Endocrinology with diabetes Flashcards
Screening for DM
Recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40-70 years who are
overweight or obese.
Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.
Retinopathy prevention and screening
American Diabetes Association
- pts > 10 years old with type 1 diabetes should have initial dilated CEE within 3-5 years of onset
- patients with type 2 should have initial dilated CEE shortly after Dx exams (type 1 or 2) yearly, or potentially every 2 years if no retinopathy
- CEE when planning pregnancy, during 1st trimester with close follow-up throughout pregnancy, and 1 year post-partum
- general recommendations: optimize glycemic and blood pressure control to lower risk and slow progression of retinopathy
- BP is a very substantial vascular disease factor – retinal and renal in DM
55 y.o male presents for physical – no health insurance or medical care for several years.
- No medical history or meds
- Father has diabetes, mother has CAD
- Social History: Limited exercise, eats fast food 2x/day most days, 2 beers/day, non-smoker.
- Vital Signs: BP elevated at 146/92. BMI obese at 32.
- Which of the following options are appropriate?
a. screen for DM by asking about polyuria, polydipsia – no need for further testing if negative
b. screen for DM using Hb A1c
c. screen for DM using fasting glucose
d. screen for DM with random plasma glucose
e. don’t screen for DM, it is not indicated
b. screen for DM using Hb A1c
c. screen for DM using fasting glucose
d. screen for DM with random plasma glucose
Explanations:
A.(we want to screen but these questions are not sensitive enough)
Polyuria - excessive urination
Polydipsia- excessive thirst
Fair to ask about symptoms but you want to be able to pick up pre diabetes which is asymptomatic - so further testing is needed.
B.(fasting doesn’t matter when measuring A1c so this may be a good option – no preparation needed)
C.(he may not come back for a fasting glucose – you do not want to lose this patient) fasting glucose - patient has not eaten - more
homogenous test because pt is in a more physiological state when doing the test.
D.not a typical screening, but if measure normal random glucose then he is not diabetic and if it is high you can do additional tests – you can measure this right away and the patient does not need to come back for a fasting glucose – patients are more likely to
return for additional testing if an initial lab comes back abnormal)
- Random plasma will be more variable since patient has eaten
E. pt has CAD and obesity so he has pre dm risk , you want to screen for DM
DM screening reveals an elevated random glucose level, pt is asymptomatic – you should:
a. diagnose diabetes
b. repeat a DM screening test to confirm
c. check his cholesterol
d. counsel on diet and exercise
b. repeat a DM screening test to confirm
c. check his cholesterol
d. counsel on diet and exercise
A. If he reported symptoms , then you could potentially diagnose diabetes, without the symptoms you can’t really diagnose diabetes based on a single screening test- should do a different test like a A1C in addition or a fasting glucose
B. True
C. Possibly has cardiovascular risk, based on his family history, vital signs, obesity
D. never too early to counsel patients on diet and exercise to lower risks- recommend walking (something simple and achievable is perfectly good just to get your patient going)
DM screening reveals an elevated random glucose level, pt is asymptomatic
Follow-up fasting glucose is obtained the next week – results are elevated and diagnosis of DM is confirmed
a. this is type 1 diabetes and initiation of insulin is critical
b. treatment with lifestyle might be an appropriate first step
c. tight treatment goals will increase risk of hypoglycemia
b. treatment with lifestyle might be an appropriate first step
c. tight treatment goals will increase risk of hypoglycemia
Explanations:
A. Classic case of diabetes type 2 which due to lifestyle risk factors develops overtime. Large risk factors and changes in
lifestyle as well as changes in weight contributes.
B. Depends how elevated his hemoglobin glucose is - check A1C to see if it meets criteria of dm- lifestyle would be the
appropriate first step. Person like this who is young and will live a healthy lifestyle - you can have his a1c at a level 7.
C. As you decrease risk of dm - you do increase risk of hypoglycemia - in general curves for dm control - as alc levels go up , risk of complications (retinopathy, nephropathy) climb. Another curve - as your A1C goes down, risk for hypoglycemia goes up. The risk for retinopathy and hypoglycemia go in opp directions. So you want to find the balance between the two-
varies between different people depending on comorbidities and age.
In type 1- tighter control for hypoglycemia since there is only insulin to help with control
DM screening reveals an elevated random glucose level, pt is asymptomatic
Follow-up fasting glucose is obtained the next week – results are elevated and diagnosis of DM is confirmed
in addition to treating glucose level and assessing other cardio/macrovascular risks (and Tx as appropriate) what else
should be done:
a. screen for nephropathy now using office urinalysis
b. examine feet for signs of poor hygiene, infection, etc. etc.
c. provide counseling on foot care
d. eye exam can be safely deferred for several years
b. examine feet for signs of poor hygiene, infection, etc. etc.
c. provide counseling on foot care
A. trick answer – yes you want to screen him now for nephropathy but an office urinalysis is not sensitive enough because
microalbumin screen is needed and that can only be performed by a lab – actually measure a microalbumin/creatinine ratio
to determine how much solute is in the urine while making the measure independent of hydration level.
