DM

Question 1

A 17-year-old male with a history of type 2 diabetes sees you because of fatigue and a 15-lb weight loss in the past month. The patient reports excessive and frequent urination, thirst, and nausea. His only medication has been metformin, but he states that he stopped taking it 6 months ago. His current weight in your office is 93 kg (205 lb), which confirms the reported weight loss. His blood pressure is 130/78 mm Hg, his pulse rate is 90 beats/min, and his temperature is 37.0°C (98.6°F). A physical examination is otherwise unremarkable. A capillary blood glucose level is 348 mg/dL, a hemoglobin A1c is 11.5%, serum ketones are negative, and a urinalysis shows 3+ glucosuria with concentrated urine but is otherwise normal.

Which one of the following would be the most appropriate treatment? (check one)
Resuming oral metformin
Starting oral empagliflozin (Jardiance)
Starting subcutaneous insulin
Starting subcutaneous liraglutide (Victoza)
Hospitalization for continuous intravenous insulin

Answer 1

Starting subcutaneous insulin

This patient presents with symptomatic hyperglycemia in a catabolic state. In such cases insulin therapy is the most reliable way to control hyperglycemia and reverse catabolism. Oral metformin would not be adequate to control this degree of hyperglycemia and might not be tolerated well, given that the current symptoms include nausea and weight loss. Similarly, both empagliflozin, which increases glucosuria and volume contraction, and liraglutide, which decreases gastric emptying and is likely to exacerbate nausea, are likely to be poorly tolerated in this situation. While rapid and effective treatment is essential to prevent further complications, hospitalization is not necessary since the patient has no evidence of diabetic ketoacidosis.

Question 2

A 32-year-old male presents with a 1-year history of increasing fatigue, polyuria, and a gradual 30-lb weight loss. Serum chemistries reveal a bicarbonate level of 23 mEq/L (N 22–28), a corrected anion gap of 8 mEq/L (N 3–11), and a glucose level of 658 mg/dL (N 60–110). The patient is admitted to the hospital and his serum glucose drops to 174 mg/dL after he is given 2 L of intravenous normal saline and 10 units of regular insulin subcutaneously. He is observed overnight and further laboratory testing is done the next morning.

Which one of the following is more consistent with type 2 diabetes mellitus than with type 1 diabetes mellitus? (check one)
The patient’s history of weight loss
The patient’s response to the initial dose of insulin
The time course of symptom onset
Morning laboratory studies showing a C-peptide level of <1.1 ng/mL (N 1.1–4.4)

Answer 2

The time course of symptom onset

This patient presents with marked hyperglycemia but no evidence of ketoacidosis or nonketotic coma. Differentiating between type 1 and type 2 diabetes mellitus is important for guiding therapy. The gradual onset of symptoms is more consistent with type 2 diabetes mellitus, whereas type 1 diabetes typically has a more rapid onset. Patients with type 1 diabetes typically need lower doses of insulin to correct hyperglycemia, as they lack the insulin insensitivity that is the hallmark of type 2 diabetes. Positive anti-GAD antibodies and low C-peptide at the time of the initial diagnosis are also consistent with type 1 diabetes, although C-peptide levels can also be low in long-standing type 2 diabetes. Weight loss occurs in both types of diabetes mellitus when glucose is profoundly elevated.

Question 3

Which one of the following is most likely to cause hypoglycemia in elderly patients? (check one)
Metformin (Glucophage)
Pioglitazone (Actos)
Glipizide (Glucotrol)
Sitagliptin (Januvia)
Glyburide (DiaBeta)

Answer 3

Glyburide (DiaBeta)

The sulfonylureas are the oral hypoglycemic agents most likely to cause hypoglycemia, with glyburide more likely to cause low glucose levels than glipizide, due to its longer half-life. The use of these agents should be rare in elderly patients with diabetes mellitus.

Question 4

You see a 26-year-old male who was diagnosed with maturity-onset diabetes of the young at age 22. He has a BMI of 24 kg/m2 and his hemoglobin A1c is now 8.5%.

Which one of the following would be most appropriate for this patient? (check one)
A ketogenic diet
Glipizide (Glucotrol)
Metformin
Short-acting sliding scale insulin with meals
Basal insulin at bedtime

Answer 4

Glipizide (Glucotrol)

Maturity-onset diabetes of the young (MODY) is a form of diabetes mellitus in nonobese young adults (under age 30) who have preserved pancreatic β-cell function. Nearly 80% of patients with MODY are misdiagnosed as having type 1 or type 2 diabetes. These patients exhibit no signs of insulin resistance (metabolic syndrome, acanthosis nigricans, skin tags, androgenic alopecia), are not obese, have positive C-peptide levels, and have a strong family history of diabetes. MODY does not respond to metformin, but because β-cell function is preserved, the hyperglycemia does respond to sulfonylureas. While exercise and a balanced diet of appropriate portions and low carbohydrates are also necessary in patients with MODY, a ketogenic diet is not specifically indicated. Insulin is required only during pregnancy

Question 5

A 48-year-old female sees you for routine follow-up. She was diagnosed with type 2 diabetes mellitus 2 years ago and has been treated with metformin (Glucophage), 850 mg orally 3 times daily, and glipizide (Glucotrol XL), 20 mg orally daily, along with diet and exercise. Her other medical problems include hypertension and obesity. She has no known cardiovascular disease or microvascular complications. She came in for laboratory testing yesterday, and her hemoglobin A1c is 8.0% (N <5.7%).

Which one of the following medications would help with both glycemic control and weight loss for this patient? (check one)
Exenatide (Byetta)
Pioglitazone (Actos)
Sitagliptin (Januvia)
Insulin

Answer 5

Exenatide (Byetta)

Given the information about this patient, such as her relatively recent diagnosis, her age, and her lack of macro-or microvascular complications, a more strict hemoglobin A1c goal is indicated. There are several oral and injectable medicines that are reasonable choices in this case. Exenatide is an injectable GLP-1 agonist that is associated with weight loss. Pioglitazone is also effective but is associated with fluid retention rather than weight loss. Sitagliptin is a dipeptidyl peptidase IV (DPP-IV) inhibitor that may be a reasonable option in this case, but is not associated with weight loss. Insulin, either basal only, mixed, or basal-bolus regimens, may also be the best option for the patient described, but it does cause weight gain. Cost is another major consideration in treatment decisions, but more information would be needed to address this issue.

Question 6

A 56-year-old female comes to your office for an acute visit because she has had increased urinary frequency, thirst, and fatigue over the past month. Her medical history includes hypertension and type 2 diabetes with microalbuminuria, and her current medications are extended-release metformin, 1500 mg daily; losartan (Cozaar), 50 mg daily; and rosuvastatin (Crestor), 10 mg daily. Her current BMI is 36 kg/m2, and you note that she has lost 5 kg (11 lb) since her last visit 4 months ago. A point-of-care hemoglobin A1c is 12%.

