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Answer and Critique (Correct Answer = A) Because of increasing childhood obesity and a lack of physical activity, Type 2 diabetes is increasingly seen at younger ages. Obese children with a body mass index greater than the 85th percentile for age and sex who are of an ethnic group with a high prevalence of diabetes (e.g., African American, Hispanic, Pacific Islander); have family history of diabetes; have signs of insulin resistance (i.e., acanthosis nigricans); or have coexisting hypertension, hypercholesterolemia, or polycystic ovary syndrome are considered at high risk for developing diabetes. In these children, screening is recommended to start at age 10 years by measuring fasting blood glucose. If the fasting blood glucose level is 126 mg/dL (6.99 mmol/L) or greater, the test should be repeated on another day to confirm a diagnosis of diabetes. If the fasting blood glucose level is normal, then high-risk persons should undergo screening every 2 years Key Point: The prevalence of Type 2 diabetes is increasing in children and young adults. Screening in high-risk children should be encouraged so that lifestyle modifications and treatment can be started early in the disease. Measurement of islet cell antibodies has no role in screening or diagnosing diabetes. On physical examination, this patient has acanthosis nigricans, a sign of insulin resistance. However, no other signs or symptoms of Cushing's syndrome are present; thus a 24-hour urinary cortisol measurement is unnecessary. A 2-hour oral glucose tolerance test is not recommended for screening of diabetes at this time. Because this patient has several features that place him at high risk of diabetes, waiting until age 16 years to screen for diabetes is inappropriate. Bibliography Type 2 diabetes in children and adolescents. American Diabetes Association. Diabetes Care. 2000;23:381-9. [PMID: 10868870] [PubMed]        
Answer and Critique (Correct Answer = D) Although this patient's statement regarding her fear of needles is important, it is equally important to ascertain the exact nature of her fear in order to respond appropriately. Often what patients first identify as their concern is not the real problem. Therefore, solutions developed to address the initial statement will be ineffective because the underlying issue is not addressed. For example, a morbid fear of needles may refer to injection pain, a concern that taking insulin will affect her independence or lifestyle, misinformation about insulin being a cause of complications, or the fear of being mistaken for a drug addict; the strategies to address these specific fears differ. For example, if her fear is painful injections, showing her the needle size and/or asking her to experience an injection may be appropriate. If, on the other hand, her concern is the need to carry syringes, the impact of injections on her lifestyle, or the possibility of being mistaken for a drug user, showing her an insulin pen may help allay her fear. Key Point: Many patients with Type 2 diabetes are hesitant to initiate insulin therapy. Much of this resistance derives from fears or beliefs about insulin and its impact on lives. A discussion of her fears may lead to a completely different and often unrelated cause for her hesitation. Patients who have diabetes very commonly view the need for insulin as a failure if they have heard statements such as “You've failed oral agents” or are promised that insulin can be avoided with weight loss and exercise. Using the need for insulin as a threat to induce weight loss and exercise is counterproductive. Presenting insulin as the next step in the treatment of a progressive disease early in the Type 2 diabetes care and educational process will help pave the way for initiation of insulin. This approach also helps address another common mistaken belief that insulin is not effective for treating Type 2 diabetes. Because Type 2 diabetes is a progressive disease and this patient already pays attention to her food intake and exercise, additional weight loss and exercise are highly unlikely to be effective at this point. Telling her that the newer needles are less painful than the older ones or providing information about the safety of insulin may become appropriate responses once the basis of her fears is known but are premature as the initial response. In addition, providing facts often is of limited value for alleviating fear. Bibliography 1. Funnell MM, Kruger DF, Spencer M. Self-management support for insulin therapy in type 2 diabetes. Diabetes Educ. 2004;30:274-80. [PMID: 15095517][PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15095517&dopt=Abstract)] 2. Funnell MM, Kruger DF. Type 2 diabetes: treat to target. Nurse Pract. 2004;29:11-5, 19-23; quiz 23-5. [PMID: 14726786] [PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14726786&dopt=Abstract)] 3. Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, et al; The International DAWN Advisory Panel. Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care. 2005;28:2673-9. [PMID: 16249538] [PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16249538&dopt=Abstract)]  
