Diabetes Flashcards
P.A. is a 55-year-old woman with a history of type
2 diabetes mellitus (T2DM), hypertension (HTN),
hyperlipidemia, and chronic urinary tract infections.
She has tolerated metformin well but has noticed an
increase in hemoglobin A1C values during the past
6–9 months. A review of blood glucose (BG) readings
reveals a record of fasting blood glucose (FBG) values
at 140–190 mg/dL and premeal BG values at 180–260
mg/dL. In addition, today’s laboratory values include
the following: A1C 8.4%; aspartate aminotransferase
(AST) 28 U/L; alanine aminotransferase (ALT) 35
U/L; serum creatinine concentration 1.4 mg/dL, and
estimated glomerular filtration rate (eGFR) 52 mL/
minute/1.73 m2. The patient has a current body mass
index (BMI) of 31 kg/m2, and she is concerned about
weight gain with changes in her regimen. Which is the
most appropriate therapeutic change for this patient?
A. Discontinue metformin (Glucophage) because of
poor renal function and start basal/bolus insulin.
B. Add glargine (Lantus) insulin 10 units subcutaneously at bedtime to her current regimen.
C. Add liraglutide 0.6 mg subcutaneously every day,
with a goal of titrating to a dose of 1.8 mg every
day, to her current regimen.
D. Add empagliflozin 10 mg in the morning, with a
goal of titrating to a dose of 25 mg, to her current
regimen.
This patient’s fasting, premeal BG, and A1C values are high representing poor glucose control. Empagliflozin could potentially be synergistic with metformin, but this patient’s history of recurrent urinary tract infections does not make her a good candidate for this therapy (Answer D is incorrect).
Both glargine and liraglutide would be appropriate
options in such a patient, with similar initial A1C reduction potential. However, glargine has the potential to cause weight gain, which is of concern to the patient, whereas liraglutide has the potential for weight loss (Answer B is incorrect; Answer C is correct). Plus guidelines clearly advocate that the first injectable should be a GLP-1 RA over insulin in people with T2DM. This patient’s estimated creatinine clearance is greater than 30 mL/minute/1.73 m2; therefore, discontinuing metformin would not be necessary (Answer A is incorrect).
Correct Answer: C
Which is the best recommendation for preventive measures and screening assessments for patients with diabetes mellitus (DM).
A. Annual: fasting lipid panel, influenza vaccine,
dilated eye examination, A1C assessment
B. Each visit: blood pressure assessment, urinary
albumin, comprehensive foot examination
C. Annual: urinary albumin, comprehensive foot
examination, dilated eye examination, influenza
vaccine
D. Each visit: fasting lipid panel, blood pressure
assessment, urinary albumin, A1C assessment
The following measures should be done at least annually for assessment and prevention in patients with diabetes: influenza vaccine, urinary albumin assessment (e.g., spot urinary albumin/creatinine ratio), comprehensive foot examination, dilated eye examination, and fasting lipid panel.
Other preventive measures with varying recommendations regarding frequency are vaccines (pneumococcal, hepatitis B), dental examinations, blood pressure assessment, A1C assessment, use of aspirin, smoking cessation counseling, and exercise/weight loss counseling (Answer C is correct).
The A1C should be assessed every 3–6
months (Answer A is incorrect). Urinary albumin should
be assessed annually (Answer B is incorrect). For adults
not taking statins, it is reasonable to obtain a lipid profile
at the time of diabetes diagnosis, then every 5 years thereafter, or more often if indicated, but not every visit. A lipid profile should be obtained at initiation of statin therapy and periodically thereafter because it may help monitor the response to therapy and inform adherence (Answer D is incorrect).
Correct Answer: C
Which option most appropriately lists the insulins in
order from fastest acting to the longest acting?
