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+ Therapeutics 2 Tutoring Sarah Darby [email protected] November 4, 2016 + Lectures Covered Diabetes + Diabetes FR is a 58 yo WF. BMI = 32. PMH: HTN, asthma, PCOS, hx of gest. diabetes, hysterectomy. She lives alone, works long days at a desk job, and spends her evenings binging on Netflix. How many risk factors for DM does she have? A. 4 B. 5 C. 6 D. 7 + Diabetes What is the role of insulin in lowering blood glucose? A. Insulin binds directly to glucose and transports it across the cell membrane of muscle and fat cells. B. Insulin binds to the insulin receptor, which stimulates GLUT4 to move to the cell membrane to allow glucose entry into the cell. C. Insulin binds to the GLUT4 receptor, which increases membrane permeability to glucose. + Diabetes Which of the following does not occur in the pathophysiology of T2DM? A. Decreased glucose uptake in muscle B. Increased glucose production in liver C. Increased lipolysis in adipocytes D. Decreased release of glucagon + Diabetes RW came to clinic this morning for a repeat fasting blood glucose measurement. Which of the following measurements would indicate he has diabetes? A. 95 mg/dL B. 105mg/dL C. 120mg/dL D. 134mg/dL + Diabetes JT’s physician has ordered an oral glucose tolerance test for him. At the 2 hour mark, JT’s glucose level is 175mg/dL. This does not confirm a diabetes diagnosis for JT. True False + Diabetes DC is in for his yearly check up. The nurse tells you that his blood glucose is 324mg/dL and he has complaints of increased thirst and fatigue. This does not confirm a diabetes diagnosis for DC. True False + Diabetes Which of the following patients does not have diabetes? A. 68 yo with SOB and RPG=170mg/dL B. 54 yo with polyuria and FPG=145mg/dL C. 57yo with 2HPG=220mg/dL D. 65 yo with dehydration and A1C=6.2% + Diabetes – diagnostic criteria Random + Sx ≥ 200 mg/dL 2 hours after OGTT ≥ 200 mg/dL Fasting ≥ 126 mg/dL A1C ≥ 6.5% + Diabetes MJ has been really off his game since retiring from the NBA. In clinic today, his fasting blood glucose measurement was 123mg/dL. What diagnosis can be made? A. Impaired glucose tolerance + diabetes B. Impaired fasting glucose + diabetes C. Impaired glucose tolerance + pre-diabetes D. Impaired fasting glucose + pre-diabetes + Pre-Diabetes – diagnostic criteria Impaired fasting glucose 100-125mg/dl Impaired glucose tolerance 140-199mg/dl A1C 5.7-6.4% + Diabetes KM is presenting for her first prenatal visit. Her fasting blood glucose level = 155mg/dl. What diagnosis can be made? A. Pre-diabetes B. T2DM C. T1DM D. Gestational diabetes + Gestational Diabetes (24-28wks) One Step Two Step OGTT 75g OGTT 50g Measure glucose: Measure glucose: 1 hour Fasting 1 hour If ≥140mg/dL , continue… 2 hour OGTT 100g Measure glucose: 3 hours GDM if: ≥ 140 mg/dL First step is non-fasting. Second step is fasting. GDM if: Fasting ≥ 92 mg/dL 1 hour ≥ 180 mg/dL 2 hour ≥ 153 mg/dL *Requires 8 hour fast + Diabetes HH is a 50 yo WF who recently had a FPG of 114mg/dL. Her BMI is 38. Which is the least appropriate recommendation? A. Exercise 150min/week B. Lose 7% of body weight C. Initiate Metformin D. Initiate insulin + Diabetes – goals Non-pregnant Gestational diabetes Pregnant w/ preexisting diabetes A1C Pre-prandial Peak postprandial <7.0% 80–130 mg/dL <180 mg/dL Fasting and preprandial 1 hour postprandial 1 hour postprandial ≤95mg/dL ≤140mg/dL ≤120mg/dL A1C Pre-meal, bedtime, overnight Peak postprandial <6% 60-99mg/dL 100-129mg/dL + Diabetes PK has recently been diagnosed with T2DM. When he measures his blood glucose