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Test Your Knowledge

Take a quiz and test your knowledge on diabetes and related health concerns.

CLINICAL CASE VIGNETTE: Antihyperglycemic Treatments

Mr. Huang is a 61-year-old Asian American businessman who comes in to see you for a follow-up appointment. He was diagnosed with type 2 diabetes four years ago and has a long-standing history (15 years) of hypertension and hypercholesterolemia, which are currently well-controlled. Current medications are metformin (1500 mg/day), lisinopril, and simvastatin. He has excess weight (BMI 29 kg/m2) but feels he has a healthy diet and gets out for a 25-30 minute walk 3 or 4 times per week. He feels great, but over the last nine months or so, he has noticed that his home average glucose levels are in the 180-198 mg/dL range. At today’s visit, his A1C is 8.3%. Based on Mr. Huang’s individual glycemic target of A1C<7%, you would like to add another antihyperglycemic. You choose linagliptin over glimepiride. What is the best reason for your choice?

A. Greater weight loss benefits
B. More effective at lowering blood glucose levels
C. Lower cost of treatment

Follow the link for the answer.

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CLINICAL CASE VIGNETTES: Morning Distress

Mrs. Wilson is woman who is 71 years of age, African American and has excess weight. She has come to your clinic today for a new patient visit. She recently moved to the area to live with her daughter and is concerned about her diabetes care plan. She was diagnosed with type 2 diabetes 12 years ago at a wellness check through routine screening. In hindsight, she wonders if maybe she “went undiagnosed for a while” because she “didn’t get to the clinic very often and was having some problems with frequent urination at night” before she was screened. She currently takes metformin, glyburide, captopril, pravastatin, and aspirin, and has recently titrated to.6 U/kg/day insulin NPH as a nightly basal dose. Her current A1C goal is less than 7.5% and she has been working hard to get to that level. However, for the first time her life, she is finding herself to be nauseated and irritable in the morning, but always feels better after a little breakfast. She states she feels “pretty good for her age,” although she occasionally has “a little chest tightness when walking more than 4 or 5 blocks.” Last time she remembered to check her glucose was a few days ago. GHer postprandial glucose was “a little high” at 214 mg/dL. Her office A1C is 8.6%. Based on what you know about the patient, what is the most likely cause of her morning distress? A. Hyperglycemia B. Hypoglycemia C. Anxiety D. Cognitive decline Follow the link for the answer.

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CLINICAL CASE VIGNETTES: Diabetes Management Steps

Mr. Huang manages his diabetes with his lifestyle modifications, metformin, and linagliptin, and returns every 6 months for follow-up visits. Three years after initiating this treatment plan, he returns to your clinic for his 6-month check-up. When asked how his diabetes management is going at home, he shares that recently he has been “unable to really get out and get as much exercise as he knows he should due to his creaky, old knees acting up.” His current office A1C is 8.8%. You discuss with him what the next management steps may be to achieve his individualized glycemic goal. What would your next medical management step be? A. Add a rapid-acting insulin analogue B. Add a long-acting insulin analogue C. Add a GLP-1 agonist D. Add a sulfonylurea Follow the link for the answer.

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Test Your Knowledge: Clinical Case Vignette: Smoking and Type 2

You are concerned about Mr. Carlson’s cigarette use because cigarette smoking has been shown to have multiple physiological impacts on health. Which one of the following statements regarding smoking and type 2 diabetes is true? A. It equally affects all-cause mortality in individuals with and without diabetes B. In individuals with diabetes, it causes more rapid progression to micro- and macroalbuminuria C. It has not been linked to worsening glycemic control D. The use of bupropion in contraindicated in diabetes Follow the link to see the answer,

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Clinical Case Vignette: Macronutrients

Mr. Carlson is a man, 52-years of age. He is Caucasian and works as a grocery store manager. His labs show that they were significant for elevated random plasma glucose 166 mg/dL, A1C 7.6% and elevated lipids (TG=175 mg/dL, LDL 148 mg/dL, HDL 38 mg/dL, total cholesterol 221 mg/dL). His physical exam is notable for central abdominal obesity (waist circumference 42”), BP 147/91, HR 72, RR 18, BMI 36 kg/m2, but otherwise normal. He is started on metformin and a dietitian is recommended. The dietitian discusses with him the benefits of medical nutrition therapy on weight, glycemic control, blood pressure, lipid profile, and overall wellbeing. Which following statement regarding macronutrients is true? A. The ratio of carbohydrates, protein and fat is the same for all patients. B. Total calories consumed per day is the key strategy for achieving glycemic control. C. Reduced intake of trans fat lowers the HDL and raises the LDL. D. Saturated fat should be less than 7% of total calories. Follow the link for the answer.

