Diabetes

Question 1

Diabetic Nephropathy diagnosis can be presumed in patients who have persistent albuminuria and/or ↓ GFR and either long history or ____.

Answer 1

Proliferative diabetic retinopathy (PDR) (ie, retinal neovascularization)

Question 2

Stress hyperglycemia if Mild do not require treatment.
Marked elevations (eg, >___ mg/dL) are associated with increased mortality and should be corrected with short-acting insulin (Lispro)

Answer 2

180-200

with a target glucose of 140-180 mg/dL.

Question 3

HHS (hyperosmolar hyperglycemic state) is more common in type 2 diabetes and is characterized by severe hyperglycemia (>__mg/dL) and ___ anion gap with little or no ketonemia or acidosis.

Answer 3

> 600
Normal Anion Gap

Question 4

Does Hyperosmolar Hyperglycemic State cause metabolic acidosis or elevated anion gap?

Answer 4

NO & NO
(bicarb wnl)

Question 5

List 4 inciting factors for HHS (hyperosmolar hyperglycemic state)

Answer 5

Infection
Insulin nonadherence/Interruptions
Medications: (glucocorticoids, thiazide diuretics, atypical antipsychotics)
Tauma

Question 6

Patients with hyperosmolar hyperglycemic state or diabetic ketoacidosis have a total body ___ deficit due to excessive urinary loss caused by glucosuria-induced osmotic diuresis.

Answer 6

potassium deficit

(give potassium with Insulin. K+ lost due to osmotic diuresis)

Question 7

Hemoglobin A1 should be ___% for most patients with type 2 diabetes mellitus.

Answer 7

≤7%
Hemoglobin A1c is influenced by both fasting and postprandial glucose concentrations.

Question 8

acceptable fasting glucose target range: ___ mg/dL

Answer 8

80-130
(If within this range in the AM this suggests adequate basal insulin coverage)

Question 9

acceptable fasting glucose target range is 80-130 mg/dL
If AM glucose within this range this suggests adequate ___ insulin coverage.

Answer 9

basal insulin

ex: Glargine

Question 10

acceptable non-fasting glucose goal for diabetic patients is <___ mg/dL

Answer 10

<125
(if within range after meals this suggests adequate rapid-acting insulin bolus (basal-bolus)).

Question 11

If non-fasting glucose is <125 mg/dL this suggest adequate control of postprandial hyperglycemia with a ____ bolus.

Answer 11

rapid-acting insulin bolus (basal-bolus)

ex: Aspart, Lispro

Question 12

IV insulin infusion is indicated for patients with severe hyperglycemia (BGL >___ mg/dL).
Most patients with diabetes mellitus are managed with ____ insulin while hospitalized.

Answer 12

> 400 (IV insulin needed)
subcutaneous insulin

Question 13

Patients with diabetes mellitus who have an elevated hemoglobin A1c >7% despite normal fasting glucose levels may have ___.

Answer 13

postprandial hyperglycemia

Question 14

Hyperosmolar hyperglycemic state in T2DM is characterized by severe hyperglycemia and hyperosmolality without significant ___. Altered sensorium is due to high ____.

Answer 14

ketoacidosis
plasma osmolality (>320)

Question 15

Annual random urine albumin/creatinine ratio for DM
Normal value: <__ mg/g

Answer 15

<30

Question 16

Patients with diabetes mellitus and albuminuria (≥30 alb:cr) or hypertension should be treated with ____ to lower blood pressure and/or slow the progression of nephropathy.

Answer 16

ACE inhibitors
or
angiotensin II receptor blockers

Question 17

[Large/Small] fiber neuropathy:
Diminished/absent ankle reflexes
poor balance
Reduced/absent vibration & proprioception

Answer 17

Large fiber Axonopathy

Question 18

[Large/Small] fiber neuropathy:
Reduced pinprick sensation
Burning pain, paresthesia, and allodynia
Ankle reflexes possibly preserved

Answer 18

Small Fiber Axonopathy

Question 19

Administration of insulin drives potassium into cells, resulting in ___.

Answer 19

hypokalemia

(Insulin deficiency causes an extracellular shift of potassium, and serum potassium levels may be normal or elevated despite a total body deficit.)

Question 20

Treatment of DKA starts with:
(AMS, Hyperglycemia, Anion Gap Metabolic Acidosis)

Answer 20

Normal saline & regular insulin IV infusion

Question 21

sodium-glucose cotransporter 2 inhibitors (SGLT2–I) reduce the progression of DKD in patients with T2DM, but are contraindicated if estimated GFR is < ___ mL/min/1.73 m2.

Answer 21

<30

Question 22

canagliflozin, dapagliflozin & empagliflozin are what drug class?

Answer 22

SGLT-2 Inhibitors
Increased urinary glucose excretion
⎯
(contraindicated if GFR <30 or h/o DKA)

Question 23

SGLT-2 Inhibitors adverse effects (2)

Answer 23

Euglycemic ketoacidosis
Increased risk of genitourinary infections (UTIs)

Question 24

Medication:
stimulate endogenous pancreatic insulin secretion.
Like insulin, they are associated with weight gain and increased risk for hypoglycemia.

Answer 24

Sulfonylureas (glipizide)

Question 25

what 2 medications can be added to **decrease cardiovascular mortality**, induce **weight loss**, and minimize the risk for hypoglycemia in patients with diabetes?

Answer 25

glucagon-like peptide-1 receptor agonists (exenatide, liraglutide, semaglutide) SGLT-2 Inhibitors (–flozin)

Question 26

Patients with hypertension should be screened for ___. Even in the absence of hypertension, screening is advised for patients age ___ with a **BMI ≥25**.