A. Degludec (Tresiba), glargine (Lantus), regular
insulin, aspart (NovoLog)
B. Lispro (Humalog), regular insulin, neutral protamine Hagedorn (NPH), degludec (Tresiba)
C. Glargine (Lantus), detemir (Levemir), regular
insulin, glulisine (Apidra)
D. Regular insulin, NPH, glulisine (Apidra), glargine
(Lantus)
The fastest-acting insulins consist of the rapid-acting
insulin analogs lispro (Humalog), aspart (NovoLog), and
glulisine (Apidra).
Regular insulin is next choice because it is a short-acting insulin. Neutral protamine Hagedorn insulin has an intermediate duration of action, followed by the long-acting insulin analog detemir (Levemir), the long-acting glargine (Lantus and Toujeo), and finally degludec (Tresiba) (Answer B is correct).
The other options list the agents incorrectly from rapid to long-acting (Answers A, C, and D are incorrect).
Correct Answer: B
G.D. is a 76-year-old woman who lives alone. She was
given a diagnosis of T2DM 2 years ago. Yesterday her
A1C reading was 8.5%, and her most recent eGFR
value was 28 mL/minute/1.73 m2. She has a history
of osteoporosis and had a hip fracture 3 years ago;
she still often uses a walker for stability. Her family is
concerned about hypoglycemia in anticipation of her
starting DM medication. Which medication is best for
this patient?
A. Glipizide
B. Metformin
C. Pioglitazone
D. Alogliptin
Glipizide and alogliptin are insulin secretion stimulators; however, only alogliptin causes an increase in insulin secretion in a glucose-dependent manner, thereby minimizing the risk of hypoglycemia (Answer D is correct).
Although metformin is typically a first-line choice for most people with T2DM, it is contraindicated in patients with poor renal function. This patient’s renal function and her age (76 years) would preclude her from receiving metformin because she would have an increased risk of developing lactic acidosis (Answer B is incorrect).
She would not be a good candidate for pioglitazone because of her history of osteoporosis (Answers A and C are incorrect).
Correct Answer: D
E.C. is a 38-year-old patient with no history of HTN
but a 2-year history of T2DM. Results of the previous two urine analyses have shown results with urine albumin/creatinine ratio values greater than 30 mg/dL.
Which intervention is best to slow the progression of
this patient’s diabetic nephropathy?
A. Low-sodium diet
B. Angiotensin-converting enzyme inhibitor (ACEI)
C. Dihydropyridine calcium channel blocker
(DHP-CCB)
D. Aspirin
The ACEIs decrease proteinuria, increase the time to
doubling of serum creatinine, and delay the need for kidney transplantation and dialysis (Answer B is correct).
Although aspirin reduces CV risk, it has no effect on the progression of renal disease (Answer D is incorrect). Blood pressure reduction, such as what would result from a low sodium diet, can delay the progression of renal disease in patients with HTN (Answer A is incorrect). Although nonDHP-CCBs (diltiazem and verapamil) decrease proteinuria independently of the blood pressure effect, DHP-CCBs can exacerbate proteinuria in patients with well-controlled blood pressure who are not receiving renin-angiotensin aldosterone system suppression (Answer C is incorrect).
Correct Answer: B
Which statement is the most accurate regarding the
use of antiplatelet therapy in patients with DM?
A. Aspirin 325 mg once daily should be used as a
secondary-prevention strategy in patients with
DM and atherosclerotic cardiovascular (CV)
disease.
B. Dual antiplatelet therapy is recommended for
patients with DM with a 10-year CV risk of
greater than 10%
C. Aspirin 75–162 mg once daily should be used for
primary prevention in patients older than 65 years
with a history of renal disease.
D. Aspirin 75–162 mg once daily may be considered as a primary prevention strategy in patients
with DM who are at increased CV risk, after a
discussion with the patient on the benefits versus
increased risk of bleeding.
Aspirin therapy (75–162 mg/day) should be used for
secondary prevention in patients with diabetes unless a contraindication exists (Answer A is incorrect).