before eating lunch, what is his goal? A. <100mg/dl B. 100-125mg/dl C. 80-130mg/dl D. 126-180mg/dl + Diabetes PK has recently been diagnosed with T2DM. When he measures his blood glucose 1-2 hours after his dinner, what is his goal? A. <200mg/dl B. <180mg/dl C. 80-130mg/dl D. <100mg/dl + Diabetes PK has recently been diagnosed with T2DM. What is the initial DOC for his therapy? A. Insulin B. Metformin C. Glipizide D. Pioglitazone + Diabetes Which agent has the highest risk of hypoglycemia? A. Metformin B. Glimepiride C. Pioglitazone D. Insulin + Diabetes Which agent does not cause weight gain? A. Glyburide B. Pioglitazone C. Insulin D. Exenatide + Diabetes Which agent is not considered to be low cost? A. Metformin B. Glipizide C. Canagliflozin D. Rosiglitazone + Diabetes After using max Metformin dosing and not achieving the desired A1C target, when do you add a second oral agent? A. 2 weeks B. 1 month C. 3 months D. 6 months + Diabetes Which of the following is not true about Metformin? A. It is excreted unchanged in the urine. B. It should be titrated upward to help alleviate GI upset/diarrhea. C. It may acutely increase vitamin B12 levels. D. It should be used with caution in alcoholics due to the risk of lactic acidosis. E. It should be discontinued before receiving iodinated contrast dyes. + Diabetes Which agents increase insulin secretion from the pancreas? A. Sulfonylureas B. Thiazolidinediones C. Metformin D. SGLT2 inhibitors + Diabetes Which of the following is not true about sulfonylureas? A. They should be D/C’d upon initiation of prandial insulin. B. First generation agents are as equally effective but have shorter half lives. C. All are metabolized to active metabolites. D. Important adverse effects include hypoglycemia and weight gain. E. One disadvantage is low durability. + Diabetes Which of the following is not an adverse effect of thiazolidinedione use? A. Heart failure B. Hepatic toxicity C. Acute renal failure D. Fractures E. Macular edema + Diabetes Which DPP-4 inhibitor does not require dose adjustments based on renal or hepatic function? A. Sitagliptin B. Saxagliptin C. Linagliptin D. Alogliptin + Diabetes Which agent increases urinary glucose excretion by reducing the reabsorption of filtered glucose? A. Canagliflozin B. Glyburide C. Pioglitazone D. Sitagliptin + Diabetes Which of the following is not true of SGLT2 inhibitors? A. They increase the risk of genital fungal infections. B. Their metabolism may be induced by phenytoin. C. They are safe in ESRD and dialysis. D. They may induce symptomatic hypotension. + Diabetes CH is visiting your clinic today to discuss medication therapy for his diabetes. His blood glucose levels have been all over the board lately. He often skips meals because he gets busy at work and forgets to eat. What might be a good treatment option for him? A. Glipizide B. Linagliptin C. Repaglinide D. Acarbose + Diabetes Which of the following agents is given SQ once weekly? A. Exenatide B. Liraglutide C. Albiglutide D. Dulaglutide E. A and B F. C and D + Diabetes Which of the following agents is given BID? A. Exenatide B. Liraglutide C. Albiglutide D. Dulaglutide + Diabetes In which patient should you avoid the use of GLP-1 agonists? A. 29 yo female on oral contraceptives B. 54 yo female with family hx of thyroid carcinoma C. 65 yo male with COPD D. 62 yo male with family hx of bipolar disorder + Diabetes Which agents have warning for use due to pancreatitis or hx of pancreatitis? A. GLP-1 agonists B. Sulfonylureas C. DPP-4 inhibitors D. SGLT-2 inhibitors E. A and C F. A and B + Diabetes Which of