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Type 2 Diabetes Diagnosis/Prevention
Type 2 Diabetes Treatment
Type 2 Diabetes Treatment...GONE WRONG!!
TIA
Potpourri
100
Which of the following endocrinopathies are associated with diabetes mellitus? (choose all that apply) A) Cushing's Syndrome B) Acromegaly C) Pheochromocytoma D) Gastrinoma E) Glucagonoma
A) Cushing's Syndrome-cortisol B) Acromegaly-GH C) Pheochromocytoma-epi/norepi E) Glucagonoma-glucagon
100
Which of the following agents is most likely to produce weight loss in diabetics? a) sulfonylureas b) thiazolidinediones c) metformin d) GLP-1–receptor agonists e) α-Glucosidase inhibitors
Of all available agents used for the treatment of type 2 diabetes mellitus, the GLP-1–receptor agonists (exenatide and liraglutide)are most likely to result in weight reduction. Metformin is generally considered to be weight neutral with chronic use. Weight loss is not typically seen in patients treated with an α-glucosidase inhibitor. Weight gain is commonly seen in patients treated with insulin, sulfonylureas, meglitinides, and thiazolidinediones.
100
Which of the following antidiabetic agents is associated with an increased risk of MI? a) rosiglitazone (Avandia) b) sitagliptin (Januvia) c) pioglitazone (Actos) d) metformin (Glucophage) e) exenatide (Byetta)
A meta-analysis of 42 studies showed a 43% increased risk of myocardial infarction in patients taking rosiglitazone compared with other antidiabetic agents. Even though it is also a thiazolidinedione, a separate meta-analysis found that pioglitazone is associated with a significantly lower risk of death, myocardial infarction, and stroke among a broad population of patients with diabetes mellitus. It should be noted, however, that in June 2011, the FDA issued a drug safety alert reporting that use of pioglitazone for more than 1 year may be associated with an increased risk of bladder cancer. Intensive treatment with metformin in the UKPDS study was associated with a reduced risk of macrovascular complications. A higher risk of myocardial infarction has not been reported with either sitagliptin or exenatide, which are both incretin-based agents.
100
Common TIA mimics include which of the following (choose 2) ? a) seizure b) hypoglycemia c) migraine d) delirium
The most common TIA mimics include: seizure, migraine, metabolic disturbances, syncope. Mimics have gradual onset with non-specific symptoms.
100
The median age of diagnosis of Crohn's Disease is: a) 10-20 years b) 20-30 years c) 30-40 years d) 40-50 years
Median age of diagnosis of Crohn's Disease is 20-30 years.
200
Name the criteria for the metabolic syndrome.
Metabolic syndrome is a constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistance. Diagnostic criteria for metabolic syndrome, according to the National Cholesterol Education Program (Adult Treatment Panel III Guidelines), include the presence of three or more of the following: (1) obesity, with a waist circumference exceeding 102 cm (40 inches) in men or 88 cm (35 inches) in women; (2) blood pressure ≥130 mm Hg systolic and/or 85 mm Hg diastolic; (3) a fasting glucose level ≥110 mg/dL; (4) a serum triglyceride level ≥150 mg/dL; and (5) an HDL-cholesterol level <40 mg/dL in men or <50 mg/dL in women.
200
A sedentary, obese 55 y/o male with DM2 is on metformin, 500 mg BID, and has an A1C of 7.5 %. How should you counsel him about physical activity? (choose all that are true). A) Aerobic exercise will lower A1C at least 1 percentage point B) Resistance training will improve glycemic control C) Combined resistance and aerobic training will result in greater improvement in glycemic control than either method alone D) A minimum of 150 minutes/week of moderate intensity exercise is recommended E) Improved glycemic control is only achieved in exercising individuals who achieve a reduction in BMI
Both aerobic training and resistance training have both been shown to improve glycemic control. In a randomized, controlled trial, an aerobic exercise program consisting of three exercise sessions per week, consisting of up to 45 minutes per session at 70%–75% of the maximum predicted heart rate reduced hemoglobin A1c by 0.5 percentage points. A resistance training program performed three times per week improved hemoglobin A1c by 0.38 percentage points. Combined exercise training produced an additional improvement of 0.46 percentage points compared to aerobic training alone, and an improvement of 0.59 percentage points compared to resistance training alone. Notably, in patients with a baseline hemoglobin A1c <7.5%, significant glycemic improvement was observed only in those in the combined exercise training groups. The American Heart Association recommends that patients with type 2 diabetes mellitus accumulate a minimum of 150 minutes per week of moderate-intensity exercise and/or 90 minutes per week of vigorous-intensity cardiorespiratory exercise. Structured exercise interventions have been shown to lower hemoglobin A1c even with no significant change in BMI.
