Diabetes Mellitus

Case studies

By Dr. MONA SHALABY

Case 1
Patient history: Rose is a 51-year-old woman with a 5-year history of type 2 diabetes. She has an elevated glycated hemoglobin A1c (HbA1c) level of 7.5% that has risen through the years. She was started on metformin at diagnosis and is now on 1000 mg twice daily. Glipizide 10 mg daily was added to her regimen 2 years ago. Rose has gained 5.1 kg over the past 5 years, with 3.8 kg of that weight gain in the last 2 years. She exercises by walking 30 minutes 3 times a week. She self-monitors her blood glucose twice a day, once upon rising and after one of her 3 meals, varying the meal. Her average fasting plasma glucose (FPG) is 162 mg/dL and her postprandial glucose (PPG) averages 200 mg/dL, sometimes going as high as 220 mg/dL. She is a nonsmoker, she is married with no children, and works as a bank lending officer.

Case 1
At her examination today, Rose weighs 82.8 kg and is 5 ft 5 in tall (body mass index [BMI], 31). Her lipid levels are within target range, according to laboratory blood tests done 2 days ago. Her blood pressure (BP) is 130/85 mm Hg. Because Rose is concerned about the weight gain she is experiencing, she has stopped taking the glipizide every day. She also is concerned about her elevated HbA1c. She admits that her exercise regimen is erratic, and that owing to stress related to her work she snacks through the day on highcalorie food available in the employee break room.

Which of the following statements is most likely correct with regard to treatment considerations for this patient?

1-Her erratic exercise and snacking are likely leading to her weight gain 2-The glipizide treatment is most likely contributing to her weight gain 3-She should cut back on metformin and take a smaller dose 4-She should stop glipizide only if it causes low blood glucose when she exercises

Which statement describes the best next step for treating this patient, according to the American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) position statement and the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) treatment algorithm for type 2 diabetes when dual therapy with metformin and a sulfonylurea has failed?

1-Add a GLP-1 receptor agonist or a DPP-4 inhibitor to the metformin and consider reducing the sulfonylurea 2-Add insulin to metformin therapy and reduce the sulfonylurea 3-Add a TZD to metformin and reduce the sulfonylurea 4-Keep the metformin and sulfonylurea and improve lifestyle issues of diet, exercise, and stress reduction

Which statement is most relevant in determining whether to add insulin or an incretin-based therapy to Rose's therapy?
1-Insulin contributes to weight gain, whereas incretin-based therapies are weight neutral or contribute to weight loss 2-Insulin is associated with hypoglycemia, whereas incretinbased therapies generally are not associated with hypoglycemia 3-Tests to determine how much endogenous insulin exists should be done before determining whether insulin or an incretin-based therapy is the best therapy 4-The patient may be more satisfied with an incretin-based therapy than with insulin because management is easier

In discussing placing Rose on incretin-based therapy, which of the following statements is correct and relevant to Rose's case?
1-A person with gastroparesis should not be placed on GLP-1 receptor agonists or DPP-4 inhibitors because they delay gastric emptying 2-Both GLP-1 receptor agonists and DPP-4 inhibitors are contraindicated in patients with renal impairment 3-GLP-1 receptor agonists and DPP-4 inhibitors reduce HbA1c and PPG levels 4-Both GLP-1 receptor agonists and DPP-4 inhibitors exacerbate systolic BP problems in patients

If an incretin-based therapy is to be added to Rose's treatment, which statement best describes reasons to use a GLP-1 receptor agonist or a DPP-4 inhibitor that are relevant to her?

1-GLP-1 receptor agonists are associated with weight loss and DPP-4 inhibitors are weight neutral 2-GLP-1 receptor agonists are injected, whereas DPP-4 inhibitors are taken orally 3-GLP-1 receptor agonists decrease glucagon production more than DPP-4 inhibitors 4-GLP-1 receptor agonists increase GLP-1 activity more than DPP-4 inhibitors

Which statement is NOT accurate in describing additional benefits for this patient?

Nausea occurs less frequently with exenatide than with liraglutide Treatment with twice-daily exenatide results in greater reduction in HbA1c compared with liraglutide Liraglutide is taken once a day and exenatide is taken once a week Liraglutide and exenatide may preserve betacell function

Case 2
James is a 62-year-old white man who has had type 2 diabetes for 6 years. He is an information technology professional who is considering retirement in the next 2 years. His weight has steadily increased over the last 8 years, and his BMI is 33. His first therapy for diabetes was metformin, which controlled his diabetes well for 4 years. His HbA1c subsequently started to rise, as did his fasting glucose. He was placed on insulin glargine for basal insulin in addition to the metformin 2 years ago. Since starting insulin glargine, he has gained 4 kg. .

Case 2
At the examination today, his FPG averages 154 mg/dL but his PPG averages 230 mg/dL. His creatinine is at 1.0 mg/dL. His BP is 138/85 mm Hg. His most recent laboratory results, from 3 days ago, show an HbA1c of 8.1%. His low-density lipoprotein (LDL) cholesterol is 110 mg/dL, his triglycerides are 120 mg/dL, and his high-density lipoprotein (HDL) cholesterol is 50 mg/dL James' lipids are treated with simvastatin 20 mg once daily. He takes 10 mg of ramipril once daily for his hypertension. He is a nonsmoker, has a glass of wine with dinner every night, lives with his wife, and has no children. James is concerned about his weight, elevated PPG, and rising HbA1c.