- need the microalbumin screening to check for nephropathy
B. Poor hygiene can cause small cuts and dry skin that can be a portal of infection. So you want to check for resik and signs
of early infection, vascular perfusion versus a cold foot. There is risk with neuropathy– imagine pt doesn’t feel something
he has stepped on and has a vascular disease which means less immune cells can reach the site or hyperglycemia which
increases the risk for infection. Foot exam - is necessary for diabetics.
C. Counsel to have foot care so that no infections can appear. Even if someone comes in for eye care and has dm - ask them
if they have kidneys checked for microalbumin or urine – never go barefoot and maybe have handouts in the office. If they
have some degree of retinopathy - counsel about other organ risk factors.
D. typical advice for new onset of type 1 dm. Type 1 develops rapidly and microvascular complications (retinopathy) happens
in several years. (type 1 they haven’t had it for long so no retinopathy will show) with people who have type 2 - they may
have had it for a while so retinopathy may have been developing for quite some time. (cataracts, ulcer risk factors can
happen) This is false for people with type 2 dm
DM screening reveals an elevated random glucose level, pt is asymptomatic
Follow-up fasting glucose is obtained the next week – results are elevated and diagnosis of DM is confirmed
Treatment of his BP (once elevated level confirmed) should ideally begin with:
a. α-adrenergic blocker
b. β-blocker
c. ACE inhibitor
d. statin drug
c. ACE inhibitor
A. α receptors are on blood vessels and the bladder outlet – blocking α relaxes the vascular tone. Normally, α constricts in legs to get blood to the head when you stand up, so a major side effect of α-blockers is orthostatic hypotension. Α can also be useful in benign prostatic hypertrophy because they can help with blocked urethra opening . Basically, with this patient there is no compelling reason to use an α-blocker, and they aren’t really 1st line drugs, so this is not the best answer.
B. β-blockers do decrease myocardial o2 demand - MI and ischemia - decreases post MI. Not ideal, but probably a 2nd
line Tx in DM because of hypoglycemic unawareness. They can be trouble in pts that already have a slow heart rate; asthmatics because β-stimulation dilates the airways so β-blockers may block the effect of inhalers; You can use B-blockers in the mix in addition to other medications if they had other contraindications along with the diabetics but not first line.
C. has a renal protective benefit for people with dm. Well tolerated angiotensin receptor blocker can be used if cough develops (usually use first in diabetics with hypertension because these reduce the nephropathy risk – the other 1st line HTN drug probably diuretic)
- Important first line for HTN and DM - be aware of side effects
D.(this is a cholesterol med – the pt described probably needs this too but it has nothing to do with blood pressure lowering) statins are used with anti-Hypertensives but they themselves are not anti hypertensives
DM screening reveals an elevated random glucose level, pt is asymptomatic
Follow-up fasting glucose is obtained the next week – results are elevated and diagnosis of DM is confirmed
Px is on BP meds
He begins oral agent for DM and is followed for several years; Unfortunately, he has difficulty adhering to lifestyle and
gains weight; referred to nutritionist/weight loss clinic but doesn’t follow up.
Over time, he takes max doses of 3 oral DM agents, has symptomatic hyperglycemia with frequent thirst and urination.
He begins insulin, but needs a large dose to obtain good blood glucose control.
this is not an atypical progression – sometimes even in pts who are compliant/adherent)… (there are 2 key factors in type 2
DM – insulin resistance where at first pancreas makes more insulin, followed by inadequate insulin production where the
pancreas can’t keep up)
Large insulin requirements in type 2 diabetes:
a. is often termed insulin resistance
b. may get better with weight loss
c. may improve with exercise
d. may improve with concurrent use of insulin-sensitizing drugs, i.e. Metformin (try to overcome some insulin
resistance to help decrease pt’s insulin needs)
a. is often termed insulin resistance
b. may get better with weight loss
c. may improve with exercise
d. may improve with concurrent use of insulin-sensitizing drugs, i.e. Metformin (try to overcome some insulin
resistance to help decrease pt’s insulin needs)
Explanations:
A. Insulin resistance - high needs of insulin with type 2 specifically- related to lifestyle factors (obesity, can improve with
weightloss and excersise) people who lose weight will be able to drop insulin requirements. - Insulin sensitizing drugs like
metformin can do the same thing. (along with the insulin)
B. (more resistance seen with higher weight)
While on insulin, glucose levels improve and pt feels better – but always concerned about hypoglycemia, symptoms of
which can include:
a. Chest pain
b. Shaking
c. sweating
d. confusion
e. Loss of consciousness
b. Shaking
c. sweating
d. confusion
e. Loss of consciousness
Explanations:
A. Counter regulatory hormones kick in with hypoglycemia and most of them increase catecholemines - concerns with people
with cardiovascular risks because cardiovascular ischemia can occur. Chest pain - isnt typical but concern for
hypoglycemia risk for people who have cardiovascular ischemia. But not for dm.
