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Diabetes Management: Questions and Answers for Healthcare Professionals, Exams of Nursing

A comprehensive set of questions and answers related to diabetes management, covering topics such as insulin injection techniques, treatment recommendations for type 1 and type 2 diabetes, different types of insulin, factors influencing hepatic glucose production, advantages of continuous insulin infusion, and various models of health behavior change. It also explores patient barriers to diabetes management, physical limitations impacting self-care, pros and cons of insulin pump therapy, and the concept of diabetes distress. Valuable for healthcare professionals seeking to enhance their knowledge and understanding of diabetes management.

Typology: Exams

2023/2024

Available from 12/17/2024

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CDCES Exam questions

What are the components of good insulin injection technique? - correct answer Proper insulin injection technique includes injecting into appropriate body areas, injection site rotation, appropriate care of injection sites to avoid infection or other complications, and avoidance of intramuscular (IM) insulin delivery (64) What are the treatment recommendations for type 1 diabetes? - correct answer 9.1 Most people with type 1 diabetes should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion. A 9.2 Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk. A 9.3 Patients with type 1 diabetes should be trained to match prandial insulin doses to carbohydrate intake, premeal blood glucose, and anticipated physical activity. (64) What are the treatment recommendations for type 2 diabetes? What are the 4 reasons for early introduction of insulin? How often should treatment be re-evaluated? - correct answer "When diet and exercise are no longer sufficient:

  1. "Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes." (64)
  2. "Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin." (64)
  1. "Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high risk, established kidney disease, or heart failure, a sodium-glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors. (i.e. liraglutide, caniglifozin, empagliflozin)" (64)
  2. "The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high." (64)
  3. "The medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3-6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment" (64)

What are the types of long-acting insulin? - correct answer NPH, U-500 regular, Detemir, Glargine, U- Glargine and Degludec (12) What are the types of short-acting insulin? - correct answer Afrezza, Fiasp, Apart, Glulisine, Lispro, U- Lispro, Human regular, U-500 regular (12) What hormones influence hepatic glucose production? - correct answer Cortisol, Growth hormone, Glucagon, Epi/ Norepi, Progesterone, Estrogen (12) What are the advantages of continuous insulin infusion as compared to multiple daily injections? - correct answer Ability to account for dawn phenomenon, implement temp basal rates, have variable schedules, skip/delay meals without hypoglycemia (12) What supplies are needed for pump vacations or as a back up? - correct answer Injectable basal & bolus insulin, vial or pen, syringes/ pen needles, dosages, transition plan back to pump (12) What is the transtheoretical model? - correct answer An integrative framework for understanding how individuals and populations progress toward adopting and maintaining health behaviour change. It recognizes that behaviour occurs in steps, not all at once - precontemplation, contemplation, preparation, action, maintenance, termination What is the socio-ecological model? - correct answer The construct of health was broadly conceptualized in the SEM and focused on the major contributors that might affect health. The SEM states that health is affected by the interaction between the characteristics of the individual, the community, and the environment that includes the physical, social, and political components. - https://www.tandfonline.com/doi/full/10.1080/1059924X.2017. What is the health belief model? - correct answer The HBM derives from psychological and behavioral theory with the foundation that the two components of health-related behavior are 1) the desire to avoid illness, or conversely get well if already ill; and, 2) the belief that a specific health action will prevent, or cure, illness. Ultimately, an individual's course of action often depends on the person's perceptions of the benefits and barriers related to health behavior. - https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/ behavioralchangetheories2.html

