TYPE 2 DIABETES MELLITUS Flashcards
1
Q
What are the standards of care for the management of type 2 diabetes (T2D) mellitus?
A
Both the American Diabetes Association (ADA) and the American College of Clinical Endocrinologists (AACE) have published evidence-based minimum standards of diabetes care.
These standards include recommendations on screening, diagnosis, classification, prevention, and management of diabetes, including lifestyle modifications, glycemic treatment, cardiovascular risk management, prevention and treatment of complications, and glycemic management in specific populations and practice settings.
2
Q
What should be included in a comprehensive evaluation of a patient with T2D?
A
A complete diabetes and medical history, family history, personal history of complications and common comorbidities, lifestyle and behavior patterns, glucose monitoring, medication history, and a complete physical examination.
This includes referral for an ophthalmologic examination and smoking cessation counseling, as well as laboratory data such as a lipid panel and liver function tests.
3
Q
What are the primary goals of therapy for people with T2D mellitus?
A
To prevent or delay the progression of long-term microvascular and macrovascular complications, alleviate symptoms of hyperglycemia, minimize hypoglycemia and other adverse medication effects, minimize treatment burden, and maintain quality of life.
These goals are supported by organizations like ADA and AACE.
4
Q
What is the recommended HbA1C target for most nonpregnant adults with T2D?
A
HbA1C < 7%
This target should be individualized based on patient-specific factors.
5
Q
What are the fasting plasma glucose (FPG) and postprandial glucose (PPG) target ranges for achieving an HbA1C target of < 7%?
A
FPG: 80 to 130 mg/dL
PPG: < 180 mg/dL (1–2 hours after the beginning of a meal)
These targets correspond with the recommended HbA1C target.
6
Q
What is the optimal HbA1C target according to AACE guidelines?
A
HbA1C ≤ 6.5% if achievable safely and affordably
This is a more aggressive target compared to ADA guidelines.
7
Q
What is the recommended FPG and 2-hour PPG target according to AACE guidelines?
A
FPG: < 110 mg/dL
2-hour PPG: < 140 mg/dL
These targets align with the AACE optimal HbA1C goal.
8
Q
True or False: Both ADA and AACE recommend comprehensive medical evaluations at each visit for T2D patients.
A
True
This includes assessment of comorbidities.
9
Q
Fill in the blank: The ADA Standards of Care are available at _______.
A
https://professional.diabetes.org/content-page/standards-medical-care-diabetes
This resource provides detailed guidelines for diabetes care.
10
Q
What laboratory data should be recommended at the initial visit for T2D patients?
A
Lipid panel, liver function tests, spot urinary albumin-to-creatinine ratio, serum creatinine, estimated glomerular filtration rate (eGFR), vitamin B12 (if on metformin), serum potassium (if on ACE inhibitor, ARB, or diuretic)
Annual follow-up is also recommended for these tests.
11
Q
What psychosocial aspects should be screened for in T2D patients?
A
Psychosocial conditions, self-management education needs, hypoglycemia, and pregnancy planning
These screenings are essential for comprehensive diabetes care.
12
Q
What was the UKPDS trial focused on?
A
The impact of intensive glucose control on long-term complications in patients with T2D
UKPDS stands for the United Kingdom Prospective Diabetes Study, which was a landmark trial conducted between 1977 and 1991.
13
Q
How many patients were recruited for the UKPDS trial?
A
5102 patients
Patients were newly diagnosed with Type 2 Diabetes (T2D).
14
Q
What was the average follow-up duration for UKPDS participants?
A
10 years
15
Q
What was the HbA1C level achieved in the intensive glycemic control arm of UKPDS?
A
7%
The conventional group achieved an HbA1C of 7.9%.
16
Q
What was the percentage reduction in diabetes-related complications due to intensive glycemic control in UKPDS?
A
12%
This was statistically significant (P = 0.029).
17
Q
What specific reduction was observed in microvascular complications in the intensive treatment arm of UKPDS?
A
25%
18
Q
Was there a significant reduction in ASCVD events in the intensive group of UKPDS?
A
Yes, but it did not quite reach statistical significance (P = 0.052)
ASCVD stands for Atherosclerotic Cardiovascular Disease.
19
Q
What long-term outcomes were observed 10 years after the UKPDS trial?
A
Significant long-term reduction in myocardial infarction (MI) and all-cause mortality
20
Q
What were the names of three additional studies conducted after UKPDS?