Which one of the following would be the most appropriate pharmacotherapy to add at this time? (check one)
Basal insulin
A DPP-4 inhibitor
A GLP-1 receptor agonist
An SGLT2 inhibitor
A thiazolidinedione

Answer 6

Basal insulin

This patient presents with symptomatic hyperglycemia associated with uncontrolled type 2 diabetes. She is in a catabolic state, experiencing symptoms, and has a hemoglobin A1c ³10%. According to the American Diabetes Association (ADA) Standards of Care in Diabetes, early initiation of insulin is recommended. Once the acute glucose toxicity has resolved with insulin treatment, this patient could be switched to a noninsulin agent. With her comorbid hypertension, albuminuria, and obesity, a GLP-1 receptor agonist or an SGLT2 inhibitor with proven cardiovascular and renal benefits would be the next best choices. DPP-4 inhibitors have intermediate efficacy for lowering glucose with neutral cardiovascular and heart failure benefit and a neutral effect on weight and progression of chronic kidney disease. Thiazolidinediones have high efficacy for lowering glucose but are associated with weight gain and increased risk of heart failure.

Question 7

Which one of the following classes of diabetes medications increases the risk of genitourinary
infections by blocking glucose reabsorption by the kidneys?

(check one)
SGLT2 inhibitors such as canagliflozin (Invokana)
GLP-1 receptor agonists such as exenatide (Byetta)
DPP-4 inhibitors such as sitagliptin (Januvia)
Prednisone, 2–3 mg/kg daily
Meglitinides such as repaglinide (Prandin)

Answer 7

SGLT2 inhibitors such as canagliflozin (Invokana)

SGLT2 inhibitors inhibit SGLT2 in the proximal nephron. This blocks glucose reabsorption by the kidney,
increasing glucosuria. The advantages of this medication include no hypoglycemia, decreased weight,
decreased blood pressure, and effectiveness at all stages of type 2 diabetes mellitus. Disadvantages are that
it increases the risk of genitourinary infections, polyuria, and volume depletion and increases
LDL-cholesterol and creatinine levels. GLP-1 receptor agonists work by activating the GLP-1 receptors,
causing an increase in insulin secretion, a decrease in glucagon secretion, slowing of gastric emptying, and
increasing satiety. DPP-4 inhibitors inhibit DPP-4 activity, which increases postprandial active incretin
concentration. This increases insulin secretion and decreases glucagon secretion. Meglitinides act by
closing the ATP-sensitive K+ channels on the B-cell plasma membranes, which increases insulin secretion.
“-Glucosidase inhibitors inhibit intestinal “-glucosidase, which slows intestinal carbohydrate digestion and
absorption.

Question 8

A 49-year-old uninsured female with diabetes mellitus presents with painful burning of her feet, particularly at night. She has tried ibuprofen and acetaminophen without relief. Her last hemoglobin A1c was 7.1%. Her medications include metformin (Glucophage), glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and lovastatin (Mevacor).

Which one of the following would be the best choice to treat her foot pain? (check one)
Amitriptyline
Topiramate (Topamax)
Fluoxetine (Prozac)
Lamotrigine (Lamictal)

Answer 8

Amitriptyline

First-line treatment for diabetic peripheral neuropathy, according to the American Diabetes Association, is tricyclic antidepressants. Anticonvulsants are second line and opioids are third line. Many medications have been found to be effective, including the tricyclics, duloxetine, pregabalin, oxycodone, and tramadol (SOR A).
Among the tricyclics, amitriptyline, imipramine, and nortriptyline have been found to be the most effective (SOR A). For an uninsured patient, the tricyclics are also the most affordable.

Question 9

A 55-year-old male with a 4-year history of type 2 diabetes mellitus was noted to have microalbuminuria 6 months ago, and returns for a follow-up visit. He has been on an ACE inhibitor and his blood pressure is 140/90 mm Hg.
The addition of which one of the following medications would INCREASE the likelihood that dialysis would become necessary?
(check one)
Hydrochlorothiazide
Amlodipine (Norvasc)
Atenolol (Tenormin)
Clonidine (Catapres)
Losartan (Cozaar)

Answer 9

Losartan (Cozaar)

Patients with diabetes mellitus, atherosclerosis, and end-organ damage benefit from ACE inhibitors and angiotensin receptor blockers (ARBs) equally when they are used to prevent progression of diabetic nephropathy. Combining an ACE inhibitor with an ARB is not recommended, as it provides no additional benefit and leads to higher creatinine levels, along with an increased likelihood that dialysis will become necessary.

Question 10

A 75-year-old female with a 10-year history of type 2 diabetes mellitus presents with moderate bilateral burning pain in the distal portion of her feet. Her hemoglobin A1c is 8.1%.

Which one of the following is recommended as first-line therapy for improvement of this patient’s pain? (check one)
Amitriptyline
Ibuprofen
Pregabalin (Lyrica)
Tramadol (Ultram)

Answer 10

Pregabalin (Lyrica)

This patient’s condition is consistent with distal symmetric polyneuropathy (DSPN). It may be present in up to 10%–15% of newly diagnosed patients with type 2 diabetes mellitus and in up to 50% of patients within 10 years of diagnosis. Pregabalin or duloxetine is recommended as the initial approach in the symptomatic treatment of neuropathic pain in diabetes (SOR A). There is no significant evidence supporting glycemic control or lifestyle interventions as effective treatment for the condition. Narcotics, including tramadol, are not first- or second-line choices, and although tricyclic antidepressants such as amitriptyline are effective, they present a higher risk for serious side effects, especially in the elderly. There are no recommendations for the use of NSAIDs.

Question 11

Which one of the following is most likely to cause hypoglycemia in elderly patients?

(check one)
Metformin (Glucophage)
Pioglitazone (Actos)
Glipizide (Glucotrol)
Sitagliptin (Januvia)
Glyburide (DiaBeta)

Answer 11

Glyburide (DiaBeta)

Among the oral antiglycemic drugs, the sulfonylurea agents are the most likely to cause hypoglycemia, and glyburide is more likely to cause hypoglycemia than glipizide. Glyburide should rarely be used in the elderly.

Question 12

A 56-year-old female with type 2 diabetes is hospitalized with acute epigastric pain, nausea, and vomiting. She reports that several of her diabetes medications were recently changed. Findings on physical examination and laboratory studies are consistent with acute pancreatitis.

Which one of the following classes of medications is the most likely cause? (check one)
Biguanides
GLP-1 receptor agonists
Insulin
SGLT2 inhibitors

Answer 12

GLP-1 receptor agonists

GLP-1 receptor agonists should be discontinued in patients suspected to have pancreatitis. Additionally, therapy with GLP-1 receptor agonists should not be restarted once the pancreatitis has resolved. Although pancreatitis has been reported in clinical trials, the causality between GLP-1 receptor agonists and pancreatitis has not been established. Other medication classes such as DPP-4 inhibitors can also cause pancreatitis. Biguanides, insulin, and SGLT2 inhibitors do not cause pancreatitis (SOR C).

Question 13

A 34-year-old gravida 2 para 2 presents for a postpartum examination 6 weeks after an uncomplicated vaginal delivery. Both the mother and infant are doing well. Her only complication during the pregnancy was an abnormal 3-hour glucose tolerance test. She managed her blood glucose with a combination of diet and exercise and delivered at 39 weeks gestation. The patient’s vital signs and a physical examination are normal today. | Which one of the following should you recommend for this patient based on her history of gestational diabetes? (check one)
No glucose testing today, and initiation of metformin to prevent diabetes
No glucose testing today, and annual screening with a fasting plasma glucose level starting 1 year after delivery
No further glucose testing unless she becomes pregnant again
A 2-hour plasma glucose level using a 75-g oral glucose load

Answer 13

A 2-hour plasma glucose level using a 75-g oral glucose load

A 2-hour, 75-g glucose tolerance test should be performed at 4–12 weeks post partum following a pregnancy in which gestational diabetes was diagnosed. This will identify patients who have developed diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance. Women who have a history of gestational diabetes have a sevenfold increased risk of developing type 2 diabetes compared to women without a history of gestational diabetes. | This patient should not begin taking metformin because she may not be a candidate for treatment. Testing is required to make the diagnosis of diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance. | If a patient who was diagnosed with gestational diabetes tests negative for diabetes mellitus on postpartum screening, fasting glucose levels should still be assessed every 1–3 years regardless of pregnancy status. With the next pregnancy the patient should have early screening with a 1-hour glucose tolerance test at the time the pregnancy is confirmed.