200
A 58-year-old male with type 2 diabetes mellitus comes in during the early afternoon for his annual physical examination. His current medication regimen consists of insulin glargine (Lantus), 18 units in the evening; glipizide (Glucotrol), 20 mg/day; metformin (Glucophage), 1000 mg twice a day; and acarbose (Precose), 100 mg three times a day. He suddenly becomes shaky, diaphoretic, and pale, and tells you he thinks it is because he skipped lunch before his appointment. Which of the following would be effective for managing this episode? (Mark all that are true.) A) Glucose tablets B) Sugar cube C) Orange juice D) Candy E) Glucagon injection
Acarbose, an α-glucosidase inhibitor, inhibits an enzyme present in the brush border of the proximal intestinal epithelium that breaks down disaccharides and more complex carbohydrates. As a result, if hypoglycemia were to occur in a patient on an α-glucosidase inhibitor, reversal requires either the consumption of glucose itself (as opposed to complex carbohydrates) or the injection of glucagon. Glucagon is released by the pancreas in response to hypoglycemia. It prompts hepatic conversion of glycogen into glucose.
200
Choose the 2 signs/symptoms most predictive of TIA versus TIA mimic. a) blurred vision b) memory loss/cognitive impairment c) unilateral paresis d) dysarthria e) headache
Unilateral paresis occurs in 58% of TIA versus 29% of TIA mimics. Dysarthria occurs in 20.6% of TIA versus 12% of TIA mimic. Memory loss occurs in 2-12% of TIA versus 18-26% of TIA mimic. Blurred vision occurs in 5.2% of TIA versus 21.8% of TIA mimic. Headace occurs in 2-36% of TIA versus 14-23% of TIA mimic. Odds ratio of TIA mimic for the following symptoms: Memory loss 9.17, HA 3.71, blurred vision 2.48, Unilateral paresis 0.35, transient monocular blindness 0.15, diplopia 0.14.
200
At what age is nocturnal urinary incontinence during sleep considered enuresis? What are the 2 medications approved by the FDA for treatment of enuresis?
Age 5. Imipramine, desmopressin.
300
In a patient with pre-diabetes, what is the first line treatment for prevention of progression to diabetes?
Lifestyle modification focusing on weight loss and physical exercise is regarded as first-line therapy for preventing or delaying diabetes mellitus in patients with prediabetes. In the Diabetes Prevention Program (DPP), lifestyle modification (5%–10% weight loss and moderate physical activity of 30 min/day) was associated with a 58% reduction of risk for developing diabetes. Metformin can be considered for very high-risk individuals (elevation of both IFG and IGT and at least one other risk factor such as hemoglobin A1C >6%, hypertension, low HDL-cholesterol, elevated serum triglycerides, or family history of type 2 diabetes mellitus in a first degree relative); in the DPP it was associated with a 31% reduction in risk. It was most effective in patients with a BMI of at least 35 kg/m2 who were under age 60.
300
Which 3 are most effective for lowering hemoglobin A1C? a) Thiazolidinediones b) Metformin (Glucophage) c) Sulfonylureas d) Dipeptidyl-peptidase 4 inhibitors e) α-Glucosidase inhibitors
Metformin, sulfonylureas, and thiazolidinediones are the most effective monotherapy agents for treating hyperglycemia; they typically lower hemoglobin A1c by 0.9%–2.5%, 1.1%–3.0%, and 1.5%–1.6% respectively. Dipeptidyl-peptidase 4 inhibitors and α-glucosidase inhibitors are less effective agents, typically reducing hemoglobin A1c by 0.6%–1.3% and 0.8%, respectively.