A
- ACCORD
- ADVANCE
- VADT
21
Q
What was the main finding of the ACCORD study regarding macrovascular complications?
A
No reduction in macrovascular complications despite lower HbA1C levels
The achieved mean HbA1C was 6.4% versus 7.5%.
22
Q
What was a significant risk associated with the intensive treatment group in the ACCORD study?
A
Increased risk of hypoglycemia
23
Q
What was the reason for stopping the ACCORD study early?
A
Increase in mortality in the intensive treatment arm
24
Q
Did the ADVANCE study show significant differences in ASCVD outcomes?
A
No significant differences
Achieved mean HbA1C was 6.3% versus 7%.
25
What did the ADVANCE study reveal about microvascular complications?
More intensive glucose control reduced microvascular complications
26
What were the results of the VADT regarding microvascular complications?
Suggested reduced microvascular complications
## Footnote
Achieved HbA1C was 6.9% versus 8.5%.
27
What conclusion can be drawn about intensive glycemic control from these studies?
The effort required for more stringent glucose control should be considered when setting targets.
28
Fill in the blank: The glycemic target recommendation for most nonpregnant adults with diabetes by the ADA is _______.
HbA1C < 7.0%
29
What is the fasting plasma glucose (FPG) target recommended by the ADA?
80–130 mg/dL
30
What is the postprandial glucose (PPG) target recommended by the ADA?
< 180 mg/dL
31
Fill in the blank: The glycemic target recommendation for most nonpregnant adults with diabetes by the AACE is _______.
HbA1C < 6.5%
32
What are the fasting plasma glucose (FPG) and postprandial glucose (PPG) targets recommended by AACE?
* FPG: 110 mg/dL
* PPG: 140 mg/dL
33
True or False: Glycemic targets should be individualized.
True
34
How should glycemic targets be determined?
Glycemic targets must be individualized based on patient-specific factors and the potential risks and benefits of treatment.
## Footnote
Factors include treatment-related risks, disease duration, life expectancy, comorbidities, established vascular complications, patient attitude, resources, and support systems.
35
What is the recommended HbA1C target for most nonpregnant adults with T2D?
An HbA1C < 7% is recommended by the ADA for most nonpregnant adults with T2D.
## Footnote
A more stringent goal (< 6.5%) may be appropriate for some patients if achievable without significant adverse effects.
36
In which patients may less stringent HbA1C goals (e.g., < 8%) be appropriate?
Less stringent goals may be appropriate for:
* Older patients
* Those with limited life expectancy
* Those with a long duration of diabetes
* Those with a history of severe hypoglycemia
* Those with extensive serious comorbidities or advanced complications.
37
What HbA1C goal is reasonable for healthy older adults?
An HbA1C goal of < 7.5% is reasonable for healthy older adults.
## Footnote
This may be adjusted for older adults with multiple chronic diseases or cognitive impairments.
38
What lifestyle modifications are recommended for patients with T2D?
All patients should participate in diabetes self-management education (DSME) and follow nutrition therapy goals.
## Footnote
DSME should occur at diagnosis, annually, when complicating factors arise, and during transitions of care.
39
What are the goals of nutrition therapy for patients with T2D?
Goals include:
* Promote healthy eating patterns
* Achieve and maintain body weight goals
* Achieve individualized glycemic, blood pressure, and lipid goals
* Delay or prevent complications of diabetes.
40
What should be the focus of healthy eating and meal plans?
Meal plans should focus on:
* Eating more nutrient-dense foods
* Eating less saturated fat and added sugar
* Eating a variety of foods
* Making half of grain consumption whole grains.
41
What weight loss is recommended for overweight or obese patients with T2D?
Weight loss of at least 5% of body weight should be recommended.
## Footnote
Evidence supports focusing on calorie intake reduction rather than macronutrient distribution.
42
How can carbohydrate counting help patients with T2D?
Carbohydrate counting can minimize postmeal glucose excursions by educating patients on carbohydrate sources and their effects on blood glucose levels.
## Footnote
The diabetes plate method can help identify reasonable carbohydrate intake per meal.
43
What is the recommended amount of physical activity for adults with T2D?
Adults should engage in 150 minutes or more of moderate-to-vigorous intensity aerobic activity per week.
## Footnote
No more than two consecutive days without activity.