Key Point: Postprandial blood glucose levels correlate with hemoglobin A1c values, so lowering postprandial blood glucose levels improves A1c values. Meglitinides are short-acting nonsulfonylurea insulin secretagogues that enhance endogenous insulin secretion and affect early insulin release. These agents specifically target postprandial hyperglycemia because of their very rapid onset of action and short half-life. Using meglitinides preprandially effectively lowers postprandial blood glucose levels and leads to lower hemoglobin A1c values. Meglitinides are considerably more expensive than sulfonylureas but, because of their unique pharmacokinetics, are less likely to cause postabsorptive hypoglycemia and can be adjusted to match prandial needs. In this case, the patient is experiencing postprandial hyperglycemia after breakfast and dinner but not after lunch. A meglitinide, such as repaglinide or nateglinide, before breakfast and dinner would correct postprandial hyperglycemia at these times without increasing the hypoglycemia risk at other times. Metformin lowers fasting, but not postprandial, blood glucose levels. In this case, fasting glucose values are within the target range, which suggests that the current metformin dosage is appropriate. Metformin inhibits hepatic glucose production and increases insulin sensitivity but does not increase insulin secretion. Therefore, increasing the dosage to 1000 mg twice daily is unlikely to have any impact on postprandial blood glucose levels. Using preprandial fast-acting insulin (lispro, aspart) would correct postprandial hyperglycemia but would also increase the risk for hypoglycemia. Addition of a second oral agent is a reasonable choice before considering insulin injections, especially because her current A1c value does not indicate a significant degree of hyperglycemia. However, glargine, a long-acting nonpeaking insulin, which is typically used to provide basal or background insulinemia, does not target postprandial glycemic excursions. Bibliography   Ceriello A. Postprandial hyperglycemia and diabetes complications: is it time to treat? Diabetes. 2005;54:1-7. [PMID: 15616004] [ PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15616004&dopt=Abstract) ] Ceriello A, Hanefeld M, Leiter L, Monnier L, Moses A, Owens D, et al. Postprandial glucose regulation and diabetic complications. Arch Intern Med. 2004;164:2090-5. [PMID: 15505121] [ PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15505121&dopt=Abstract) ] Gerich JE. Clinical significance, pathogenesis, and management of postprandial hyperglycemia. Arch Intern Med. 2003;163:1306-16. [PMID: 12796066] PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12796066&dopt=Abstract)  
Answer and Critique (Correct Answer = D)   Although some studies have used oral anti-diabetes drugs in cases of gestational diabetes (starting the medication after the first trimester), insulin is still regarded as the treatment of choice for pregnant patients with Type 2 diabetes and for patients with gestational diabetes who are not achieving treatment targets with medical nutrition therapy and exercise. Ideally, this patient should have started insulin prior to conception -- the insulin regimen that is most likely to achieve her goal is an intensive regimen of basal and prandial insulin. Normal 0 false false false MicrosoftInternetExplorer4 /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-style-parent:""; font-size:10.0pt;"Times New Roman";} Key Points: Women with Type 2 diabetes who become pregnant while taking oral anti-diabetes agents should be switched to insulin. Tight glucose control during pregnancy is paramount for the health of the baby and of the mother. Premixed insulin is not the preferred insulin regimen for this patient because it provides less flexible insulin dosing, which may reduce her likelihood of achieving the therapeutic goal during pregnancy. Continuing glyburide and rosiglitazone in this patient is inappropriate despite evidence of insulin resistance because oral anti-diabetes medications are not recommended during pregnancy. The patient does not have time to modify her meal plan and start an exercise regimen in the hope that her hemoglobin A1c value will drop significantly, given that she is already 5 weeks' pregnant with an elevated A1c value. Because elevated glucose levels affect organogenesis, she needs rapid intensification of treatment to achieve the therapeutic goals of a fasting glucose level of less than 95 mg/dL (5.27 mmol/L) and a 1-hour postprandial glucose level of less than 130 mg/dL (7.22 mmol/L). In some situations, metformin may be continued during the first trimester for patients with polycystic ovary syndrome or with Type 2 diabetes who have anovulatory infertility. (NB: The use of metformin may result in ovulatory cycles.) However, metformin should not be used beyond the first trimester or in place of insulin. Moreover, the use of insulin glargine is not recommended in pregnancy because no outcome data support its safety. Bibliography 1. Joslin Diabetes Center and Joslin Clinic Guideline for Detection and Management of Diabetes During in Pregnancy. Available at: www.joslin.org/Files/Gest_guide.pdf (http://www.joslin.org/Files/Gest_guide.pdf). Accessed 3 October 2006.      
