Clinical Approach to Diabetes and Hypoglycemia

Question 1

In what area of the U.S. is DM most prevalent?

Answer 1

• deep southeast

Question 2

What is Latent Autoimmune Adult Diabetes (LADA)?

Answer 2

• diabetics who do not fit type 1 or 2 categories

Question 3

Is the onset of T1DM abrupt?

Answer 3

YES

Question 4

Is the onset of T2DM abrupt?

Answer 4

NO

Question 5

What is double diabetes?

Answer 5

• pt has T1DM with a family hx of T2DM

Question 6

What is impaired glucose tolerance (pre-diabetes)?

Answer 6

• risk of developing DM.

Question 7

How many adults in the U.S. have pre-diabetes (risk of developing T2DM)?

Answer 7

• 78 million

Question 8

How many adults in the U.S. have T2DM?

Answer 8

• 29 million and growing

Question 9

Do whites or black have a higher risk of developing T2DM?

Answer 9

• blacks

Question 10

What is the fastest growing minority group in the U.S. for T2DM?

Answer 10

• hispanic americans

Question 11

What are some environmental (acquired factors) that can lead to T1DM?

Answer 11

• viral infections
• nutrition
• chemical agents

Question 12

How is insulin secreted in non-diabetics?

Answer 12

• in 2 phases

Question 13

• how is insulin secreted in pts with T2DM?

Answer 13

• loss of phase 1 secretion

* so we want to try to promote phase 1 secretion when treating.

Question 14

What is Hgb A1c?

Answer 14

• 3 month average of plasma glucose attached to valine on B-chain of hemoglobin A; benchmark for assessment of glycemic control (we want it to be less than 7% in T2DM).

Question 15

To what does a reduction in HbA1c correlate in T2DM?

Answer 15

• reduction in risk for microvascular complications: retinopathy, nephropathy, and neuropathy.

Question 16

How do steroids impact diabetics?

Answer 16

• increase hepatic gluconeogenesis, glycogenolysis, and antagonist peripheral insulin response, decreasing glucose uptake.

Question 17

What is the first line treatment for T2DM?

Answer 17

• metformin

Question 18

What is the most common ADR of metformin?

Answer 18

• lactic acidosis

Question 19

What agents can we use when we need supplementation with metformin?

Answer 19

• sulfonylureas (glipizide..)= cheapest.
• incretins (GLP agonists or DPP-4 inhibitors)= well tolerated and oral.
• SGLT-2 inhibitors= increase glycosuria.
• amylin
• insulin

Question 20

What are the 3 rapid-acting mealtime insulins?

Answer 20

1. aspart
2. lispro
3. glulisine

Question 21

What are the long-acting (24 hour) peakless insulins?

Answer 21

• glargine

- detimir

Question 22

What are insulin pumps?

Answer 22

• senses sugar and injects insulin as needed

Question 23

What are the complications of T2DM?

Answer 23

• MICROvascular= retinopathy, neuropathy, nephropathy

- MACROvascular= MI, stroke, peripheral vascular disease

Question 24

If we reduce HbA1c by just 1%, by what percent will microvascular complications be reduced?

Answer 24

• 35%

Question 25

What may you see in the rare case of autonomic neuropathy associated with T2DM?

Answer 25

- GI dysfunciton - orthostatic hypotension - cardiorespiratory arrest - bladder dysfunciton - impotence

Question 26

What is the number one cause of end-stage renal disease?

Answer 26

- T2DM

Question 27

Does diabetic neuropathy tend to affect the lower or upper extremities first?

Answer 27

- lower (symmetrical)

Question 28

Can diabetics present with atypical symptoms of MI?

Answer 28

- YES. They may not present with chest pain.

Question 29

Can pts with DM have postgustotory sweating?

Answer 29

- YES

Question 30

What are the nonparmacologic therapies for T2DM?

Answer 30

- diet (restricting refined carbs) - exercise - vitamins

Question 31

What are the 2 endocrine emergencies?

Answer 31

1. DKA= hyperglycemia, acidosis, and ketosis | 2. hyperosmolar nonketoitic coma

Question 32

What causes the mortality in DKA?

Answer 32

- acidosis and dehydration

Question 33

How do you treat DKA?

Answer 33

- fluids (normal saline) and insulin

Question 34

How do you treat hyperosmolar nonketotic coma?

Answer 34

- fluids

Question 35

What is hypoglycemia?

Answer 35

- neuroglycopenic and/or neurogenic symptoms - low plasma glucose (less than 70 mg/dL - symptom relief after administration of carbohydrates

Question 36

What are the symptoms of hypoglycemia?

Answer 36

- neurogenic (autonomic)= trembling, palpitations, sweating, anxiety, hunger, nausea, tingling. - neurglycopenic= confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness.

Question 37

Who is at risk to develop hypoglycemia?

Answer 37

those with: - autonomic neuropathy - DM with a beta blocker - deficiencies in counter-regulatory hormones

Question 38

What is reactive hypoglycemia?

Answer 38

- post-prandial symptoms, which are usually ADRENERGIC responses.

Question 39

How do we treat reactive hypoglycemia?

Answer 39

- frequent small meals - propantheline bromide or calcium channel blockers - acarbose (delays carbohydrate absorption)

Question 40

What is alimentary hypoglycemia?

Answer 40

- occurs following GI surgery or vagotomy. | - a short-circuited GI tract results in increased carbohydrate absorption.

Question 41

How do you resolve alimentary hypoglycemia quickly?

Answer 41

- feeding

Question 42

What is fasting hypoglycemia?

Answer 42

- wake up with a glucose less than 70. - neuroglycopenic symptoms including stroke may occur. * more serious implications than reactive hypoglycemia.

Question 43

Are most islet cell tumors malignant or benign?

Answer 43

- benign

Question 44

What is factitious hypoglycemia?

Answer 44

- hypoglycemia that doesn't make sense. Typically in patients with access to insulin or sulfonylureas, making themselves hypoglycemic. * will see low c-peptide levels, bc it is being taken exogenously.

Question 45

What is the most common cause of drug induced hypoglycemia?

Answer 45

- alcohol= reduces gluconeogenesis acutely.

Question 46

Can renal disease cause hypoglycemia?

Answer 46

- YES bc the kidneys are necessary for insulin clearance.

Question 47

What does the workup involve for hypoglycemia?

Answer 47

- exclude drug induced - pre-existing hepatic or renal disease - pituitary or adrenal disease - retroperitoneal tumor - carbohydrate or meal induced

Question 48

How do you treat hypoglycemia?

Answer 48

- glucose - glucagon - terbutaline (B2 agonist) - somatostain analogue= reduces insulin.