AANP BOARD EXAM WITH DETAILED QUESTIONS AND
VERIFIED CORRECT ANSWERS/ ALREADY GRADED A++
Sulfonylurea therapy in Type 2 DM - ANSWER - Ex: glipizide, glyburide,
glimepiride
- Increases insulin resistance, works on fasting and PP glucose
- Hypoglycemia risk, esp. in elders or CKD
- Usually given as add-on to metformin
- SE: photosensitivity, weight gain
- Causes beta cell burnout after 5 years of use
- DON'T GIVE IF SULFA ALLERGY!
Thiazolidinedione (TZD) therapy in Type 2 DM - ANSWER - Ex:
pioglitazone, rosiglitazone
- Insulin sensitizer, works on fasting and PP glucose
- No risk of hypoglycemia
- DON'T GIVE IF CHF OR WITH INSULIN/NITRATES!
- SE: edema
- Check AST/ALT Q 6-12 months
Type 2 DM drug classes - ANSWER - Biguanide (metformin)
- Sulfonylurea (glipizide, glyburide, glimepiride)
- TZD (pioglitazone, rosiglitazone)
- DPP-4 inhibitor (sitagliptin, saxagliptin, linagliptin, alogliptin)
- GLP-1 agonist (exenatide, liraglutide, albiglutide)--SQ
- SGLT-2 (canagliflozin, dapagliflozin, empagliflozin)
DPP-4 inhibitor therapy in Type 2 DM - ANSWER - Ex: sitagliptin (Januvia),
saxagliptin, linagliptin, alogliptin
- Increases insulin release, works on PP BG
- No risk of hypoglycemia
- DO NOT GIVE WITH GLP-1 AGONISTS!
- May use saxagliptin and alogliptin in CHF pts
- DO NOT GIVE WITH HX OF PANCREATITIS!
- Adjust dose with CKD
GLP-1 agonist therapy in Type 2 DM - ANSWER - Ex: exenatide (Byetta),
liraglutide (Victoza), albiglutide
- DO NOT GIVE WITH DPP-4 INHIBITOR!
,- Increases insulin release, workds on PP BG
- Slows gastric emptying, causing appetite suppression, N/V, and
subsequent weight loss
- DO NOT GIVE WITH GASTROPARESIS!
- PANCREATITIS RISK!
- Adjust dose with CKD
SGLT2 therapy in Type 2 DM - ANSWER - Ex: canagliflozin (Invokana),
dapagliflozin, empagliflozin
- Increases amount of glucose excreted in urine, works on PP BG
- Risk of hypoglycemia
- SE: genital infections, UTI, increased urination
- Adjust dose with CKDd
- D/C with GFR <60
- Risk of DKA and urosepsis
Type 2 DM tx guidelines - ANSWER 1. Metformin
2. Metformin + 2nd drug if no improvement in 3 months
3. Metformin + 2nd and 3rd drug if no improvement in 3 months
4. Metformin + injectables (metformin + basal insulin + mealtime insulin or
GLP-1)
Indications for initiating insulin therapy at time of dx in Type 1 or Type 2 DM
- ANSWER - Type 1: always use insulin to manage; need basal (long-
acting) insulin with bolus insulin (short-acting) adjusted for meals via pump
or injection; NEVER MANAGE ALONE!
- Type 2: A1C >9% with sx (may need short course for 2-3 weeks), when
2+ standard meds aren't working, or when acutely ill
Short- and rapid-acting insulins - ANSWER - Ex: glulisine, lispro
(Humalog), aspart (NovoLog)
- Onset: 15 min
- Peak: 2 hours
- Duration: 4 hours
Short-acting insulins - ANSWER - Ex: regular (Humulin R)
- Onset: 40 min
- Peak: 2-3 hours
- Duration: 3-6 hours
,Long-acting insulins - ANSWER - Ex: detemir (Levemir), glargine (Lantus)
- Onset: 1-2 hours
- Peak: none
- Duration: 24 hours
Intermediate-acting insulins - ANSWER - Ex: NPH (Humulin N)
- Onset: 1-2 hours
- Peak: 6-14 hours
- Duration: 16-24 hours
Acanthosis nigricans - ANSWER Hyperpigmented plaques with velvet-like
appearance on neck , groin folds, knuckles, elbows, and axillae; indicated
Type 2 DM
Supportive therapy in Type 2 DM patients (in addition to DM meds)--
ABCDEFG approach - ANSWER - A: ASA in men >50 years and women
>60 years with DM + CVD risk factors
- B: BP control to keep <140/90
- C: Cholesterol control with statin for patients >40 years; check lipids,
creatinine, GFR, and urine microalbumin annually
- D: diet--limit fats, refer to dietician; regular dental visits