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CLINICAL CASE VIGNETTE: Treating Weight Concerns

After four years of good glycemic control with metformin 1500 mg a day, Mrs. Hunter returns for her 6-month follow-up visit. At this time, her office A1C is 8.2% and she has gained seven pounds. She is very concerned about her weight gain. If weight is a concern, what would be the best antiglycemic drug to add to her regimen? A. A sulfonylurea B. A DPP-4 inhibitor C. A thiazolidinedione D. A GLP-1 receptor agonist Follow the link for the answer.

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BMI for Bariatric Surgery

Mr. Carlson is 52-year old Caucasian grocery store manager you saw last week for a new patient visit. His labs from that visit were significant for elevated random plasma glucose 166 mg/dL, A1C 7.4% and elevated lipids (TG equals 175 mg/dL, LDL 148 mg/dL, HDL 38 mg/dL, total cholesterol 221 mg/dL). He has returned to your clinic for a follow-up appointment. His physical exam is notable for central abdominal obesity (waist circumference 42”),left eyelid xanthelasma, BP 147/91, HR 72, RR 18, BMI 36 kg/m2, but otherwise normal. A repeat A1C test shows A1C 7.6% Mr. Carlson smokes between 1 and 1.5 packs of cigarettes daily. After discussing the labs and your findings with Mr. Carlson, you begin collaborating on a management plan. You write prescriptions for metformin, a statin and ACE inhibitor. Mr. Carlson doesn’t think “taking medication will be too tough” but expresses skepticism about your recommendations for a change in his diet, exercise and smoking programs because he has tried them, without success in the past. What is considered the starting BMI for consideration of bariatric surgery? 1. BMI greater than 28 kg/m2 2. BMI greater than 30 kg/m2 3. BMI greater than 35 kg/m2 4. BMI greater than 37 kg/m2 Follow the link for the answer.

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Clinical Case Vignette Follow-up: Two Steps Back

Mrs. Hunter is 36-year-old African-American who comes to your office for her annual wellness exam. She has excessive weight (BMI 27 kg/m2), but is otherwise healthy. She jokes that she, “just can’t seem to lose that extra baby weight” after giving birth 3 years ago. However, her daughter recently started preschool so she has been able to go to her new gym several times per week. In fact, one of the added bonuses of her membership is that she has been participating in their free, weekly nutrition and exercise support groups. In addition to her routine labs, you order an A1C, which comes back elevated at 7.1%. You and Mrs. Hunter set a goal for A1C<6.5%. She returns 3 months later for a follow-up visit and her office labs show an A1C 6.8%. You congratulate her on her progress and ask her to return in another 3–4 months. When she does, she is above her goal with an A1C 8.1%. She explains that she has gone back to full-time work and just doesn’t have the time to get to the gym anymore. At this time, what would your next step be and what would her individualized glycemic targets be?

A. Encourage lifestyle modifications and start metformin with a target A1C less than 6.5%
B. Encourage lifestyle modifications and start metformin with a target A1C less than 7.5%
C. Encourage lifestyle modifications and start a 2-drug combination target A1C target less than 7%
D. Encourage lifestyle modifications and do not initiate drug therapy at this time

Follow the link for the answer.

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Clinical Case Vignette: Treatment Next Steps

Mrs. Hunter is a 36-year-old African-American who comes to your office for her annual wellness exam. She has excess weight (BMI 27 kg/m2), but is otherwise healthy. She jokes that she, “just can’t seem to lose that extra baby weight” after giving birth 3 years ago. However, her daughter recently started preschool so she has been able to go to her new gym several times per week. In fact, one of the added bonuses of her membership is that she has been participating in their free, weekly nutrition and exercise support groups. In addition to her routine labs, you order an A1C, which comes back elevated at 7.1%. This measurement is confirmed several days later. Based on Mrs. Hunter’s profile, what would a reasonable next step be? A. Encourage lifestyle modifications and start metformin with an A1C target of < 7.0%.
B. Encourage lifestyle modifications and start metformin with an A1C target of < 6.0%.
C. Encourage lifestyle modifications and do not initiate drug therapy at this time.
D. Encourage lifestyle modifications and start metformin and a sulfonylurea.
Follow the link for the answer.

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