  Answer and Critique (Correct Answer = A)   Key Point: Patients experience marked distress at the time of diagnosis and need time to process this information before diabetes education can begin.   Given this patient's age, the acute onset of symptoms, his blood glucose level, and the presence of ketones, he likely has Type 1 diabetes. Most patients experience a great deal of emotional distress at the time of their diagnosis with diabetes and report feeling shocked, guilty, angry, anxious, depressed, and helpless. During the initial discussion of the diagnosis, a physician should ask this patient how he feels about the diagnosis, what fears and questions he has, and how the physician can be of help. The messages provided to the patient should be factual but hopeful, stressing that diabetes is a manageable disease, that occasional feelings of being overwhelmed, angry, and frustrated are common, and that the physician will help the patient get all the information and support he needs.   Because many patients continue to struggle despite their ability to manage their diabetes and achieve metabolic targets, these issues must be assessed throughout their lifetime. Unfortunately, patients raise these issues with their providers more often than the issues are addressed. For example, in a review of patient–provider interactions, only 21% of attempts made by patients to bring up psychosocial concerns were addressed. Surprisingly, not responding to attempts to address these concerns lengthened rather than shortened the visit.   At the time of diagnosis and at subsequent visits, it is essential to assess how the patient is coping with the diagnosis and to determine and address any concerns. Although diabetes self-management education is an essential treatment component, the initial interaction needs to focus on fears, questions, and concerns. Once these issues are addressed, “survival-level” information can be given about insulin injection and glucose-monitoring skills, hypoglycemia treatment, and initial dietary therapy. Although some of this information was given in the emergency department, the patient must have the opportunity to review these skills and ask questions. Dilated eye examinations and urine albumin testing are not indicated at diagnosis for patients with Type 1 diabetes.   Bibliography  Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284:1021-7. [PMID: 10944650] [PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10944650&dopt=Abstract)] .Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE, et al. Assessment of diabetes-related distress. Diabetes Care. 1995;18:754-60. [PMID: 7555499] [PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7555499&dopt=Abstract)] Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care. 2001;24:1821-33. [PMID: 11574449] [PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11574449&dopt=Abstract)] Skovlund SE, Peyrot M; DAWN International Advisory Panel. The Diabetes Attitudes, Wishes and Needs (DAWN) program: a new approach to improving outcomes of diabetes care. Diabetes Spectrum. 2005;18:136-42. Williams GC, Zeldman A. Patient-centered diabetes self-management education. Current Medicine. 2002;2:145-52.        