44
What is the recommended physical activity for adults with T2D who are overweight or obese?
They should participate in 200 to 300 minutes of physical activity per week as part of a long-term weight maintenance program.
45
What is the first-line medical treatment for T2D?
Metformin
## Footnote
Metformin is a biguanide that decreases glucose production by the liver, reduces intestinal glucose absorption, and improves insulin sensitivity.
46
Why is metformin recommended as a first-line agent for T2D?
Effective, reduces CV outcomes, inexpensive, no long-term safety issues, does not cause hypoglycemia or weight gain
## Footnote
Supported by evidence from the UKPDS trial.
47
What is the recommended starting dose of metformin?
500 mg orally daily
## Footnote
The dose should be titrated up by 500 mg each week until a maximum of 2000 mg daily is achieved.
48
What is the target dose of metformin?
2000 mg/day
## Footnote
Usually given in two divided doses.
49
What are common gastrointestinal side effects of metformin?
Diarrhea, nausea, vomiting, flatulence
## Footnote
These side effects can be minimized by starting at a low dose.
50
How can the adverse effects of metformin be minimized?
Initiate at a low dose, titrate up, take with food, use extended-release preparations
## Footnote
Patients may see parts of ER tablets in stool.
51
What vitamin deficiency can occur with prolonged use of metformin?
Vitamin B12 deficiency
## Footnote
Monitoring of serum B12 levels is recommended every 2 to 3 years.
52
What are second-line medical options for the treatment of T2D?
SGLT-2 inhibitors, GLP-1 RAs, DPP-4 inhibitors, sulfonylureas, TZDs, basal insulin
## Footnote
These are used if metformin monotherapy is unsuccessful or not tolerated.
53
What is the renal dosing recommendation for metformin based on eGFR?
Indicated for eGFR ≥ 30 mL/min/1.73m2, not recommended for starting between 30 and 45 mL/min/1.73m2
## Footnote
If started, the dose should not exceed 1000 mg daily.
54
What are the mechanisms of action for metformin?
Decreases glucose production, reduces intestinal glucose absorption, improves insulin sensitivity
## Footnote
These actions contribute to its effectiveness in managing T2D.
55
True or False: Metformin can cause weight gain.
False
## Footnote
Metformin does not cause weight gain, making it preferable for many patients.
56
Fill in the blank: Metformin is available as fixed-dose combination products with several other oral agents, including _______.
sulfonylureas, TZDs, DPP-4 inhibitors, SGLT-2 inhibitors, meglitinides
## Footnote
Fixed-dose combinations can increase adherence and minimize pill burden.
57
What is the primary compound in the biguanides class?
Metformin
58
Name three second generation sulfonylureas.
* Glyburide
* Glipizide
* Glimepiride
59
What are the two thiazolidinediones (TZD) mentioned?
* Pioglitazone
* Rosiglitazone
60
List the Dipeptidyl peptidase-4 (DPP-4) inhibitors.
* Sitagliptin
* Saxagliptin
* Linagliptin
* Alogliptin
61
What is the mechanism of action for sodium-glucose cotransporter (SGLT)-2 inhibitors?
Inhibits SGLT-2 in the proximal nephron
62
Name the glucagon-like peptide (GLP)-1 receptor agonists.
* Dulaglutide
* Exenatide
* Exenatide XR
* Liraglutide
* Lixisenatide
* Semaglutide
63
What are the three basal insulin options listed?
* Degludec
* Detemir
* Glargine
64
What is the renal dosing recommendation for metformin if eGFR drops to 45?
Consider a maximum of 1000 mg daily
65
True or False: Glyburide should be avoided in renal impairment.
True
66
What is the maximum eGFR for initiating DPP-4 inhibitors like sitagliptin and saxagliptin?
50
67
What happens to insulin doses with decreased eGFR?
Lower insulin doses may be required
68
Fill in the blank: The primary physiologic action of metformin is to decrease _______ production.
Hepatic glucose
69
What does the activation of AMP kinase lead to?
Inhibition of hepatic glucose production and increased insulin sensitivity
70
What is the effect of closing KATP channels on beta cell plasma membranes?
Increased insulin secretion
71
What is the physiological effect of activating GLP-1 receptors?
* Insulin secretion (glucose dependent)
* Glucagon secretion (glucose dependent)
* Slows gastric emptying
* Increases satiety
72
What is the action of SGLT-2 inhibitors on glucose?