Aspirin therapy (75–162 mg/day) may be recommended as a primary prevention strategy in those with diabetes who are at increased risk of CV (10-year risk of 10% or greater), including men or women age 50 years with one additional risk factor, such as family history of CVD, HTN, smoking, dyslipidemia, or albuminuria after considering risk of bleeding (Answer D is correct). Aspirin therapy is not recommended as a primary prevention strategy in those with diabetes and at low risk of CV (10-year risk of less than 5%), such as men or women younger than age 50 years with no additional risk factors or in patients at increased risk of bleeding such as older age, anemia, renal disease (Answer
C is incorrect).
Dual antiplatelet therapy is reasonable for up to 1 year after an acute coronary syndrome (Answer B is incorrect).
Correct Answer: D
Which activity best differentiates the mechanisms of action of semaglutide compared with linagliptin?
A. Semaglutide causes a glucose-dependent increase
in insulin secretion.
B. Semaglutide causes a glucose-dependent decrease
in glucagon secretion.
C. Semaglutide increases satiety.
D. Semaglutide reduces the extent of postmeal carbohydrate absorption.
Linagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor,
and, similar to semaglutide, affects actions of incretin hormones. By definition, incretins increase insulin secretion and decrease glucagon production in a glucose-dependent mechanism (Answers A and B are incorrect).
However, unlike GLP-1 receptor agonists, DPP-4 inhibitors do not have activity in the central nervous system and therefore do not affect satiety (Answer C is correct).
Neither class of medications changes the extent of carbohydrate absorption (Answer D is incorrect).
Correct Answer: C
J.C. is a 62-year-old man with a BMI of 32.5 kg/m2
who was given a diagnosis of T2DM about 5 years
ago and is concerned about weight gain. He has taken
oral antihyperglycemic agents since the time of diagnosis. J.C. was prescribed insulin protamine/lispro
(Humalog 75/25) 40 units twice daily 5 months ago
because of an increased A1C of 9.4%. Since starting
therapy with Humalog 75/25, his A1C has decreased
to 7.2%. However, J.C. notes that he has hypoglycemic episodes midmorning most days of the week. His
BG logs show FBG values in the near-normal range.
Which is the most appropriate adjustment to this
patient’s therapy?
A. Decrease the morning dose of Humalog 75/25 to
30 units, and keep the evening dose at 40 units.
B. Increase the amount of carbohydrates eaten during breakfast.
C. Stop Humalog 75/25 and start 48 units of insulin
glargine daily and 6-7-7 units of insulin aspart at
meals.
D. Stop Humalog 75/25 and start 60 units of insulin glargine daily and 8 units of insulin aspart at
meals.
Mixed insulin can be more convenient for patients to use; however, it is not as easily titrated as two single insulins.
For many patients, insulin needs do not match the ratio of the commercially available combination insulin products.
As a result, titrating insulin doses to correct one problem often results in BG readings that are too high or too low at another time. In this case, the patient is receiving the equivalent of 60 units of intermediate-acting insulin and 20 units of rapid-acting insulin each day. The almost daily midmorning hypoglycemic reactions are caused by
too much (10 units) rapid-acting insulin in the morning (Humalog 75/25 dose). Reducing the morning dose will alleviate the midmorning low glucose concentration but will also likely cause a rise in the predinner (post lunch) BG (Answer A is incorrect).
Consuming more calories as carbohydrates at breakfast will help prevent the midmorning hypoglycemia but at the expense of weight gain (Answer B is incorrect).
Humalog 75/25 contains 75% insulin lispro protamine suspension (which acts similarly to NPH insulin) and 25% insulin lispro. The recommendations for converting intermediate-acting insulin to long-acting insulin call for using 80% of the original NPH dose (0.8 × 60= 48 units) To prevent further midmorning hypoglycemia, the morning quick-acting insulin dose should be less than 10 units (Answer C is correct; Answer D is incorrect).
