answer 3

4. Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl

Question 4

4. Routine screening of asymptomatic adults for diabetes is appropriate for:
5. Individuals who are older than 45 and have a BMI of less than 25 kg/m2
6. Native Americans, African Americans, and Hispanics
7. Persons with HDL cholesterol greater than 100 mg/dl
8. Persons with prediabetes confirmed on at least two occasions

Answer 4

2. Native Americans, African Americans, and Hispanics

Question 5

5. Screening for children who meet the following criteria should begin at age 10 and occur every 3 years thereafter:
6. BMI above the 85th percentile for age and sex
7. Family history of diabetes in first- or second-degree relative
8. Hypertension based on criteria for children
9. Any of the above

Answer 5

4. Any of the above

Question 6

6. Insulin is used to treat both types of diabetes. It acts by:
7. Increasing beta cell response to low blood-glucose levels
8. Stimulating hepatic glucose production
9. Increasing peripheral glucose uptake by skeletal muscle and fat
10. Improving the circulation of free fatty acids

Answer 6

3. Increasing peripheral glucose uptake by skeletal muscle and fat

Question 7

7. Adam has type 1 diabetes and plays tennis for his university. He exhibits a knowledge deficit about his insulin and his diagnosis. He should be taught that:
8. He should increase his carbohydrate intake during times of exercise.
9. Each brand of insulin is equal in bioavailability, so buy the least expensive.
10. Alcohol produces hypoglycemia and can help control his diabetes when taken in small amounts.
11. If he does not want to learn to give himself injections, he may substitute an oral hypoglycemic to control his diabetes.

Answer 7

1. He should increase his carbohydrate intake during times of exercise.

Question 8

8. Insulin preparations are divided into categories based on onset, duration, and intensity of action following subcutaneous injection. Which of the following insulin preparations has the shortest onset and duration of action?
9. Lispro
10. Glulisine
11. Glargine
12. Detemir

Answer 8

2. Glulisine

Question 9

9. The drug of choice for type 2 diabetics is metformin. Metformin:
10. Decreases glycogenolysis by the liver
11. Increases the release of insulin from beta cells
12. Increases intestinal uptake of glucose
13. Prevents weight gain associated with hyperglycemia

Answer 9

1. Decreases glycogenolysis by the liver

Question 10

10. Before prescribing metformin, the provider should:
11. Draw a serum creatinine level to assess renal function.
12. Try the patient on insulin.
13. Prescribe a thyroid preparation if the patient needs to lose weight.
14. All of the above

Answer 10

1. Draw a serum creatinine level to assess renal function.

Question 11

11. Sulfonylureas may be added to a treatment regimen for type 2 diabetics when lifestyle modifications and metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy because they:
12. Increase endogenous insulin secretion
13. Have a significant risk for hypoglycemia
14. Address the insulin resistance found in type 2 diabetics
15. Improve insulin binding to receptors

Answer 11

2. Have a significant risk for hypoglycemia

Question 12

12. Dipeptidyl peptidase-4 inhibitors (gliptins) act on the incretin system to improve glycemic control. Advantages of these drugs include:
13. Better reduction in glucose levels than other classes
14. Less weight gain than sulfonylureas
15. Low risk for hypoglycemia
16. Can be given twice daily

Answer 12

3. Low risk for hypoglycemia

Question 13

13. Control targets for patients with diabetes include:
14. HbA1C between 7 and 8
15. Fasting blood glucose levels between 100 and 120 mg/dl
16. Blood pressure less than 130/80 mm Hg
17. LDL lipids less than 130 mg/dl

Answer 13

3. Blood pressure less than 130/80 mm Hg

Question 14

14. Establishing glycemic targets is the first step in treatment of both types of diabetes. For type 1 diabetes:
15. Tight control/intensive therapy can be given to adults who are willing to test their blood glucose at least twice daily.
16. Tight control is acceptable for older adults if they are without complications.
17. Plasma glucose levels are the same for children as adults.
18. Conventional therapy has a fasting plasma glucose target between 120 and 150 mg/dl.