Question 14

Which one of the following is the major mechanism of action of metformin (Glucophage)? (check one)
Stimulation of pancreatic insulin release
Inhibition of glucose production by the liver
Inhibition of carbohydrate absorption in the small intestine
Improved insulin sensitivity of skeletal muscle

Answer 14

Inhibition of glucose production by the liver

Metformin has multiple mechanisms of action, but its main effect on serum glucose results from inhibition of gluconeogenesis in the liver. Sulfonylureas and meglitinides stimulate insulin release from the pancreas, and thiazolidinediones sensitize peripheral tissues to insulin. Carbohydrate absorption in the small intestine is inhibited by the “-glucosidase inhibitors.

Question 15

A 52-year-old male with diabetes mellitus reports that he ran out of insulin a week ago. He is
drowsy but responds to your verbal commands, and the remainder of his examination is
unremarkable.
Laboratory Findings
Blood glucose. . . . . . . . . . . . . . . . . . . . . . . . . 625 mg/dL
Serum sodium. . . . . . . . . . . . . . . . . . . . . . . . . 128 mEq/L (N 135–145)
Serum potassium. . . . . . . . . . . . . . . . . . . . . . . 5.9 mEq/L (N 3.5–5.0)
Serum bicarbonate. . . . . . . . . . . . . . . . . . . . . . 12 mEq/L (N 22–26)
BUN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 mg/dL (N 8–25)
Which one of the laboratory abnormalities is an indication that he has severe diabetic
ketoacidosis?
(check one)
Glucose
Sodium
Potassium
Bicarbonate
BUN

Answer 15

Bicarbonate

The diagnosis of diabetic ketoacidosis (DKA) is based on an elevated serum glucose level (>250 mg/dL),
an elevated serum ketone level, a pH <7.3, and a serum bicarbonate level <18 mEq/L. The severity of
DKA is determined by the arterial pH, bicarbonate level, anion gap, and mental status of the patient.
Elevation of BUN and serum creatinine levels reflects intravascular volume loss. The measured serum
sodium is reduced as a result of the hyperglycemia, as serum sodium is reduced by 1.6 mEq/L for each
100 mg/dL rise in serum glucose. The degree of hyperglycemia does not necessarily correlate closely with
the degree of DKA since a variety of factors determine the level of hyperglycemia, such as oral intake and
urinary glucose loss (SOR C).

Question 16

A 63-year-old retired banker presents for follow-up of diabetes mellitus. He has an 8-year history of diabetes and started metformin 7 years ago. His hemoglobin A1c gradually worsened and glipizide (Glucotrol) was added 6 months ago. Since starting this medication he has had episodes of symptomatic hypoglycemia twice per week. His weight has been increasing and his current BMI is 29 kg/m2. At the office visit today his hemoglobin A1c is 7.7%. He tells you that his uncle with diabetes recently died from heart disease.

You discuss discontinuing glipizide since it is causing hypoglycemic episodes. He wants to remain on oral medications and does not want to start any medications that will make it harder to lose weight.

Given his priorities, which one of the following would be the most appropriate recommendation for this patient? (check one)
No additional medications
Glyburide
Insulin glargine (Lantus)
Semaglutide (Rybelsus)
Sitagliptin (Januvia)

Answer 16

Semaglutide (Rybelsus)

Combination treatment has been shown to be more effective than metformin alone in terms of lowering hemoglobin A1c, controlling weight, and improving blood pressure control. This otherwise healthy patient should be able to tolerate a hemoglobin A1c <7% and therefore remains above goal, so consideration of an additional medication is reasonable. It is important to consider the patient’s goals when determining which medication to add. Of the options listed, semaglutide has been shown to produce a reduction in cardiovascular mortality and weight and is preferred over sulfonylureas such as glyburide and DPP-4 inhibitors such as sitagliptin. The potentially high cost of semaglutide would need to be discussed with the patient. Insulin is always a reasonable option but would not meet the patient’s stated priorities.

Question 17

A 43-year-old male complains of difficulty washing his face and combing his hair with his right hand. On examination a nodule, band, and slight contracture are noted in the palm proximal to the fourth finger. This patient’s symptoms are associated with which one of the following? (check one)
Hyperparathyroidism
Diabetes mellitus
Hyperthyroidism
Hypothyroidism
Adrenal insufficiency

Answer 17

Diabetes mellitus

The patient has Dupuytren’s disease, which is most common in men over 40 years of age. It is a progressive condition that causes the fibrous fascia of the palmar surface to shorten and thicken. It initially can be managed with observation, but corticosteroid injection and surgery may be needed. The condition will regress in 10% of patients. There is a 3%-33% prevalence of Dupuytren’s contracture in patients with diabetes mellitus; however, these patients tend to have a mild form of the disease with slow progression.

Question 18

A 34-year-old gravida 2 para 2 presents for a postpartum examination 6 weeks after an uncomplicated vaginal delivery. Both the mother and infant are doing well. Her only complication during the pregnancy was an abnormal 3-hour glucose tolerance test. She managed her blood glucose with a combination of diet and exercise and delivered at 39 weeks gestation. The patient’s vital signs and a physical examination are normal today.

Which one of the following should you recommend for this patient based on her history of gestational diabetes? (check one)
No glucose testing today, and initiation of metformin to prevent diabetes
No glucose testing today, and annual screening with a fasting plasma glucose level starting 1 year after delivery
No further glucose testing unless she becomes pregnant again
A 2-hour plasma glucose level using a 75-g oral glucose load

Answer 18

A 2-hour plasma glucose level using a 75-g oral glucose load

A 2-hour, 75-g glucose tolerance test should be performed at 4–12 weeks post partum following a pregnancy in which gestational diabetes was diagnosed. This will identify patients who have developed diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance. Women who have a history of gestational diabetes have a sevenfold increased risk of developing type 2 diabetes compared to women without a history of gestational diabetes.

This patient should not begin taking metformin because she may not be a candidate for treatment. Testing is required to make the diagnosis of diabetes mellitus, impaired fasting glucose, or impaired glucose tolerance.

If a patient who was diagnosed with gestational diabetes tests negative for diabetes mellitus on postpartum screening, fasting glucose levels should still be assessed every 1–3 years regardless of pregnancy status. With the next pregnancy the patient should have early screening with a 1-hour glucose tolerance test at the time the pregnancy is confirmed.