B. true
C. (catecholamine release, may be blocked by β-blocker)
D. Neurogylcopenia
E. More severe sx- poor glucose delivery to the brain : neuroglycopenia: brain has one energy source (glucose). If there is hypoglycemia - the worse it is the worse the brain function is impaired. Can be seen as confusion at first but will loose
consciousness.
Treatment of hypoglycemia includes:
a. assessing pt’s mental state/severity of the hypo
b. administering table sugar - does help but can block break down of carbs slowly
c. Administration of glucagon if pt is unconscious
d. forcing glucose into mouth of comatose person
e. short and long acting glucose sources
f. monitoring status, appropriate defensive action
a. assessing pt’s mental state/severity of the hypo
b. administering table sugar - does help but can block break down of carbs slowly
c. Administration of glucagon if pt is unconscious
e. short and long acting glucose sources
f. monitoring status, appropriate defensive action
a. True and important. If you see a patient that is hypoglycemic in any situation- you want to assess their mental state and
see if they are confused or aware. Low sugar reading with mild symptoms - they can take some glucose. If they have
impairment in mental state they would need glucagon injections.
b. Table sugar is fine but not if taking α-glucosidase inhibitors because the table sugar is a disaccharide and will not be
broken down. It blocks breakdown of complex carbohydrates like disaccharides (the breakdown process will be slowed)-
but if all you have is table sugar its okay.
c. Glucagon should be the way to go if they are unconscious. Pts on insulin should have glucagon kits and a person that
knows how to administer/inject if needed during hypo)
d. (debatable – may not hurt the patient but depends – maybe a little buccal absorption of glucose but risking
aspiration/inhalation)
e. Not only do you want to give the short acting source to help with the hypo, you would want the long acting as well to cover
long term causes of hypoglycemia. – you don’t want them to faint if they’re driving or walking down the stairs etc.
(two components to combating hypo – first need to treat the “here and now” with a short-acting source such as OJ/candy/
glucose tablet; secondly the pt will probably rebound when the short-acting wears off so need to give a long-acting source
such as IV glucose or bread/granola bar – especially patients on long-acting insulin or sulfonylureas you need to cover
longer term)
f. People should not drive, only if they know that the glucose is up enough to prevent any hypoglycemia episodes. They need
to recheck glucose and have plan in place so that they should not
Which of the following is least likely to cause hypoglycemia
a. A patient with autonomic neuropathy takes pre-meal fast-acting insulin then eats his lunch; unfortunately he then has a
episode of emesis (vomiting)
b. A patient takes his sulfonylurea dose, then gets distracted at work and skips a meal
c. Patient on metformin is on board a plane that sits on the tarmac for several hours due to a flight delay. He did not
bring any food with him.
d. A patient inadvertently takes an extra dose of long-acting insulin without noticing
c. Patient on metformin is on board a plane that sits on the tarmac for several hours due to a flight delay. He did not
bring any food with him.
A. Risk factor because the carbs that he ate are not helping counteract the fast-acting insulin he just took since he vomited
B. sulfonylurea triggers pancreas to secrete more insulin. Only when your stomach sees glucose that the pancreas will
secrete insulin. Sulfonylurea - significant risk factors, once they are taken the insulin will release and patient needs to eat to
counteract that - hypoglycemia may occur
C. Metformin - decreases glucose synthesis and decreases hypoglycemic risk. Typically people on metformin will not have
hypoglycemia - they can develop rare hypoglycemia in rare situations. But this is a least likely cause of hypoglycemia.
D. More insulin in the system - causing more risk for hypoglycemia
Which of the following is TRUE about the cardiovascular risk assessment and treatment of patients with diabetes?
a. Treating diabetes is the only known way to lower cardiovascular risk in patients with diabetes
b. An increase in the number of risk factors- including diabetes- increases the cardiovascular risk for a given patient
c. Studies show that statin (HMG CoA reductase inhibitor) cholesterol-lowering drugs have no effect on cardiovascular risk
d. Drugs in the SGLT-2 and GLP-1 classes can lower CVD risk
b. An increase in the number of risk factors- including diabetes- increases the cardiovascular risk for a given patient
d. Drugs in the SGLT-2 and GLP-1 classes can lower CVD risk
A. False - we know that treating dm will lower cardiac risk but there is also smoking cessation, lowering BP and lifestyle
changes - lowering dm is not the only way to lower cardio
B. The more risk factors (smoking, high bp and cholesterol, adding dm) - the risk of cardio will go up. The more risk factors
you can treat the more you can lower the cardio risk.– treat as many as possible (however advancing age you can’t lower
so you can just push to treat the other risk factors.
