Diabetes Overview and Case Take-Home Points

Question 1

What is the USPSTF screening guidelines for diabetes?

Answer 1

screen all adults 40-70 who are overweight or obese every three years (Grade B)

Question 2

What are some other groups of patients the ADA recommends screening for diabetes?

Answer 2

anyone over 45

yougner than 45 if:
- BMI over 25 with other risk factors: physical inactivity, fam hx, high-risk ethnicity, women with big babies or hx of GDM, HTN, low HDL, high TGs, hx of PCOS, acanthosis nigricans, hx of CVD

Question 3

You can give a diagnosis of diabets for a fasting plasma glucose over what?

Answer 3

126 mg/dL

Question 4

How about after a 2 hr oral GTT?

Answer 4

200 mg/dL

Question 5

What is the A1c cutoff for diabetes diagnosis?

Answer 5

6.5%

Question 6

If someone has a random plasma glucose over 200 mg/dL, what else do they need to get the diagnosis?

Answer 6

syptoms of hyperglycemia or hyperglycemic crisis

Question 7

What are some confounders that will make an A1c appear falsely low?

Answer 7

acute/chronic blood loss
hemolysis
renal failure
sickle cell anemia
thalassemia's
hereditary spherocytosis

Question 8

What are some confounders that will make an A1c falsely high?

Answer 8

(slow blood turnover)

iron deficiency anemia
B12 def.
Folate def.
Splenectomy

Question 9

What is the general conversion from A1c to average blood glucose?

Answer 9

A1c of 5 = average glucose of 97 (normal)

then every 1% of A1c you go up, add about 30 to the average glucose

Question 10

What is the main symptom of hypoblycemia?

Answer 10

altered consciousness

Question 11

What are the symptoms of hyperglycemia?

Answer 11

poor wound healing
fatigue
vascular damage
blurred vision
polyuria, polydipsia, polyphagia, weight loss, dry mouth

eventually altered consciousness or coma

Question 12

What is the accuracy range for glucometers?

Answer 12

about 15% for most

Question 13

How often should someone with diabetes have a foot exam?

Answer 13

annually

unless they already have neuropathy, in which case every visit

Question 14

How often should a patient with diabetes have a retinal exam?

Answer 14

annually

Question 15

What labwork should you check with the initial diagnosis of diabetes?

Answer 15

creatinine/eGFR

urinary microalbumin-creatinine ratio

liver function

A1c

Fasting lipids

TSH

Question 16

How often should you check A1c

Answer 16

every 3 months if not controlled, every 6 months if controlled

Question 17

What labs should you check yearly in a patient with diabetes?

Answer 17

creatinine/eGFR

urinary microalbumin-creatinine ratio

Lipid profile

Question 18

Which oral medication is the only that has been proven to decrease mortality and complications in RCTs?

Answer 18

metformin

Question 19

What are the 4 contraindications for metformin?

Answer 19

renal dysfunction (creatinine over 1.5 men or 1.4 women)

impaired hepatic function

possible CHF

Acute or chronic metabolic acidosis

Question 20

How much will metformin typically reduce an A1c?

Answer 20

0.5-1.0%

Question 21

What should you do if A1c target is not met within 3 months of metformin therapy?

Answer 21

1. determine cause
2. ensure compliance
3. titrate metformin up
4. consider adding another agent

Question 22

What is the typical A1c goal?

Answer 22

7.5%, but that varies depending on age

Question 23

What is the most common side effect of metformin? The scary one everyone worries about?

Answer 23

diarrhea

lactic acidosis

Question 24

Side note: I’m not going to make cards for all the other orals meds because I really don’t want to

Answer 24

sorry

Question 25

When should you consider initiating insulin therapy (with or without oral agents) in patients with NEWLY diagnosed DM2?

Answer 25

if they have markedly symptomatic or elevated blood glucose levels or A1c over 9%

Question 26

What oral medications can be continued with insulin and which ones should you consider stopping?

Answer 26

continue metformin, GLP-1 agonists to help control weight loss.

stop sulfonylureas, DPP-4 inhibitors and SGLT2 inhibitors

Question 27

What is the time of onset for the rapid acting insulins (lispro, aspart, inhaled)?

Answer 27

0-30 min

Question 28

What is the onset for short-acting insulin (human regular)?

Answer 28

0.5 to 1 hr

Question 29

What is the osnet for intermediate-acting insulin (human NPH)?

Answer 29

0.5-4 hrs

Question 30

What are the options for basal insulin?

Answer 30

glargine (lantus)
Determir (levemir)
Degludec

Question 31

When adjusting insulin according to target values, what value do you try to fix first?

Answer 31

the fasting

Question 32

What’s usually a good basal insulin dose to start with?

Answer 32

10U/day

or

0.1-0.2 U/kg/day

Question 33

If they are still not controlled after the fasting blood glucose target is reached, what are your options?

Answer 33

1. you can add a rapid insulin injection before the largest meal
2. You can add rapid acting insulin before all meals
3. You can change to premixed insulin twice daily

Question 34

What percentage of patients with diabetes will go on to have diabetic kidney disease?

Answer 34

20-30%

Question 35

What is the leading cause of morbidity and mortality for peopel wtih diabetics?

Answer 35

cardiovascular disease

Question 36

At what age should all diabetics be started on at least a moderate-intensity statin?

Answer 36

40

Question 37

True or false: all diabetics should also be started on a daily aspirin.

Answer 37

false

not recommended for diabetic patients with a 10yr risk less than 5%

Question 38

How do you make the diagnosis of gestational diabetes?

Answer 38

100-g OGTT

Fasting over 95
1 hr over 180
2 hr over 155
3 hr over 140

(but criteria differ between groups, so probably won’t ask a question)