James wants to know why his diabetes has worsened as shown by his HbA1c and PPG levels even though he has taken his medications and his BP and cholesterol are controlled. Which is not true regarding diabetes and its therapy?

1-Diabetes is a progressive disease, and beta-cell function and mass deteriorate over time 2-Intensive glycemic control early in the disease appears to improve insulin secretion by the beta cell 3-Insulin is the only antidiabetic agent that can improve the remaining beta-cell function 4-Good diabetes control prevents microvascular therapy disease

Which of the following steps would you take to help this patient improve glucose control?
1-Keep the metformin and basal insulin and add prandial insulin to each of his meals to control PPG levels 2-Keep metformin and basal insulin and add a GLP-1 receptor agonist to lower HbA1c and help with weight gain 3-Keep metformin and basal insulin and add DPP4 inhibitor to help control PPG levels 4-Discontinue metformin, keep basal insulin, and add a GLP-1 receptor agonist to help control PPG levels

Which of the following statements would you include when counseling this patient to improve adherence with GLP-1 receptor agonists?
1-There is a risk for hypoglycemia when GLP-1 receptor agonists are used in combination with metformin 2-There is a risk for transient nausea when a GLP-1 receptor agonist is used alone or with metformin 3-GLP-1 receptor agonists are not recommended for patients with renal impairment or gastroparesis 4-There is an increased risk for lactic acidosis when GLP-1 receptor agonists are used in combination with metformin

James is concerned about his weight gain. In addition to counseling him about diet and exercise, which of the following statements regarding the next step in treatment for him would be least correct?

1-GLP-1 receptor agonists are associated with weight loss 2-DPP-4 inhibitors are generally weight neutral 3-Metformin is associated with a small amount of weight gain 4-The addition of prandial insulin is associated with significant weight gain

To decide whether to put James on a DPP-4 inhibitor or a GLP-1 receptor agonist, which statement holds the least importance relative to James' particular glycemic concerns?

1-GLP-1 receptor agonists reduce FPG more than DPP-4 inhibitors 2-GLP-1 receptor agonists lead to weight loss and DPP-4 inhibitors are weight neutral 3-GLP-1 receptor agonists reduce HbA1c more than DPP-4 inhibitors 4-GLP-1 receptor agonists are injectable and DPP-4 inhibitors are oral medications

Case 1
The patient is a 52-year-old male who presents for a routine diabetes follow-up appointment The patient works a fairly regular schedule as a bus driver but is sometimes required to work outside normal business hours. Because of his employment, the patient is concerned about eventually needing treatments that may not cause hypoglycemia Weight = 121kg Most recent eye exam (3 months ago) revealed hemorrhages consistent with background diabetic retinopathy Last year he has previous MI and Now his EF=33%

LAB RESULTS
ITEMS A1C FPG PPG TC LDL HDL TG PULSE BP RESULTS 7.6 125 215 188 mg/DL 125 mg/DL 44mg/dl 94 mg/dl NORMAL M 122/88 mm/hg

Current medication
Metformin2000 mg Pioglitazone 45 mg Co-DIOVAN 160/25 ASPRIN 81 mg once daily Zocor 20 mg

Which of the following changes to this patients antidiabetic medications would you most likely recommend to add instead of pioglitazone ?

1-Add sulfonylurea 2-ADD GLINIDE 3-ADD INSULIN 4- ADD GLUCOSIDASE Inhibitor 5-ADD DPP-4 INHIBITOR

Which of the following is not a core defect in type 2 diabetes

1-insulin resistance in peripheral tissue 2-insulin deficiency due to insufficient pancreatic insulin release 3-express hepatic glucose production due to increase glucagon secretion and insulin insufficiency 4- insufficient triglyceride production

Which of the following characteristics make this patient a good candidate for incretin therapy?

Higher BMI Duration of T2DM A1C level Elevated PPG Currently on metformin therapy All of the above

Which of the following inhibit glucagon secretion by alpha cell in the pancreas

1- GLp-1 2- GIP 3- both GLp-1 and GIP 4- neither GLp-1 nor GIP

Which of the following is not an action of GLP-1?

Increased urinary loss of glucose Increased secrection of insulin Increased postprandial satiety Decreased seretion of glucagon after meals

Januvia is indicated :
1-In a patient with type 2 diabetes to provide glycemic control in combination with metformin or TZDs when diet and exercise plus single agent do not provide adequate glycemic control. 2- In a patient with type 2 diabetes to provide glycemic control in combination with sulphonylurea or insulin when diet and exercise plus single agent do not provide adequate glycemic control. 3-all of the above.

Which of the following is true regarding dosing of januvia:

1-dose adjustment is necessary in patient with mild hepatic impairment 2-januvia must taken with the first meal of the day. 3- dose adjustment is necessary in patient with moderate and severe renal impairment or ESRD. 4-dosage adjustment to 50 mg is recommended in all patient above 65 years

THANK YOU