Answer 14

4. Conventional therapy has a fasting plasma glucose target between 120 and 150 mg/dl.

Question 15

15. Treatment with insulin for type 1 diabetics:
16. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight
17. Divides the total doses into three injections based on meal size
18. Uses a total daily dose of insulin glargine given once daily with no other insulin required
19. Is based on the level of blood glucose

Answer 15

1. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight

Question 16

16. When the total daily insulin dose is split and given twice daily, which of the following rules may be followed?
17. Give two-thirds of the total dose in the morning and one-third in the evening.
18. Give 0.3 units per kg of premixed 70/30 insulin with one-third in the morning and two-thirds in the evening.
19. Give 50% of an insulin glargine dose in the morning and 50% in the evening.
20. Give long-acting insulin in the morning and short-acting insulin at bedtime.

Answer 16

1. Give two-thirds of the total dose in the morning and one-third in the evening.

Question 17

17. Studies have shown that control targets that reduce the HbA1C to less than 7% are associated with fewer long-term complications of diabetes. Patients who should have such a target include:
18. Those with long-standing diabetes
19. Older adults
20. Those with no significant cardiovascular disease
21. Young children who are early in their disease

Answer 17

3. Those with no significant cardiovascular disease

Question 18

18. Prevention of conversion from prediabetes to diabetes in young children must take highest priority and should focus on:
19. Aggressive dietary manipulation to prevent obesity
20. Fostering LDL levels less than 100 mg/dl and total cholesterol less than 170 mg/dl to prevent cardiovascular disease
21. Maintaining a blood pressure that is less than 80% based on weight and height to prevent hypertension
22. All of the above

Answer 18

2. Fostering LDL levels less than 100 mg/dl and total cholesterol less than 170 mg/dl to prevent cardiovascular disease

Question 19

19. The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (depending upon type of diabetes) are:
20. Metformin and insulin
21. Sulfonylureas and insulin glargine
22. Split-mixed dose insulin and GPL-1 agonists
23. Biguanides and insulin lispro

Answer 19

1. Metformin and insulin

Question 20

20. Unlike most type 2 diabetics where obesity is a major issue, older adults with low body weight have higher risks for morbidity and mortality. The most reliable indicator of poor nutritional status in older adults is:
21. Weight loss in previously overweight persons
22. Involuntary loss of 10% of body weight in less than 6 months
23. Decline in lean body mass over a 12-month period
24. Increase in central versus peripheral body adiposity

Answer 20

2. Involuntary loss of 10% of body weight in less than 6 months

Question 21

21. The drugs recommended for older adults with type 2 diabetes include:
22. Second-generation sulfonylureas
23. Metformin
24. Pioglitazone
25. Third-generation sulfonylureas

Answer 21

4. Third-generation sulfonylureas

Question 22

22. Ethnic groups differ in their risk for and presentation of diabetes. Hispanics:
23. Have a high incidence of obesity, elevated triglycerides, and hypertension
24. Do best with drugs that foster weight loss, such as metformin
25. Both 1 and 2
26. Neither 1 nor 2

Answer 22

3. Both 1 and 2

Question 23

23. The American Heart Association states that people with diabetes have a 2- to 4-fold increase in the risk of dying from cardiovascular disease. Treatments and targets that do not appear to decrease risk for micro- and macro-vascular complications include:
24. Glycemic targets between 7% and 7.5%
25. Use of insulin in type 2 diabetics
26. Control of hypertension and hyperlipidemia
27. Stopping smoking

Answer 23

1. Glycemic targets between 7% and 7.5%

Question 24

24. All diabetic patients with known cardiovascular disease should be treated with:
25. Beta blockers to prevent MIs
26. Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of cardiovascular events
27. Sulfonylureas to decrease cardiovascular mortality
28. Pioglitazone to decrease atherosclerotic plaque buildup

Answer 24

2. Angiotensin-converting enzyme inhibitors and aspirin to reduce risk of cardiovascular events

Question 25

25. All diabetic patients with hyperlipidemia should be treated with:
26. HMG-CoA reductase inhibitors
27. Fibric acid derivatives
28. Nicotinic acid
29. Colestipol

