Exam (elaborations)
ABFM DIABETES – Q’s And A’s
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ABFM DIABETES – Q’s And A’s
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ABFM DIABETES – Q’s And A’sTrue statements regarding nonpharmacologic therapy to reduce insulin
resistance include which of the following? (Mark all that are true.)
Decreasing caloric intake will increase insulin sensitivity independent of
weight loss
Moderate alcohol intake increases insulin resistance
Exercise has been shown to enhance insulin action in skeletal muscle
A decrease of as little as 5% in body weight can result in a substantial
reduction in insulin resistance
If there are no contraindications, patients with insulin resistance syndrome
should be advised to engage in 30 minutes of modest aerobic exercise at
least 4-5 times/week - -A, C, D, E
Lifestyle interventions play a pivotal role in the management of insulin
resistance syndrome. Losing even 5% of body weight has been shown to
substantially reduce insulin resistance. In addition, insulin sensitivity can be
increased by reducing caloric intake, even if no weight is lost. Exercise is an
important adjunct to weight loss, since it has been shown to enhance insulin
action in skeletal muscle not only during physical activity but for up to a
week following exercise. All patients with insulin resistance syndrome should
be advised to engage in 30 minutes of aerobic exercise at least 4-5
times/week. Moderate alcohol intake lowers insulin resistance.
-Which one of the following neurologic tests is most useful for predicting the
future occurrence of a diabetic foot ulcer?
Pressure sensation with Semmes-Weinstein monofilament (10 g)
Deep tendon reflexes of the ankle
Proprioception
Vibratory sensation with a 128-mHz tuning fork
Light touch with a wisp of cotton - -A
Failure to perceive a pressure sensation produced by Semmes-Weinstein
monofilament indicates a loss of protective sensation in the diabetic foot and
is highly predictive of foot ulceration. Traditional neurologic examination
techniques for evaluating reflexes, proprioception, vibration, or light touch
are highly subjective and less predictive of future ulceration.
-Which of the following lipid-lowering agents can worsen glycemic control?
(Mark all that are true.)
Colestipol (Colestid)
Ezetimibe (Zetia)
Gemfibrozil (Lopid)
,Niacin
Atorvastatin (Lipitor) - -D AND E
Niacin is not only the most effective agent for raising HDL-cholesterol,
producing an increase of 15%-35%, it also reduces triglycerides by 20%-50%
and LDL-cholesterol by 5%-25%. Hyperglycemia is a side effect of niacin
therapy, particularly at high doses. A dosage of 750-2000 mg/day is
associated with only moderate rises in blood glucose, and at one time was
considered a treatment option in patients with diabetes, particularly those
with low HDL-cholesterol levels. However, the recommendations for niacin
use were changed as a result of the AIM-HIGH trial (Atherothrombosis
Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact
on Global Health Outcomes), which found no incremental clinical benefit
from the addition of niacin to statin therapy in patients with coronary heart
disease and LDL-cholesterol levels >70 mg/dL.Recent studies support a link
between statin use and the development of diabetes mellitus. In a meta-
analysis of 13 studies, statin therapy was associated with a 9% increased
risk for incident diabetes. Another meta-analysis corroborated this result and
found that intensive-dose statin therapy was associated with a higher risk of
new-onset diabetes compared with moderate-dose statin therapy. In 2012,
the FDA modified the package labeling of statins to include the risk of
increased blood glucose levels and the development of type 2 diabetes. The
benefit of statin therapy, however, outweighs the risk; it was estimated there
would be 1 additional case of diabetes for every 498 patients treated for 1
year, compared with 1 less patient experiencing a cardiovascular event for
every 155 patients treated for 1 year.
-A 58-year-old male with type 2 diabetes mellitus comes in during the early
afternoon for his annual physical examination. His current medication
regimen consists of insulin glargine (Lantus), 18 units in the evening;
glipizide (Glucotrol), 20 mg/day; metformin (Glucophage), 1000 mg twice a
day; and acarbose (Precose), 100 mg three times a day. He suddenly
becomes shaky, diaphoretic, and pale, and tells you he thinks it is because
he skipped lunch before his appointment.Which of the following would be
effective for managing this episode? (Mark all that are true.)
Glucose tablets
A sugar cube
A banana
A soft drink containing sugar
Raisins
Glucagon - -A AND F
Acarbose, an α-glucosidase inhibitor, inhibits an enzyme present in the brush
border of the proximal intestinal epithelium that breaks down disaccharides
and more complex carbohydrates. As a result, if hypoglycemia were to occur
,in a patient on an α-glucosidase inhibitor, reversal requires either the
consumption of glucose itself (as opposed to complex carbohydrates) or the
injection of glucagon.
-Which of the following medications can cause hyperglycemia? (Mark all that
are true.)
