Endocrine Diabetes

Question 1

Hypoglycemia Whipples Triad

(3)

Answer 1

1. Symptoms suggestive of hypoglycemia
2. A documented low blood glucose level (<65)
   
   1. Need to ro lab error (FSG and plasma glucose both prone to false lows)
3. Improvement of symptoms and glucose levels by administration of glucose

hypoglycemia is a constellation of symptoms depending on the patient bc people’s baselines are different - runners have baseline blood sugars of 65

Question 2

Hypoglycemia Symptoms

Autonomic Symptoms (glucose <65)

• Adreno-Medullary-Neural-Sympathetic = Tr_____, anx_____, pal______
• Neural-Parasympathetic = H_____, sw______, para______

Neuroglycopenic symptoms (glucose <50)

• Glucose <50 = ____Ness, _____ vision, impaired cog_____ (leth_____, conf____)
• Glucose <30 = C____, Seiz______

Answer 2

Autonomic Symptoms (glucose <65)

• Adreno-Medullary-Neural-Sympathetic = Tremors, anxiety, palpitations
• Neural-Parasympathetic = Hunger, sweating, parasthesias

Neuroglycopenic symptoms (glucose <50)

• Glucose <50 = Weakness, Blurred vision, impaired cognition (lethargy, confusion)
• Glucose <30 = Coma, Seizures

long standing diabetics sometimes don’t feel low blood sugar so we really worry about Type 1’s especially - (Hypoglycemia awareness)

Question 3

Causes of Hypoglycemia

In a Medicated Individual

Drugs

• Ins_____
• Sulf_______ (especially in elderly!)
• Alc_____
• Others

Critical Illness

• Hepatic, renal, or cardiac failure
• S______ (including malaria)

Hormone deficiency

• Cor______
• Gluc_____ and epinephrine (in insulin-deficient diabetes mellitus)
• Severe ____thyroidism
• Adrenal ______

Non___ cell tumor

Answer 3

Drugs

• Insulin
• Sulfonylurea (especially in elderly!)
• Alcohol
• Others

Critical Illness

• Hepatic, renal, or cardiac failure
• Sepsis (including malaria)

Hormone deficiency

• Cortisol
• Glucagon and epinephrine (in insulin-deficient diabetes mellitus)
• Severe hypothyroidism
• Adrenal insufficiency

Nonislet cell tumor

• sulfonylureas are falling out of favor*
• Sulfonylurea + insulin is always a wrong answer - can especially precipitate hypoglycemia especially in elderly*

Question 4

Causes of Hypoglycemia

Seemingly Well Individual

Endogenous hyperinsulinism

• In_____oma (↑ _-peptide)
• Functional __-cell disorders (nesidioblastosis)
• Noninsulinoma pacreatogenous hypoglycemia
• Post gastric _____ hypoglycemia

Accidental, surreptitious, or malicious hypoglycemia

Artifactual hypoglycemia - poor peripheral ______

Answer 4

Endogenous hyperinsulinism

• Insulinoma (↑ C-peptide)
• Functional B-cell disorders (nesidioblastosis)
• Noninsulinoma pacreatogenous hypoglycemia
• Post gastric bypass hypoglycemia

Accidental, surreptitious, or malicious hypoglycemia

Artifactual hypoglycemia - poor peripheral perfusion

Question 5

Hypoglycemia- Variability

• Diabetes (1) >>> Diabetes (1), because:
  
  • Deficits in glucagon
  • Medication used more likely to precipitate hypoglycemia
  • Recurrent hypoglycemia can lead to hypoglycemic _______ (due to impaired counterregulatory system)
• DM1 patients receiving _____ therapy have a threefold increased risk of severe hypoglycemia
• ______ also more prone due to impaired counterregulatory mechanism and impaired appetite

Answer 5

• DM1 >>> DM2, because:
  
  • Deficits in glucagon
  • Medication used more likely to precipitate hypoglycemia
  • Recurrent hypoglycemia can lead to hypoglycemic unawareness (due to impaired counterregulatory system)
• DM1 patients receiving intensive therapy have a threefold increased risk of severe hypoglycemia
• Elderly also more prone due to impaired counterregulatory mechanism and impaired appetite

Question 6

Rule of 15s

(conscious patient)

=

Answer 6

When glucose < 70, start by

• 15G-20G CHO PO (e;g ½ cup orange juice, glucose tablets, hard candy, glucose paste).
• Recheck in 15 min, and repeat treatment if still < 100.