Blocks glucose reabsorption by the kidney, increasing glycosuria
73
Fill in the blank: The physiological action of thiazolidinediones includes activating the nuclear transcription factor _______.
PPARgamma
74
What is the effect of DPP-4 inhibition on incretin concentrations?
Increases postprandial incretin (GLP-1, GIP) concentrations
75
What is a sulfonylurea?
Oral agents that stimulate endogenous insulin secretion by pancreatic beta cells
## Footnote
Common examples include glipizide, glyburide, and glimepiride.
76
What are the primary effects of sulfonylureas?
Lower postprandial glucose (PPG) and positively affect fasting plasma glucose (FPG)
## Footnote
They are only useful in patients with some residual beta cell function.
77
What are the side effects of sulfonylureas?
Weight gain and hypoglycemia
## Footnote
Cross-reactivity with antibiotic sulfonamides is significantly low.
78
Which sulfonylureas are shorter acting?
Glipizide and glimepiride
## Footnote
They may cause less hypoglycemia compared to glyburide.
79
How is glyburide excreted?
Renally
## Footnote
Active metabolites may accumulate in patients with renal dysfunction.
80
What is a GLP-1 RA?
Agents that mimic the effects of endogenous incretins, specifically GLP-1
## Footnote
Also known as incretin mimetics.
81
What are the primary actions of GLP-1 RAs?
* Stimulating insulin secretion after eating
* Inhibiting glucagon release
* Slowing gastric emptying
## Footnote
These actions increase satiety and slow glucose absorption into the blood.
82
What is the risk of hypoglycemia with GLP-1 RAs?
Low when used as monotherapy or with other low-risk agents like metformin
## Footnote
Risk may increase when combined with agents known to cause hypoglycemia.
83
List some currently available GLP-1 RAs.
* Dulaglutide
* Exenatide (twice daily)
* Exenatide (once weekly)
* Liraglutide
* Lixisenatide
* Semaglutide
## Footnote
Liraglutide and lixisenatide are available in fixed-ratio combinations with basal insulin.
84
What are the most common side effects of GLP-1 RAs?
GI related, with nausea being the most common
## Footnote
Titration to target doses is important to minimize nausea.
85
What should be done if a patient experiences pancreatitis while using a GLP-1 RA?
The drug should be discontinued
## Footnote
If confirmed to be related to the GLP-1 RA, the patient should not be rechallenged with this drug class.
86
What is a DPP-4 inhibitor?
Agents that block DPP-4, increasing circulating levels of incretin hormones
## Footnote
They promote glucose-dependent insulin secretion and inhibit glucagon secretion.
87
How do DPP-4 inhibitors affect weight?
They are weight neutral
## Footnote
Unlike GLP-1 RAs, they do not promote weight loss.
88
List some examples of DPP-4 inhibitors.
* Alogliptin
* Linagliptin
* Saxagliptin
* Sitagliptin
## Footnote
All have similar glycemic efficacy.
89
What cardiovascular concerns are associated with DPP-4 inhibitors?
Generally neutral outcomes, but saxagliptin showed an increased risk of hospitalizations for heart failure
## Footnote
This has led to warnings about their use in patients at risk for heart failure.
90
What should be done if a patient develops pancreatitis while taking a DPP-4 inhibitor?
Discontinue the DPP-4 inhibitor
## Footnote
If implicated, a drug from this class should not be reused.
91
What rare side effect is associated with DPP-4 inhibitors?
Increased risk of joint pain
## Footnote
If this occurs, the DPP-4 inhibitor should be discontinued.
92
What is a SGLT-2 inhibitor?
SGLT-2 inhibitors prevent the kidneys from reabsorbing glucose from urine, leading to increased glucose excretion in urine and lowering both FPG and PPG
## Footnote
Other effects include modest weight loss and potential benefits for hypertension; side effects include urinary tract infections.
93
What are the common side effects of SGLT-2 inhibitors?
Increased risk of urinary tract and genital mycotic infections
## Footnote
These side effects arise from the increased glucose in urine.
94
Name some examples of SGLT-2 inhibitors.
* Canagliflozin
* Dapagliflozin
* Empagliflozin
* Ertugliflozin
95
What is a TZD?
TZDs are agents that target the peroxisome proliferator-activated receptor (PPAR) gamma and activate genes influencing glucose metabolism and fat storage
## Footnote
Examples include pioglitazone and rosiglitazone.
