Day 3 - Endo1 Glucose Metabolism

Question 1

NOT high-yield for step 2: Anti-islet antibodies seen in pts w/ diabetes

Answer 1

Review after step 2: anti-isulin, anti-islet cell cytoplasm, anti-glutamic acid decarboxylase, anti-tyrosine phosphatase

Question 2

Distinguish somygi effect from dawn phenonmenon

Answer 2

Both cause high glucose levels upon waking in the AM; Somogyi effect - glucose too low in middle of night (e.g., evening NPH dose too high), stress hormone (e.g., catecholamines) aka counterregulatory hormones - boost glucose, Tx - decrease evening NPH, NPH at bedtime instead of dinner, snack before bedtime; Dawn phenomenon - because not take enough NPH, glucose never got low, Tx - increase evening NPH; Distinguish w/ 3 AM blood glucose check

Question 3

DM agents - lactic acidosis as rare but worrisome side effect

Answer 3

Metformin

Question 4

DM agents - most common side effect hypoglycemia

Answer 4

Sulfonylureas (also meglitinides)

Question 5

DM agents - oldest and cheapest

Answer 5

Sulfonylureas

Question 6

DM agents - often used in combo w/ any of other agents

Answer 6

Metformin (often 1st line)

Question 7

DM agents - also help lower LDL and TG

Answer 7

Metformin

Question 8

DM agents - Contraindicated in CHF

Answer 8

Thiazolidinediones (pioglitazone, rosiglitazone)

Question 9

DM agents - not used in pts w/ elevated serum Cr

Answer 9

Metformin; Sulfonylureas

Question 10

DM agents - not used in patients in IBD

Answer 10

Alpha-glucosidase inhibitors (acarbose); Note: mechanism to decrease GI absorption of starch & dissacharides

Question 11

DM agents - hepatic serum transaminase levels must be carefully monitored

Answer 11

Metformin (also Thiazolidinediones - pioglitazone, rosiglitazone)

Question 12

DM agents - not cause weight gain

Answer 12

Metformin

Question 13

DM agents - metabolized by liver, excellent choice in patients with renal disease

Answer 13

Glitazones

Question 14

DM agents - Primary affects postprandial glucose & taken w/ meals

Answer 14

Alpha-glucosidase inhibitors (acarbose)

Question 15

DM agents - 3 newer drugs

Answer 15

(1) Exenatide (2) Sitagliptin (3) Pramlintide (see p. 113 in text) - Review details after step 2

Question 16

If DM pt not controlled on 2 oral agents

Answer 16

Option 1 - add 3rd agent; Option 2 - add insulin

Question 17

Should DM patient requiring insulin be on sulfonylurea

Answer 17

No, since sulfonylurea work by insulin release

Question 18

Criteria for dx metabolic syndrome

Answer 18

3 of 5 following: (1) Abdominal/Truncal obesity (>40” in men or 35” in women) (2) TG > 150 (3) HDL 130/85 (prehypertension) (5) Fasting serum glucose > 100 (or 2 hours post orgal glucose challenge, glucose > 140, not 200)

Question 19

Common causes of DKA

Answer 19

Excess glucagon, steroids, or catecholamines; Infx (pna, gastroenteritis, dka), severe medical illness (stroke, trauma), dehydration, alcohol/drug abuse, steroids

Question 20

Necessary steps in tx DKA

Answer 20

Isotonic fluid boluses (LR preferred over NS, may be as much as 4L), 2x maintenance fluid (2:4:1 rule), IV Insulin (regular), identify/tx underlying cause, Replace K, likely replace Ca/Mg/Phos; Serum below 2-300, start IV glucose & continue IV insulin, check anion gap; Once anion gap normalizes, can return to normal insulin regimen

Question 21

Dx ; Tx gastroparesis

Answer 21

Gastric emptying study (swallow barium, watch under fluoroscope in radiology; if not emptying stomach into duodenum); GI motility agents - Cisapride, erythromycin, metoclopramide

Question 22

Meds not taken with cisapride due to risk of cardiac arrhythmias

Answer 22

Metabolized by same P450 - Macrolides (e.g., erythromycin), Antifungals, Phenothiazines (e.g., Prochloperazine or Chlorpromazine)

Question 23

Standard care for DM pts

Answer 23

Exercising daily (proven to reduce mortality), Healthy diet, Daily blood glucose, Insulin (several times per day, if necessary), Physical exam every 3-6 mo [with attention to BP (avoid pre-HTN, 7,