Question 7

Rule of 15s

(Severe hypoglycemia, unable to take PO)

=

Answer 7

• Give 20-50ml 50% dextrose IV then D5W IV infusion, to maintain blood glucose > 100mg/dl.
• Glucagon 1mg IM as initial therapy, if patients can’t take PO or no IV access.

All patient’s at risk for hypoglycemia should be given an Rx for glucagon (I give to all my Type 1 Patients for emergencies)

Question 8

Diabetes Transition of Care

Acute (2)

Subacute (1)

Chronic (2)

Answer 8

Question 9

(1) = ______ deficiency of insulin leading to state of starvation

(1) = ______ insulin deficiency and profound dehydration

Answer 9

Diabetic Ketoacidosis (DKA) = Significant deficiency of insulin leading to state of starvation

Hyperglycemic Hyperosmolar State (HHS) = Relative insulin deficiency and profound dehydration

Question 10

Causes of DKA

• ______ - (40%) – impaired insulin secretion or insulin resistance (DKA frequent presentation of COVID PNA)
• Inadequate insulin treatment or non_______ (25%).
• _____ -onset diabetes (15%)
• ________ diseases (MI, stroke) – increase in counterregulatory hormones
• Acute St_____
• Insulin pump f______

Answer 10

• Infection - (40%) – impaired insulin secretion or insulin resistance (DKA frequent presentation of COVID PNA)
• Inadequate insulin treatment or noncompliance (25%).
• New-onset diabetes (15%)
• Cardiovascular diseases (MI, stroke) – increase in counterregulatory hormones
• Acute Stress
• Insulin pump failure

Question 11

DKA Patho

Answer 11

Question 12

DKA Management

Answer 12

Question 13

Hyperglycemic Hyperosmolar State (HHS)

• ~33% new onset diabetics present with HHS
• Non-ad______ or in______ to receive medical therapy
• In______
• Often, a preceding ______ results in several days of increasing de_______.

Answer 13

• ~33% new onset diabetics present with HHS
• Non-adherence or inability to receive medical therapy
• Infection
• Often, a preceding illness results in several days of increasing dehydration.

Question 14

Hyperglycemic Hyperosmolar State Key Features

• Hyperglycemia Hyperosmolar State (HHS) is a metabolic derangement that occurs principally in patients with T__DM.
• Severe _______ and n_______ deficits.
• Characterized by hyperglycemia, _____osmolarity, _____ketosis
  
  • (BUT ketosis ≠ Type 1).
• HHS and DKA can overlap!
  
  • “Ketosis Prone”
  • SGLT2
  • Infection (lots of DKA in COVID-19)

Answer 14

• Hyperglycemia Hyperosmolar State (HHS) is a metabolic derangement that occurs principally in patients with T2DM.
• Severe dehydration and neurologic deficits.
• Characterized by hyperglycemia, hyperosmolarity, minimal ketosis
  
  • (BUT ketosis ≠ Type 1).
• HHS and DKA can overlap!
  
  • “Ketosis Prone”
  • SGLT2
  • Infection (lots of DKA in COVID-19)

Question 15

HHS Patho

Answer 15

Question 16

HHS Management

Answer 16

Question 17

Treating Diabetes in the Acute/Subacute Setting

• Most anti-diabetic oral agents _____ while hospitalized
• Until more data is available Type 1 and Type 2 Diabetes are often treated similarly though are different diseases.
• Several unavoidable problems:
  
  • Diabetic meal? (“consistent carb”)
  • Unpredictable procedures
  • Patient “refusal” of insulin
  • Change in patient appetite
  • Steroids
  • Dialysis
  • Infections
  • Outside meals…

Answer 17

• Most anti-diabetic oral agents stopped while hospitalized
• Until more data is available Type 1 and Type 2 Diabetes are often treated similarly though are different diseases.
• Several unavoidable problems:
  
  • Diabetic meal? (“consistent carb”)
  • Unpredictable procedures
  • Patient “refusal” of insulin
  • Change in patient appetite
  • Steroids
  • Dialysis
  • Infections
  • Outside meals…

Question 18

Treating Diabetes in the Subacute Setting

Should we use sliding scales?

