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What are the basic differences between DM1 and DM2?
Usually presents at a younger age Typically presents age > 40
Normal weight or thin Obese
Usually no family history Strong family history
Autoimmune markers may be positive (anti-GAD and anti-islet cell antibodies) Not autoimmune in nature
Insulin sensitive Insulin resistant
Requires insulin for treatment Often managed with diet or oral agents
What are the less common types of DM other than DM1, DM2 and gestational?
MODY, insulin receptor mutations, hemochromatosis, pancreatic neoplasm, cystic fibrosis, Cushing's, glucagonoma, somatostatinoma, drug-induced
Summarize the two sets of criteria in routine clinical use for the diagnosis of DM.
Symptoms of diabetes plus casual plasma glucose (PG) concentration ≥ 200 mg/dL (11.1 mmol/L). Casual is defined as any time of day without regard to last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.
Fasting PG ≥ 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.
What caveat applies to the criteria for diagnosis of DM?
In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day.
What is the oral glucose tolerance test (OGTT)?
The OGTT is a specialized test for the diagnosis of DM. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 gm of anhydrous glucose dissolved in water. A positive test is defined as 2-hour PG ≥ 200 mg/dL (11.1 mmol/L). The OGTT is an accepted method for diagnosing DM; it is just not used routinely because it is more cumbersome than the other criteria described in question 7.
Can you use Hemoglobin A1C to diagnose DM?
Define IGT and IFG.
IGT is defined as a 2-hour postload glucose of 140-199 mg/dL (7.8-11.1 mmol/L), using the OGTT. IFG is defined as fasting PG of 100-125 mg/dL (5.6-6.9 mmol/L). IGT and IFG are not truly disease entities but are associated with the metabolic syndrome and a high risk of developing DM and cardiovascular disease.
List the characteristics of the metabolic syndrome.
Abdominal obesity (waist circumference: men > 40 inches (102 cm), women > 35 inches (88 cm)
Hypertriglyceridemia (≥ 150 mg/dL)
Low HDL cholesterol (men < 40 mg/dL, women < 50 mg/dL)
Hypertension (≥ 130/85 mmHg)
Fasting hyperglycemia (≥ 110 mg/dL)
Describe the pathophysiology of diabetic ketoacidosis (DKA).
The pathogenesis of DKA involves an increase in counter-regulatory hormones (catecholamines, cortisol, glucagon, and growth hormone), accompanied by insulin deficiency. All of these hormonal factors contribute to increased hepatic and renal glucose production and decreased peripheral glucose utilization. These hormonal changes also serve to enhance lipolysis and ketogenesis as well as glycogenolysis and gluconeogenesis and serve to worsen hyperglycemia and acidosis. Lipolysis leads to increased free fatty acid synthesis for ultimate conversion by the liver to ketones. This state is associated with increased production and decreased utilization of glucose and ketones. Glucosuria leads to osmotic diuresis and dehydration that is associated with reduced renal function and worsening acidosis.
List the clinical features of DKA
Clinical features vary with the severity of DKA: polydipsia, polyphagia, polyuria, severe dehydration, altered mental status (ranges from normal to coma), gastrointestinal distress (nausea, vomiting, abdominal pain), weight loss, and weakness.
What are the triggering factors for DKA?
Infection, MI,stroke, inadequate insulin therapy, pancreatitis, alcohol abuse
Which four electrolytes are abnormal in DKA?
Sodium, bicarbonate, potassium, phosphate
What should you do 1-2 hours before discontinuing IV insulin?
A: SC insulin
E: The SC insulin must be given prior to discontinuing IV insulin (usually 1-2 hours to allow for adequate plasma insulin levels) to avoid return of hyperglycemia and/or DKA.
What are the three features of HHNS?
A: Hyperglycemia, renal impairment, altered mental status.
E: Patients with HHNS present with severe hyperglycemia, profound dehydration, and some degree of alteration in mental status (50%). Typically patients have type 2 DM and mild renal impairment. The plasma glucose is frequently very elevated (> 600 mg/dL). Ketosis is usually only very mild or absent. Patients typically have severe dehydration, and plasma hyperosmolarity (> 340 mOsm/L) is one hallmark of this condition
How often should you measure Hemoglobin A1C?
A: biannually
E: Hemoglobin A1c is an overall indicator of glycemic control. It should be measured biannually in patients who meet treatment goals (typically A1c < 7%) or quarterly in patients whose therapy is actively changing. Although an ideal goal for A1c is < 7%, this goal must be individualized. Less intensive goals may be indicated in patients with frequent hypoglycemia, and more intensive goals may be desired in some patients to further reduce diabetes complications.
What are the currently recommended goals for glycemic control in patients with DM?
Hemoglobin A1c < 7%
Preprandial glucose 90-130 mg/dL
Postprandial glucose < 180 mg/dL
What is the BP goal for diabetics?
What is the LDL goal for diabetics?