Question 19

Which one of the following interventions has been shown to increase retinal screening rates in patients with diabetes mellitus? (check one)
One minute of counseling about the importance of retinal screening at each primary care visit
Digital reminders sent monthly to patients’ cell phones until they complete their retinal screenings
Conducting an office-wide prize drawing for patients who complete retinal screenings
Asynchronous teleretinal screening performed at the primary care provider’s office
Sharing office/clinic space with an ophthalmologist

Answer 19

Asynchronous teleretinal screening performed at the primary care provider’s office

Telemedicine can be helpful in the management of many chronic conditions, including diabetes mellitus. Medicare and most private insurers pay for telemedicine visits at the same rate as in-person visits. Teleretinal screening performed at the primary care provider’s office should be considered in patients with diabetes as a cost-effective option for improving retinopathy screening rates (SOR B). Eyecare specialists can remotely evaluate the retinal photos for timely completion of annual retinopathy screening. Counseling about the importance of retinal screening, digital reminders, office-wide prize drawings, and sharing office space with an ophthalmologist have not been proven to be effective in increasing retinal screening rates in patients with diabetes.

Question 20

A 35-year-old white male who has had diabetes mellitus for 20 years begins having episodes of hypoglycemia. He was previously stable and well controlled and has not recently changed his diet or insulin regimen.
Which one of the following is the most likely cause of the hypoglycemia?
(check one)
Spontaneous improvement of β-cell function
Renal disease
Reduced physical activity
Insulin antibodies

Answer 20

Renal disease

The most common cause of hypoglycemia in a previously stable, well-controlled diabetic patient who has not changed his or her diet or insulin dosage is diabetic renal disease. A reduction in physical activity or the appearance of insulin antibodies (unlikely after 20 years of therapy) would increase insulin requirements and produce hyperglycemia. Spontaneous improvement β -cell function after 20 years would be very rare.

Question 21

In patients with type 2 diabetes, medications from which one of the following classes have been shown to reduce the progression of chronic kidney disease? (check one)
Biguanides
DPP-4 inhibitors
SGLT2 inhibitors
Thiazolidinediones

Answer 21

SGLT2 inhibitors

SGLT2 inhibitors are recommended for people with stage 3 or higher chronic kidney disease (CKD) and type 2 diabetes, as they slow CKD progression, reduce cardiovascular events, and reduce heart failure risk independent of glucose management. GLP-1 receptor agonists reduce the risk of cardiovascular disease events and hypoglycemia and appear to slow CKD progression. Biguanides (e.g., metformin), DPP-4 inhibitors, and thiazolidinediones have not been shown to reduce the progression of CKD in patients with type 2 diabetes (SOR B).

Question 22

According to the American Diabetes Association, which one of the following hemoglobin A1c measurements fits the criteria for prediabetes? (check one)
5%
5.50%
6%
6.50%

Answer 22

6%

Classifying prediabetes is important because it identifies a population at increased risk for developing type 2 diabetes in the future and provides an opportunity for prevention. According to the American Diabetes Association, a hemoglobin A1c of 5.7%–6.4% fits the criteria for prediabetes. Patients whose hemoglobin A1c falls into this range should attempt diabetes prevention including lifestyle changes, medication, cardiovascular risk prevention, and monitoring.

Question 23

A 57-year-old female is admitted to the hospital with lower lobe pneumonia. She has no history of diabetes mellitus. She has not met sepsis criteria but had a blood glucose level of 172 mg/dL in the emergency department.

Insulin should be started if this patient has a persistent blood glucose level greater than or equal to (check one)
120 mg/dL
140 mg/dL
160 mg/dL
180 mg/dL

Answer 23

180 mg/dL

Insulin therapy should be initiated in hospitalized patients with persistent hyperglycemia, starting at a threshold of 180 mg/dL. Once insulin therapy is started, a target glucose range of 140–180 mg/dL is recommended for the majority of hospitalized patients, regardless of whether they have a critical illness.

Question 24

A 55-year-old female with type 2 diabetes, obesity, and hypertension presents for routine follow-up. Despite her best efforts with diet and exercise, she has been unable to achieve a healthy BMI. Her current medications include metformin, lisinopril (Zestril), and atorvastatin (Lipitor). A physical examination is remarkable only for a BMI of 32 kg/m2. A hemoglobin A1c is 7.5%, which is unchanged from 3 months ago. A basic metabolic panel shows normal electrolytes and renal function.

Which one of the following additional medications would be most likely to improve her glucose control and help her achieve weight loss? (check one)
Glipizide (Glucotrol)
Insulin glargine (Lantus)
Liraglutide (Victoza)
Nateglinide (Starlix)

Answer 24

Liraglutide (Victoza)

While each of the listed medications has evidence of benefit for improving glycemic control, only the GLP-1 agonist liraglutide would be expected to cause weight loss. SGLT2 inhibitors are also associated with weight loss. Sulfonylureas such as glipizide, insulins such as glargine, and meglitinides such as nateglinide all increase the risk of weight gain. DPP-4 inhibitors such as sitagliptin are weight neutral.

Question 25

A 38-year-old female presents for ongoing management of type 2 diabetes mellitus, obesity, and chronic abdominal pain related to her history of recurrent pancreatitis. She says that her self-monitored blood glucose has been running in the range of 200–300 mg/dL on most occasions. She is not currently taking any medications but has tried metformin (Glucophage) and extended-release metformin (Glucophage XR) unsuccessfully in the past. On both occasions she experienced worsening abdominal pain and diarrhea. She does not feel she can manage insulin and requests an oral medication. Her hemoglobin A1c in your office today is 9.0%.

In addition to lifestyle and nutrition counseling, which one of the following would be the best treatment at this time? (check one)
Restart metformin
Start empagliflozin (Jardiance)
Start liraglutide (Victoza)
Start sitagliptin (Januvia)

Answer 25

Start empagliflozin (Jardiance)

Metformin should be used as first-line therapy in type 2 diabetes to reduce microvascular complications, assist in weight management, reduce the risk of cardiovascular events, and reduce the risk of mortality in patients (SOR A). Patients who are intolerant of metformin are unlikely to be successful with a third trial of that agent. Empagliflozin, an SGLT2 inhibitor, is considered a second-line choice for patients who are intolerant of metformin. Both sitagliptin, a DPP-4 inhibitor, and liraglutide, a GLP-1 receptor agonist, should be avoided or used with caution in patients with a history of pancreatitis.

Question 26

Which one of the following comorbidities would falsely lower the hemoglobin A1c level in a patient with type 2 diabetes mellitus? (check one)
Vitamin B12 deficiency
Iron deficiency anemia
Hemolytic anemia
Chronic kidney disease
A history of splenectomy

Answer 26

Hemolytic anemia

Several factors can alter the hemoglobin A1c value, including variability and erythrocyte lifespan. When the mean erythrocyte lifespan is increased by a condition such as asplenia, hemoglobin A1c increases because of increased RBC exposure time for glycation. Conversely, when the mean erythrocyte lifespan is decreased by conditions such as hemolytic anemia, hemoglobin A1c is decreased because of reduced RBC exposure time for glycation. Conditions that decrease erythropoiesis, such as iron deficiency anemia, increase the mean age of the RBC, thereby increasing hemoglobin A1c. Severe chronic kidney disease may increase RBC glycation through lipid peroxidase of hemoglobin and by extending the erythrocyte lifespan due to decreased erythropoietin levels, causing a false elevation of hemoglobin A1c. Vitamin B12 deficiency also decreases erythropoiesis and leads to falsely elevated hemoglobin A1c.

Question 27

A 48-year-old female with type 2 diabetes mellitus has been unable to achieve optimal glycemic control with lifestyle modifications alone. You recommend that she start medication.

