EXAM - DM Flashcards
Sam, 34 year old cis male, presents to your clinic for a health check up. He is concerned about the weight he has gained over the past few years. Which risk factors will you assess Sam for to determine if he should be screened for T2DM?
Family history
High risk populations (non-white (?????), low socioeconomic status)
History of GDM, pre-diabetes
CVD risk factors
End organ damage associated with DM
Conditions/Medications associated with DM
(QRG p.1)
You learn that Sam’s parents both have T2DM. As part of your work up you send him for labs. His FPG is 6.5 and his A1C is 6.2. What do you diagnose Sam with?
These are the criteria for impaired fasting glucose/pre-diabetes
(QRG p.1)
You provide teaching on the risk of progression to DM and lifestyle modifications to avoid this. When do you rescreen Sam?
Screen every 6-12 months due to the presence of risk factors
(QRG p.1)
Unfortunately 2 years pass before Sam re-presented to your clinic. He has been struggling with his mental health and has gained weight, he reports he has not been active or eating well due to feeling low and being tired often. His labs are now FPG = 8.1, A1C=8.4. What do you diagnose and what are other avenues you should explore for Sam’s care?
Sam meets criteria for T2DM
It would be wise to assess him for depression, suicidality, OSA and CVD including HTN and dyslipidemia.
What do you set as an A1C target for Sam?
I would go with less than or equal to 7 at this time. Sam sounds rather depressed, I would worry about sub-optimal monitoring for hypoglycemia and so wouldn’t want to aim as low as 6.5 at this time
What are your initial interventions following the diagnosis of T2DM?
According to the QPG, initial care involves assessment, setting A1C target, referring to diabetic educator and starting healthy behavior monitoring.
If A1C target is not achieved after 3 months of healthy behavior then Metformin is to be started. I think I would start Metformin concurrently with initial behavior monitoring due to low motivation. Hopefully Sam can get some treatment for depression and/or OSA management and make some gains
(QPG p.2)
You decide to prescribe metformin, what dose?
250 mg po daily, titrate up to 1000 mg BID
RxFiles p.45
You reassess Sam’s A1C after 3 months. How much can you expect his A1C to decrease with the metformin.
1-1.5%
RxFiles p.45
Sam’s A1C is now 7.8, What would you do now?
Maybe a GLP1 – Semaglutide0.25 mg sc weekly, increased in 4 weeks to 0.5mg
Sam does well on his therapy for several years. Eventually his beta cell function declines and he presents to your office with polydipsia, polyphagia and general malaise. What’s your move? A1C 9.1
Symptomatic hyperglycemia. Definitely check for DKA. Treat/hospitalize if needed. Let’s say no DKA – time to start insulin
(QPG p.2)
What do you start Sam on for insulin? How do you titrate?
NPH 10 u HS, instruct to increase by 1 unit every 1-2 days until pre-breakfast FBG 4-7
(RxFiles p.51)
What does your monitoring look like for Sam now that you are starting insulin?
According to RxFiles – call patient in 2-3 weeks and repeat A1C in 3 months
Patient to monitor glucose levels at home
(p.51)
What are major teaching points for insulin use?
Hypoglycemia recognition and treatment
Fix the lows first and the highs next
Preferred sites for injection and injection techniques
(RxFiles p.52)
Fred, 89 with T2DM has an A1C of 6.5. Great glucose control Fred and great work prescriber! Right?
No, this is probably a dangerously low A1C for a patient this age who is at risk for complications related to hypoglycemia. A more appropriate target A1C would be 7.1-8.5. This patient’s therapy should be decreased.
Molly, 64 has T2DM, she is prescribed a DPP4i, and metformin for her DM and hydrochlorothiazide 12.5 mg daily for HTN. Her A1C is 7.4 and her BP 135/70. You decide to switch her DPP4i to an SGLT2i to improve her glucose control. What else should you do?
If planning to start an SGLT2i I would consider stopping her hydrochlorothiazide. She will get likely comparable diuresis with the SGLT2.
Based on her age and the diagnosis of HTN she also should be prescribed an ACEi and statin
(QRG p.5)
