Diabetes Mellitus

Question 1

Different criteria for diagnosis of DM (name 4)

Answer 1

1. Fasting glucose greater than 126
2. Plasma glucose greater than 200 after 2 hour GTT (75 g glucose load)
3. Any plasma glucose over 200 + symptoms (polydipsia, polyuria, etc)
4. HbA1c 6.5% or more

Question 2

What can you measure to differentiate between T1DM and T2DM

Answer 2

C-peptide and insulin levels

Question 3

When does glucosuria occur?

Answer 3

When bood glucose level is greater than renal “threshold”; often at serum level of 180 which corresponds to HbA1c of 8%

So absence of glucose on urinalysis does not exclude DM!

Question 4

What other physical symptoms are more consistent with T2DM

Answer 4

HTN, acanthosis nigracans, obesity…all overt signs of insulin resistance

Question 5

Upon initial dx of DM, and regulary after dx, what testing?

Answer 5

fasting lipid profile, serum creatinine and creatinine ratio, U/A, urinemicroalbumin, annual dilated eye exams, regular foot exam, ECG and thyroid dx screening with TSH (in T1DM)

Question 6

General approach to treatment of DM

Answer 6

aimed at secondary prevention of macrovascular (CAD, cerebral/peripheral vascular dx) and microvascular (retinopathy, nephropathy, and neuropathy) complications

Question 7

Pathophysiology of T1DM (aka IDDM)

Answer 7

not entirely known, may be autoimmune that attacks pancreatic B cells, thereby rendering body unable to produce insulin…body is then unable to metabolize glucose and carbs, so must resort to metabolizing fats…leading to ketones

Question 8

DKA

Answer 8

syndrome characterized by hyperglycemia, high levels of serum acetone, b-hydroxybutarate, and anion gap metabolic acidosis

usually happens under stress or when person forgets to take insulin

Question 9

Treatment of DKA

Answer 9

emergent hospitalization for IV hydration with NS, correction of acidosis and electrolyte disturbances (give K), aggessive insulin mgmt, evaluation for underlying cause

Question 10

Pathophysiology T2DM (NIDDM)

Answer 10

insulin resistance in peripheral tissues often due to visceral adiposity and obesity…may have hyperinsulinemia then eventually less insulin
majority of cases, stronger family component

Question 11

Comlications of T2DM

Answer 11

cardiometabolic syndrome, hyperinsulinemia, HTN, dyslipidemia, hyperglycemia, central obesity

Question 12

T2DM less prone to developing ketosis and acidosis, but is more prone to ________ states due to high blood sugar

Answer 12

hyperosmolar

aka hyperosmolar hyperglycemic non-ketotic syndrome (HHNS)

Question 13

Characteristics of HHNS

Answer 13

blood glucose substantially elevated (often reaching up to 1000), with elevated serum osmolarity and large fluid deficit…severe coma or death may occur due to electrolyte abnormalities, dehydration, and toxic effects of metabolic acidosis

Question 14

How to treat HHNS

Answer 14

similar to DKA;

hospitalization, aggresive rehydration, with NS and electrolyte correction; insulin and treatment of underlying disorder

Question 15

GDM (gestational DM)

Answer 15

increased levels of human placental lactogen (hpL), estrogen and progesterone produced by placenta antagonize insulin -> insulin resistance and carb intolerance

Question 16

Maternal complications of GDM

Answer 16

hyperglycemia, DKA, increased UTI, increased HTN/pre-eclampsia, retinopathy

Question 17

Fetal complications of GDM

Answer 17

congenital malformations, macrosomia, RDS, hypoglycemia, hyperbilirubinemia, hpocalcemia, polycythemia, and hydramnios

Question 18

What are mothers who have GDM more at risk of after pregnancy and how to mitigate this risk

Answer 18

T2DM, should be screened with GTT postpartum and annual diabetic screening

Question 19

When to screen for GDM and how to screen

Answer 19

between 24-28 weeks
first with 1hr 50 g GTT….
then if that shows greater than 140, do 3 hr 100g GTT, which takes fasting, 1hr, 2hr, and 3hr measurements…
if 2 or more abnormal values (95,180,155,140)…then that is diagnosis

Question 20

How to treat GDM

Answer 20

strict dietary mgmt, and if necessary oral diabetic agents with or without insulin.

Question 21

Once GDM is diagnosed, what must be monitored for during pregnancy

Answer 21

Increased surveillance for UFD (uterine fetal demise)

Question 22

Goals to achieve “controlled status” in diabetic patient

Answer 22

• strict glycemic control with goal a1c of less than 7

- LDL

Question 23

Treatment for T1DM

Answer 23

• insulin administration (usually short acting before meals + long acting basal insulin) via injection or pump (if labile sugar)
• strict glucose monitoring
• calorie restricted and low carb diet and exercise

Question 24

First line medication of T2DM

Answer 24

biguanides (METFORMIN)

Question 25

Biguanide mechanism

Answer 25

act on liver to decrease gluocse output during gluconeogenesis.

secondary: improved insulin sensitivity in liver and muscle; possible decrease in intestinal absorption of glucose

Question 26

Other advatnages of metformin

Answer 26

no risk of hypoglycemia, good for weight loss, reduced serum insulin levels, reduction in triglycerides and LDL

Question 27

Metformin side effects common and dangerous

Answer 27

common: nausea and diarrhea
dangerous: development of lactic acidosis caused by renal insufficency and CKD (contraindication in patients with Cr> 1.4-1.5)

Question 28

Is metformin safe for pregnancy?

Answer 28

Yes; Cat B, also good for children older than 10

Question 29

Examples of sulfonlyureas

Answer 29

glimepiride glyburide, glipizide

Question 30

Mechanism of sulfonylureas

Answer 30

insulin secretagogues that stimulate pancreatic B cells to secrete insulin