Which one of the following medications is generally recommended as the first-line medication for initiating treatment for type 2 diabetes mellitus? (check one)
Alogliptin (Nesina)
Empagliflozin (Jardiance)
Glipizide (Glucotrol)
Metformin (Glucophage)
Pioglitazone (Actos)

Answer 27

Metformin (Glucophage)

Metformin should be the first medication prescribed for diabetes mellitus when an oral agent is required (SOR A). Metformin can efficiently lower glycemic levels and is linked to weight loss and fewer occurrences of hypoglycemia. It is also less expensive than most other options. If more than one agent is required, continuing metformin is recommended along with the addition of one or more of the following: a sulfonylurea such as glipizide, a thiazolidinedione such as pioglitazone, an SGLT2 inhibitor such as empagliflozin, or a DPP-4 inhibitor such as alogliptin.

Question 28

Which one of the following diabetes mellitus medications is MOST likely to cause weight gain? (check one)
Empagliflozin (Jardiance)
Glimepiride (Amaryl)
Liraglutide (Victoza)
Metformin (Glucophage)
Sitagliptin (Januvia)

Answer 28

Glimepiride (Amaryl)

Since many patients with diabetes mellitus are obese, the impact of medications on the patient’s weight is important to consider. Treatment with sulfonylureas, including glimepiride, is associated with weight gain. Empagliflozin, liraglutide, metformin, and sitagliptin are not associated with weight gain. In particular, the SGLT2 inhibitors such as empagliflozin and the GLP1 agonists such as liraglutide are associated with clinically significant weight loss.

Question 29

A 58-year-old male sees you for follow-up of diabetic gastroparesis. He has tried managing his symptoms with more frequent meals and taking in more calories in semisolid or liquid form. These approaches have been unsuccessful in controlling his symptoms and he would like to try a medication.

Which one of the following would be considered first-line pharmacotherapy for this patient? (check one)
Metoclopramide (Reglan)
Nortriptyline (Pamelor)
Omeprazole (Prilosec)
Ondansetron (Zofran)
Ranitidine (Zantac)

Answer 29

Metoclopramide (Reglan)

Diabetic gastroparesis is a delay in the emptying of food from the upper gastrointestinal tract in the absence
of a mechanical obstruction of the stomach or duodenum. Metoclopramide is the only prokinetic agent that
has been studied specifically for long-term use in gastroparesis and is considered first-line therapy (SOR
B). It is among the only FDA-approved medications for gastroparesis. Nortriptyline is a prokinetic agent
but has not been shown to be more effective than placebo for decreasing gastroparesis symptoms. Proton
pump inhibitors such as omeprazole, histamine H2-receptor antagonists such as ranitidine, and ondansetron
delay gastric emptying and should be withheld in patients with gastroparesis whenever possible.

Question 30

A 72-year-old male with type 2 diabetes mellitus sees you for routine follow-up. He takes metformin (Glucophage), 1000 mg twice daily. He is sedentary and does not adhere to his diet. His BMI is 32 kg/m2. The examination is otherwise within normal limits. His hemoglobin A1c is 9.5%.

Which one of the following is recommended by the American Diabetes Association to better control his blood glucose? (check one)
Start an intensive diet and exercise program for weight loss
Start home monitoring of blood glucose with close follow-up
Start basal insulin at 10 units/day
Stop metformin and start a sulfonylurea
Stop metformin and start a basal and bolus insulin regimen

Answer 30

Start basal insulin at 10 units/day

According to the American Diabetes Association’s 2018 guidelines for the management of diabetes, a healthy person with a reasonable life expectancy should have a hemoglobin A1c goal of <7%. Metformin is recommended as first-line therapy as long as there are no contraindications. If the hemoglobin A1c is not at the goal or is ≥9%, then adding another agent to metformin is recommended. Basal insulin at 10 units/day is an acceptable choice for additional therapy to improve blood glucose control. Diet, exercise, and home monitoring of blood glucose are recommended in addition to starting another agent for blood glucose control.

Question 31

A 39-year-old female with a BMI of 42 kg/m2 and a history of hypertension, diabetes mellitus, hyperlipidemia, obstructive sleep apnea, and hypothyroidism has been struggling to lose weight. Her medical conditions are controlled. She asks you if weight loss surgery would be better for her than continued dietary efforts.

Which one of the following is true regarding weight loss surgery? (check one)
Post-surgical dietary recommendations include consuming carbohydrates first at each meal
Post-surgical dietary recommendations include drinking fluid with each meal
Diabetes remission occurs in the majority of patients 2 years after a Roux-en-Y procedure
Surgical treatment for obesity is equivalent to nonsurgical interventions in overall length of survival
Surgical treatment for obesity leads to a lifelong need for quarterly laboratory studies to check for nutritional deficiencies

Answer 31

Diabetes remission occurs in the majority of patients 2 years after a Roux-en-Y procedure

Surgical treatment for obesity results in remission of diabetes mellitus in 60%–80% of patients at 2 years and sustained remission in 30% at 15 years after a Roux-en-Y procedure. Postsurgical dietary recommendations include consuming protein first at each meal, rather than carbohydrates, to prevent malnutrition, and separating consumption of liquids from solids by 15–30 minutes to avoid food passing through the stomach too quickly, which can lead to a decreased sensation of satiety. Patients who are treated surgically for obesity rather than with nonsurgical interventions have a longer overall length of survival. All-cause mortality is decreased by 30%–50% at 7–15 years after surgery. Evaluation for nutritional deficiencies should be performed quarterly for the first year after surgery; after that, annual checks are recommended.

Question 32

A patient has a past medical history that includes a sleeve gastrectomy for weight loss. Which one of the following medications should be AVOIDED in this patient?

(check one)
Acetaminophen
Gabapentin (Neurontin)
Hydrocodone
Ibuprofen
Tramadol (Ultram)

Answer 32

Ibuprofen

NSAIDs such as ibuprofen are thought to increase the risk of anastomotic ulcerations or perforations in patients who have had bariatric surgery and should be completely avoided after such surgery if possible (C Recommendation, Level of evidence 3). It is also recommended that alternative pain medications that can be used are identified prior to the surgery (D Recommendation). Options such as acetaminophen, gabapentin, hydrocodone, and tramadol can be considered in patients who have had bariatric surgery if the medications are clinically appropriate otherwise.

Question 33

A 69-year-old male with type 2 diabetes mellitus, obesity, and a history of coronary artery disease sees you for follow-up of his diabetes. His hemoglobin A1c has increased to 8.7% despite therapy with metformin (Glucophage), 1000 mg twice daily, and insulin glargine (Lantus).

Which one of the following additional medications would be most effective for reducing his blood glucose level and lowering his risk of cardiovascular events? (check one)
Exenatide (Byetta)
Glipizide (Glucotrol)
Liraglutide (Victoza)
Rosiglitazone (Avandia)
Sitagliptin (Januvia)

Answer 33

Liraglutide (Victoza)

Liraglutide, exenatide, and dulaglutide are all GLP-1 receptor agonists. Of these, only liraglutide has been shown to lower the risk of recurrent cardiovascular events and has received FDA approval for this indication. Glipizide (a sulfonylurea), rosiglitazone, and sitagliptin have not been associated with improved cardiovascular outcomes. Empagliflozin, an SGLT2 inhibitor, has also been associated with secondary prevention of cardiovascular disease.

