MKSAP 1: Disorders of Glucose Metabolism

Question 1

What are the classic symptoms of diabetes mellitus?

Answer 1

Polyuria, polydipsia, polyphagia or more commonly, asymptomatic

Question 2

What do the following guidelines say about screening for T2DM in asymptomatic adults? :

• USPSTF 2015 guidelines
• ADA Standards of Medical Care in Diabetes 2016

Answer 2

• USPSTF 2015: Adults aged 40 -70 years who are overweight or obese as part of cardiovascular risk assessment q3 yr for adults with normal plasma glucose
• ADA: all adults beginning age 45 regardless of weight; also for asymptomatic adults of any age who are overweight or obese and who have 1 or more risk factors for diabetes, q3 yr if normal

Question 3

What are the diagnostic criteria for prediabetes and diabetes?

Answer 3

RPG > 200 with classic hyperglycemic symptoms -> Diabetes
FPG 100 - 125 prediabetes; > 126 diabetes
OGTT 140 - 199 -> prediabetes; > 200 diabetes
A1C 5.7 - 6.4 -> prediabetes; > 6.5 diabetes
** FPG, OGTT and A1C need to be positive x3=2, RPG only once

Question 4

Which test best reflects the pathophysiology of diabetes?

What are the conditions that alter A1C?

Answer 4

OGTT

anemia, hemoglobinopathies, kidney or liver disease

Question 5

What do you do if two different tests are performed and only 1 has abnormal results?

Answer 5

ADA recommends repeating the test with the abnormal result

Question 6

What are the main categories of Diabetes?

Answer 6

Insulin deficiency
Insulin resistance
Other or rare types

Question 7

What are the main categories of insulin deficiency causing diabetes?

Answer 7

Immune mediated ( T1DM, LADA)
Idiopathic (seronegative)
Acquired (diseases of the exocrine pancreas, infections, drug related)

Question 8

What factors can lead to autoimmune mediated T1DM?

Answer 8

Combination of genetic, environmental, autoimmune factors.

One or more precipitating events such as viral infections can trigger destruction of beta cells

Question 9

What tests can confirm T1DM?

Answer 9

glutamic acid decarboxylase (GAD65)

tyrosine phosphatases IA-2

Question 10

You confirm T1DM in a patient and start them on insulin, they experience hypoglycemic episodes over this time. What is this called and what should be done?

Answer 10

Honeymoon phase when some of the beta cells regain their ability to produce insulin. Should titrate and decrease insulin doses

Question 11

Define LADA and what other conditions should be screened for an considered in these patients?

Answer 11

Late autoimmune diabetes in adults (LADA) presents in patients with autoantibodies to pancreatic beta cell antigens and beta cell destruction who did not require insulin initially but eventually progressed to an insulin requirement.
At risk for other autoimmune diseases such as thyroiditis and celiac disease

Question 12

What are the components of the criteria for metabolic syndrome?

Answer 12

impaired glucose metabolism
central body obesity
HTN
HLD

Question 13

What does the ADA recommend for prevention of T2DM?

Answer 13

IN high risk persons, consider metformin for prevention of T2DM particularly in patients younger than 60, have BMI > 35, of hx of gestational diabetes

Question 14

What does the ADA say about the preferred agent for management of T1DM and T2DM in pregnancy?

Answer 14

Insulin

Question 15

What are the screening guidelines for women in pregnancy?

Answer 15

For women wiht hx of gestational DM, diabetes screening using standard criteria should occur at 4 - 12 weeks postpartum and every 3 years thereafter

Question 16

What is MODY and when should it be expected?

Answer 16

Maturity onset diabetes of the young - autosomal dominant monogenetic defect that affects beta cell function but not insulin action.
Suspect in non-obese patients with strong fam hx of DM when the onset of diabetes occurs before 25 years of age in the absence of autoantibodies.

Question 17

What are the recommendations/indications for bariatric surgery for T2DM?

Answer 17

Appropriate surgical candidates with BMI > 40 (BMI > 37.5 in Asian Americans) regardless of the level of glycemic control or complexity of glucose lowering regimens.
Adults BMI 35 - 39.9 (32.5 - 37.4 in Asians) when hyperglycemia is inadequately controlled despite lifestyle and optimal medical therapy.
BMI 30-34.9 (27.5-32.4 in Asians) if hyperglycemia is inadequately controlled despite optimal medical treatment with either oral or injectable meds

Question 18

Name the insulins from shortest acting to long acting

Answer 18

Lispro, aspart, glulisine
Short acting (regular) insulin
Detemir
Glargine

Question 19

Which patients should be considered for insulin pumps?

Answer 19

in T1DM if adequate glycemic control is not achieved with adherence to MDI therapy
Significant early morning hyperglycemia (dawn phenomenon), labile plasma glucose values and frequent DKA, frequent severe hypoglycemia or hypoglycemic unawareness, preconception and pregnancy or active lifestyle/patient preference