Diabetes

Question 1

Diagnosis

Answer 1

• Hgb A1c > 6.5%
• FBG > 126
• random glucose >200 + symptoms of diabetes

Question 2

Pharmacologic Mx of CV risk factors

Answer 2

• Aspirin 81mg daily unless bleeding risk
• Mod-high intensity statin, all pt’s w/ DM >40y
• ACE-I and BP management, goal <140/90

Question 3

Immunizations

Answer 3

• PPSV23
• annual influenza
• hep B series

Question 4

complications screening and Mx (retinopathy, nephropathy, neuropathy, and foot ulcers)

Answer 4

Retinopathy
-annual retinal exam; q2y if two in a row normal

Nephropathy
-annual urine microalbumin and GFR; ACE/ARB

Neuropathy

• annual monofilament test
• 1st line pregabalin or duloxetine

Foot complications

• Rx tinea pedis (terbinafine) to reduce complications
• counsel on appropriate footwear
• podiatry referral: smokers, hx of foot infection/deformity, or PAD

Question 5

Glycemic control (target A1c, FBG, postprandial)

Answer 5

A1c: <7%, consider less intensive goals in older patients

FBG: 80-130

Postprandial: <180, check 1-2h after beginning of meal

monitoring supplies: glucometer, test strips, lancets

Question 6

Metformin

Answer 6

• increases insulin sensitivity, and decreases gluconeogenesis
• SE: GI upset, lactic acidosis, and B12 deficiency
• max dose 1000mg daily if CrCl <45
• contraindicated in CrCl <30, hold in AKI

Question 7

sulfonylureas (glipizide)

Answer 7

• cleared hepatically
• increase insulin sensitivity and release
• high failure rate over time due to decreased B cell funciton
• elderly/CKD risk of HYPOGLYCEMIA esp w/ metformin

SE: wt gain, caution in liver and renal disease, contraindicated in sulfa allergy

Question 8

GLP-1 receptor agonists (exenatide, liraglutide)

Answer 8

-increase insulin secretion and delays gastric emptying

SE: wt loss, n/v, pancreatitis, adjust dose in CKD
-benefit w/ CVD

Question 9

thiazolidenediones (TZDs like pioglitazone)

Answer 9

-increase insulin sensitivity

SE: weight gain, CHF exacerbation and fluid retention, fractures, hepatotoxicity, monitor LFTs

Question 10

a-glucosidase inhibitor (acarbose)

Answer 10

-inhibit GI tract CHO metabolism

SE: GI upset

Question 11

Meglitinides (repaglinide, nateglinide)

Answer 11

• increase B cell secretion
• like sulfonylureas but shorter action

SE: weight gain, hypoglycemia

Question 12

DPP-4 inhibitor (stigaliptin)

Answer 12

-blocks activation of incretins

SE: dose adjust in CKD, weight neutral, associated w/ pancreatitis

Question 13

SGLT2 inhibitors

Answer 13

-blocks renal glucose absorption, increase glucosuria

weight loss, decrase BP, decrased CVD risk

SE: increase GU infections, polyuria, volume depletion, normoglycemic DKA

Question 14

Insulin indication

Answer 14

• Pts w/ T2DM with A1c >10%

- on 3 meds with A1c > goal on 2 occasions, 3 months apart

Question 15

Insulin intiation

Answer 15

-start basal insuin (0.1mg/kg/d)
-increase by 2 units q3rd night until FSBG <130 (take insulin at the same time each evening)
-

Question 16

When to refer: podiatry

Answer 16

• pts who smoke
• hx lower extremity complications
• neuropathy
• structural abnormalities
• PAD

Question 17

when to refer: renal

Answer 17

• all pts with Stage IV CKD
• pt’s w/ CKDIII and progression
• urine microalbumin >300

Question 18

when to refer: opthalmology

Answer 18

• annually

- can space to q2y if >1 normal exam

Question 19

when to refer: endocrinology

Answer 19

• if pt requiring >80u basal insulin w/o adequate control of FBG
• frequent episodes of hypoglycemia

Question 20

when to refer: surgery

Answer 20

• BMI >40 (37.5 in asians)

- or BMI 35-39 in uncontrolled diabetic

Question 21

hypoglycemia etiologies

Answer 21

• insulin dosing
• exercise
• drug interactions?
• alcohol use
• renal clearance of insulin