Question 34

A 46-year-old female with known chronic kidney disease presents to discuss treatment of her recently diagnosed type 2 diabetes. She also has long-standing hypertension and her current medications include telmisartan/hydrochlorothiazide (Micardis HCT), amlodipine (Norvasc), and metformin. Her most recent estimated glomerular filtration rate is 52 mL/min/1.73 m2 and her hemoglobin A1c is 7.6%. Her serum electrolytes are all within the normal range. You refer her to a diabetes educator for counseling on self-management and lifestyle modification.

Which one of the following is the recommended additional pharmacologic treatment for this patient?

(check one)
Empagliflozin (Jardiance)
Glipizide (Glucotrol)
Insulin glargine (Lantus)
Pioglitazone (Actos)
Sitagliptin (Januvia)

Answer 34

Empagliflozin (Jardiance)

The American Diabetes Association and the Kidney Disease: Improving Global Outcomes group recommend combination treatment with metformin and an SGLT2 inhibitor for patients with type 2 diabetes and chronic kidney disease (CKD) with an estimated glomerular filtration rate >30 mL/min/1.73 m2. Metformin is first-line medical therapy for the majority of patients with type 2 diabetes. The addition of an SGLT2 inhibitor limits the progression of kidney disease and improves cardiac outcomes (SOR A). They should be considered first-line treatment along with metformin regardless of the baseline or target hemoglobin A1c.

Sulfonylureas and thiazolidinediones would not be used as first-line therapy in this scenario. Their use is now recommended secondarily only when cost is a major issue. Insulin is not indicated in this patient as oral hypoglycemics are first-line therapy unless the hemoglobin A1c is >10% or the patient is experiencing persistent symptoms of hyperglycemia. DPP-4 inhibitors such as sitagliptin are second-line therapy to help patients reach glycemic targets. They are not used as first-line treatment with metformin or as monotherapy. The significant weight loss benefits of GLP-1 receptor agonists and SGLT2 inhibitors make them preferred choices.

Question 35

A 36-year-old female sees you for a 6-week postpartum visit. Her pregnancy was complicated by gestational diabetes mellitus. Her BMI at this visit is 33.0 kg/m2 and she has a family history of diabetes.

Which one of the following is this patient’s greatest risk factor for developing type 2 diabetes in the future? (check one)
Her age
Obesity
The history of a completed pregnancy
The history of gestational diabetes
The family history of diabetes

Answer 35

The history of gestational diabetes

A history of gestational diabetes mellitus (GDM) is the greatest risk factor for future development of diabetes mellitus. It is thought that GDM unmasks an underlying propensity to diabetes. While a healthy pregnancy is a diabetogenic state, it is not thought to lead to future diabetes. This patient’s age is not a risk factor. Obesity and family history are risk factors for the development of diabetes, but having GDM leads to a fourfold greater risk of developing diabetes, independent of other risk factors (SOR C). It is thought that 5%–10% of women who have GDM will be diagnosed with type 2 diabetes within 6 months of delivery. About 50% of women with a history of GDM will develop type 2 diabetes within 10 years of the affected pregnancy.

Question 36

A 55-year-old male sees you for follow-up. His medical problems include morbid obesity, type 2 diabetes mellitus, hypertension, hyperlipidemia, and major depressive disorder. His medications include metformin (Glucophage), glipizide (Glucotrol XL), lisinopril (Prinivil, Zestril), aspirin, simvastatin (Zocor), and fluoxetine (Prozac). His BMI is 52.4 kg/m2 and he is struggling to lose weight.

Which one of the following medication replacements could help promote weight loss? (check one)
Atorvastatin (Lipitor) instead of simvastatin
Canagliflozin (Invokana) instead of glipizide
Carvedilol (Coreg) instead of lisinopril
Paroxetine (Paxil) instead of fluoxetine
Pioglitazone (Actos) instead of glipizide

Answer 36

Canagliflozin (Invokana) instead of glipizide

Given the obesity epidemic in the United States, an awareness of therapies that affect weight is imperative for family physicians. This patient is taking medications that help with weight loss (metformin) and medications that are weight neutral (lisinopril, simvastatin, and fluoxetine). Glipizide, however, causes weight gain, and switching to an SLGT2 inhibitor such as canagliflozin can help promote weight loss. Likewise, the patient could use a GLP-1 receptor agonist such as exenatide or an amylin mimetic (pramlintide) for weight loss benefits. Sulfonylureas, thiazolidinediones, and insulins all promote weight gain (SOR A).

Fluoxetine and sertraline are weight neutral, whereas paroxetine can cause weight gain (SOR B). The statins are weight neutral in general, and switching to atorvastatin should not affect weight. ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, thiazides, and β-adrenergic blockers are all weight neutral. In this patient with diabetes mellitus, an ACE inhibitor would be preferable to carvedilol in terms of renal protection (SOR A).

Question 37

A 38-year-old female who recently underwent a laparoscopic sleeve gastrectomy for weight loss presents to your office for a follow-up visit. She has had no complications with her recent postoperative course. Her medical history includes diabetes mellitus, hypertension, and hyperlipidemia. She has also had problems with bilateral knee pain from osteoarthritis.

Patient education should include advising the patient to (check one)
drink extra fluids with meals
increase her intake of fibrous vegetables
avoid pregnancy for 3 years
take ibuprofen as needed for pain
have a bone density test in 2 years

Answer 37

have a bone density test in 2 years

Treatment of adult obesity with bariatric surgery is becoming more common. In addition to counseling patients about surgical options and the risks and benefits of surgery, the family physician is in a position to provide both long-term support and postsurgical medical management. Bariatric surgery does result in greater weight loss than nonsurgical interventions and is highly effective in treating comorbidities of obesity, particularly diabetes mellitus. Bariatric surgery also reduces obesity-related mortality.

After bariatric surgery the patient’s postoperative medications may require adjustments and NSAIDs should be avoided. Patients should be encouraged to eat three meals and one or two snacks daily. Very dry foods, bread, and fibrous vegetables are most likely to cause problems. Fluids should be avoided during meals and for 15–30 minutes before and after meals.

Those desiring pregnancy should wait 12–18 months after surgery. Recommended laboratory studies include a CBC, a metabolic profile, a folic acid level, iron studies, a parathyroid hormone level, a lipid profile, vitamin B12 levels, 24-hour urinary calcium excretion, and 25-hydroxyvitamin D levels. It is recommended that bone density measurements be done every 2 years.

Question 38

Which one of the following is diagnostic for type 2 diabetes mellitus? (check one)
A fasting plasma glucose level ≥126 mg/dL on two separate occasions
An oral glucose tolerance test (75-g load) with a 2-hour glucose level ≥160 mg/dL
A random blood glucose level ≥200 mg/dL in an asymptomatic person
A hemoglobin A1c ≥6.0% on two separate occasions

Answer 38

A fasting plasma glucose level ≥126 mg/dL on two separate occasions

The American Diabetes Association recommends screening for all asymptomatic adults with a BMI >25.0 kg/m2 who have one or more additional risk factors for diabetes mellitus, and screening for all adults with no risk factors every 3 years beginning at age 35. Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A1c ≥6.5%, a fasting plasma glucose level ≥126 mg/dL, a 2-hour plasma glucose level ≥200 mg/dL, or, in a symptomatic patient, a random blood glucose level ≥200 mg/dL. In the absence of unequivocal hyperglycemia, results require confirmation by repeat testing.