Correct Answer: C
Name two glp-1 agonist that have indications for weight management
Semaglutide and liraglutide
Lada stands for
Latent autoimmune diabetes in adults
Commonly mistaken for type 2
Type 1 diabetes is associated with which type of disorder
Autoimmune
When looking at diagnosing for type 1 diabetes what’s the percent of patients that usually are diagnosed at time of diabetic ketoacidosis presentation
40-60%
What is the screening age for all adults to be screened for type 2 diabetes
Age 35
Test for prediabetes and or type 2 and asymptomatic people if overweight or obese BMI greater than 25 or bmi > in 23 in Asian Americans
What is the blood glucose Target ranges
Target fasting blood glucose and A1C until you’re below 8 and then start targeting postprandial
What is the difference between dpp4 inhibiting GLP 1 and giving a glp-1 agonist
The dpp4 inactivates the breakdown of glp-1 so DPP4 inhibitors stop the inactivation process = you have more GLP1 in the body
Yet in type 2 diabetes they tend to not make enough GLP 1
The GLP1RAgonists actually increases the amount of glp1 being released into the system at Super therapeutic levels
What is the mechanism of action of glp one agonists
Slow gastric emptying
Promotes satiety
Promotes insulin secretion from beta cells
Decreases glucagon secretion from alpha cells
Does all this in glucose dependent way, person not eating won’t experience these effects
Which two glp-1 rec agonists are approved in pediatrics age 10 and older
Liraglutide and Exenatide weekly
Which GLP1 receptor agonists have FDA approval for treatment in established cvd in type 2 DM
Liraglutide
Semaglutide
Dulaglutide
Which GLP1 did not show improvement but is considered neutral on cvd
Lixesenatide
Which GLP1 RA and formula was in the PIONEER trial and currently shows no significance on CVD
Oral semaglutide confidence interval crossed one so no significance yet the trial wasn’t powered for that it was a non-inferiority trial
Which injectable glp one causes nodules under the skin
Exenatide weekly
Which GLP1 RA can be technically used for primary prevention based on REWIND study
Dulaglutide (trulicity)
Enrolled more people with less CvD risk factors and still showed a decrease in CV events so they’re the only one that has established CVD and multiple CVD risk factors part of their indication
SGLT2 inhibitors have positive benefits on what three systems irrespective of glucose lowering
CVD
HF
Kidneys
When is SGLT2 not good as monotherapy for DM
when GFR goes below 45, poor at lowering glucose
SGLT2 are dosed how often and when
QD, in morning
Which SGLT2 did not demonstrate a reduced risk of CV death and hospitalizations
Ertugliflozin (Steglatro)
Which SGLT2 has indication to reduce CV death, hospital, risk of CKD, doubling serum creatinine, and hosp for HF in adults with T2DM and DM nephropathy with albuminuria> 300
Canaglifozin (invokana)
Which SGLT2 has indication to treat HF in adults with reduced EF
(Note pt does not have to have diabetes!)
Dapaglifozin (farxiga)
Which SGLT2 has indication to treat CKD at risk of progression
Dapaglifozin (farxiga)
SGLT2 also for heart failure without dm
Emaglifozin (Jardiance)
SGLT2 may cause euglycemia DKA true or false
Counsel point to give
True
More common in T1 DM which drug would be used off label, FDA did not grant indication for type 1 because of it.