What is self-efficacy? - correct answer This refers to the level of a person's confidence in his or her ability to successfully perform a behavior. This construct was added to the model most recently in mid-1980. Self-efficacy is a construct in many behavioral theories as it directly relates to whether a person performs the desired behavior. - https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/ behavioralchangetheories2.html What is social learning theory (Bandura)? - correct answer There are three core concepts at the heart of social learning theory. First is the idea that people can learn through observation. Next is the notion that internal mental states are an essential part of this process. Finally, this theory recognizes that just because something has been learned, it does not mean that it will result in a change in behavior. - https://www.verywellmind.com/social-learning-theory- He also emphasized that four conditions were necessary in any form of observing and modeling behavior: attention, retention, reproduction, and motivation" (39) What is health literacy? - correct answer ''the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health" (45) What are the AADE 7? - correct answer Healthy eating, Physical activity, Medications, Monitoring, Healthy coping, Problem solving, Risk reduction What are the components of an assessment for PWD? - correct answer information about the individual's relevant medical history, age, cultural influences, health beliefs and attitudes, diabetes knowledge, self-management skills and behaviors, readiness to learn, health literacy level, physical limitations, family support, and financial status. (135) Fingersticks, a1c, healing wounds, injection sites, skin irritation, foot care, last dental visit, last dilated eye exam, presence of anemia, or hemoglobinopathies (36) What are the egregious eleven? - correct answer Ominous octet (Ralph DiFranzo): 1. inc. glucose production in the liver, 2. inc. glucagon production, 3. inc. lipolysis in adipose tissue, 4. dec. glucose reabsorption in the kidneys, 5. dec. insulin secretion, 6. dec. peripheral muscle glucose uptake, 7. dec. incretin effect, 8. inc. appetite and dec. morning dopamine due to change in brain chemistry? (74, 77) +

  1. dec. amylin (inc. rate of glucose absorption), 10. inc. inflammation, 11. changes in gut microbiome contributes to inc. inflammation and dec. immune dysregulation

Egregious eleven: Abnormal GI microbiome with possible decreased GLP-1 secretion, "Systemic low- grade inflammation is observed in type 2 DM, type 1 DM, and LADA and has been shown to accompany the endoplasmic stress imposed by increased metabolic demand for insulin", "Reductions in amylin production in the diabetic state are a consequence of β-cell dysfunction. Decreased amylin levels lead to accelerated gastric emptying and increased glucose absorption in the small intestine, with corresponding increases in postprandial glucose levels." (77) When should blood sugars be tested? - correct answer i. before and after meals ii. before and after exercise (or during, if it's a long or intense session) iii. before bed iv. after intense exercise, also check in the middle of the night. v. Check more if things around you change such as, a new insulin routine, a different work schedule, an increase in physical activity, or travel across time zones (97) What are patients perceived barriers to diabetes management? - correct answer "The most common potential obstacle was poor vision (74%), followed by cannot read well (29%), hearing problems (19%), problems with English language (11%), or some other type of problem (7%; Figure 1). (43) What physical limitations impact patients' ability to manage their diabetes? - correct answer i. Disease complications such as blindness, amputations, DKA, hypoglycemia ii. Poor mobility or transportation iii. Poor dexterity for SMBG or insulin injections (adaptive devices) iv. Inability to prepare healthy meals, or perform other self-care behaviors due to physical limitations v. Impact of poor personal or dental hygiene v. Consider if physical limitation is long-term or short-term in deciding how to manage it (73) What are the pros and cons of insulin pump therapy? - correct answer Pros: Beneficial for people with active lifestyles, women who plan to become pregnant, people with frequent hypoglycemia or those who suffer from gastroparesis (48) Cons: expense, being attached to a machine, need for more frequent monitoring What is diabetes distress? - correct answer You may sometimes feel discouraged, worried, frustrated, or tired of dealing with daily diabetes care, like diabetes is controlling you instead of the other way

around ... Those overwhelming feelings, known as diabetes distress, may cause you to slip into unhealthy habits, stop checking your blood sugar, even skip doctor's appointments. It happens to many—if not most—people with diabetes, often after years of good management. In any 18-month period, 33% to 50% of people with diabetes have diabetes distress." (66) What is the "dysglycemia-based chronic disease" model (78)? - correct answer Stage 1 DBCD "Insulin Resistance" Stage 2 DBCD "Prediabetes" Stage 3 DBCD "T2D": Stage 4 DBCD "Vascular Complications" When should you check for ketones? What is the procedure if a pump user has ketones? - correct answer Check for ketones when you have an unexplained high (especially with a pump); if BS is high, but ketones are negative, the pump can be used to give a bolus, if ketones are positive, inject insulin with syringe, drink water, change out pump (12) i. Urine sampling with ketostix, or diastix, positive if > 15 mg/dl ii. Blood sampling with Novamax Plus or Precision Xtra blood meter, positive if > .5 mmol/L (12) "When you are ill (when you have a cold or the flu, for example), check for ketones every 4 to 6 hours. And check every 4 to 6 hours when your blood sugar is more than 240 mg/dl." (98) What over the counter medication should be avoided by people with diabetes? - correct answer "St. John's wort is a concern involving potential drug interactions" (117) i. "For colds, of about 11 active ingredients, only decongestants [pseudophedrine] (primarily oral) need be considered for their possible effects on blood sugar." (117) j. "NSAIDs (even at OTC doses) must be used with caution, given their cardiovascular, renal and gastrointestinal risks" (117) k. Choose sugar-free medicines, choose pills/ nasal sprays instead of liquids, avoid products with multiple active ingredients (118) What are the 7 risk reduction strategies for diabetes? - correct answer a. Schedule regular medical checkups. Plan to see your provider at least every three months. They can order blood tests such as an A1C which measures your average overall glucose level during the past 3 months, as well as check your blood pressure.

