Learning Objectives - Diabetes Mellitus

Question 1

Diagnostic criteria for impaired fasting glucose?

Answer 1

Fasting glucose between 110-125 mg/dL

Question 2

Diagnostic criteria for impaired glucose tolerance?

Answer 2

2 hour postprandial glucose between 140-199 mg/dL

Question 3

Pre-diabetes criteria?

Answer 3

HbA1c 5.7-6.4

Question 4

How is diabetes diagnosed?

Answer 4

1. 2 fasting glucose measurements of 126+ (preferred screening etst)
2. Random plasma glucose level 200+ with symptoms
3. Two hour postprandial plasma glucose level >200
4. A1C 6.5+

Need 2 separate tests

Question 5

Why is obesity the greatest risk factor for DM2?

Answer 5

Increased plasma levels of free fatty acids make muscles more insulin resistant, reduces glucose uptake

Question 6

True or false - the genetic component is stronger in DM1 than DM2.

Answer 6

False - stronger in DM2

Question 7

Presenting signs and symptoms of DKA?

Answer 7

Hyperglycemia >450
AG metabolic acidosis (serum pH <7.2
Ketosis
Kussmaul respirations

Question 8

Presenting signs and symptoms of HHS?

Answer 8

Hyperglycemia >900
Hyperosmolarity >320
Serum pH >7.3 (no acidosis)

Question 9

Cause of hyponatremia in DKA?

Answer 9

Osmotic shift of fluid from ICF to ECF (total body sodium is normal)

Question 10

Cause of hyperkalemia/hypokalemia in DKA?

Answer 10

Acidosis initially causes hyperkalemia, although total body potassium is low. As insulin is given, K shifts into cells.

Question 11

Why is ketogenesis minimal in HHS?

Answer 11

Small amount of insulin is related to blunt glucagon

Question 12

Labs needed to screen/diagnose/follow patients with DM?

Answer 12

Glucose
Electrolytes
BUN/Cr
Fasting lipids
HgA1C
Urine microalubmin/creatinine ratio
Urine dipstick

Question 13

Pros of sulfonylureas?

Answer 13

Efficacious (decrease A1C 1.2%)
Increase insulin secretion
Long track record
Inexpensive

Question 14

Cons of sulfonylureas?

Answer 14

Hypoglycemia
Weight gain
Failure in 3-5 years

Question 15

Pros of metformin?

Answer 15

Efficacious (decrease A1C 1.2%)
Long track record
Decreases hepatic glucose production (90%)
Helps increase muscle glucose uptake (10%)
Protective against colon cancer

Question 16

Cons of metformin?

Answer 16

GI upset
Hold for procedures and CT dye load
D/C if Creatinine >1.5 mg

Question 17

Pros of thiazoladinediones?

Answer 17

Efficacious
Reasonably long experience
No hypoglycemia
Beta cell preservation

Question 18

Cons of thiazoladinediones?

Answer 18

Increased CV risk?
Bladder cancer?
Edema
Weight Gain
Fractures

Question 19

Pros of GLP-1 mimetics?

Answer 19

Efficacious (decrease A1C 1.2-1.5%)
Decrease post-prandial glucose
-No hypoglycemia
-Potential for weight loss
-Possible beta cell preservation

Question 20

Cons of GLP-1 mimetics?

Answer 20

Daily/2x daily/weekly injection
GI upset
Rare reports of pancreatitis
Cost

Question 21

Pros of DPP-4 inhibitors?

Answer 21

Efficacious (decrease A1C 0.7%)
Decrease post-prandial glucose
No hypoglycemia
Weight neutral
Safe in renal disease
No Gi upset
Possible beta cell preservation

Question 22

Cons of DDP-4 inhibitors?

Answer 22

Cost

Rare reports of pancreatitis

Question 23

Pros of alpha-glucosidase inhibitors?

Answer 23

Efficacious (decrease A1C 0.5%)
Long experience
No hypoglycemia
No weight gain

Question 24

Cons of alpha-glucosidase inhibiators?

Answer 24

Dosing with meals

GI intolerance

Question 25

Pros of quick release bromocriptine?

Answer 25

Efficacoius (decreases A1C 0.5%)
Resets hypothalamic circadian clock
Surprisingly good CV profile

Question 26

Cons of quick release bromocriptine?

Answer 26

Hypotension
Short track record
Cost

Question 27

Pros of SGLT-2 inhibitors?

Answer 27

Efficacious (decrease A1C 1.0%)
Inhibits glucose reabsorption at renal level
Weight reduction
No drug interactions

Question 28

Cons of SGLT-2 inhibitors?

Answer 28

Increased UTIs/vaginitis
Short track record
Cost

Question 29

Dietary recommendations for DM1 and DM2?

Answer 29

DASH

Question 30

Manage DKA

Answer 30

1. IV insulin immediately (prime with 0.1 U/kg regular insulin, then infusion 0.1 units/kg/hour)
   - Ensure pt is not hypokalemic
   - Continue insulin until AG closes and metabolic acidosis is corrected
   - When eating again, transition to SubQ
2. IVF (NS) immediately
   - Add 5% glucose once blood glucose reaches 250 to prevent hypoglycemia
3. Replace potassium prophylactically with IV fluids
   - Monitor/replete K, Mg, Phos
4. Bicarb replacement controversial, not necessary in most cases

Question 31

NKH management?

Answer 31

1. Fluid replacement most important - NS, switch to half NS when stable, add 5% glucose once blood glucose reaches 250 mg/dL to prevent hypoglycemia
2. 5-10 unit bolus insulin, then low dose infusion 2-4 units/hr

Question 32

Basic management of blood glucose in the hospitalized patient?

Answer 32

Insulin sliding scale of regular insulin doses based on finger-stick
Monitor blood glucose Q4x daily

Question 33

HTN goals in DM

Answer 33

SBP <140
SBP <130 if can be achieved without undue treatment burden
DBP <90

At least one anti-HTN med at bedtime

Question 34

Lipid goals in DM

Answer 34

LDL <100 if no overt CVD
If CVD or 40+ with 1+ risk factor, LDL <70
HDL >40
TG <150
TC<200
LDL targeted statin therapy is preferred strategy

Question 35

Mechanism of metformin?

Answer 35

Decreased hepatic glucose output via decreasing glycogenolysis and gluconeogenesis

Question 36

How are microvascular complications evaluated?

Answer 36

Eye exam
Microalbumin
Foot care

Question 37

How are macrovascular complications evaluated?

Answer 37

Carotid Doppler

ABI

Question 38

Which patients with DM should get aspirin for primary prevention?

Answer 38

Patients with DM1/2 at increased CV risk