Answer 18

• Sliding scales are an antiquated and dangerous way to manage sugar control in any setting:
  
  • By definition, giving insulin based upon pre-meal glucose is reacting to high sugars that have been present since the previous meal

Question 19

Basal-Bolus Insulin

How much insulin a day should Type 1 DM, and organ failure patients receive (CHF, ESRD, liver failure)?

How much insulin a day should stable type 2 DM patients get?

Basal Insulin ___-____% of TDD

How much percentage of the total daily dose of insulin should be bolus insulin (the insulin we give in addition to basal insulin for meals)?

Answer 19

0.2-0.3 units/kg/day in Type 1/End organ failure

0.5 units/kg/day in stable medical patients with Type 2 DM

Basal Insulin 40-50% of TDD

Bolus Insulin should be 50-60% of TDD

Question 20

Diabetes Management

Target glucose for majority of patients =

• Basal Insulin without bolus may be preferred in many patients. DPP4s are safe in the hospital and may be added in many for post-prandial control
• Basal plus bolus (with meal) insulin is essential for patients with Type __ Diabetes and a diabetes specialist should always be consulted to comanage
• If they have insulin pump sometimes best for patient to manage glucose
• Never ____ basal insulin in a Type 1 Diabetic even if not eating!!
• B____/_______ insulin remains standard of care for most diabetics whether they have Type 1 or Type 2 Diabetes.

Answer 20

Target glucose 140-180 for majority of patients

• Basal Insulin without bolus may be preferred in many patients. DPP4s are safe in the hospital and may be added in many for post-prandial control
• Basal plus bolus (with meal) insulin is essential for patients with Type __ Diabetes and a diabetes specialist should always be consulted to comanage
• If they have insulin pump sometimes best for patient to manage glucose
• Never stop basal insulin in a Type 1 Diabetic even if not eating!!*
• Basal/Bolus insulin remains standard of care for most diabetics whether they have Type 1 or Type 2 Diabetes.

Question 21

Diabetes and COVID

Is a higher A1C associated with increased mortality when hospitalized for covid?

Does diabetes increase risk for mortality when hospitalized for covid?

Mortality rate is close to 50% higher in those with covid-19 presenting with ___

Hyperglycemia is now further compounded/complicated by positive outcome data on high dose ______ and mortality

Answer 21

Pre-hospitalization A1c – unclear tight glycemic control changes outcomes, A1c NOT associated with mortality, Tight glycemic control in hospital may be beneficial however no data is available to show that tight glycemic control during hospitalization changes outcomes

Compared to pt without diabetes, individuals with diabetes showed higher levels of IL-6, ferritin, hsCRP and ddimer upon admission, overall mortality 33.1%

Mortality rate is close to 50% higher in those with covid-19 presenting with DKA

Hyperglycemia is now further compounded/complicated by positive outcome data on high dose dexamethasone and mortality

Question 22

Types of Diabetes

1. Type 1 diabetes =
2. Type 2 diabetes =
3. _______ Diabetes Mellitus (GDM)
4. Other specific types of diabetes due to other causes:

• ____genic diabetes syndromes (>20 types)
• Diseases of the exocrine pancreas, e.g., cystic ____ , chronic p_______
• D____- or chemical-induced diabetes
• In_______ disease (ie hemochromatosis)

Answer 22

1. Type 1 diabetes = β-cell destruction
2. Type 2 diabetes = Progressive insulin secretory defect
3. Gestational Diabetes Mellitus (GDM)
4. Other specific types of diabetes due to other causes:

• Monogenic diabetes syndromes (>20 types)
• Diseases of the exocrine pancreas, e.g., cystic fibrosis, chronic pancreatitis
• Drug- or chemical-induced diabetes
• Infiltrative disease (ie hemochromatosis)

Question 23

Old Paradigms

• Type 1 Diabetes use to be thought of as
  
  • Age?
  • Insulin?
  • Onset
• Type 2 Diabetes use to be thought of as
  
  • Age?
  • Insulin?
  • Onset?

Answer 23

• Type 1 Diabetes use to be thought of as
  
  • Young <20
  • Insulin dependent
  • Abrupt
• Type 2 Diabetes use to be thought of as
  
  • Older >60
  • May not need insulin
  • Insidious Onset

Question 24

New Paradigms

What has changed? Why?

Obesity higher in what populations? what income? What education levels?