the following is not an advantage to GLP-1 agonists? A. Do not cause hypoglycemia B. Weight loss C. No GI side effects D. May decrease some CV risk factors + Diabetes Which of the following is not a rapid acting insulin? A. Lispro B. Detemir C. Glulisine D. Aspart + Diabetes Which is not an advantage to using analog insulin over regular insulin? A. More rapid onset of action B. Convenient administration C. Less variation in absorption D. Less expensive + Diabetes Which product has no peak of its action? A. Glargine B. Lispro C. Detemir D. Glargine concentrate + Diabetes PK (56kg) is starting insulin therapy with 4 injections daily. If we want his total daily dose to be 0.5 units/kg/day, what should his basal insulin dose be? A. 7 units HS B. 14 units HS C. 28 units HS D. 56 units HS + Diabetes KM (84kg) still has an A1C of 9.2% after being adherent on multiple oral medications. How do you start glargine? 0.1-0.2 units/kg/day A. 4.2 units HS B. 12 units HS C. 22 units HS D. 25 units HS + Diabetes KM (84kg) still has an A1C of 9.2% after being adherent on multiple oral medications. He started insulin glargine 12 units daily at his last visit. His BG diary shows fasting glucose levels of 140-160mg/dl. What do you recommend? A. Increase 2-4 units. B. Maintain therapy. C. Decrease 2-4 units. D. Discontinue. + Diabetes WH (60kg) has been taking detemir for the past 3 months and has controlled her fasting blood glucose levels. However, she now needs to start before meal insulin. What do you recommend? A. 2 units TID AC B. 6 units TID AC C. 12 units TID AC D. 18 units TID AC + Diabetes FT (60kg) has an A1C of 11.2% and is starting basal/bolus insulin along with metformin. Calculate his: Total daily dose (0.5 units/kg/day): 30units/d Basal dose: 30 units/2 = 15 units Bolus dose per meal: 15units/3=5 units/meal + Diabetes Basal Bolus Start 0.1-0.2 units/kg/d or 10 units 0.1 units/kg or 4 units Adjust Inc. 2-4 units or 10-15% Inc. 1-2 units or 10-15% Hypoglycemia Dec. by 4 units or 10-20% Dec. by 2-4 units or 10-20% + Diabetes Expected A1C changes Metformin 1-2% Sulfonylureas ~1-2% Thiazolidinediones 0.5-1.4% DPP-4 inhibitors 0.5-0.9% SGLT-2 inhibitors 0.7-1.0% GLP-1 agonists 1-1.5% Insulin 1.5-3.5% + Diabetes Which of the following is not an acute complication of diabetes? A. DKA B. HHS C. Hypoglycemia D. Peripheral neuropathy + Diabetes A patient has had T2DM for 10 years and has recently developed numerous UTIs due to a high post-void residual volume. This is an example of autonomic neuropathy. A. True B. False + Diabetes Which of the following is false regarding diabetic peripheral neuropathy? A. Pts with T2DM should be screened at diagnosis B. Pts with T1DM should be screened 10 years after diagnosis C. The screening test should be performed with a 10g monofilament D. Tight glycemic control can slow the progression of neuropathy + Diabetes Which agent has a level A recommendation for the treatment of diabetic peripheral neuropathy? A. Gabapentin B. Amitriptyline C. Pregabalin D. Tramadol + Diabetes Which of the following patients should be taking an ACE inhibitor or ARB? A. 33 yo female, T2DM, 2nd trimester of pregnancy B. 54 yo male, T2DM, no HTN C. 49 yo female, T2DM, no HTN, urine albumin 150mg/day D. 58 yo female, T2DM, HTN, urine albumin 320mg/day + Diabetes When this is elevated… Change this… BG before breakfast Adjust nightly basal dose BG before lunch Adjust morning bolus dose BG before dinner Adjust lunch bolus dose BG before bedtime Adjust dinner bolus dose + Therapeutics 2 Tutoring Questions? Sarah Darby [email protected] November 4, 2016