A 48-year-old female presents with a new onset of polyuria and polydypsia. A random finger-stick blood glucose level is 17.6 mmol/L.
Which one of her medications listed below is most likely to be linked to her new onset of diabetes?
Correct Answer C:
Recent data suggests a link between atypical antipsychotics and diabetes. In particular, studies have suggested an increased risk of diabetes for patients on risperidone (choice C), quetiapine, clozapine, and olanzapine. This association has been noted even in patients who do not gain weight on the antipsychotic. The other medications listed have not been implicated in diabetes.
Some experts recommend checking a fasting glucose level before and soon after initiating an atypical antipsychotic. In addition, monitoring blood glucose every 3-6 months should be considered, especially in patients with other risk factors for developing diabetes. Patients with preexisting diabetes may suffer worsened glycemic control when started on an atypical antipsychotic.
A contraindication to the use of metformin (Glucophage) in a patient with type 2 diabetes mellitus is:
Metformin decreases glucose production in the liver and increases glucose uptake. It has no effect on pancreatic insulin secretion. It is useful to help overcome insulin resistance, and can be used concurrently with a sulfonylurea. Studies have proven its safety and usefulness in the obese diabetic. It is contraindicated in renal insufficiency, as increased concentrations of the drug can cause lactic acidosis. Other contraindications include hepatic disease, a previous history of lactic acidosis, heart failure treated with drugs, and chronic lung disease.
A 45-year-old male comes to your office for follow-up of his diabetes mellitus, which was diagnosed 3 months ago. He wanted to try lifestyle modification, including diet, exercise, and weight loss, before trying medications. He has lost 3 kg (7 lb), but still is 14 kg (31 lb) overweight. His examination is unremarkable, as is his chemistry profile. His hemoglobin A1c level is 8.3%.
Which one of the following would be most appropriate at this point?
Correct Answer D:
The Diabetes Association recommends lifestyle intervention along with metformin as initial therapy for type 2 diabetes. If the follow-up hemoglobin A1c is more than 7.0%, then insulin (most effective), a sulfonylurea (least expensive), or a glitazone (no risk of hypoglycemia) can be added. The hemoglobin A1c should be checked every 3 months until it is less than 7.0%, and every 6 months thereafter.
Which one of the following statements regarding blood glucose monitoring in patients with type 1 diabetes is most correct?
Correct Answer A:
According to the Diabetes Control and Complications Trial, patients should assess fingertip blood glucose levels at least 3 times per day, including at bedtime, as well as before and after exercising and before driving. Although testing from other sites is usually reliable, it can be inaccurate if performed within 60 minutes of meals or after exercise. If a patient’s random blood glucose level is less than 5.6 mmol/L (100 mg/dL), a small snack should be eaten. Preprandial results should be 5.0-7.3 mmol/L (90-130 mg/dL), and postprandial levels should be less than 10.0 mmol/L (180 mg/dL). Continuous blood glucose monitoring has been shown to generally lead to tighter control and lower hemoglobin A1c levels.
A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a nursing home. His blood glucose level, which he rarely checks, is typically over 11.1 mmol/L. His serum creatinine level is 167 µmol/L. He also has had several episodes of heart failure. His current medications include glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and furosemide (Lasix).
Which one of the following would be most appropriate to add to this patient’s regimen to treat his diabetes mellitus?
Correct Answer E:
For geriatric patients in long-term care facilities, the predictable glucose control of insulin glargine is the best approach to consider initially.
→ The current guidelines do not recommend a strict diet for frail diabetic patients in nursing homes.
→ Exenatide is not recommended for the frail elderly because of concerns about weight loss and nausea.
→ Heart failure precludes the use of pioglitazone, and renal failure precludes the use of metformin.
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