b. Get all of the recommended health checks: Sleep apnea screening, Hearing loss screening, Dental exam, Eye exam, Kidney function screening, Get a cholesterol check c. Take care of your feet. Look closely at the tops and bottoms of your feet every day. Look for redness, cuts, bruises or sores that won't heal. Use a mirror if needed. Don't go barefoot. Keep your feet clean and dry. Call your provider right away if you find a problem with your feet. d. Get recommended vaccines. This includes flu, pneumonia and hepatitis B. e. Don't smoke. Smoking damages your blood vessels and increases your risk of stroke and heart attack. f. Monitor your food, medications, exams, target levels and more. Use the data gathered to problem solve and come up with the most appropriate strategies. g. Talk about your feelings. It is easy to feel overwhelmed, anxious, or depressed. Talk to your diabetes care and education specialist, healthcare provider or counselor about your feelings. (18) What lab tests indicate a patient is prediabetic? - correct answer FPG between 100-125 mg/dl A1c between 5.5% and 6.4% Glucose of 140-199 2 hours after a 75 g glucose load* What lab tests indicate a patient is diabetic? - correct answer FPG >/= 126 mg/dl* A1c > 6.5%* Plasma glucose >/= 200 mg/dl 2 hours after a 75 g glucose load* Glucose > 200 mg/dl with increased urination, thirst or hunger What lab tests indicate a patient has gestational diabetes? - correct answer At 24 to 28 weeks, FPG > 92 mg/dl GTT

/= 180 mg/dl after 1 hour /= 153 mg/dl after 2 hours What are the modifiable risk factors for diabetes? - correct answer BMI/ obesity, diet, exercise, hypertension, NAFLD, heart disease, smoking

What are the non-modifiable risk factors for diabetes? - correct answer Family history of diabetes, or auto-immune disease (type 1) history of gestational diabetes, race, age, cystic fibrosis, organ transplant, PCOS Biguanides (medications, mechanism, contraindications, side effects) - correct answer metformin/glucophage/fortamet/ glumetza/riomet 500 mg/ 1000 mg once/ twice daily after a meal "Decreases hepatic glucose production, decreases intestinal absorption of glucose, and improve insulin sensitivity by increasing peripheral glucose uptake and utilization" (3)

  1. "Renal disease or renal dysfunction (e.g. serum creatinine levels >/= 1.5 mg/dL [males], 1.4 mg/dL [females] or abnormal creatinine clearance), which may result from conditions such as cardiovascular collapse (shock), acute MI, and septicemia" (3)
  2. not recommended during pregnancy or breastfeeding, or for pediatric patients (3) 3) use conservative doses with geriatric patients, who may have decreased renal clearance (3)
  3. not for use with unstable CHF patients Side effects: Gastrointestinal (diarrhea, abdominal cramping, nausea), Lactic acidosis (rare), Vitamin B- deficiency Thiazolidinediones (medications, mechanism, contraindications, side effects) - correct answer rosiglitazone/ avandia, pioglitazone/ actos 2 mg/ 4 mg once/ twice daily with/ without food "TZDs reduce insulin resistance in adipose tissue, muscle and the liver. However, PPAR gamma is predominantly expressed in adipose tissue."(5)
  4. Patients with heart failure, and macular edema (may cause swelling or fluid retention), and
  5. women who are pregnant or breastfeeding (3); caution should be taken when combined with insulin (3) Side effects: Edema, CHF, Bone fractures, Weight gain, Inc. LDL (rosiglitazone), Hepatotoxicity