96
What is the mechanism of action of TZDs?
Improve insulin sensitivity in muscle and fat tissue and protect pancreatic beta cells.
97
What is the onset of action for TZDs?
Slow onset; full glycemic effects realized in several weeks.
98
What risk is associated with rosiglitazone?
Increased risk of myocardial infarction (MI) and death
## Footnote
This was identified in a meta-analysis.
99
What potential risk is associated with pioglitazone?
Potential increased risk of bladder cancer
## Footnote
Clinical trial data on this risk is inconsistent.
100
What is basal insulin?
Background insulin providing 24-hour glycemic control by suppressing hepatic glucose production.
101
When is basal insulin typically used?
In patients with T2D to supplement endogenous insulin production, especially if HbA1C is ≥ 10%.
102
Name some available basal insulins.
* Insulin degludec (U-100 and U-200)
* Detemir
* Glargine (U-100 and U-300)
* NPH
103
What are common side effects of basal insulin?
Hypoglycemia and weight gain.
104
What is the role of stepwise titration of basal insulin?
Minimizes the risk of hypoglycemia.
105
What are third-line classes of diabetes medications?
Less frequently used classes include meglitinides, alpha-glucosidase inhibitors, colesevelam, and bromocriptine.
106
What is the mechanism of action of meglitinides?
Enhance endogenous insulin secretion to reduce postprandial hyperglycemia.
107
How do meglitinides compare to sulfonylureas?
Meglitinides have a more rapid onset and are shorter acting.
108
What are common side effects of alpha-glucosidase inhibitors?
GI intolerance, including flatulence and diarrhea.
109
What is the effect of colesevelam on HbA1C?
Modestly improves HbA1C by 0.5%.
110
How does bromocriptine lower blood glucose?
By activating central dopamine-2 receptors and increasing insulin sensitivity.
111
True or False: Bromocriptine is commonly used in diabetes treatment.
False
## Footnote
Its high cost and side effect profile limit its use.
112
How should basal insulin therapy be initiated?
At a low dose of 10 units or 0.1–0.2 units/kg subcutaneously daily
## Footnote
This approach is taken for safety before titration.
113
By what percentage should basal insulin be titrated up?
By 10% to 15% (or 2–4 units) once or twice a week
## Footnote
This titration continues until the patient reaches the FPG target or a basal insulin dose of 0.5 units/kg.
114
What is the average daily insulin dose for people with T2D treated with insulin glargine U-100?
Around 45 units
## Footnote
This average can vary based on individual patient needs.
115
What is the 3-0-3 method in insulin titration?
If 3-day FPG average is above goal, increase by 3 units; if at goal, no change; if below goal, decrease by 3 units
## Footnote
This method helps guide insulin dosing adjustments.
116
What does 'EFFICACY' refer to in drug therapy for T2D?
The effectiveness of a drug in achieving desired outcomes
## Footnote
For example, Metformin and SUs have high efficacy.
117
Which drug therapy for T2D has a risk of hypoglycemia?
Sulfonylureas (SUs) and Basal Insulin
## Footnote
Other therapies like Metformin and DPP-4 inhibitors do not carry this risk.
118
What is the effect on weight for SGLT-2 inhibitors?
Weight loss
## Footnote
This contrasts with other therapies that may lead to weight gain.
119
What are the adverse effects of Metformin?
GI (diarrhea), B12 deficiency
## Footnote
These effects are important considerations in patient management.
120
True or False: Thiazolidinediones (TZDs) have a potential benefit for atherosclerotic cardiovascular disease (ASCVD).
True
## Footnote
Specifically, pioglitazone is noted for this potential benefit.
121
Fill in the blank: Insulin degludec doses should not be adjusted more frequently than every _______ days.
3 to 4
## Footnote
This is due to its longer half-life.
122
What should be done if a patient experiences hypoglycemia?
Reduce the basal insulin dose by 10% to 20% or 4 units
## Footnote
This adjustment helps manage blood sugar levels safely.
123
What is essential for patients who are unable or unwilling to self-titrate their insulin dose?
Close follow-up is needed
## Footnote
This ensures timely and effective insulin dosing adjustments.
124
When should insulin therapy be intensified?
If a patient does not reach HbA1C goal despite adequately titrated basal insulin
125
How can insulin therapy be intensified?