Answer 24

• We are now seeing older patients with type 1 and younger patients with type 2 because more obesity over the past 20 years = More diabetes*
• Obesity higher in Hispanic/Black ethnicity, Obesity higher in lower income, Obesity higher in those with lower levels of education*

Question 25

Metabolic Syndrome and Diabetes =

Answer 25

* *87% of patients with diabetes have metabolic syndrome* * *Obesity and diabetes should not be thought of as two separate diseases - they largely overl*

Question 26

Normal Regulation of Glucose

Answer 26

Question 27

Hyperglycemia Patho

Answer 27

Question 28

Diabetes Patho Overtime what happens what builds up in the body? leading to?

Answer 28

*Eventually overtime, there is a buildup of inflammatory factors that leads to cardiovascular disease*

Question 29

Natural History of Type 2 Diabetes What happens with B cells? What happens with the body's response to insulin?

Answer 29

Beta Cell Dysfunction Insulin Resistance

Question 30

What needs to happen before a patient with type 2 diabetes even presents with hyperglycemia?

Answer 30

*Many things happen before a patient even presents with hyperglycemia → diabetes does NOT start with hyperglycemia → there are many variables which is why we have many tools/medications to use when treating diabetes*

Question 31

Managing Diabetes

Answer 31

Question 32

Dietary Changes Which diet is most effective? * A reduced-\_\_\_\_\_\_diet is effective at weight loss but hard long term * \_\_\_\_genic diet may be effective but needs more study * Being wary of _____ fixes

Answer 32

**Mediterranean Diet** most effective * A reduced-calorie diet is effective at weight loss but hard long term * Ketogenic diet may be effective but needs more study * Being wary of quick fixes

Question 33

Exercise and Activity How much exercise a week? But stress importance that?

Answer 33

**150 minutes a week of moderate-intensity physical activity is a goal** Stress importance of ANY physical activity better than none

Question 34

FDA Approved Obesity Drugs (4)

Answer 34

Orlistat Liraglutide/Semiglutide Phentermine-topiramate Bupropion-naltrexone * *orlistat bascially inhibits fat absorption and you end up with fatty stools - not great long term* * *With all of these meds - they can't be suddenly stopped* * *given for a 1 year and weight is lossed then they are stopped bc not approved by insurance for chronic therapy and they gain all the weight back* * *ozempic (semiglutide) - new and looking pretty good - not shown in chart*

Question 35

Bariatric Surgery and Weight Loss Overall difference between control and bariatric surgery? Which type of bariatric surgery has highest long term percentage weight loss?

Answer 35

Compared with control, better overall weight loss Gastric bypass best overall weight loss compared to other bariatric surgeries

Question 36

Type 2 DM Pharmacotherapy History * *\_\_\_\_\_\_ were mainstay for a long time* * *Biguanide = ______ then approved in the 90’s* * *In 2015, order of which medications to choose from was not clear → we started with _____ and then it came down to c\_\_\_\_ and tol\_\_\_\_\_\_ when adding other medications*

Answer 36

* *Sulfonylureas were mainstay for a long time* * *Biguanide = metformin then approved in the 90’s* * *In 2015, order of which medications to choose from was not clear → we started with metformin and then it came down to cost and tolerability when adding other medications*

Question 37

Diabetes Medications

Answer 37

Question 38

Diabetes Medications and Effect on Weight Which Diabetes medications cause weight gain? (3) Which Diabetes medications are best at causing weight loss? (2)

Answer 38

* Insulin, Sulfonylureas, and Meglitinides (glinides) CAUSE WEIGHT GAIN* * GLP-1 analogues and SGLT inhibitors BEST AT CAUSING WEIGHT LOSS*

Question 39

Potential CVD Benefits of Metformin * **MI ______ 39% c/w conventional rx** * **All cause mortality ______ 36%** * *Metformin is better than _____ at decreasing MI risk*

Answer 39

* **MI reduced 39% c/w conventional rx** * **All cause mortality reduced 36%** * *Metformin is better than sulfonylureas at decreasing MI risk*

Question 40

Sulfonylureas MOA

Answer 40

Stimulate release of insulin from pancreatic beta cells

Question 41

Sulfonylureas Pros * ______ (*for uninsured is sometimes the only option)* * Sometimes benefits “\_\_\_” Type 2 Diabetics * Drug of choice for ______ Diabetes

Answer 41

* Cheap (*for uninsured is sometimes the only option)* * Sometimes benefits “old” Type 2 Diabetics * Drug of choice for Monogenetic Diabetes