Sulfonylureas (medications, mechanism, contraindications, side effects) - correct answer glibenclamide, gliclazide, glimepiride/ amaryl, glipizide, glynase/ glyburide, /tolbutamide, chlorpropamide, tolbutamide, tolazamide 2.5 to 10 mg twice daily Insulin secretagogue - increases beta cell production of insulin, by "closing ATP-sensitive potassium channels, which leads to an enhanced insulin secretion independent of glucose." (6)

  1. Not recommended for patients without functioning beta cells (i.e. type 1 diabetes, or advanced type 2 diabetes) (6);
  2. Not for pregnant women or those with impaired renal/ hepatic function (6)
  3. Increased risk of hypoglycemia with garlic extract vs synergistic effect (34) Side effects: hypoglycemia, weight gain DPP-4 inhibitors (medications, mechanism, contraindications, side effects) - correct answer sitagliptin/ januvia, saxagliptin/ onglyza, linagliptin/ tradjenta, and alogliptin/ nesina taken by mouth "DPP-4 is a ubiquitous enzyme expressed on the surface of most cell types that deactivates a variety of other bioactive peptides, including glucose-dependent insulinotropic polypeptide (GIP) and GLP-1; therefore, its inhibition could potentially affect glucose regulation through multiple effects." (7)
  4. Reactions to gliptins;
  5. may need to lower dose of sulfonylureas when used together to prevent hypoglycemia;
  6. decreased dosages for renal impairment or ESRD (15);
  7. not appropriate for patients with pancreatitis Side effects: rare

GLP-1 agonist (medications, mechanism, contraindications, side effects) - correct answer liraglutide/ victoza, dulaglutide/ trulicity, lixisenatide/ adlyxin, exenatide/ byetta, semaglutide/ ozempic, albiglutide/ tanzeum (injectables) "These medications mimic the action of a hormone called glucagon-like peptide 1. When blood sugar levels start to rise after someone eats, these drugs stimulate the body to secrete more insulin. The extra insulin helps lower blood sugar levels." (35) dec. glucagon secretion dec. gastric emptying inc. satiety (160)

  1. "personal or family history of medullary thyroid carcinoma or
  2. patients with Multiple Endocrine Neoplasia syndrome type 2" (176)
  3. Fear of injections
  4. Patients with severe gastrointestinal disease, such as gastroparesis (Trulicity due to frequent GI symptoms, Victoza due to delayed gastric emptying) (177) side effects: Gastrointestinal (N/V/D), Acute pancreatitis (160) SGLT-2 inhibitors (medications, mechanism, contraindications, side effects) - correct answer canagliflozin/ invokana, dapagliflozin/ farxiga, and empagliflozin/ jardiance "SGLT2 inhibitors lower blood sugar by causing the kidneys to remove sugar from the body through the urine." (13) "blocks glucose reabsorption, increasing glucosuria" (160) Not recommended for severe kidney disease or dialysis (16) side effects: Dehydration, Bone fractures, Genital mycotic (fungal) infections (160)

Amylin analog (medication, mechanism, contraindications, side effects) - correct answer symlin/ pramlintide acetate "Pramlintide is an analog of human amylin. Amylin is colocated with insulin in secretory granules and cosecreted with insulin by pancreatic beta cells in response to food intake" (178) "In human studies, pramlintide, acting as an amylin analog, slows gastric emptying, reduces the postprandial rise in plasma glucagon, and modulates satiety leading to decreased caloric intake." (178)

  1. hypoglycemia unawareness
  2. confirmed gastroparesis (178) side effects: Hypoglycemia, Injection site reactions, Nausea/ vomiting, Decreased appetite, Stomach pain, Headache (178) Dopamine receptor agonists (medications, mechanism, contraindications, side effects) - correct answer cycloset/ bromocriptine "... bromocriptine mesylate, an ergot derivative that is a dopamine receptor agonist. The mechanism by which CYCLOSET improves glycemic control is unknown. Morning administration of CYCLOSET improves glycemic control in patients with type 2 diabetes without increasing plasma insulin concentrations." (174)
  3. "Patients with syncopal migraine. Bromocriptine increases the likelihood of a hypotensive episode among patients with syncopal migraine. Loss of consciousness during a migraine may reflect dopamine receptor hypersensitivity. CYCLOSET is a dopamine receptor agonist, and may, therefore, potentiate the risk for syncope in these patients.
  4. Women who are nursing their children. CYLOSET may inhibit lactation." (174) side effects: Nausea/ Vomiting, Headache, Tired/ Dizzy (161)

