Diabetic Jeopardy

Diagnosis

100

What clinical test and corresponding values are needed to confirm a diagnosis of diabetes?

PG > 126 - fasting no caloric intake for 8 hours/ 2-hour PG > 200 during an OGTT/ A1C > 6.5%/ A pt with classic symptoms of hyperglycemia or hyperglycemic crisis, a random glucose > 200mg

200

Risk factors for developing diabetes?

A1C> 5.7% / First degree relative with diabetes / High risk race/ethnicity (AF, Latino, NA, Asian Pacific Islander) / Women diagnosed with GDM / Physical inactivity / HTN > 140/90 / HDL <35 and TG >250

300

What is glycosylated hemoglobin HbA1c?

The glycosylated hemoglobin test shows what a person's average blood glucose level was for the 2 to 3 months before the test.

400

True or False? African Americans may have higher A1C levels than non-Hispanic whites despite similar fasting and post- glucose load glucose levels.

African Americans may also have higher levels of fructosamine and glycated albumin and lower levels of 1,5-anhydroglucitol, suggesting that their glycemic burden (particularly postprandially) may be higher.

500

Which test catches the most diagnoses of diabetes?

The 2-h PG value diagnoses more people with diabetes. Followed by a fasting glucose cut point of >126 mg/dL (7.0 mmol/L) and lastly A1C cut point of >6.5% (48 mmol/mol)

Drug Classes

100

What is MOA of metformin?

Decrease hepatic glucose production

200

What is the MOA of sulfonylureas? Glyburide, Glipizide, Glimepiride

Increase insulin secretion

300

What is MOA GLP-1 receptor agonist? Liraglutide, Lixisenatide, Dulaglutide

Increases insulin secretion Decreases glucagon secretion Slows gastric emptying Increases satiety

400

What is MOA of SGLT2 Inhibitors? Canagliflozin,Dapagliflozin, Empaglifozin

Blocks glucose reabsorption by the kidney increasing glycosuria.

500

What is MOA of DPP-4 inhibitors?

Increases postprandial incretin concentration which reduces gastric emptying Increases insulin secretion Decreases glucagon secretion

Side Effects

100

Which drug classes are associated most with hypoglycemia?

Sulfonylureas and Meglitinides especially with insulin Meglitinides- Increase insulin secretion repaglinide, nateglinide

200

Which medications are associated with weight loss?

SGLT2 inhibitors, GLP-1 receptor agonist, Amylin mimetics Amylin mimetics- pramlinitides Decrease glucagon secretion Slows gastric emptying Increases satiety

300

What are s/s of hypoglycemia and treatment?

Symptoms: shakiness, irritability, confusion, tachycardia, hunger, blurred vision, headaches, trembling Treatment: 1. Check blood sugar (<70mg/dl) 2. Eat 15 grams of carbs 3. Wait 15 mins and recheck blood sugar

400

True or False? All diabetic patients should be on an ACE or ARB to protect their kidneys.

False: ACE and ARB’s are first line therapy for diabetic kidney disease. ACE inhibitor or ARB therapy has been demonstrated to reduce progression to more advanced albuminuria (>300 mg/g Cr) and cardiovascular events.

500

Long term use of this medication is associated with vitamin B12 deficiency.

Periodic measurement of vitamin B12 levels should be considered in metformin-treated patients, especially in those with anemia or peripheral neuropathy

Treatment

100

What initial monotherapy should be started at the diagnosis of diabetes?

Metformin Metformin may be safely used in patients with estimated glomerular filtration rate (eGFR) as low as 30 mL/min/1.73 m2

200

At what A1C should a patient begin dual drug therapy?

At A1C >9% consider metformin + Sulfonylurea, Thiazolidinedione, DPP-4 Inhihibitor, SGLT2 inhibitors, GLP-1 receptor, Insulin (basil)

300

At what A1C should insulin be considered? What is an appropriate starting dose?

For A1C > 10 or blood glucose greater than 300 consider combination therapy with basal insulin (glargine, detemir, degludec) Start with 10 units or 0.1-0.2 units/kg/day Adjust 10-15% or 2-4 units once or twice a week until FBG target is reached

400

What is the target glucose range for non-critically ill hospitalized patients?

A target glucose range of 140–180 mg/dLis recommended for the majority of non critically patients. Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for non critically ill patients with poor oral intake or those who are taking nothing by mouth.

500

If A1C is not controlled with basal insulin only which insulin or injection can be added to patient's medication therapy?

Add 1 rapid acting insulin injection before the largest meal 4 units or 10% of basal dose Add GLP-1 agonist Change to premixed insulin twice daily (breakfast and supper) Current basal dose into 2/3 AM and 1/3PM

Co-morbid Diseases

100

What is the blood pressure goal for diabetic patients?

Less than 140/90

200

What is 1st line therapy for diabetic neuropathy?

Either pregabalin or duloxetine are recommended as initial pharmacologic treatments for neuropathic pain in diabetes

300

What risk factors indicate that a patient should be placed on a high intensity statin?

ASCVD risk factors include LDL cholesterol >100 mg/dL (2.6 mmol/L), high blood pressure, smoking, chronic kidney disease, albuminuria, and family history of premature ASCVD.

400

At what age should should antiplatelet therapy (aspirin) be initiated diabetic patients?

Use aspirin therapy (75–162 mg/day) as as primary prevention include both men and women aged > 50 years with diabetes and at least one additional major risk factor: family history of premature ASCVD, hypertension, dyslipidemia, smoking, or chronic kidney disease/ albuminuria - who are not at increased risk of bleeding.

500

What immunizations should be recommended for all diabetic patients?

Annual Influenza, Pneumococcal Polysaccharide vaccine (PPSV23) and (PCV13), Hepatitis B vaccine