Question 39

A 70-year-old male is being treated with medication for type 2 diabetes mellitus. Which one of the following hemoglobin A1c values is associated with the lowest mortality in this situation? (check one)
5.0%–5.9%
6.0%–6.9%
7.0%–7.9%
9.0%–9.9%

Answer 39

7.0%–7.9%

In patients ≥65 years of age treated with medication for type 2 diabetes mellitus, hemoglobin A1c values of 7%–8% have shown the greatest reduction in mortality in multiple studies. It is suggested that frequent hypoglycemia is associated with lower hemoglobin A1c values, and that presents a greater risk. Values over 9% are associated with greater mortality (SOR B). Thus, while the risk of complications increases linearly with hemoglobin A1c, mortality has a V-shaped curve.

Question 40

A 42-year-old female who has been your patient for 5 years has uncontrolled type 2 diabetes mellitus. She asks your opinion about bariatric surgery to reduce her BMI of 41.1 kg/m2 and improve her diabetes because she is “sick of all the pills and doctor visits.”

You inform her that bariatric surgery (check one)
decreases the risk of dying from obesity-related illness
usually results in weight loss similar to that seen with diet and exercise
usually allows patients to lose weight without changing their diet
often allows patients to stop all medications and supplements

Answer 40

decreases the risk of dying from obesity-related illness

In 2013 nearly 180,000 bariatric surgery procedures were performed in the United States. Bariatric surgery does result in reduced all-cause mortality and more weight loss. National Institutes of Health Consensus Development Conference eligibility criteria include comprehension of risks, benefits, expected outcomes, alternatives, and required lifestyle
changes, including required postoperative lifelong supplements, diet changes, and follow-up appointments.

Question 41

GLP-1 agonists such as exenatide (Byetta) can be used as second-line agents to help improve glycemic control in patients with type 2 diabetes mellitus. Which one of the following is a CONTRAINDICATION to their use? (check one)
Hypothyroidism
Thyroid cancer
Coronary artery disease
Heart failure

Answer 41

Thyroid cancer

GLP-1 agonists are contraindicated in patients with medullary thyroid cancer or multiple endocrine neoplasm syndrome, or with a family history of these conditions. They are not associated with heart failure, coronary artery disease, or hypothyroidism. They have been associated with pancreatitis in rare cases, but this is not a contraindication to prescribing them.

Question 42

A 75-year-old male is admitted to the intensive-care unit with sepsis. His past medical history is significant for diabetes mellitus and coronary artery disease.

Which one of the following would be the most appropriate maximum blood glucose goal? (check one)
100 mg/dL
140 mg/dL
180 mg/dL
220 mg/dL

Answer 42

180 mg/dL

Sepsis is a severe life-threatening disorder that has a 25%–30% mortality rate. Early aggressive management has been shown to decrease the mortality rate. The initial step in the management of sepsis is respiratory stabilization. Fluid resuscitation should be started and followed by vasopressor therapy if there is an inadequate blood pressure response. Antibiotics should be initiated within 1 hour of presentation. Other interventions in early goal-directed therapy that have been shown to improve mortality rates include blood transfusions, low-dose corticosteroid therapy, and conventional (not intensive) glycemic control with a target glucose level of <180 mg/dL. Intensive management of glucose in critically ill adult patients (a target glucose level of 80–110 mg/dL) has been shown to increase mortality.

Question 43

A patient with a BMI of 32 kg/m2 has type 2 diabetes that is currently controlled by lifestyle interventions, including moderate-intensity physical activity and healthy low-calorie meals. The patient asks about non-nutritive sweeteners, containing few or no calories.

According to the American Diabetes Association, which one of the following would be the most appropriate advice? (check one)
Sucrose (table sugar) is preferred
Non-nutritive sweeteners are acceptable to use
Non-nutritive sweeteners worsen glucose control
Sucralose-based sweeteners, such as Splenda, should be avoided
Sweeteners with aspartame, such as Equal, should be avoided

Answer 43

Non-nutritive sweeteners are acceptable to use

Non-nutritive sweeteners contain few or no calories. According to the American Diabetes Association, non-nutritive sweeteners may be acceptable to use instead of nutritive sweeteners such as sucrose. They should be used in moderation if they are used.
The use of non-nutritive sweeteners can help to reduce overall intake of carbohydrates and calories. They do not significantly affect glycemic control. Research is inconsistent regarding the effects of non-nutritive sweeteners on weight loss, but most systematic reviews and meta-analyses demonstrate a benefit. There is no recommendation to avoid sucralose or aspartame in patients with type 2 diabetes. Beverages sweetened with sugar are associated with an increased risk of type 2 diabetes.

Question 44

A 67-year-old male with a history of diabetes mellitus, hypertension, and heart failure with reduced ejection fraction has developed stage 5 chronic kidney disease. Which one of the following would be the best option for treatment of his diabetes? (check one)
Glimepiride (Amaryl)
Insulin glargine (Lantus)
Metformin
Pioglitazone (Actos)

Answer 44

Insulin glargine (Lantus)

Patients with end-stage renal disease and diabetes mellitus need careful monitoring of glucose because insulin requirements are difficult to predict and there is an increased risk of hypoglycemia in this setting. The optimal hemoglobin A1c has not been established but maintaining a value between 6% and 9% does decrease mortality. With close monitoring, insulin is preferred for most individuals. Sulfonylureas such as glimepiride and glyburide are associated with a high risk of hypoglycemia and should be avoided in these patients. Metformin should be avoided in those with a glomerular filtration rate <30 mL/min/1.73 m2. Pioglitazone should also be avoided in chronic kidney disease due to the risk of fluid retention and precipitating heart failure.

Question 45

A 42-year-old female with diabetes mellitus comes to your office because of recurrent yeast infections. She is taking numerous agents in an attempt to lower her glucose level.

Which one of the following classes of antidiabetic agents is associated with an increased risk for candidiasis? (check one)
Biguanides such as metformin (Glucophage)
DPP-4 inhibitors such as sitagliptin (Januvia)
SGLT2 inhibitors such as empagliflozin (Jardiance)
GLP-1 receptor agonists such as liraglutide (Victoza)
Sulfonylureas such as glipizide (Glucotrol)

Answer 45

SGLT2 inhibitors such as empagliflozin (Jardiance)

SGLT2 inhibitors are known to cause an increased risk of yeast vaginitis because their mechanism of action
involves blocking renal uptake of glucose, which results in an increase in glucosuria (SOR A). Common
side effects of metformin include gastrointestinal upset. DPP-4 inhibitors have very few side effects.
GLP-1 receptor agonists typically cause nausea and early satiety and weight loss. Sulfonylureas are
associated with weight gain and hypoglycemia.

Question 46

A 57-year-old long-time patient presents for an annual wellness visit. He has a BMI of 46 kg/m2, type 2 diabetes, obstructive sleep apnea, hypertension, and cardiomyopathy. He is adherent to his medication regimen and CPAP therapy, and these problems have been controlled.

As you discuss lifestyle modification recommendations, he tells you that he wants to address his obesity this year. You have counseled him on low-carbohydrate and low-calorie diets over the years. He has had difficulty following these recommendations due to his work obligations. He states that he has tried multiple fad diets, none of which have been helpful.