Question 42

Sulfonylureas Cons (3)\* * Risk of hypoglycemia increases with * ____ (consider __ if patient is \>70) * In\_\_\_\_ * R\_\_\_\_and H\_\_\_\_\_dysfunction * Potentiating effects of alcohol and drugs in common use * Rare \_\_\_\_\_toxicity, allergic rxn

Answer 42

**Hypoglycemia** **Weight Gain** **Cardiovascular Toxicity?** * Risk of hypoglycemia increases with * Age (consider dc if patient is \>70) *risk of hypoglycemia gets worse with age* * Insulin * Renal and hepatic dysfunction * Potentiating effects of alcohol and drugs in common use * Rare hepatotoxicity, allergic rxn

Question 43

Thiazolidinediones (2)

Answer 43

Pioglitazone Rosiglitazone

Question 44

Thiazolidinediones MOA

Answer 44

Reducing circulating fatty acid concentrations and lipid availability in liver and muscle, the drugs improve the patient's sensitivity to insulin *A complex drug - acts in liver and improves insulin signaling, decreases inflammation in walls of arteries = lot of potential good so do not discontinue this*

Question 45

Thiazolidinedione Pros Pleiotropic effects * Decreases _____ glucose production * Decreases liver \_\_\_\_\_ * Decreases NASH = * Increases _____ uptake * Decreases Ath\_\_\_\_\_\_\_ *Potent = brings down A1C by \_\_%*

Answer 45

Pleiotropic effects * Decreases hepatic glucose production * Decreases liver steatosis * Decreases NASH = Non-alcoholic steatohepatitis * Increases glucose uptake * Decreases Atherosclerosis *Potent = brings down A1C by 2%*

Question 46

Thiazolidinedione Cons/SE \_\_\_\_\_\_ often maligned with sister drug ______ (avandia) that has showed increased risk of \_\_\_- BUT pioglitazone is _____ TO USE Better _____ prevention of ______ events after ischemic stroke/TIA

Answer 46

Pioglitazone often maligned with sister drug rosiglitazone (avandia) that has showed increased risk of MI - BUT pioglitazone is SAFE TO USE Better secondary prevention of cardiovascular events after ischemic stroke/TIA

Question 47

GLP-1 Agonists (Incretins) MOA * ______ to degradation by DPP-4 * Enhance _____ _stimulated_ _____ secretion * ______ glucagon secretion (lowers HGP) (4)

Answer 47

Mimic the action of endogenous GLP-1 to enhance insulin secretion and inhibit glucagon secretion from pancreatic islet cells * Resistant to degradation by DPP-4 * Enhance _nutrient stimulated_ insulin secretion * Suppress glucagon secretion (lowers HGP Exenatide Liraglutide Dulaglutide *Semaglutide*

Question 48

GLP-1 Agonists (Incretins) Pros (2)

Answer 48

Modest Weight Loss Cardiovascular Risk Benefit

Question 49

GLP 1 Agonists Weight Loss ## Footnote **\_\_\_\_\_ weight loss** \_\_\_\_\_ gastric emptying Central anorectic effect = *Causes faster rise of after meal insulin surge bc in diabetes, there is a delay in GLP-1 signaling*

Answer 49

**Modest weight loss** Delays gastric emptying Central anorectic effect (*reduces appetite)* *Causes faster rise of after meal insulin surge bc in diabetes, there is a delay in GLP-1 signaling*

Question 50

GLP-1 Agonists (Incretins) CVD Reduction ## Footnote 13% reduction in MACE (M\_\_, st\_\_\_\_\_, CVD death)\*\* 22% reduction in CVD \_\_\_\_\*\* **CV RRR - dulaglutide (12%), liraglutide (13%), and _______ (26%)** **(3) has FDA indication for glycemic improvement for decreased MI, decreased CVA, and CV mortality**

Answer 50

13% reduction in MACE (MI, stroke, CVD death)\*\* 22% reduction in CVD death\*\* **CV RRR - dulaglutide (12%), liraglutide (13%), and semaglutide (26%)** **Liraglutide, Semaglutide, Dulaglutide has FDA indication for glycemic improvement for decreased MI, decreased CVA, and CV mortality** ***MACE = major adverse cardiovascular events***

Question 51

SGLT-2 Inhibitors MOA (3)

Answer 51

Reduces renal glucose reabsorption and increases excretion **Empagliflozin** **Canagliflozin** **Dapagliflozin**