Meglitinides (medications, mechanism, contraindications, side effects) - correct answer prandin/ repaglinide, starlix/ nateglinide "insulinotropic agents, ... They are secretagogue molecules with a more rapid anti-hyperglycemic action and a shorter duration than sulfonylureas, thus providing better control of post-prandial hyperglycemia and reducing the risk of late hypoglycemia... mediated via adenosine triphosphate (ATP)-dependent potassium channels "(162)

  1. "Diabetic ketoacidosis, with or without coma. This condition should be treated with insulin.
  2. Type 1 diabetes [or Type 2 diabetes without functioning beta cells]
  3. Co-administration of gemfibrozil.
  4. PRANDIN is not indicated for use in combination with NPH-insulin" (175) side effects: Hypoglycemia, Joint aches, flu-like symptoms (163) Alpha-glucosidase Inhibitors (medications, mechanism, contraindications, side effects) - correct answer glyset/ miglitol, precose/ acarbose "antihyperglycemic action of acarbose results from a competitive, reversible inhibition of pancreatic alpha-amylase and membrane-bound intestinal alpha-glucoside hydrolase enzymes. In diabetic patients, this enzyme inhibition results in a delayed glucose absorption and a lowering of postprandial hyperglycemia." (173) "PRECOSE is also contraindicated in patients with inflammatory bowel disease, colonic ulceration, partial intestinal obstruction or in patients predisposed to intestinal obstruction" (173) side effects: Abdominal pain/ diarrhea/ flatulence (173), Abnormal liver tests (161)

What is the formula to calculate a starting insulin dose for type 1 diabetes? - correct answer "the starting insulin dose is based on weight, with doses ranging from 0.4 to 1.0 units/kg/day of total insulin with higher amounts required during puberty. The American Diabetes Association/JDRF Type 1 Diabetes Sourcebook notes 0.5 units/kg/day as a typical starting dose in patients with type 1 diabetes who are metabolically stable" (197) In type 2 diabetes, what medications are recommended for:

  1. a1c < 9%
  2. a1c >/ = 9%
  3. a1c >/ = 10% - correct answer 1) a1c < 9%: initiate metformin or other monotherapy, encourage lifestyle modifications
  4. a1c >/ = 9%: lifestyle modification + metformin + additional agent, preferably with ASCVD benefit
  5. a1c >/ = 10%: lifestyle modification + metformin + additional agent + basal insulin Start 10 units per day basal insulin, or .1-.2 units/kg/day Adjust 10-15% or 2-4 units once or twice weekly (197) Adjust down for hypoglycemia. When would you add a rapid-acting insulin injection? What would the starting dose be? - correct answer If a1c is not controlled after the addition of basal insulin, add 1 insulin injection before largest meal. If A1c is still not controlled, then add >/= 2 rapid-acting insulin injections before meals (basal-bolus), depending on how many meals the patient eats. Start 4 units, .1 units/ kg or 10% of basal dose. If A1c < 8% consider dec. basal by same amount. Adjust dose up by 1-2 units or 10-15% once or twice weekly until SMBG target reached. If no clear reason for hypoglycemic events, dec. dose by 2-4 units or 10-20% Same rec's for first injection and subsequent injections. (197)

How/ why would you initiate (and advance) premixed insulin? - correct answer If a1c is not controlled after the addition of basal insulin, change to premixed insulin twice daily (NPH/Regular 70/30, 70/ aspart mix, 75/25 or 50/50 lispro mix) Divide current basal dose into 2/3 AM, 1/3 PM or 1/2 AM, 1/2 PM Inc. dose by 1-2 units or 10-15% once or twice weekly until SMBG target reached Dec. dose by 2-4 units or 10-20% for hypoglycemia If A1c does not improve, change to premixed insulin 3 times daily. (197) What oral medications should be stopped once meal-time insulin is initiated? What medications should be used instead? - correct answer "Sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists are typically stopped once more complex insulin regimens beyond basal are used." (197) "In patients with suboptimal blood glucose control, especially those requiring large insulin doses, adjunctive use of a thiazolidinedione or SGLT2 inhibitor may help to improve control and reduce the amount of insulin needed, though potential side effects should be considered." (197) What diabetes medications reduce cardiovascular events? - correct answer "There are now three large randomized controlled trials reporting statistically significant reductions in cardiovascular events for two SGLT2 inhibitors (empagliflozin and canagliflozin) and one GLP-1 receptor agonist (liraglutide) where the majority, if not all patients, in the trial had ASCVD. The empagliflozin and liraglutide trials demonstrated significant reductions in cardiovascular death." (197) What is non-handicapping language? - correct answer "Nonhandicapping language maintains the integrity of individuals as whole human beings by avoiding language that implies that a person as a whole is disabled (e.g., diabetic child), equates a person with his or her condition (e.g., diabetic), has superfluous and negative overtones (e.g., unmotivated, suffering with/from diabetes), is regarded as a judgment (e.g., non-compliant, nonadherent, poorly con- trolled)" (198)