Answer and Critique
Key Point: Therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers retards the rate of progression of nephropathy in patients with diabetes mellitus. Answer and Critique (Correct Answer = E) A number of medications effectively treat hypertension in patients who have diabetes and a blood pressure goal of less than 130/80 mm Hg, which is lower than the goal in patients without diabetes. However, patients with diabetes often need multiple drugs to achieve their goal. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) such as valsartan have a selective benefit in diabetes. These drugs block the renin-angiotensin system and not only lower blood pressure but also can retard the rate of progression of any underlying nephropathy. In this patient, the presence of microalbuminuria (a urinary albumin–creatinine ratio of 30 to 300 mg/g) indicates early nephropathy. Even if nonpharmacologic therapy has lowered the blood pressure to normal levels, ACE inhibitors or ARBs should be given because these drugs can retard the progression of microalbuminuria. Studies have found stronger evidence for the benefits of ARBs compared with ACE inhibitors in patients with Type 2 diabetes and nephropathy. Additionally, ACE inhibitors can cause hyperkalemia; because patients who have diabetes are susceptible to hyporeninemic hypoaldosteronism (type IV renal tubular acidosis), their potassium levels must be monitored during therapy.   Other agents, such as calcium-channel blockers (e.g., amlodipine), beta-blockers (e.g., atenolol), central sympatholytic agents (e.g., clonidine), and thiazide diuretics (e.g., hydrochlorothiazide) lack this selective benefit and are used as second-line treatment or in patients who cannot tolerate ACE inhibitors or ARBs. Thiazide diuretics also can exacerbate hyperglycemia; however, these drugs are often given in low dosages in addition to other agents to achieve optimal blood pressure.   Bibliography  American Diabetes Association. Standards of medical care in diabetes—2006 [published erratum appears in Diabetes Care 2006;29:1192]. Diabetes Care 2006;29 Suppl 1:S4-42. [PMID: 16373931] [PubMed] National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-72. [PMID: 12748199] [PubMed] Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med. 1993;329:1456-62. [PMID: 8413456] [PubMed]  
  Answer and Critique (Correct Answer = C)   Key Points: An individualized weight reduction program consisting of medical nutrition therapy as developed by a registered dietitian is most likely to achieve a sustained weight loss and improved glycemic control. Bariatric surgery guidelines indicate that the criteria for selection in patients with diabetes are a body mass index of 40 or of 35 to 39.9, the presence of severe diabetes, and repeated failure at medically supervised weight loss.   Weight reduction improves insulin sensitivity and glycemic control. However, weight loss in patients with diabetes who use insulin is a challenge for both the patient and the health-care provider. Research has shown that as little as a 7% change in total weight can effect a change in diabetes control and cardiovascular health. Meal plan modification should involve a registered dietitian and include meal-to-meal consistency of carbohydrate content and the elimination of snacks as part of an individualized plan. An assessment by a dietitian with a comprehensive review of medical management and treatment goals is necessary to select an approach that is likely to succeed and includes exercise. If the goals have not been reached in 6 months, reassessment of the patient's eligibility for bariatric surgery is appropriate. Bariatric surgery has been shown to be effective in preventing and managing Type 2 diabetes for those patients who are obese and meet the criteria below.                      The American Society for Bariatric Surgery guidelines for patient selection:   Patients who are severely obese (body mass index of 40 or more) or who have a body mass index of 35 to 39.9 with serious medical conditions (e.g., high blood cholesterol and triglycerides, hypertension, sleep apnea, Type 2 diabetes, and other serious cardiopulmonary disorders); Patients who have tried other weight-loss methods, such as changes in eating and behavior, increased physical activity, and/or drug therapy, and remain severely obese; Patients who are unable to physically perform routine daily activities (work-related and family functions) and have a seriously impaired quality of life because of the severity of their obesity; Patients who understand the procedure, risks of surgery, and effects after surgery; and Patients who are motivated to commit to lifelong behavioral changes that include well-balanced eating and the physical-activity habits needed to achieve the best results. Until this patient meets these criteria, it is premature to check with her insurer for referral requirements for bariatric surgery coverage. Assessment of cardiac risk is part of the preoperative assessment of all patients and would be necessary should this patient become a candidate for bariatric surgery. Requesting bariatric surgery is not a criterion for a psychological assessment unless there is a pre-existing psychological issue or unrealistic expectations of the surgical outcomes.   