Question 52

SGLT-2 Inhibitors Cons * Increased ______ infections (*yeast infection in women, give \_\_\_\_\_),* risk for Fournier’s \_\_\_\_\_\_ * U\_\_\_\_, Vag\_\_\_\_\_ * \_\_\_\_\_uria * H\_\_\_\_tension/dehydration - not practical in elderly or CKD * Euglycemic DKA * Increased risk of bone ______ (\_\_\_\_liflozin) * Increased rate of toe ______ (\_\_\_\_\_liflozin (invokana) black box warning) - *however most people have just accepted this risk bc the drug is so good*

Answer 52

* Increased genital infections (*yeast infection in women, give fluconazole),* risk for Fournier’s gangrene * UTIs, Vaginitis * Polyuria * Hypotension/dehydration - not practical in elderly or CKD * Euglycemic DKA * Increased risk of bone fractures (canagliflozin) * Increased rate of toe amputations (canagliflozin (invokana) black box warning) - *however most people have just accepted this risk bc the drug is so good*

Question 53

SGLT-2 Inhibitors * In general ____ tolerated * Improves ______ BP **Decreases ____ morbidity and mortality** * **14% reduction in Major Adverse Cardiovascular Events (MI, stroke, CVD death)** * **38% reduction in CVD death** **CV RR Canagliflozin and Empagliflozin (14%)** * **\_\_\_\_\_\_\_liflozin decreases RR for HF and mortality 17%** **FDA indication for empaglifozin and canagliflozin** * **Glycemic improvement** * **Decrease CV mortality**

Answer 53

* In general well tolerated * Improves systolic BP **Decreases CV morbidity and mortality** * **14% reduction in Major Adverse Cardiovascular Events (MI, stroke, CVD death)** * **38% reduction in CVD death** **CV RR Canagliflozin and Empagliflozin (14%)** * **Empagliflozin decreases RR for HF and mortality 17%** **FDA indication for empaglifozin and canagliflozin** * **Glycemic improvement** * **Decrease CV mortality**

Question 54

Medications FDA - CVD Approved (2) Classes (2) examples from each class

Answer 54

**GLP-1 agonists= Liraglutide (Victoza), Semaglutide (Ozempic)** **SGLT-2 inhibitors = Canagliflozin (Invokana), Empagliflozin (Jardiance)**

Question 55

**Other Medications needed for Type 2 Diabetes** * **Statins\* =** * **Blood pressure medications\* =** * **Aspirin =**

Answer 55

* **Statins\* for heart disease prevention ✔** * **Blood pressure medications\* to prevent death, MI, Stroke ✔** * **Aspirin = no overall benefit for primary prevention of first heart attack or stroke**

Question 56

2022 Type 2 Diabetes Guidelines 1. First line therapy = 2. If ASCVD high risk = 3. If HF+ = 4. If CKD+ =

Answer 56

1. First line therapy = Metformin 2. If ASCVD high risk = SGLT-2i or GLP-1 RA 3. If HF+ = SGLT-2 4. If CKD+ =SGLT-2 or GLP-1 RA

Question 57

2022 Type 2 Diabetes Guidelines 1. Minimize Hyperglycemia = 2. Promote Weight Loss = 3. Consider Cost and Access =

Answer 57

1. Minimize Hyperglycemia = 1. No/low inherent risk of hypoglycemia with DPP-4, GLP-1, SGLT2, TZD 2. Careful to choose sulfonylureas or basal insulin with lower risk of hypoglycemia 2. Promote Weight Loss =GLP-1 RA or SGLT-2i 3. Consider Cost and Access = Sulfonylureas, TZD, certain insulins

Question 58

Practice Question **52 yo woman with 10 yr hx of Diabetes presents to your office for initial visit** * She has an A1c of 11.6% * BMI 36 * FHx: diabetes in mother and father * Problems: Hypertension, HLD, Coronary Artery Disease, Fatty liver disease * She takes metformin, 90 units of Lantus at night and 10 units of novolog with meals * She wants to lose weight but seems to have lots of trouble though she is trying to watch what she is eating. What are your Recommendations? 1. Increase lantus to 120 units at night, continue metformin and novolog. 2. Recommend she “eat less” and ”exercise more” and tell her to check her sugars 4x daily 3. Discontinue all of her insulin and start Semaglutide, Empaglifozin and continue metformin 4. Refer for bariatric surgery 5. Add on Glimeperide to her regimen