What are the ADA recommendations for language use? - correct answer 1. is neutral, nonjudgmental, and based on facts, actions, or physiology/biology

  1. is free from stigma
  2. is strengths based, respectful, inclusive, and imparts hope
  3. fosters collaboration between patients and providers 5. is person centered (198) What is strengths-based language? - correct answer Opposite of a deficit approach; emphasizing what people know and what they can do (7). Focusing on strengths that can empower people to take more control over their own health and healing (103). Example: Lee takes her insulin 50% of the time because of cost concerns (instead of Lee is noncompliant/nonadherent). (198) What is person-first language? - correct answer Words that indicate awareness, a sense of dignity, and positive attitudes toward people with a disability/disease. Places emphasis on the person, rather than the disability/disease (88). Example: Lee has diabetes (instead of Lee is a diabetic). (198) What are the glucose targets for pregnant women with pre-existing diabetes (assuming no serious hypoglycemia)? - correct answer According to the 2008 consensus statement on managing pregnancy with pre-existing diabetes, optimal glucose targets are: pre-meal/fasting glucose: 60 to 99 mg/dL; peak postprandial: <129 mg/dL; HbA1c <6%. 1 hour post prandial < 140 mg/dl 2 hour post prandial < 120 mg/dl What are the average glucose levels for an a1c of: 5.7%? 6.5%? 8%? 9%? 10%? 14%? - correct answer 117 mg/dl 140 mg/dl 183 mg/dl

215 mg/dl 240 mg/dl 355 mg/dl What are the ADA recommendations for adults starting a new exercise regimen? - correct answer "No current evidence suggests that any screening protocol beyond usual diabetes care reduces risk of exercise-induced adverse events in asymptomatic individuals with diabetes (112,113). Thus, pre-exercise medical clearance is not necessary for asymptomatic individuals receiving diabetes care consistent with guidelines who wish to begin low- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living." (199) "However, some individuals who plan to increase their exercise intensity or who meet certain higher-risk criteria may benefit from referral to a health care provider for a checkup and possible exercise stress test before starting such activities (6). In addition, most adults with diabetes may also benefit from working with a diabetes-knowledgeable exercise physiologist or certified fitness professional to assist them in formulating a safe and effective exercise prescription." (199) What risk factors would suggest the need for a stress test prior to increasing the intensity of exercise? - correct answer In general, electrocardiogram (ECG) stress testing may be indicated for individuals matching one or more of these criteria:

  • Age >40 years, with or without CVD risk factors other than diabetes
  • Age >30 years and Type 1 or type 2 diabetes of >10 years in duration
  • Hypertension
  • Cigarette smoking
  • Dyslipidemia
  • Proliferative or preproliferative retinopathy
  • Nephropathy including microalbuminuria Any of the following, regardless of age
  • Known or suspected CAD, cerebrovascular disease, and/or peripheral artery disease (PAD)
  • Autonomic neuropathy
  • Advanced nephropathy with renal failure

Use of these criteria does not exclude the possibility of conducting ECG stress testing on individuals with a low CAD risk or those who planning to engage in less intense exercise (248). In the absence of contraindications to maximal stress testing, it can still be considered for anyone with type 2 diabetes. (200) When should a patient with diabetes be referred to a nephrologist? - correct answer 1. When GFR < 30 ml/min (stage IV)