Bibliography   Bariatric surgery: American Society for Bariatric Surgery Guidelines. Available at: www.lapsurgery.com/BARIATRIC%20SURGERY/ASBS.htm. Accessed 3 October 2006. Joslin Diabetes Center & Joslin Clinic. Clinical nutrition guidelines for overweight and obese adults with type 2 diabetes, prediabetes or at high risk for developing type 2 diabetes: 9/30/05. Available at: www.joslin.org/Files/Nutrition_ClinGuide.pdf. Accessed 3 October 2006. Need a review of your diabetes knowledge? Check out all of our questions at http://www.diabetesincontrol.com/tyk/index.php   Diabetesincontrol.com The Newsletter for Medical Professionals in Diabetes Care
  Key Points: Metformin is contraindicated in patients with serum creatinine levels >1.5 mg/dL in men or >1.4 mg/dL in women. Insulin should be started when oral anti-diabetes drugs are no longer sufficient to achieve the target A1c value.   Answer and Critique (Correct Answer = D) This patient's glycemic control is clearly suboptimal on his current treatment with glyburide and metformin; in fact, the latter drug is now contraindicated because the patient's serum creatinine concentration has exceeded 1.5 mg/dL (132.63 µmol/L;1.4 mg/dL [123.79 µmol/L] in women). The most appropriate approach is to stop the metformin and glyburide and start insulin treatment. In this case, starting a premixed insulin such as 70% neutral protamine aspart -- 30% insulin aspart twice daily before breakfast and dinner is appropriate because his carbohydrate intake is consistent and his glucose pattern shows quite a narrow range of glucose levels without wide swings.   Continuing metformin and glyburide while adding basal insulin to his treatment or adding a premixed insulin before dinner and continuing his oral anti-diabetes medications would not be appropriate for the reasons listed above. In addition, substituting rosiglitazone for metformin is not likely to further lower the hemoglobin A1c value; if the patient were able to continue metformin, the addition of rosiglitazone would lower the A1c value by no more than 1.5 percentage points, which would not achieve the target of less than 7%.         Bibliography Yale JF, Valiquett TR, Ghazzi MN, Owens-Grillo JK, Whitcomb RW, Foyt HL. The effect of a thiazolidinedione drug, troglitazone, on glycemia in patients with type 2 diabetes mellitus poorly controlled with sulfonylurea and metformin. A multicenter, randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2001;134:737-45. [PMID: 11329231] [PubMed] Need a review of your diabetes knowledge? Check out all of our questions at http://www.diabetesincontrol.com/tyk/index.php   Diabetesincontrol.com The Newsletter for Medical Professionals in Diabetes Care
Answer and Critique (Correct Answer = B)   Key Point In patients with diabetes, statin therapy reduces cardiovascular event rates significantly and should be used regardless of cholesterol level in nearly all cases. It is important to recognize that patients who have diabetes have a higher risk of coronary disease at any given serum cholesterol value. The current recommended target for the LDL cholesterol level is less than 100 mg/dL (2.59 mmol/L); this target may be lower in patients who have coronary artery disease. Multiple studies have suggested that statins can lower the risk of major cardiovascular disease in patients who have diabetes, even for those with excellent blood pressure and glycemic control. Exercise and diet are important, but statins have been shown to lead to a 22% to 24% reduction in major cardiovascular events. Therefore, adding a statin is the most appropriate strategy in this case. Metformin might improve his glycemic control, but it is already at an acceptable level. Niacin can worsen glycemic control in patients who have diabetes and is reserved primarily for treating hypertriglyceridemia.   Bibliography Colhoun HM, Betterridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, et al.Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet. 2004;364:685-96. [PMID: 15325833] [PubMed] Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-97. [PMID: 11368702] [PubMed] Heart Protection Study Collaborative Group. The effects of cholesterol lowering with simvastatin on cause-specific mortality and on cancer incidence in 20,536 high-risk people: a randomised placebo-controlled trial [ISRCTN48489393]. BMC Med. 2005;3:6. [PMID: 15771782] [PubMed] Snow V, Aronson MD, Hornbake ER, Mottur-Pilson C, Weiss KB; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2004;140:644-9. [PMID: 15096336] [PubMed]   Need a review of your diabetes knowledge? Check out all of our questions at http://www.diabetesincontrol.com/tyk/index.php     Diabetesincontrol.com The Newsletter for Medical Professionals in Diabetes Care  
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