By adding an injection of rapid-acting insulin before the largest meal or changing to premixed insulin twice daily
126
What is the initial dose of rapid-acting insulin recommended before the largest meal?
4 units
127
How should the current basal dose be divided when switching to premixed insulin?
Two thirds in the morning and one third in the evening or one half in the morning and one half in the evening
128
What is the titration strategy for insulin doses?
Increase by 1 to 2 units or 10% to 15% once or twice a week until BG targets are achieved
129
What should be done if hypoglycemia occurs during insulin titration?
Decrease the dose by 10% to 20% or 2 to 4 units
130
If HbA1C goal is not achieved with initial strategies, what can be done?
Give rapid-acting insulin at the two largest meals or administer premixed insulin three times daily
131
What is a GLP-1 RA?
Glucagon-like peptide-1 receptor agonist
132
What are the benefits of adding a GLP-1 RA to basal insulin?
Provides complementary mechanisms, effective at any stage of disease, and may lower risk of adverse effects
133
What adverse effects are associated with basal insulin?
Hypoglycemia and weight gain
134
What effects do GLP-1 RAs have on weight?
Lead to weight loss
135
What does overbasalization refer to?
Continued use of escalating doses of basal insulin to target FPG without improvement in PPG or HbA1C
136
What is the total daily insulin requirement for most patients with T2D?
Approximately 1 unit/kg/day
137
What is the recommended insulin distribution for T2D patients?
50% basal insulin and 50% rapid-acting insulin with meals
138
What can happen if the 50/50 guideline for insulin distribution is violated?
Overbasalization occurs, potentially leading to peaks and hypoglycemia
139
When should the up-titration of basal insulin stop?
Once the FPG is in target range or total basal dose is 0.5 units/kg/day
140
What is SMBG?
Self-monitoring of blood glucose
141
Who requires SMBG?
Patients with T1D on intensive insulin regimens and those on medications that increase hypoglycemia risk
142
What is the role of SMBG in T2D?
It is only effective if results are used to modify management strategies
143
What should SMBG be used for in patients on basal insulin?
For basal insulin dose titration
144
What are the recommendations for metformin use in patients with CKD?
May be used with eGFR ≥ 30 mL/min/1.73 m2; not recommended to initiate with eGFR 30-45 mL/min/1.73 m2
145
What should be considered if a patient's eGFR falls below 45 mL/min/1.73 m2 while on metformin?
Discuss continued use and consider a half-maximal dose (1000 mg daily)
146
Which sulfonylurea is preferred in patients with impaired renal function?
Glipizide
147
Which DPP-4 inhibitor does not require renal dose adjustments?
Linagliptin
148
At what eGFR are SGLT-2 inhibitors not recommended?
Dapagliflozin and ertugliflozin not recommended below 60 mL/min/1.73 m2; canagliflozin and empagliflozin below 45 mL/min/1.73 m2
149
What should be monitored in patients receiving exenatide with a CrCl of 30 to 50 mL/min?
Careful monitoring when increasing from 5 to 10 mcg doses
150
What is the CrCl threshold for using lixisenatide?
Should not be used with a CrCl < 15 mL/min
151
Which diabetes medication classes should not be used in combination?
GLP-1 RAs and DPP-4 inhibitors
## Footnote
Both enhance circulating GLP-1 activity and do not show increased efficacy when combined.
152
What is the recommended action if a GLP-1 RA is initiated in a patient on 30 units of rapid-acting insulin daily?
Decrease the rapid-acting insulin dose by approximately 50%
## Footnote
This helps avoid additive prandial effects.
153
What is clinical inertia in diabetes management?
Failure to establish appropriate glycemic targets and escalate treatment
## Footnote
It leads to preventable complications and increased health care costs.
154
What are contributing factors to clinical inertia?
* Hesitation to start therapy early
* Fear of side effects
* Lack of provider support
## Footnote
These factors hinder proper monitoring and titration of medications.
155
What was the main finding of the Diabetes Prevention Program (DPP)?
Intensive lifestyle intervention reduced the incidence of T2D by 58% over 3 years
## Footnote
It focused on achieving 7% weight loss and 150 minutes of physical activity per week.
156
What was metformin's effectiveness in reducing the incidence of T2D compared to lifestyle modifications?
Metformin reduced the incidence of T2D by 31%
## Footnote
This makes it about half as effective as lifestyle modifications.
