Prediabetes
Diabetes and other stuff
All about the effects
Are you in-sulin or out?
Cases
100
What is the first treatment in a patient with prediabetes?
lifestyle interventions such as nutrition changes, physical activity, sleep hygiene
100
What medication would you start a patient with T2DM and heart failure?
SGLT2
100
What GFR would you avoid using metformin?
eGFR<30 and use with caution of CKD stage 3a/3b
100
How often do you titrate insulin to reach glycemic goal?
every 2-3 days
100
Your patient has symptomatic hyperglycemia, an A1C >10% and BG >300 mg/dL. What do you start them on?
Basal insulin should be started to reduce glucose as safely and promptly as possible.
200
What a1c range is classified as pre diabetes?
5.7-6.4
200
What medication would you start if patient had history of T2DM and stroke/TIA?
GLP1 or pioglitazone
200
Your patient tells you she has a history of medullary thyroid cancer. What medication class do you avoid?
GLP-1
200
How do you decide what dose of insulin to start a patient on?
If a1c <8%, 0.1-.2 U/kg
If a1c >8, TDD .2-.3 U/kg
200
Your patient has a1c>8 and weighs 80 kg. What dose would you start them on?
16 units
300
What surgery can be considered in patients with pre diabetes that are overweight or obese?
Bariatric surgery
300
What medication would you start if patient has T2DM and CKD?
SGLT2 or GLP1
300
Name 2 classes of medications that help with weight loss
GLP1
SLGT2
300
What reason would you add prandial insulin?
Glycemic goal is not met
Basal dose >0.5 kg/day
300
A 58-year-old gentleman working as a lawyer, known to have T2DM for 10 years, systemic hypertension, and dyslipidemia, is on tablet metformin 1 g twice daily, tablet glimepiride 4 mg twice daily, tablet sitagliptin 50 mg once daily, tablet telmisartan 40 mg once daily, and tablet atorvastatin 10 mg bedtime. His biochemical evaluation shows fasting plasma glucose of 210 mg/dl, postprandial plasma glucose of 280 mg/dl, and HbA1c of 8.5%. What would you advise?
This individual has uncontrolled T2DM despite being on maximum dose of oral glucose-lowering agents (OGLAs). Augmentation therapy with basal insulin analog such as glargine or detemir can be advised at bedtime with an initial dose of 10 units or 0.2 U/kg in addition to the current OGLAs. He should also be educated on self-monitoring of blood glucose (SMBG) and titration of insulin dose to target the fasting glucose of 80–120 mg/dl and postprandial glucose of 120–140 mg/dl. If on subsequent follow-up, the postprandial sugars show rising trend or if HbA1c >7%, he can be started with premixed insulin at an initiation dose of 0.3 unit/kg/day with the total dose split into 2/3rd before breakfast and 1/3rd before dinner and subsequently titrated based on SMBG.
400
What two medications can you start if a patient is overweight or obese with a goal weight loss >7%-10%?
GLP-1
Phenteramine/topirimate
400
What medication has benefit for a patient with fatty liver?
GLP1
SGLT2 has potential benefit
TZD has benefit
400
Which 2 classes of medications have high hypoglycemic risk?
Insulin
Sulfonylurea
400
How do you begin prandial insulin?
Begin before the largest meal (10% of basal or 5 units)
400
A 38-year-old woman diagnosed to have type 2 diabetes for 6 years, well controlled on tablet metformin 1 mg twice daily and tablet gliclazide 40 mg twice daily, is admitted with autoimmune hemolytic anemia. She is now started on tablet prednisolone 60 mg/day. Blood glucose monitoring in the ward shows fasting glucose of 360 mg/dl and postprandial glucose of 420 mg/dl, with negative urine ketones. What would you advise?
this patient needs insulin therapy either in the form of basal bolus insulin regimen which would be ideal or twice daily premixed insulin at an initial dose of 0.3–0.5 U/kg/day with subsequent dose titration based on SMBG.
500
What medications can you start if a patient is NOT overweight or obese?
Metformin
Pioglitazone
Acarbose
500
What medication would you start for a patient with T2DM, heart disease who is already on a statin and you now find has TAG >135?
Icosapent ethyl
500
In what order from least to most effective do the following classes of medications lower glucose levels?
GLP1, metformin, insulin
Metformin, GLP1, insulin
500
If your patient is having hypoglycemic episodes, by what percent do you reduce insulin?
If Bg <70, 10-20%
500
67-year-old postmenopausal woman was diagnosed to have T2DM 4 years back and is currently on maximal-tolerated dosage of metformin. Her glycemic levels for the past few weeks have not been controlled well with only metformin and needs suggestion for an additional oral antidiabetic agent. The only other comorbidity she had was related to her osteoporosis. She had a fragility fracture recently and is currently on calcium, Vitamin D, and bisphosphonates for prevention of further fractures. She is a lean, frail-looking woman who stays alone in a flat and manages her other daily activities by herself. Which oral antidiabetic agents will best suit her in her current situation?
DPP4 such as sitagliptin
Pioglitazone and SGLT2 inhibitors are not ideal for her as they have shown to worsen osteoporosis. Sulphonylureas are very potent and may not be wise to be used in an elderly woman who stays alone given a possible risk of severe hypoglycemia.