7/8/2016. Sol Jacobs MD, FACE Division of Endocrinology Emory University School of Medicine

Transcription

1 Sol Jacobs MD, FACE Division of Endocrinology Emory University School of Medicine Participation in investigator initiated clinical research supported by: Merck Boehringer Ingelheim Novo Nordisk Astra Zeneca 2 1) Understand the diagnostic criteria and pathophysiology of type 1 and type 2 Diabetes Mellitus 2) Understand the treatment options and goals of therapy in the management of hypergycemia and co-morbidities in Diabetes. 3) Identify and manage the complications of diabetes. 3 4 Prevalence of Self-Reported Obesity Among Non-Hispanic White Adults, by State and Territory, BRFSS, *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%. 6 1

2 Which example below is classified as Type 2 Diabetes, diagnosed in a 35 year old woman? 1) recently diagnosed with pancreatic cancer 2) with history of chronic pancreatitis 3) with documented hemochromatosis 4) GAD 65 antibody positive 5) fasting plasma glucose of 157 mg/dl as new diagnosis in pregnant patient at14 weeks gestation, confirmed with HbA1C 7.1%. Obesity Diabetes Mellitus 8 5) Now termed Overt (type2) diabetes islet antibodies reveal an autoimmune mediated process, ie type 1, others are classified as secondary diabetes. 9 Which of following are risk factors for type 2 diabetes 1) Advancing age 2) Increasing weight 3) Minority background 4) History of GDM 5) PCOS 6) All the above 10 6) all the above PCOS is classically an insulin resistance syndrome increasing risk for DM. Remember post partum Which below is diagnostic of pre-diabetes (now termed high risk for diabetes) and obesity? 1) FBS 119 and BMI 29 2) 2hr GTT glucose of 190 and BMI 31 3) FBS 126 and BMI 30 4) FBS 119 and BMI 25 OGTT for GDM pts

3 2) High risk for DM = FBS >99 or 75 gm OGTT >140 at 2 hrs HbA1C 5.7% (ADA). BMI 25 overweight BMI 30 obesity stage 1 BMI 35 obesity stage 2 By definition which below must be present for hyperglycemia/diabetes to occur? 1) weight gain 2) peripheral insulin resistance 3) beta cell failure 4) none of the above BMI 40 obesity stage ) By definition if there is hyperglycemia there is beta cell failure 15 Which of the following has not been shown to delay/prevent the onset of type 2 diabetes? A) acarbose B) lifestyle modification C) metformin D) TZDs E) sulfonylureas 16 E) sulfonylureas Which primary mechanism of action is direct effect on beta cell insulin secretion? 17 A) netaglinide B) metformin and pioglitazone C) liraglutide and saxagliptin D) pramlintide E) glimepiride F) canagliflozin G) a, c, e 18 3

4 G) there is some secondary improvement in beta cell function as result of improved glucose control or insulin sensitivity at liver and peripherally from other agents Glucose Dependent Insulin Secretion SU K glucose GLP1 glycolysis ATP INSULIN ATP dependent Potassium channel calcium How is basal or intermediate acting insulin best dosed to reduce risk of 2-3 AM hypoglycemia and improve fasting glucose control 1) as 70/30 (NPH/Reg) mix at breakfast and supper 2) NPH and regular mixed from separate vials at breakfast and supper 3) AM NPH dosing only 4) NPH separated from mealtime (supper) regular and given at HS 5) glargine insulin at HS 5) glargine- less overnight hypoglycemia compared to NPH NPH has approx 6-8 hour peak ; next best option is NPH at HS y/o female No PMH other than HTN and cholecystectomy Lisinopril 2.5 mg per day BMI 37 BP 128/78 exam nl HbA1C 6.7% She has been dx d type 2 DM: HbA1C of 6.7% You review lifestyle modification and refer her to diabetes education What therapeutic intervention would be most appropriate as next step? Chemistries and Cr nl

5 1) Start pioglitazone at 30 mg/d 2) Start glargine at 10 units qhs 3) 6 months of diet and exercise 4) Metformin to start at 500 mg and titrate up as tolerated 5) Start exenatide 5 mcg SQ BID 4) Newest guidelines recommend pharmacotherapy at diagnosis. Metformin considered first line therapy if no contraindications Which medication approved for treatment of type 2 diabetes can be used in pt with history of pancreatitis 1) exenatide 2) colesevelam 3) bromocriptine mesylate 4) sitagliptin 5) 2 and 3 Answer is 5 1 and 4 should not be used with history of pancreatitis. (make sure watch TGs with colesevelam) Which are true re diagnosis/classification DM 1) Type 1 diabetes can be diagnosed at any age and patients can live years with enough endogenous insulin to avoid DKA 2) 25% of type 1 diabetics will have autoantibodies to islets and/or insulin at time hyperglycemia diagnosed 3) Type 1 diabetes is not found in obese patients. 1) LADA Latent Autoimmune Diabetes in Adults