C. Statin drugs are good drugs for lowering cardio- not 100% but they do lower the risk and for people who have high risk will
have more effect with it. Statins are effective for primary event - someone who hasn’t had a cardiac event and secondary
event- someone who has had a cardiac event and is trying to prevent another one.
D. SGLT-2 -blocks resorption of glucose - glucose is filtered through the kidney then resorbed. When the body has a glucose
level greater than how much is filtered - glucose will go into the urine. SGLT-2 blocks glucose resorption in the kidney–
patient loses fluid (diuretic) and glucose gets discarded in the urine. Can lower BP and lower CVD risk.
Weight gain may be seen with which of the following drugs/drug classes?
a. Sulfonylureas
b. Metformin
c. GLP-1 analogues
d. Insulin
e. DDP-4 inhibitors
f. SGLT-2 inhibitors
a. Sulfonylureas
d. Insulin
A.correlate in increase in weight because increases insulin release which increases weight.
B. metformin induces a little weight loss -sometimes
C. patient eat glucose and extra stimulation of insulin release- at the same time there is gastric emptying (which helps correlates
with weight loss- some are indicated just for weight loss)
D. Yes can cause weight gain- needs to be managed. Sometimes people will alter insulin therapy to avoid weight gain but can
cause hypoglycemia if they do that.
E. inhibits breakdown of GLP-1 - not very potent drugs does not lower Alc too much. - Pancreatitis can often result from this drug. Can associate with weight loss.
F. Associated with weight loss (can be neutral weight as well)
A 9 y.o boy is seen in clinic after developing an acute illness with hunger, thirst, enuresis and weight loss. He has no fevers.
Urinalysis reveals ketones and glucose. For treatment, he will most likely require:
a. Metformin
b. An ACE inhibitor
c. Glucagon
d. Insulin
d. Insulin
A. Will not help
B. helpful for dm kidney disease
C. helpful for hypoglycemia
D. treatment of choice - you need the insulin to replace the insulin that is not being made. (risks hypoglycemia so you need to monitor) - type 2 can be treated with insulin so you need to be able to tell apart the difference between type 1 - which
requires insulin or type 2 which needs some insulin on top of their oral meds to better control their blood sugar.
Patients who are type 1 typically only have insulin, type 2 have oral meds on top of the insulin.
Patient is thirsty because he is hypoglycemic and spilling glucose in the urine - glucose is bringing extra fluid to urine (thirst) - weight loss because he is not absorbing any glucose - getting lost in the urine.
- No fevers so these symptoms are not due to infections. Ketones and glucose lost in urine- starvation must be occurring:
ketones start producing if your body has no glucose in the body. In DM- the glucose is lost in the urine, so even if the
patient is producing the glucose its not getting absorbed into the body. The body sees no glucose absorption so it starts
producing ketones to help produce energy for the body. If you see ketones and glucose in urine - the body must be starving
and have no energy source
Regarding diabetes type 1:
a. Oral medications are often a useful adjunct to insulin therapy
b. Overweight and obesity are risk factors for development of diabetes type1
c. The incidence of hypoglycemia increases as hemoglobin A1c level falls
d. Tight control with hemoglobin A1c under 7.0% is a critical goal that should be achieved for all patients with type 1 dm
c. The incidence of hypoglycemia increases as hemoglobin A1c level falls
A. False - type 2 oral meds can be added to their insulin therapy. Type 1 is all insulin therapy
B. This is false - risk factors for worsening type 1 - type 1 is autoimmune attack on pancreatic b cells. Overweight and obesity
are risk factors for diabetes type 2- can be for poor control in type 1 but not the main risk factors for it.
C. HBA1C - correlates dm control. As HBA1c goes up dm control goes down. If patients have hypoglycemia history you can have patients be around 7a1c. Anything over 7A1C - vascular complications (retinopathy) and other risks.
Risk for Hypoglycemia goes up - from tighter control of A1C
D. False - goals should be individualized. If you have a 25y.o who has type 1 dm and they are adherent to their regime and
keeping things under control then they should be under 7.0% of A1c since they have tight control of the A1C
If its a younger child- harder to control what they will have to eat and how much exercise they do or a child who is not
adherent to the control for A1c - you would want a higher A1C goal. Even with an older patient who has memory loss - you
may have a different goal for A1c. Based upon life situation and patient preference - the A1C level goals vary upon the
individual and their living circumstances.