300
Hypoglycemia can occur with which of the following diabetes treatments? a) Insulin b) thiazolidinedione-pioglitazone (Actos) c) biguanide-metformin (Glucophage) d) sulfonylureas-glipizide, glyburide e) meglitinides-repaglinide (Prandin) f) alpha-glucosidase inhibitor-acarbose (Precose)
Hypoglycemia is a well-known complication of insulin therapy. Since sulfonylureas and meglitinides work by enhancing insulin secretion, hypoglycemia is a complication of these two agents as well. Used alone, acarbose, metformin, and thiazolidinediones (e.g., pioglitazone) are not associated with the development of hypoglycemia. It should be noted, however, that in June 2011, the FDA issued a drug safety alert reporting that use of pioglitazone for more than 1 year may be associated with an increased risk of bladder cancer.
300
What is the first line therapy for prevention of stroke after TIA? a) blood letting b) Aggrenox (dipyridamole/aspirin) c) Plavix d) baby aspirin e) warfarin
baby aspirin
300
List the following: -City where the Birkie starts -City where the Birkie ends -Length of the Birkie skate race -Number of Birkies Dr. Scheibel has completed -The nationality of man who won the Birkie this year -How many Birkies have there been
-City where the Birkie starts: Cable -City where the Birkie ends: Hayward -Length of the Birkie skate race: 50K -Number of Birkies Dr. Scheibel has completed: 20 -The nationality of man who won the Birkie this year: Italian -How many Birkies have there been: 40
400
At what age should you start screening for DM2?
Screening is recommended in asymptomatic adults beginning at age 45 in the absence of risk factors, and should be repeated at least once every 3 years. Screening should be considered at an earlier age in patients who have a BMI ≥25.0 kg/m2 and additional risk factors, including physical inactivity, a first degree relative with diabetes mellitus, a history of gestational diabetes or of delivering an infant weighing more than 9 lb, belonging to certain racial/ethnic groups (e.g., Native Americans, African-Americans, Hispanics, Asians, South Pacific Islanders), hypertension, an HDL-cholesterol level <35 mg/dL, a serum triglyceride level >250 mg/dL, polycystic ovary syndrome, impaired fasting glucose or impaired glucose tolerance on previous testing, a history of cardiovascular disease, or other conditions associated with insulin resistance (e.g., acanthosis nigricans, severe obesity).
400
A 42-year-old female with a body mass index (BMI) of 31 kg/m2 has a 3-week history of polyuria and polydipsia, accompanied by a 10-lb weight loss. Her fasting plasma glucose level is 320 mg/dL, and her hemoglobin A1c is 11.1%. Which one of the following is most likely to reverse her glucose toxicity and improve her glycemic response? a) insulin b) metformin c) pioglitazone d) acarbose
High levels of glucose are toxic to pancreatic β-cells, leading to impairment of insulin secretion. Initial treatment with insulin not only allows for more rapid glycemic control, but also facilitates more rapid recovery of β-cell function. This in turn fosters an improved subsequent response to oral agents.
400
A 71-year-old male with a history of type 2 diabetes mellitus and long-standing hypertension sees you because of worsening ankle edema, weight gain, and “getting more winded” when climbing stairs. His current medications are glipizide (Glucotrol), 10 mg/day; pioglitazone (Actos), 30 mg/day; extended-release metformin (Glucophage XR), 1000 mg/day; acarbose (Precose), 25 mg three times a day; lisinopril (Prinivil, Zestril), 40 mg/day; and hydrochlorothiazide, 12.5 mg/day. Which one of his medications is most likely responsible for his symptoms? a) metformin b) glipizide c) pioglitazone d) acarbose
Weight gain and edema occur in 3%–5% of patients treated with thiazolidinediones. Because of their propensity to expand plasma volume, the use of these agents is contraindicated in patients with class III or IV heart failure. Two meta-analyses have shown an increased risk of heart failure in patients treated with pioglitazone and rosiglitazone. Following its review of post-marketing adverse event reports, the FDA announced on August 14, 2007, that the manufacturers of both of these agents agreed to add a stronger warning to the package insert about the risk of their products causing or worsening heart failure.