6 A 55 year old male presents to your office for treatment of type 2 diabetes of 7 years duration. He has mild lower extremity sensory neuropathy but no other diabetic complications. His medical regimen includes glyburide 10 mg BID and metformin 1000 mg BID. A recently-obtained Hb A1c is 7.8%. 31 All but which would be reasonable additions to his diabetic regimen A) insulin B) pioglitazone C) exenatide D) repaglinide E) sitagliptin 32 D) repaglinide- it is an insulin secretagogue, as is the sulfonylurea. Biguanides Metformin Sulfonylureas Glipizide Glimepiride Glyburide Meglitinides Nateglinide repaglinide Alpha-glucosidase inhibitors Acarbose miglitol TZD Pioglitazone Rosiglitazone DPP 4 Inhibitors Sitagliptin Saxagliptin Linagliptin alogliptin SGLT2 inhibitors Dapagliflozin Canagliflozin empagliflozin Dopamine agonists Quick release bromocriptine Bile acid sequestrants colesevelam 33 Incretin mimetics Exenatide Liraglutide Dulaglutide albiglutide Amylin analogs pramlintide Insulins NPH U100 Regular U100 Regular U500 (pen) Glargine U100 Glargine U300 (pen) Detemir U100 Degludec U100 Lispro U100 Lispro U200 (pen) Aspart U100 Glulisine U100 What is this pts goal HbA1C A) <7.5% B) <7.0% C) <6.5% D) <6.0% 36 6

7 B)<7.0% (without hypoglycemia) ADA <7% AACE/ACE <6.5% Individualized depending on pt Remember PRBCs, erythropoietin, IV Fe, ESLD, ESRD, hemoglobinopathy y/o male type 2 diabetic with NO hx of CAD or PVD. A1C 6.1%, BP 158/94, HR 85 Cholesterol 229, TG 335, HDL 32, LDL 130 Start? A) ACE I and fibrate B) Beta blocker and statin C) ACE I and niacin D) ACE I and statin 38 D) ACE I and statin Treat BP to goal BP <140/90 First line therapy with ACE I or ARB (expect combination therapy will be needed) <130/80 may be appropriate in certain pts ( younger ) Lipids : Risk based decision for Rx with statin- DM yr old with additional CV RF consider high dose statin Combination Rx (fibrate or niacin in addition to the statin not generally recommended) 39 The following are true re DKA except: A) increased lipolysis B) non specific increase in serum amylase C) non-ag acidosis can occur with treatment D) type 1 DM only E) must continue IV insulin even when BS drops to normal F) Insulin therapy will worsen electrolyte abnormalities. 40 D) can occur in type 2 diabetics at diagnosis or with acute illness 41 All below are true re Diabetic 3 rd CN palsy except: A) most common CN palsy in DM B) is painful C) causes diplopia D) is usually permanent E) spares the pupil 42 7

8 D) Typically resolves in 3-6 months Consulted for inpt hyperglycemia management. Pt is NPO s/p major abdominal surgery. Goal BS on IV insulin drip in surgical ICU will be: 43 A) mg/dl B) mg/dl C) mg/dl D) mg/dl E) mg/dl 44 C) in most critically ill pts Start IV insulin for BS 180 mg/dl May be beneficial to aim for lower end of range Lower targets in selected pts BS <110 not recommended AACE ADA consensus statement Diabetes Care June year old female type 1 diabetes since age 9, poor control until last 2 years. ESRD being considered for kidney transplant HbA1C is 5.8% on basal bolus regimen Check home glucose 3-6 times per day 5 times last year severe hypoglycemia requiring 911, is not driving Feels loopy when blood sugar in 30s Does not feel low with BS in 40s-50s Has proliferative DR & painful neuropathy 46 1) Loosen control; reduce insulin doses to re-establish some hypoglycemic awareness 2) diabetes education 3) Insulin pump 4) continuous glucose sensor 5) pancreas+kidney transplant eval 6) all the above 47 6) Indications for pump,pancreas transplant or islet transplant protocol 48 8

9 30 year old physician in training: Sxs diaphoresis, disorientation, feels better with PO carbs Had syncopal episode while driving and wrecked car EMT found POC fingerstick glucose 29 mg/dl in field Another episode similar presentation with ER plasma glucose 35 mg/dl. No history of diabetes, not ill, thyroid and adrenal function are normal; denies insulin or any meds Admitted for inpatient 72 hour fast Develops typical sxs with corresponding plasma glucose 40 mg/dl at 8 hours. Further labs drawn per protocol- fast ended 49 Data: Glucose 40 mg/dl Insulin level high C peptide level low Betahydroxybutyrate level is low What is next step in management? 50 A) CT scan pancreas B) Referral to surgeon C) Psychiatry referral D) Await sulfonylurea screen C Expect both c peptide and insulin to be high in insulinoma Same for sulfonylureas or glinides Good Luck 53 9