- E: Exercise 150 min/week of moderate activity; annual eye exam
- F: visual foot exam with every visit; full exam annually
- G: goals--review periodically
Metabolic syndrome components - ANSWER - Large waistline
- Hypercholesterolemia
- Low HDL
- High BP
- High BG
Metabolic syndrome tx - ANSWER - Lifestyle changes (weight loss, diet,
activity, smoking cessation)
- Reduce LDL with statins
- Increase HDL with lifestyle changes, fibrate, or niacin
- Reduce BP with meds
- Reduce BG with oral meds or insulin
- ASA to reduce risk of clots and stroke
, Target organs impacted by HTN - ANSWER - Brain (stroke, vascular
dementia)
- CV (atherosclerosis, MI, LVH, CHF)
- Kidneys (nephropathy)
- Eyes (retinopathy)
Fundoscopic exam findings in HTN - ANSWER - Grade 1: reversible;
narrowing of terminal branches
- Grade 2: reversible; narrowing of vessels with severe local constriction
(AV nicking)
- Grade 3: striate hemorrhages, soft exudates, silver-copper wire arterioles;
visual change may be permanent
- Grade 4: k flame hemorrhages; papilledema d/t increased ICP--
EMERGENCY, SEND TO ER!!! Visual changes may be permanent
Lifestyle modifications for HTN with dyslipidemia - ANSWER - Weight
reduction
- DASH diet (fruits, veg, low-fat dairy)
- Sodium restriction (esp. AA and elderly)
- Physical activity x40 min, 3-4 days/week
- Control alcohol consumption: men <2 drinks/day, women <1 drink/day
HTN tx BP goals - ANSWER - Age >60 years: <150/90
- Age <60 years: <140/90
- All ages with DM but no CKD: <140/90
- All ages with CKD: <140/90
HTN tx guidelines - ANSWER - Whites: thiazide, ACEI, ARB, or CCB
- Blacks: thiazide or CCB
- All races with CKD: ACEI or ARB
1. Maximize first med, add 2nd before maximizing first, or start with 2 meds
(if >20 systolic or >10 diastolic over goal)
2. Recheck in 4 weeks; if not at goal, add another drug or if already on 2,
titrate up; DO NOT COMBINE ACEI AND ARB!
3. Repeat #2
4. Recheck in 4 weeks; refer if still not at goal
Thiazide (diuretic) therapy in HTN - ANSWER - Ex: HCTZ, chlothalidone
VERIFIED CORRECT ANSWERS/ ALREADY GRADED A++
Sulfonylurea therapy in Type 2 DM - ANSWER - Ex: glipizide, glyburide,
glimepiride
- Increases insulin resistance, works on fasting and PP glucose
- Hypoglycemia risk, esp. in elders or CKD
- Usually given as add-on to metformin
- SE: photosensitivity, weight gain
- Causes beta cell burnout after 5 years of use
- DON'T GIVE IF SULFA ALLERGY!
Thiazolidinedione (TZD) therapy in Type 2 DM - ANSWER - Ex:
pioglitazone, rosiglitazone
- Insulin sensitizer, works on fasting and PP glucose
- No risk of hypoglycemia
- DON'T GIVE IF CHF OR WITH INSULIN/NITRATES!
- SE: edema
- Check AST/ALT Q 6-12 months
Type 2 DM drug classes - ANSWER - Biguanide (metformin)
- Sulfonylurea (glipizide, glyburide, glimepiride)
- TZD (pioglitazone, rosiglitazone)
- DPP-4 inhibitor (sitagliptin, saxagliptin, linagliptin, alogliptin)
- GLP-1 agonist (exenatide, liraglutide, albiglutide)--SQ
- SGLT-2 (canagliflozin, dapagliflozin, empagliflozin)
DPP-4 inhibitor therapy in Type 2 DM - ANSWER - Ex: sitagliptin (Januvia),
saxagliptin, linagliptin, alogliptin
- Increases insulin release, works on PP BG
- No risk of hypoglycemia
- DO NOT GIVE WITH GLP-1 AGONISTS!
- May use saxagliptin and alogliptin in CHF pts
- DO NOT GIVE WITH HX OF PANCREATITIS!
- Adjust dose with CKD
GLP-1 agonist therapy in Type 2 DM - ANSWER - Ex: exenatide (Byetta),
liraglutide (Victoza), albiglutide
- DO NOT GIVE WITH DPP-4 INHIBITOR!
,- Increases insulin release, workds on PP BG
- Slows gastric emptying, causing appetite suppression, N/V, and
subsequent weight loss
- DO NOT GIVE WITH GASTROPARESIS!
- PANCREATITIS RISK!