400
The risk of stroke in the 90 days after TIA is? a) 0-10% b) 10-20% c) 20-30% d) 30-40%
10-20% with one half occurring within the first 48 hours. Early initiation of treatment (medical and surgical) along with availability of TPA should stroke occur are possible reasons for admission.
400
Name the most reliable injection technique to achieve an intra-articular injection into the knee and give the percentage that will be intra-articular (+/- 8%). (orthopedic surgeon performing injection)
The lateral mid-patellar approach can achieve a rate of 93% intra-articular. The antero-medial and antero-lateral approach are inside the joint ~ 72% of the time.
500
A 55 y/o male with DM 2 presents with chronic decreased libido and ED. On exam you note testicular atrophy and hepatomegaly. Labs reveal fasting glucose of 245, mildly elevated LFTs, normal LH and FSH, and low testosterone. What is the diagnosis?
Hemochromatosis results from excessive iron storage. Its idiopathic form, seen primarily in European populations, is one of the most common autosomal recessive disorders. It arises from the massive deposition of iron in parenchymal tissues (especially the liver, pancreas, pituitary gland, and heart), causing fibrotic changes and functional impairment of the involved organs. Symptoms usually develop between the ages of 40 and 60 years. Classic clinical features include bronze skin pigmentation, diabetes mellitus, hepatomegaly with hepatic dysfunction, cardiac failure, and evidence of hypogonadism. Screening and greater awareness of the disease among clinicians has facilitated recognition of the disease at earlier stages; common symptoms now include fatigue, malaise, arthralgia, and hepatomegaly.
500
A 72-year-old African-American female with a history of hypertension, stage 3 chronic kidney disease, heart failure, and recurrent urinary tract infections is found to have type 2 diabetes mellitus. A trial of dietary therapy is unsuccessful. Her laboratory evaluation is notable for a random glucose level of 240 mg/dL, a hemoglobin A1c of 8.2%, macroalbuminuria, and a serum creatinine level of 2.4 mg/dL. Which one of the following diabetes agents would be most appropriate? a) Metformin (Glucophage) b) Glyburide (Micronase, DiaBeta) c) Pioglitazone (Actos) d) Repaglinide (Prandin)
Repaglinide is minimally cleared by the kidney and can be used safely in patients with even severe renal impairment. Metformin is contraindicated in female patients with a serum creatinine >1.4 mg/dL. Sulfonylureas are metabolized by the liver and cleared by the kidneys and should be used cautiously in patients with hepatic or renal impairment. Glyburide, which has a prolonged duration of action and active metabolites, should be avoided in these patients. Thiazolidinediones are associated with fluid retention and can cause or exacerbate heart failure in some patients. In addition, it should be noted that in June 2011, the FDA issued a drug safety alert reporting that use of pioglitazone for more than 1 year may be associated with an increased risk of bladder cancer.
500
Mechanisms of action of exenatide (Byetta) include which of the following? (Mark all that are true.) a) Enhanced insulin secretion b) Suppression of glucagon secretion c) Enhanced insulin sensitivity of muscle d) Slowing of gastric motility e) Reduction of the rate of polysaccharide digestion in the small intestine
Incretin hormones, which include glucagon-like peptide 1 (GLP-1) and glucose-independent insulinotropic polypeptide (GIP), are released from the gastrointestinal tract after a meal. These hormones are responsible for 70% of postprandial insulin secretion. Exenatide is a synthetic GLP-1 that is administered subcutaneously twice a day and potentiates glucose-mediated insulin secretion. In addition, exenatide may lower blood glucose levels by suppressing glucagon secretion and slowing gastric motility. By lowering postprandial blood glucose levels, exenatide lowers hemoglobin A1c by 0.5–1.0 percentage points.
500
Five modifiable risk factors account for 82% of stroke. Name them.
1) HTN 2) current smoking 3) obesity 4) unhealthy diet 5) physical inactivity
500
Carotid artery stenosis is a risk factor for stroke. If a patient has relatively low surgical risk, what percentage of stenosis is considered an indication for carotid endarterectomy?
Carotid endarterectomy is indicated if stenosis is greater than 70% and surgical morbidity and mortality are estimated to be less than 6%. If stenosis is less than 50% medical management is indicated. From 50-70% patient factors must be considered.