Niacin
Clozapine (Clozaril)
Prednisone
Spironolactone
Ramipril (Altace) - -A, B, C
Several medications have been shown to affect glucose homeostasis,
resulting in impaired glucose tolerance and hyperglycemia. Agents
associated with the development of hyperglycemia include pentamidine,
niacin, glucocorticoids, thyroid hormone, diazoxide, β-adrenergic agonists,
thiazide diuretics, phenytoin, and α-interferon. In addition, second-
generation antipsychotic agents, particularly clozapine and olanzapine, have
also been linked to the development of hyperglycemia and diabetes mellitus.
Spironolactone and ramipril have not been linked to the development of
diabetes. In fact, in the HOPE (Heart Outcomes Prevention Evaluation) study,
the use of ramipril, an ACE inhibitor, appeared to reduce the risk for
developing type 2 diabetes mellitus by 20%-35%.
-A 55-year-old African-American male sees you for a routine visit. His past
medical history is notable for an 8-year history of diabetes mellitus and a
past history of hypercholesterolemia. His current medications are
atorvastatin (Lipitor), 20 mg/day, and extended-release metformin
(Glucophage XR), 1000 mg/day. He also reports a history of peanut allergy
manifested by lip angioedema, and carries an epinephrine auto-injector
(EpiPen).On examination he has a blood pressure of 124/80 mm Hg. His
hemoglobin A1c is 6.7%. A spot urine sample contains 40 µg albumin/mg
creatinine.You see the patient 6 months later for a follow-up visit, and a spot
urine sample has an albumin/creatinine ratio of 45 µg/mg.Which one of the
following would be most appropriate initially?
Have the patient return in 6 months for a repeat urine test for albumin and
creatinine
Order a 24-hour urine collection for creatinine
Recommend that the patien - -E
Diabetic nephropathy develops in 20%-40% of patients with diabetes, and is
the leading cause of end-stage renal disease. Persistent albuminuria in the
range of 30-200 mg/24 hr (microalbuminuria) is the earliest sign of
nephropathy in patients with type 1 diabetes, and is a marker for
nephropathy in type 2 diabetes. Patients with microalbuminuria who
, progress to macroalbuminuria (>300 mg/24 hr) are likely to progress to end-
stage renal disease over a period of years.Although timed 4- and 24-hour
urine collections for creatinine can be used to screen for microalbuminuria, a
random spot urine specimen for measurement of the albumin-to-creatinine
ratio is the preferred method. A minimum of two of three tests showing a
urine albumin level >30 µg/mg creatinine or more over a 6-month period
confirms the diagnosis of microalbuminuria.Intensive diabetic management
and the use of ACE inhibitors and angiotensin receptor blockers (ARBs) have
been shown to delay the progression from microalbuminuria to
macroalbuminuria in patients with type 1 or type 2 diabetes. Since the
antiproteinuric effect is believed to be independent of blood pressure,
current ADA guidelines recommend the use of ACE inhibitors or ARBs as first-
line therapy for both type 1 and type 2 diabetic patients with
microalbuminuria, even if their blood pressure is normal. Some studies,
however, have raised questions about the value of early renin-angiotensin
blockade for preventing microalbuminuria in normotensive patients with type
1 or type 2 diabetes, and ADA guidelines recommend against the use of
these drugs for patients with normal blood pressure and no
albuminuria.Compared to whites, African-Americans and Asians have a
three- to fourfold higher risk of angioedema associated with the use of ACE
inhibitors. The American Heart Association recommends that ACE i
-True statements regarding carbohydrate intake and diabetes mellitus
include which of the following? (Mark all that are true.)
The glycemic index is not useful in the management of diabetes mellitus
Carbohydrate sources high in protein are effective for treating hypoglycemia
Low-fat diets are more effective for achieving weight loss than low-
carbohydrate diets (<130 g/day)
Excessive intake of sugar-sweetened beverages has been shown to increase
the risk for diabetes mellitus
Carbohydrates have fewer calories per gram than alcohol - -D AND E
Weight loss is an important therapeutic objective in overweight or obese
individuals with prediabetes or diabetes mellitus. Although low-fat diets have
traditionally been promoted for weight loss, studies indicate that diets that
provide the same caloric restriction but differ in protein, carbohydrate, or fat
content are equally effective (SOR A). Both the amount and type of
carbohydrates in food influence blood glucose levels. Monitoring the total
grams of carbohydrates and using the glycemic index are both regarded as
helpful strategies for achieving glycemic control. Dietary sucrose does not
increase glycemia more than isocaloric amounts of starch, and intake of
sucrose and sucrose-containing foods does not need to be restricted because
of concerns about aggravating hyperglycemia in patients with diabetes
mellitus. The use of nonnutritive sweeteners in place of caloric sweeteners
has the potential to reduce carbohydrate intake. However, it has been shown
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