Answer 25

1. HMG-CoA reductase inhibitors

Question 26

26. Both angiotensin converting enzyme inhibitors and some angiotensin II receptor blockers have been approved in treating:
27. Hypertension in diabetic patients
28. Diabetic nephropathy
29. Both 1 and 2
30. Neither 1 nor 2

Answer 26

3. Both 1 and 2

Question 27

27. Protein restriction helps slow the progression of albuminuria, glomerular filtration rate, decline, and end stage renal disease in some patients with diabetes. It is useful for patients who:
28. Cannot tolerate angiotensin converting enzyme inhibitors or angiotensin receptor blockers
29. Have uncontrolled hypertension
30. Have HbA1C levels above 7%
31. Show progression of diabetic nephropathy despite optimal glucose and blood pressure control

Answer 27

4. Show progression of diabetic nephropathy despite optimal glucose and blood pressure control

Question 28

28. Diabetic autonomic neuropathy (DAN) is the earliest and most common complication of diabetes. Symptoms associated with DAN include:
29. Resting tachycardia, exercise intolerance, and orthostatic hypotension
30. Gastroparesis, cold intolerance, and moist skin
31. Hyperglycemia, erectile dysfunction, and deficiency of free fatty acids
32. Pain, loss of sensation, and muscle weakness

Answer 28

1. Resting tachycardia, exercise intolerance, and orthostatic hypotension

Question 29

29. Drugs used to treat diabetic peripheral neuropathy include:
30. Metoclopramide
31. Cholinergic agonists
32. Cardioselective beta blockers
33. Gabapentin

Answer 29

4. Gabapentin

Question 30

30. The American Diabetic Association has recommended which of the following tests for ongoing management of diabetes?
31. Fasting blood glucose
32. HbA1C
33. Thyroid function tests
34. Electrocardiograms

Answer 30

2. HbA1C

Question 31

31. Allison is an 18-year-old college student with type 1 diabetes. She is on NPH twice daily and Novolog before meals. She usually walks for 40 minutes each evening as part of her exercise regimen. She is beginning a 30-minute swimming class three times a week at 1 p.m. What is important for her to do with this change in routine?
32. Delay eating the midday meal until after the swimming class.
33. Increase the morning dose of NPH insulin on days of the swimming class.
34. Adjust the morning insulin injection so that the peak occurs while swimming.
35. Check glucose level before, during, and after swimming.

Answer 31

4. Check glucose level before, during, and after swimming.

Question 32

32. Allison is an 18-year-old college student with type 1 diabetes. Allison’s pre-meal BG at 11:30 a.m. is 130. She eats an apple and has a sugar-free soft drink. At 1 p.m. before swimming her BG is 80. What should she do?
33. Proceed with the swimming class.
34. Recheck her BG immediately.
35. Eat a granola bar or other snack with CHO.
36. Take an additional dose of insulin.

Answer 32

3. Eat a granola bar or other snack with CHO.

Question 33

33. Bart is a patient is a 67-year-old male with T2 DM. He is on glipizide and metformin. He presents to the clinic with confusion, sluggishness, and extreme thirst. His wife tells you Bart does not follow his meal plan or exercise regularly, and hasn’t checked his BG for 1 week. A random glucose is drawn and it is 500. What is a likely diagnosis based on preliminary assessment?
34. Diabetic keto acidosis (DKA)
35. Hyperglycemic hyperosmolar syndrome (HHS)
36. Infection
37. Hypoglycemia

Answer 33

2. Hyperglycemic hyperosmolar syndrome (HHS)

Question 34

34. What would one expected assessment finding be for hyperglycemic hyperosmolar syndrome?
35. Low hemoglobin
36. Ketones in the urine
37. Deep, labored breathing
38. pH of 7.35

Answer 34

2. Ketones in the urine

Question 35

35. A patient on metformin and glipizide arrives at her 11:30 a.m. clinic appointment diaphoretic and dizzy. She reports taking her medication this morning and ate a bagel and coffee for breakfast. BP is 110/70 and random finger-stick glucose is 64. How should this patient be treated?
36. 12 oz apple juice with 1 tsp sugar
37. 10 oz diet soda
38. 8 oz milk or 4 oz orange juice
39. 4 cookies and 8 oz chocolate milk

Answer 35

3. 8 oz milk or 4 oz orange juice