- Adjust dose with CKD
SGLT2 therapy in Type 2 DM - ANSWER - Ex: canagliflozin (Invokana),
dapagliflozin, empagliflozin
- Increases amount of glucose excreted in urine, works on PP BG
- Risk of hypoglycemia
- SE: genital infections, UTI, increased urination
- Adjust dose with CKDd
- D/C with GFR <60
- Risk of DKA and urosepsis
Type 2 DM tx guidelines - ANSWER 1. Metformin
2. Metformin + 2nd drug if no improvement in 3 months
3. Metformin + 2nd and 3rd drug if no improvement in 3 months
4. Metformin + injectables (metformin + basal insulin + mealtime insulin or
GLP-1)
Indications for initiating insulin therapy at time of dx in Type 1 or Type 2 DM
- ANSWER - Type 1: always use insulin to manage; need basal (long-
acting) insulin with bolus insulin (short-acting) adjusted for meals via pump
or injection; NEVER MANAGE ALONE!
- Type 2: A1C >9% with sx (may need short course for 2-3 weeks), when
2+ standard meds aren't working, or when acutely ill
Short- and rapid-acting insulins - ANSWER - Ex: glulisine, lispro
(Humalog), aspart (NovoLog)
- Onset: 15 min
- Peak: 2 hours
- Duration: 4 hours
Short-acting insulins - ANSWER - Ex: regular (Humulin R)
- Onset: 40 min
- Peak: 2-3 hours
- Duration: 3-6 hours
,Long-acting insulins - ANSWER - Ex: detemir (Levemir), glargine (Lantus)
- Onset: 1-2 hours
- Peak: none
- Duration: 24 hours
Intermediate-acting insulins - ANSWER - Ex: NPH (Humulin N)
- Onset: 1-2 hours
- Peak: 6-14 hours
- Duration: 16-24 hours
Acanthosis nigricans - ANSWER Hyperpigmented plaques with velvet-like
appearance on neck , groin folds, knuckles, elbows, and axillae; indicated
Type 2 DM
Supportive therapy in Type 2 DM patients (in addition to DM meds)--
ABCDEFG approach - ANSWER - A: ASA in men >50 years and women
>60 years with DM + CVD risk factors
- B: BP control to keep <140/90
- C: Cholesterol control with statin for patients >40 years; check lipids,
creatinine, GFR, and urine microalbumin annually
- D: diet--limit fats, refer to dietician; regular dental visits
- E: Exercise 150 min/week of moderate activity; annual eye exam
- F: visual foot exam with every visit; full exam annually
- G: goals--review periodically
Metabolic syndrome components - ANSWER - Large waistline
- Hypercholesterolemia
- Low HDL
- High BP
- High BG
Metabolic syndrome tx - ANSWER - Lifestyle changes (weight loss, diet,
activity, smoking cessation)
- Reduce LDL with statins
- Increase HDL with lifestyle changes, fibrate, or niacin
- Reduce BP with meds
- Reduce BG with oral meds or insulin
- ASA to reduce risk of clots and stroke
, Target organs impacted by HTN - ANSWER - Brain (stroke, vascular
dementia)
- CV (atherosclerosis, MI, LVH, CHF)
- Kidneys (nephropathy)
- Eyes (retinopathy)
Fundoscopic exam findings in HTN - ANSWER - Grade 1: reversible;
narrowing of terminal branches
- Grade 2: reversible; narrowing of vessels with severe local constriction
(AV nicking)
- Grade 3: striate hemorrhages, soft exudates, silver-copper wire arterioles;
visual change may be permanent
- Grade 4: k flame hemorrhages; papilledema d/t increased ICP--
EMERGENCY, SEND TO ER!!! Visual changes may be permanent
Lifestyle modifications for HTN with dyslipidemia - ANSWER - Weight
reduction
- DASH diet (fruits, veg, low-fat dairy)
- Sodium restriction (esp. AA and elderly)
- Physical activity x40 min, 3-4 days/week
- Control alcohol consumption: men <2 drinks/day, women <1 drink/day
HTN tx BP goals - ANSWER - Age >60 years: <150/90
- Age <60 years: <140/90
- All ages with DM but no CKD: <140/90
- All ages with CKD: <140/90
HTN tx guidelines - ANSWER - Whites: thiazide, ACEI, ARB, or CCB
- Blacks: thiazide or CCB
- All races with CKD: ACEI or ARB
1. Maximize first med, add 2nd before maximizing first, or start with 2 meds
(if >20 systolic or >10 diastolic over goal)
2. Recheck in 4 weeks; if not at goal, add another drug or if already on 2,
titrate up; DO NOT COMBINE ACEI AND ARB!
3. Repeat #2
4. Recheck in 4 weeks; refer if still not at goal
Thiazide (diuretic) therapy in HTN - ANSWER - Ex: HCTZ, chlothalidone
