PANCE Blueprint Endocrinology (6%)

Diabetes Mellitus Type 2

Patient will present with → a 35 year old Mexican American male presents to your office complaining of increased thirst, frequent urination, hunger, fatigue, and blurred vision random finger stick blood glucose is 225

Know your medication - side effects and functions

Metformin: decreases hepatic glucose production and peripheral glucose utilization, decreases intestinal glucose absorption (these are reasons it leads to weight loss),  can cause lactic acidosis and needs to be discontinued 24 hours before contrast and resumed 48 hours after with monitoring for creatinine, stop if creatine is > 1.5

Sulfonylureas (glyburide and glipizide): Stimulates pancreatic beta cell insulin release (insulin secretagogue), causes hypoglycemia and weight gain

Thiazolidinediones (Pioglitazone Actos and Rosiglitazone Avandia): Increases insulin sensitivity in peripheral receptor site adipose and muscle has no effect on pancreatic beta cells, fluid retention and edema, cardiovascular toxicity with avandia

α-Glucosidase inhibitors (Acarbose precose and Miglitol glyset): Delays intestinal glucose absorption, may cause increased LFTs and hepatitis, diarrhea, flatulence

Meglitinides (Repaglinide pranding and Nateglinide): Stimulates pancreatic beta cell insulin release, hypoglycemia

GLP-1 Agonists (Exenatide Byetta): Lowers blood sugar by mimicking incretin - causes insulin secretion and decreased glucagon and delays gastric emptying, hypoglycemia, caution if gastroparesis

DDP-4 Inhibitors (Sitagliptin Januvia): Dipetpidylpetase inhibition - inhibits degradation of GLP-1 so more circulating GLP-1, pancreatits and renal failure

SGLT2 Inhibitor (Canagliflozin): SGLT2 inhibition lowers renal glucose threshold which results in increased urinary glucose excretion

Normal fasting glucose is between 70 and 100

Diagnostic criteria for DM Type II

  1. Fasting blood glucose > 126 mg/dl fasting at least 8 hours on two occasions GOLD STANDARD!
  2. Hemoglobin A1C > 6.5 indicates average blood sugar 10-12 weeks prior to measurement
  3. 2 hour plasma glucose of > 200 on an oral glucose tolerance test (3 hour GTT is gold standard in GDM)
  4. Random plasma glucose > 220 in patients with classical symptoms of hyperglycemia

Diagnostic criteria for prediabetes

  1. A1C 5.7-6.4, Fasting glucose 100-125, 2-hour oral glucose tolerance test 140-199

Diet and exercise with lifestyle changes are first line - carbs 50-60%, protein 15-20%,

Glucose goals and management

  • A1C < 7.0 % check every 3 months if not controlled and 2x per year if controlled
  • Preprandial glucose 80-110 (60-90 if pregnant)
  • Postprandial blood glucose goal is < 140
  • Annual dilated eye exams, ACEI if microalbuminuria, annual foot examination
  • Blood pressure should be maintained at < 130/80
  • New statin guidelines: recommend statins in persons with diabetes mellitus who are 40 to 75 years of age with LDL-C levels of 70 to 189 mg per dL but without clinical ASCVD (see guidelines)
Question 1
Which of the following glucose-lowering agents acts by decreasing peripheral tissue resistance to insulin resistance?
A
acarbose
Hint:
α-Glucosidase inhibitors, such as acarbose (Precose), reduce glucose by delaying carbohydrate absorption
B
glipizide
Hint:
Glipizide (Glucotrol) and other sulfonylureas work by increased insulin secretion from pancreatic β cells.
C
metformin
Hint:
Metformin (Glucophage), a biguanide, lowers glucose by decreasing hepatic glucose production and increasing glucose utilization.
D
Pioglitazone
Question 1 Explanation: 
Pioglitazone (Actos) is a thiazolidinedione (TZD) and decreases insulin resistance and increases glucose utilization by sensitizing peripheral tissues to insulin.
Question 2
A 66-year-old male was found wandering in the streets by the police. There are no signs of trauma. BP is 90/54 mm Hg, pulse rate is 115 bpm, and respiratory rate is 12 breaths/min. Physical exam reveals mild dehydration as well as decreased mental state without focal neurological findings. Initial laboratory findings include glucose of 750 mg/dL, Na of 124 mEq/L, K of 3.0 mEq/L, Cl of 102 mEq/dL, CO2 of 37 mEq/L, BUN of 101 mg/dL, creatinine of 1.0 mg/dL, blood pH of 7.3. Which of the following is the most appropriate first step in managing this patient?
A
glucagon
Hint:
Glucagon would further increase the blood glucose
B
insulin
Hint:
Insulin is typically not needed unless the glucose is resistant to fluids
C
bicarbonate
Hint:
Bicarbonate should not be administered because the blood pH is above 7.0
D
saline
Question 2 Explanation: 
Hyperglycemia in the absence of ketosis is common in elderly type 2 diabetics. With mild dehydration, sodium is low but rises as the dehydration worsens. Elevated BUN is key to diagnosis. This patient is presenting with hyperglycemic hyperosmolar state and is dehydrated. Correction of the hypovolemia will reduce the hyperglycemia and thereby allow the kidneys to excrete the glucose
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