Answer 26

diabetes mellitus 35+

Question 27

In patients with diabetes mellitus, intensive blood glucose control with **insulin** decreases the risk of ____ complications **only**.

Answer 27

microvascular complications (**retinopathy, nephropathy**)

Question 28

**Very strict** glycemic control (goal A1c ≤6.5%) is associated with increased risk of **hypoglycemia** and increased _____.

Answer 28

cardiovascular mortality

Question 29

DKA is characterized by an ____ that reduces total body potassium even though serum potassium may be normal or elevated.

Answer 29

osmotic diuresis

Question 30

C-peptide levels are usually ___ in T1DM & ___ in T2DM

Answer 30

Low (Type 1) High (Type 2)

Question 31

**Diabetic gastroparesis** (delayed gastric emptying) presents with nausea, postprandial emesis, early satiety, bloating, and abdominal pain in the setting of poor glycemic control. Treatment requires optimization of diabetic control and medications that **improve gastric emptying** (eg, _____).

Answer 31

metoclopramide

Question 32

___ or ___ **hypoglycemia** in patients with **long-standing diabetes** reduces the glucose-raising effects of epinephrine and suppresses hypoglycemia symptoms thus **increasing the risk** for progressively **worsening hypoglycemic episodes**.

Answer 32

Recurrent or severe hypoglycemia (**hypoglycemia-associated autonomic failure**)

Question 33

Diabetic ketoacidosis causes osmotic diuresis and secondary ____, leading to urinary potassium loss and a total body potassium deficit.

Answer 33

hyperaldosteronism

Question 34

_____ is typical for patients with **central-type obesity** & is the **key pathogenic factor** in the development of type-2 diabetes mellitus and associated abnormalities (hypertension, dyslipidemia).

Answer 34

Insulin resistance

Question 35

Initial treatment of HHS is _____.

Answer 35

immediate IVF resuscitation with **normal saline** (then insulin)

Question 36

Infusion of sodium bicarbonate is sometimes used in patients with DKA and severe acidosis (pH < ___)

Answer 36

pH <6.9

Question 37

**HHS**: IV Potassium replacement if level is <___ mEq/L **DKA**: IV Potassium replacement if level is <___ mEq/L **hold** if ≥___ mEq/L

Answer 37

(HHS) **less than** 5.3 (DKA) **less than** 5.3 (Hold) 5.3 **or more**

Question 38

Patients using insulin are at risk for exercise-induced hypoglycemia. **Prior to exercise**, patients with T1DM should **increase carbohydrate intake** and _____ doses to prevent hypoglycemia.

Answer 38

Reduce bolus **and** basal insulin doses

Question 39

What medication is a potential trigger for HHS because it can precipitate hyperglycemia and metabolic derangements?

Answer 39

Olanzapine (atypical antipsychotic) ⎯ Glucocorticoids, Thiazides

Question 40

Patients taking insulin for diabetes are vulnerable to exercise-induced hypoglycemia especially patients with ___ due to **delayed clearance** of insulin by the kidneys.

Answer 40

chronic kidney disease

Question 41

The most accurate markers indicating resolution of diabetic ketoacidosis are what? (2)

Answer 41

the serum anion gap serum beta-hydroxybutyrate levels

Question 42

In pregnant women with T2DM, **fetal hyperglycemia** during the **first** trimester is associated with ____. In pregnant women with T2DM, **fetal hyperglycemia** after the first trimester is associated with perinatal complications such as ___. (3)

Answer 42

malformations (congenital heart disease, micro-colon) macrosomia, birth injury (shoulder dystocia), and hypoglycemia

Question 43

Neonatal ____ is the **most common** complication among infants of diabetic mothers.

Answer 43

hypoglycemia

Question 44

Infants whose mothers have ______ are **not** at increased risk for malformations because maternal/fetal hyperglycemia does not develop until after organogenesis is complete.

Answer 44

gestational diabetes (24+ weeks gestation)

Question 45

For T2DM what is the initial first line treatment?

Answer 45

metformin

Question 46

Avoid which diabetes medication in pts with a history of CAD or Heart failure?

Answer 46

Dipeptidyl peptidase-4 inhibitor (saxagliptin, Linagliptin)

Question 47

Which diabetes medication Increases risk for **hypoglycemia** and weight gain?

Answer 47

Sulfonylureas (Glimepiride, glyburide, glipizide) stimulate endogenous pancreatic insulin secretion

Question 48

Avoid this diabetes medication in patients with **congestive heart failure**.

Answer 48

Thiazolidinedione (Pioglitazone)

Question 49

Adverse effects of this diabetes medication include weight gain, peripheral edema, heart failure, and **osteoporosis**.

Answer 49

Thiazolidinedione (Pioglitazone) Stimulate (PPAR-ɣ) receptor to reduce insulin resistance

Question 50

This diabetes medication works by: **slowing gastric emptying** suppressing **glucagon** secretion increasing glucose-dependent insulin release

Answer 50

Glucagon-like peptide-1 (GLP-1) receptor agonists (exenatide, semaglutide, liraglutide) Like, SGLT2-I, GLP-1 agonists induce **weight loss** and **reduce mortality** associated with CVD.

Question 51

exenatide, semaglutide, liraglutide are what kind of medication?

Answer 51

Glucagon-like peptide-1 (GLP-1) receptor agonists

Question 52

Glimepiride, Glyburide, Glipizide are what kind of medication?

Answer 52

Sulfonylureas

Question 53

saxagliptin, Linagliptin are what kind of medication?

Answer 53

Dipeptidyl peptidase-4 inhibitor

Question 54

canagliflozin, dapagliflozin & empagliflozin are what kind of medication?

Answer 54

SGLT-2 Inhibitors (sodium-glucose cotransporter-2 inhibitors)