Answer 58

Ans: 3

Question 59

Practice Question **A1C Target for most Adults should be** A. 8-9% B. 7-8% C. 6.5-7% D. \<6.5% E. As low as you can go F. It depends

Answer 59

Ans: C and F

Question 60

Treatment Goals Vary 1. High risk of hypoglycemia? 2. Newly diagnosed vs. long standing? 3. Long life expectancy? 4. No comorbidities? 5. No vascular complications? 6. What type of patient personality should you be more stringent with A1C target? 7. What type of resources and support system can you be more stringent with the A1C target?

Answer 60

1. High risk of hypoglycemia = less stringent 2. Newly diagnosed = more stringent 3. Long life expectancy = more stringent 4. No comorbidities = more stringent 5. No vascular complications = more stringent 6. What type of patient personality should you be more stringent with A1C target = highly motivated, excellent self-care capabilities 7. What type of resources and support system can you be more stringent with the A1C target = readily available social support * *Ie. treat a young athlete with diabetes to an A1C of 6* * *But an elderly patient with lots of hypoglycemia risk do not want such a low A1C*

Question 61

**Type 1 Diabetes** **=**

Answer 61

**Autoimmune destruction of pancreatic Beta Cells often leading to absolute insulin deficiency** *Pretty much: Type 1 diabetes will present to the ER (stage 3) and their pancreatic cells will have been completely destroyed within a week*

Question 62

Type 1 Diabetes Chronic Management **Incidence of type 1 DM** * Incidence of T1DM has been \_\_creasing worldwide by 2-5% * ~ 1 in 300 people in the US has Type 1 DM by age 18. * T1DM accounts for \_\_**-**\_\_% of all Diabetes **Inheritance of Type 1 Diabetes\* =**

Answer 62

* Incidence of T1DM has been increasing worldwide by 2-5% * ~ 1 in 300 people in the US has Type 1 DM by age 18. * T1DM accounts for 5-10% of all Diabetes. **Inheritance of Type 1 Diabetes\* =** *Low genetic component in type 1 compared to type 2*

Question 63

Antibodies in Type 1 Diabetes **(1) most specific** * \_\_\_\_\_-cell antibodies (ICA) * Insulin autoantibodies (IAA) * Tyrosine phosphatase (IA2) antibody * Zinc transporter 8 * *Sometimes will also check (1) = low levels shows a person is not making enough insulin* * *Usually will be th\_\_\_\_ and present with \_\_\_\_*

Answer 63

**Anti-GAD antibodies** * Islet-cell antibodies (ICA) * Insulin autoantibodies (IAA) * Tyrosine phosphatase (IA2) antibody * Zinc transporter 8 * *Sometimes will also check C-peptide = low c-peptide shows a person is not making enough insulin* * *Usually will be thin and present with DKA*

Question 64

Type 1 Diabetes Patho Match each description with each stage of Type 1 Diabetes 1. What stage do you feel symptomatic? 2. When are you still normoglycemic? 3. Rule of Thumb: “easy to treat” type 1 patients still? 4. Term for type of diabetics that have lost all beta cell activity (as well as alpha cell/glucagon?

Answer 64

1. Stage 3 2. Stage 1 3. “Easy to treat” diabetics still make insulin 4. “Brittle diabetics” have lost all beta cell activity and alpha cell/glucagon

Question 65

Type 1 Diabetes Management Who should be taking care of Type 1 Diabetes patients? Why?

Answer 65

**NPs, MDs, or DOs trained in endocrinology should manage type 1 DM** * Why? → tech continuously advancing, requires careful nutrition guidance, tailored follow up, regular familiarity with interpretation of complex data * *“I think type 1 diabetes should be managed by a specialist”*

Question 66

A Word About Nutrition **Type 2 DM** * Focus: weight loss * Restrict calories * Smaller portion sizes * Moderate CHO * Avoid concentrated sweets * Avoid saturated fat **Type 1 DM** * Focus: match (1) and (1) * Carb ______ vs. carb consistency * Balanced, “\_\_\_\_\_\_” diet

Answer 66

**Type 2 DM** * Focus: weight loss * Restrict calories * Smaller portion sizes * Moderate CHO * Avoid concentrated sweets * Avoid saturated fat **Type 1 DM** * Focus: match CHO (carbohydrate) and insulin * Carb counting vs. carb consistency * Balanced, “healthy” diet