  1. Uncertainty about the etiology of kidney disease
  2. Difficult management issues (anemia, hyperparathyroidism, metabolic bone disease, resistant hypertension, electrolyte disturbances)
  3. Rapidly progressing kidney disease (201) What diabetes medications are recommended for patients with CKD? - correct answer 1. SGLT inhibitors reduce renal tubule glucose reabsorption, weight, systemic blood pressure... and albuminuria and slow GFR loss through mechanisms... independent of glycemia
  4. GLP1 RAs have been reported to improve renal outcomes (semaglutide, liraglutide)& (201)
  5. Metformin use should be based on eGFR per 2016 FDA guidelines. It is contraindicated if eGFR < 30, and should not be initiated with eGFR < 45 What renal labs should be monitored for people with diabetes and how often? - correct answer urine albumin, creatine, GFR What are the general guidelines for blood pressure targets for people with diabetes? When should targets be lower? - correct answer < 140/90 mmHg to reduce CVD mortality and slow CKD progression < 130/80 mmHg may be a good target for patients with existing CKD or albuminuria > 300 mg/day (201) What medication can assist with blood pressure control when ACE inhibitors and ARBs cannot manage resistant hypertension? - correct answer Mineralocorticoid receptor agonists (spironolactone, seller one, finerenone).

More trials are necessary to confirm CKD benefits (201) What is diabetic nephropathy? - correct answer When some one has frequent high blood sugars it can damage the nephron and glomerulus capillaries and cause proteins to leak into the urine from the blood (i.e. albuminuria) High blood sugars also can cause scarring of the glomerulus, which can decrease their ability to filter out waste products (202) What is diabetic retinopathy? - correct answer "Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, with prevalence strongly related to both the duration of diabetes and the level of glycemic control" (201) What is diabetic neuropathy? - correct answer "The most common early symptoms are induced by the involvement of small fibers and include pain and dysesthesia (unpleasant sensations of burning and tingling). The involvement of large fibers may cause numbness and loss of protective sensation (LOPS). LOPS indicates the presence of distal sensorimotor polyneuropathy and is a risk factor for diabetic foot ulceration. The following clinical tests may be used to assess small- and large-fiber function and protective sensation: Small-fiber function: pinprick and temperature sensation Large-fiber function: vibration perception and 10-g monofilament Protective sensation: 10-g monofilament" (201) When should an ankle-brachial index test be performed? What follow up tests are recommended for people with low ankle pressure? - correct answer "Ankle-brachial index testing should be performed in patients with symptoms or signs of PAD." "Urgent vascular imaging and revascularization should be considered in a patient with a diabetic foot ulcer and an ankle pressure (ankle-brachial index) <50 mmHg, toe pressure <30 mmHg, or a TcPO2 < mmHg" (201) What is diabetic autonomic neuropathy? - correct answer "Major clinical manifestations of diabetic autonomic neuropathy include hypoglycemia unawareness, resting tachycardia, orthostatic hypotension,

gastroparesis, constipation, diarrhea, fecal incontinence, erectile dysfunction, neurogenic bladder, and sudomotor dysfunction with either increased or decreased sweating." (201) What medications are recommended for the treatment of neuropathic pain? - correct answer Pregabalin & duloxetine Gabapentin is similar and has shown efficacy but is not FDA approved for this purpose Opioids carry the risk of addiction and should be avoided (201) What medications are contraindicated for patients with diabetic gastroparesis? What medications are used to treat it? - correct answer Opioids, anticholinergics, tricyclic antidepressants, GLP1 RAs, pramlinitide, and DPP4 inhibitors Metoclopramide/reglan for < 12 weeks Erythromycin (short-term) Domperidone (outside US) Gastric electrical stimulation for patients with severe symptoms (201) When is insulin indicated in the inpatient setting? What is the target range for critically ill patients? When is it appropriate to have more stringent goals? - correct answer When blood glucose > 180 mg/dl Target range 140-180 mg/dl if patient can maintain 110-140 mg/dl without hypoglycemia, targets can be more stringent What are the recommendations for deintensification of insulin therapy in older adults? - correct answer

  1. Change basal insulin from bedtime to morning
  1. Fasting glucose targets 90-150 mg/dl
  2. Change premixed insulin to basal only and use 70% of total dose
  3. Change mealtime insulin < 10 units to metformin or a secondary agent
  4. For patients with mealtime dose > 10 units, cut insulin dosage by 50% and add noninsulin agent (SOC 2020) What are the 6 elements of the Chronic Care Model? - correct answer 1. Proactive care delivery delivery system design
  5. Self management support
  6. Decision support
  7. Using clinical information systems for population based support
  8. Community resources
  9. Health systems with quality oriented culture