What is the HDL goal for diabetics?
What is the triglyceride goal for DM?
Summarize the management of cardiovascular risk factors and screening guidelines for coronary disease in patients with diabetes mellitus.
Blood pressure control. The goal is < 130/80 mmHg. Therapy should be individualized for each patient. First-line agents include angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers. Second-line agents include diuretics, beta blockers, and dihydropyridine calcium channel blockers.
Smoking cessation.
Lipid management. Test annually or more frequently if patient has not met the following goals: LDL < 100 mg/dL, triglycerides < 150 mg/dL, and HDL > 40 mg/dL.
Consider aspirin therapy for primary or secondary prevention.
Consider screening for coronary artery disease.
A patient with DM1 has had DM for 5 years. What should you screen for?
A patient with DM1 has had DM1 for 3 years. What should you screen for?
A: retinopathy
E: Patients with type 1 DM should receive a comprehensive dilated eye exam within 3-5 years of diagnosis and annually thereafter. Patients with type 2 DM should receive a comprehensive dilated exam at the time of diagnosis and annually. The eye care specialist may determine altered timing of follow-up exams.
How are patients screened for diabetic neuropathy?
Patients should be assessed with monofilament sensory testing. Perform a good foot exam, and educate patients about foot care.
What are the tests that should be done on diagnosis of DM2?
Microalbuminuria, monofilament test, dilated eye exam
Summarize the immunization guidelines for diabetic patients.
Annual influenza vaccine should be given to all patients with DM greater than age 6 months. Pneumococcal vaccine is recommended for all diabetic adults at least once.
What are the drug categories for DM2?
Sulfonylureas, Biguanides, alpha-glucosidase inhibitors, thiazolidinediones
What category of drug is miglitol?
Alpha-glucosidase inhibitor
What should be monitored frequently after putting a patient on pioglitazone or rosiglitazone?
Hepatic enzymes
Which two insulins are miscible?
NPH and regular.
Name the two ultrafast insulins?
Lispro, Aspart
What are multi-component insulin regimens?
Multiple-component insulin regimens refer to the combination of basal insulin; preprandial short-acting insulin; and changes in short-acting insulin doses to accommodate the results of frequent SMBG, anticipated food intake, and physical activity.
What kind of insulins are suitable for Continuous subcutaneous insulin infusion (CSII)?
Lispro, Aspart
Which DM agents are contraindicated in patients with renal failure or CHF?
What is the diagnostic approach to hypoglycemia in patients without diabetes?
Hypoglycemia should be established using Whipple's triad: presence of symptoms consistent with hypoglycemia (such as sweating, hunger, palpitations, and weakness), documented low plasma glucose at the time of symptoms, and relief of symptoms when the plasma glucose concentration is raised to normal levels. Hypoglycemia in the fasting state is typically more clinically concerning than reactive (postprandial) hypoglycemia. Although the exact criteria are debated, glucose levels of < 50 mg/dL in men and < 40 mg/dL in women are generally accepted as indicative of hypoglycemia.
Summarize the differential diagnosis of adult hypoglycemia not related to diabetes.
E: Critical illness, including liver and renal failure.
Adrenal insufficiency (lack of the counter-regulatory hormone cortisol).
Insulinoma: tumor of the pancreatic beta cell that produces too much insulin.
Non-beta-cell tumors, including mesenchymal tumors such as fibrosarcoma, mesothelioma, and leiomyosarcoma, that produce insulin-like growth factor I (IGF-I) or IGF-II.
Insulin or insulin receptor autoantibodies (rare).

A:Drug induced, critical illness, insulinoma, adrenal insufficiency, IGF-* tumor,insulin or insulin receptor antibodies.
In sulfonylurea induced hypoglycemia, the level of C-peptide is high/low?
E:Insulin and C-peptide levels are helpful to distinguish between endogenous and exogenous hyperinsulinemia since insulin and its cleavage product C-peptide are secreted by the pancreatic beta cell in equimolar amounts. If a patient is getting exogenous insulin, insulin levels will be high and C-peptide levels low. Both values are elevated in patients with surreptitious sulfonylurea use since these drugs stimulate release of endogenous insulin and C-peptide. Sulfonylurea blood levels can also help rule out drug-induced hypoglycemia in this setting.
A: High
Identify the hereditary syndrome associated with pancreatic tumors.
E: Multiple endocrine neoplasia syndromes (MEN) are characterized by neoplastic transformation in multiple endocrine glands. MEN type 1 (MEN1) is associated with pancreatic tumors. MEN1 is now known to be caused by a mutation in the tumor suppressor MEN1 gene, whose product is named menin.
What are the components of MEN1?
E: Pituitary tumors (most commonly prolactinoma)
Primary hyperparathyroidism (typically due to parathyroid hyperplasia)
Pancreatic tumors (most commonly gastrinoma, followed by insulinoma)
A: Pit*, para*, panc*

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