Question 67

A Word About Insulin Therapy **Role of insulin in Type 2 DM?** * Basal alone (or __ insulin) may be appropriate * Often used with ____ meds * Some patients may require physiologic replacement * Starting dose at ____ U/kg if basal only used **Role of Insulin in Type 1 DM?** * (1) + (1) insulin dosing (always) * Multiple daily injections or insulin \_\_\_\_\_\_ * Starting dose _____ U/kg total daily dose

Answer 67

**Supplement** **endogenous insulin production** * Basal alone (or no insulin) may be appropriate * Often used with oral meds * Some patients may require physiologic replacement * Starting dose at 0.5 U/kg if basal only used **Attempt to** **“Replicate****” normal physiologic insulin secretion** * Basal + prandial insulin dosing (always) * Multiple daily injections or insulin pump * Starting dose 0.2 U/kg total daily dose

Question 68

Basis of Intensive Glycemic Control Intensive vs. Conventional therapy conclusions for Type 1 Diabetes *Long story short - after a 10 year cohort study comparing* *intensive vs. conventional therapy* *→ the earlier you get someone with type 1 DM to goal A1C → _____ the long term outcomes (treat e\_\_\_ and agg\_\_\_\_\_\_) →* *LESS R\_\_\_\_\_\_, LESS M\_\_\_\_\_\_\_\_\_, LESS C\_\_\_*

Answer 68

*Long story short - after a 10 year cohort study comparing* *intensive vs. conventional therapy* *→ the earlier you get someone with type 1 DM to goal A1C → better the long term outcomes (treat early and aggressively) →* *LESS RETINOPATHY, LESS MICROALBUMINURIA , LESS CVD*

Question 69

Insulin Regimen in Type 1 Diabetes Should mimic what pattern?

Answer 69

Mimics Normal Diurnal Insulin Pattern Basal insulin + Prandial Bolus Insulin doses with meals

Question 70

Advanced Carbohydrate Counting Becoming proficient in carb counting takes years of practice and requires regular follow-up with an endocrine specialist to keep on track * Basal insulin rates may require dynamic _____ throughout the day (ex\_\_\_\_\_, sl\_\_\_\_ pattern, m\_\_\_\_\_ cycle, work schedule) * Carb to insulin ratios may change due to any number of circumstances * Technology is constantly changing in this field…

Answer 70

Becoming proficient in carb counting takes years of practice and requires regular follow-up with an endocrine specialist to keep on track * Basal insulin rates may require dynamic changes throughout the day (exercise, sleep pattern, menstrual cycle, work schedule) * Carb to insulin ratios may change due to any number of circumstances * Technology is constantly changing in this field…

Question 71

Diabetes Technology (lots out there) What tech is a “closed loop”

Answer 71

Continuous glucose monitoring with insulin pump is a “closed loop” (Dexcom G6, Freestyle Libre, Freestyle Libre 2) * inPen - Bluetooth connected pen, insulin delivery recorded on smart phone * FDA approved insulin pumps (Medtronic 670g “closed loop”, Omnipod, T-slim control IQ automatically can give corrections and Basal IQ predicts and reduces low) - out of pocket cost ~10k, iLet “bionic pancreas” delivers glucagon and insulin not approved yet

Question 72

Key Points * Subacute and Acute management is _____ than chronic diabetes management (that may seem like a no-brainer but too often inpatient regimen becomes what a patient remains on) * Think about managing and treating your patient based upon their underlying pathophysiology * Type 1 Diabetic – disease of insulin \_\_\_\_\_ * Type 2 Diabetic – disease as a _____ of _____ failures * Mitigating largest health risks for diabetics (ie h\_\_\_\_\_ disease, k\_\_\_\_\_ disease, l\_\_\_\_ disease) * Treat with an understanding of what is wrong with their pathophysiology

Answer 72

* Subacute and Acute management is different than chronic diabetes management (that may seem like a no-brainer but too often inpatient regimen becomes what a patient remains on) * Think about managing and treating your patient based upon their underlying pathophysiology * Type 1 Diabetic – disease of insulin deficiency * Type 2 Diabetic – disease as a syndrome of metabolic failures * Mitigating largest health risks for diabetics (ie heart disease, kidney disease, liver disease) * Treat with an understanding of what is wrong with their pathophysiology