157
In which group was metformin as effective as lifestyle modifications?
Patients with BMI ≥ 35 kg/m2 and women with prior gestational diabetes
## Footnote
Metformin's effectiveness varies based on patient characteristics.
158
What are some pharmacologic interventions that have shown beneficial effects in preventing T2D?
* TZDs
* Alpha-glucosidase inhibitors
* GLP-1 RAs
* Orlistat
## Footnote
None of these agents are FDA approved specifically for diabetes prevention.
159
What does the current ADA standard recommend for patients with prediabetes?
Referral to an intensive behavioral lifestyle intervention program
## Footnote
This program should aim for 7% weight loss and at least 150 minutes of moderate-intensity physical activity per week.
160
What is the strongest recommendation for pharmacologic intervention to prevent or delay diabetes?
Metformin
## Footnote
It has the strongest efficacy and long-term safety evidence for diabetes prevention.
161
Fill in the blank: Clinical inertia negatively impacts patient care, including the development of preventable _______.
complications
162
True or False: Clinical inertia is only caused by patient-related factors.
False
## Footnote
Provider-related factors also contribute to clinical inertia.
163
What is the target HbA1C for most patients with type 2 diabetes?
7%
## Footnote
The target should be individualized based on patient characteristics.
164
What is the first-line therapy for type 2 diabetes?
Lifestyle modifications and metformin.
165
What is the initial dose of metformin for type 2 diabetes?
500 mg once daily.
166
What is the target dose of metformin for type 2 diabetes?
2000 mg per day (usually 1000 mg twice daily).
167
What is the most common side effect of metformin?
Diarrhea.
168
How can the side effect of diarrhea from metformin be minimized?
* Start at a low dose
* Titrate up slowly
* Take with food
* Use an extended-release (ER) formulation.
169
What is the initial goal for weight loss in overweight or obese patients with type 2 diabetes?
5% weight reduction.
170
How much physical activity is recommended for patients with type 2 diabetes?
At least 150 minutes per week of moderate to vigorous intensity exercise.
171
What dietary strategies should be encouraged for patients with type 2 diabetes?
* Decrease added sugars and solid fats
* Reduce portions
* Eat more vegetables
* Shift to whole grains and lower-fat dairy choices.
172
How often should HbA1C levels be checked after starting therapy?
After 3 months.
173
What should be done if the target HbA1C has not been achieved after 3 months?
Assess adherence and consider additional therapy.
174
What are second-line options to add to metformin?
* GLP-1 receptor agonists
* SGLT-2 inhibitors
* DPP-4 inhibitors
* Sulfonylureas
* Thiazolidinediones (TZDs)
* Basal insulin.
175
What factors should determine the addition of second-line therapy for type 2 diabetes?
* Presence of atherosclerotic cardiovascular disease (ASCVD)
* Glycemic efficacy
* Risk of hypoglycemia
* Effect on weight
* Ease of use
* Mechanism of delivery
* Cost
* Side effects.
176
Which agents have positive cardiovascular outcomes trial data for patients with type 2 diabetes and ASCVD?
* Liraglutide
* Empagliflozin
* Canagliflozin
* Semaglutide.
177
What should be done if initial therapies fail to achieve glycemic targets in patients with ASCVD?
Add liraglutide or empagliflozin to reduce cardiovascular mortality.
178
When is basal insulin recommended for patients with type 2 diabetes?
In patients with HbA1C ≥ 10% or those who cannot achieve glycemic targets despite first-line therapy.
179
What is the starting dose of basal insulin?
10 units (or 0.1–0.2 units/kg) once daily.
180
What should be done if fasting plasma glucose is controlled on basal insulin but HbA1C is not at goal?
Intensify therapy with the addition of either a GLP-1 RA or meal-time rapid-acting insulin.
181
What has been proven to prevent or delay the onset of type 2 diabetes in patients with prediabetes?
Intensive lifestyle modifications and metformin.
182
How effective is lifestyle modification compared to metformin in preventing type 2 diabetes?
Lifestyle modification is about twice as effective.
183
What is the recommended amount of weight loss and exercise for lifestyle modification in prediabetes?
* 7% weight loss
* 150 minutes of moderate-intensity exercise per week.
184
In which patients should metformin be considered in addition to lifestyle modification?
* BMI ≥ 35 kg/m2
* Age < 60 years
* Women with prior gestational diabetes.