Careful in use with insulins
If someone is sick they should hold the sglt2 inhibitor
Pancreatitis associated with which two drug classes
Dpp4 inhibitors and GLP1 agonists
Which DPP4 inhibitor does not have to be renally dosed
Linagliptin (Tradjenta) stays at 5mg daily
What is the target dose Sitagliptin (Januvia) and patients with the GFR greater than 50 ml
100mg daily
GFR 30-49, 50mg QD
<30 , 25mg QD
The target dose of saxagliptin (onglyza) over 50 GFR
5 mg QD
<50 GFR, 2.5mg qd
what is the target dose of Alogliptin (Nesina) in pts with greater than 60 GFR
25 mg QD
30-59 GFR, 12.5mg QD
<30, 6.25mg QD
When it comes to dpp4 make sure patient gets target dose because
Lower dose in normal GFR, less benefit
Sulfonylureas are associated with which two side effects
Hypoglycemia
Weight gain
What is the target dose for sulfonylureas
Half dose of efficacious, going to max dose can be too strong
When you administer sulfonylureas
30 minutes prior to meals
Skip meal, skip dose
Once or twice a day ok
How to dose meglitinides
Must be dosed TID with every meal
1 -15 minutes before meals
Short acting insulin release
Name the two meglitinides
Repaglinide (prandin)
Nateglinide (starlix)
TZD moa
Decrease insulin resistance by making muscle and adipose cells more sensitive to insulin and suppress hepatic gluconeogenesis
Exercise in a pill, helps muscle take up glucose, data coming out with it’s use in fatty liver dz
Rosiglitazone (avandia) was associated in meta analyses with increased risk Mi
What about today
No longer than case
But still not used
Pioglitazine (actos) is used
Iist 2 side effects and 2 CI for using TZD
Weight gain/ edema
Hypoglycemia
CI in impaired liver function or HF
What is dose pioglitazine
15-45mg QD
Stick to lower dose, it’s effective with less se
Name two Alpha glucosidase inhibitors
Acarbose (precose)
Miglitol (glyset)
Name 3 advantages and 3 disadvantage of alpha glucosidase inhibitors
No hypoglycemia
Decreases PPG (usually used for reactive hypoglycemia hx)
Non systemic
Less impact on A1C
GI side effects
Frequent dosing
Name the amylin mimetic
Pramlintide (symlin)
Why is pramlintide not used that often
Needs to be injected 3 times a day and only given to patients on insulin, no one wants to inject 6 times a day
Name two longer acting insulin that have lower risk for causing hypoglycemia when given monotx
Degludec
Glargine u300
Which sulfonylureas causes less hypoglycemia, glip or gly
Glipizide
According to ADA when intensify with injectable, which is first, GLP 1 or insulins
GLP1
When adding insulin which do you add first, long or short acting and what dose
Long acting
10 units or 0.1 to 0.2 units/kg per day and titrate up
Careful to avoid over basal use (> 0.5units /kg per day) and/or seeing a big difference at bedtime compared to morning readings (dropping 50 points or more overnight) means need to cover PPG better
For ppg coverage, when to start mealtime coverage
Start one injection a day, largest meal of the day
Start with 4 units and titrate 1-2 units weekly
Describe rule of 1800 which is used to estimate how much 1 unit will lower blood glucose
1800/current DAILY insulin dose = the mg/dL decrease in blood glucose per 1 unit of insulin
Eg 40 units/day, 1800/40 = 45 (1 unit will lower blood glucose by 45 mg/dl)
Describe rule of 500 which estimates 1 unit of insulin for FILL IN # grams carbohydrates
500/ total current DAILY insulin dose equals the insulin/carbohydrate ratio
50 units insulin/day so plug into equation to look like this 500/50 = 10
This means need one unit of insulin for every 10 grams of carbs ingested
Name 3 microvascular complications of diabetes
Retinopathy
Nephropathy
Neuropathy
Name 3 mACROvascular complications of diabetes
CAD
Cerebrovascular disease
PAD
What is goal blood pressure in diabetes and ASCVD risk < 15%
<140/90 m Hg
What is bp goal in diabetes and ASCVD risk > 15%
< 130/80 mmHg
What is BP goal in pregnant pts with preexisting HTN
<135/85
If a diabetic patient does not have underlying kidney disease what are the first line agents that they can use for hypertension
Thiazide
Calcium channel blockers
ACE or ARB
If a diabetic does have kidney disease, what is first line for HTN
ACE or ARB
Diabetic age 40-75 without CV risk factors or under age 40 with CV rf, what dose statin to give
Moderate intensity
All ages DM + ASCVD or very high risk
High intensity statin
Lipitor 40-80
Crestor 20-40