Which one of the following would be the most effective management? (check one)
Worksite intervention
Exercise therapy
Behavioral therapy
Pharmacotherapy
Bariatric surgery

Answer 46

Bariatric surgery

This patient presents with morbid obesity complicated by several obesity-related conditions. Bariatric
surgery has been shown to result in greater weight loss compared to nonsurgical interventions (SOR A).
It has also been shown to be highly effective in treating obesity-related comorbid conditions such as
diabetes mellitus (SOR A). Patients with a BMI 40 kg/m2 should be referred for consideration of bariatric
surgery (SOR B). While worksite intervention, exercise therapy, behavioral therapy, and pharmacotherapy
are appropriate treatments for obesity, these interventions are all less effective than bariatric surgery.

Question 47

Which one of the following medications for the treatment of type 2 diabetes has been associated with ketoacidosis? (check one)
Dapagliflozin (Farxiga)
Liraglutide (Victoza)
Metformin
Pioglitazone (Actos)
Sitagliptin (Januvia)

Answer 47

Dapagliflozin (Farxiga)

SGLT2 inhibitors such as dapagliflozin have increasingly been shown to be associated with diabetic ketoacidosis under certain circumstances. Liraglutide, metformin, pioglitazone, and sitagliptin are not associated with diabetic ketoacidosis.

Question 48

A 34-year-old male with sickle cell disease has a new onset of mild to moderate thirst and polyuria. He ate a large meal about 2 hours ago.

An examination reveals a BMI of 32 kg/m2. Results of a urinalysis performed by your staff include 3+ glucose and no ketones. His blood glucose level is 288 mg/dL and his hemoglobin A1c is 5.2%.

Which one of the following would be most appropriate at this point to help diagnose and monitor this patient’s glycemic control? (check one)
A serum fructosamine level
A repeat hemoglobin A1c
A 2-hour glucose tolerance test
Hemoglobin electrophoresis
Referral to an endocrinologist

Answer 48

A serum fructosamine level

This patient with sickle cell disease has a new onset of diabetes mellitus. Hemoglobinopathies falsely lower
hemoglobin A1c as a result of hemolysis and abnormal glycation. Fructosamine correlates well with
hemoglobin A1c levels and is recommended instead of hemoglobin A1c for monitoring glucose control in
patients with diabetes and hemoglobinopathies. A 2-hour glucose tolerance test or hemoglobin
electrophoresis would not provide useful information. Referral to an endocrinologist is not indicated at this
point because the patient has not failed primary care management.

Question 49

A 26-year-old G2P1001 at 30 weeks gestation was recently diagnosed with gestational diabetes and is ready to start testing her blood glucose at home. Which one of the following is the recommended goal for fasting blood glucose in this patient? (check one)
<75 mg/dL
<95 mg/dL
<120 mg/dL
<150 mg/dL
<180 mg/dL

Answer 49

<95 mg/dL

The goal fasting blood glucose level in patients with gestational diabetes is <95 mg/dL. A fasting glucose
level <80 mg/dL is associated with increased maternal and fetal complications. The goal 2-hour
postprandial glucose level is <120 mg/dL and the goal 1-hour postprandial glucose level is <140 mg/dL.

Question 50

A 63-year-old female sees you for evaluation of recurrent right foot swelling and redness. She has a history of obesity and type 2 diabetes with retinopathy, nephropathy, and peripheral neuropathy. She presented with similar symptoms 2 weeks ago and was diagnosed with cellulitis and treated with a 10-day course of amoxicillin/clavulanate (Augmentin). Her symptoms seemed to initially improve with this therapy along with elevation of the foot but then worsened. She does not have any pain in the foot, fever, or chills. She does not recall any trauma or other inciting event.
The patient’s vital signs include a temperature of 37.1°C (98.8°F), a pulse rate of 72 beats/min, and a blood pressure of 124/82 mm Hg. Her right foot appears swollen, red, and warm to the touch, and is not tender to palpation. There are no open sores or calluses. Her dorsalis pedis pulse is 2+. Monofilament testing confirms a diagnosis of peripheral neuropathy. A WBC count is normal. Radiographs reveal soft-tissue edema with no other abnormalities.

The most appropriate treatment at this point would be (check one)
immobilization
antibiotics
bisphosphonates
corticosteroids
surgical repair

Answer 50

immobilization

This patient has acute Charcot neuroarthropathy, an inflammatory condition that occurs in obese patients
with peripheral neuropathy and ultimately leads to foot deformities (the classic rocker-bottom foot) and
resultant ulcerations and infections. Its clinical appearance can easily be initially mistaken for cellulitis.
However, the absence of tenderness and other signs of infection such as fever, an elevated WBC count,
and inflammatory markers is not consistent with cellulitis. Radiography is an appropriate initial imaging
modality but the results are often interpreted as normal early in the disease process. MRI is the modality
of choice for a definitive diagnosis and may demonstrate periarticular bone marrow edema, adjacent
soft-tissue edema, joint effusion, and microtrabecular or stress fractures.
The treatment of acute Charcot neuroarthropathy is immobilization with total contact casting, which
increases the total surface area of contact to the entire lower extremity, distributing pressure away from
the foot. Immobilization is typically required for at least 3–4 months but in some cases may be needed for
up to 12 months. Bisphosphonates were found to be ineffective as adjunctive therapy in acute Charcot
neuroarthropathy. Corticosteroids and antibiotics have no role in the treatment of Charcot foot but would
be appropriate therapy for cellulitis or gout, which are important alternative diagnoses to consider. The
role of surgery is more controversial but may be indicated in the acute phase of Charcot neuroarthropathy
in patients with severe dislocation or instability.

Question 51

Which one of the following classes of diabetes medications is most associated with hypoglycemia? (check one)
Biguanides
DPP-4 inhibitors
SGLT2 inhibitors
Sulfonylureas
Thiazolidinediones

Answer 51

Sulfonylureas

Multiple classes of diabetes medications are used to address the pathways that lead to hyperglycemia, and it is important to select medication classes that reduce the risk of hypoglycemia while improving long-term outcomes. Hypoglycemia is associated with cardiovascular disease and all-cause mortality. Sulfonylureas, such as glipizide, glyburide, and glimepiride, commonly cause hypoglycemia as an adverse effect and require glucose monitoring when used. Biguanides most commonly cause diarrhea, vomiting, and other gastrointestinal symptoms. In high-risk patients such as those with heart failure, sepsis, or impaired kidney function, biguanides can also result in lactic acidosis. The only biguanide currently available is metformin. The most common adverse effects of DPP-4 inhibitors, which include saxagliptin, sitagliptin, linagliptin, alogliptin, are headache, nasopharyngitis, infections of the urinary tract or upper respiratory tract, and elevated liver enzymes. SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, can cause adverse effects such as urinary tract infections, candidiasis, dehydration, and hypovolemia. Only two thiazolidinediones, pioglitazone and rosiglitazone, are available in the United States. Their adverse effects include weight gain, salt retention, edema, and, for some patients, cardiovascular complications. Pioglitazone in particular is contraindicated in patients with heart failure, hemodynamic instability, and hepatic dysfunction. Thiazolidinediones may also increase the risk of bone fractures with long-term use.

Question 52

The diagnosis of type 2 diabetes can be confirmed by two hemoglobin A1c values at or above a threshold of (check one)
5.5%
6.0%
6.5%
7.0%
8.0%

Answer 52

6.5%

The diagnostic cutoff point for type 2 diabetes is a fasting plasma glucose level 126 mg/dL or a hemoglobin A1c 6.5%. The diagnosis requires confirmation by repeat testing or by obtaining both a fasting glucose level and hemoglobin A1c.