Quiz on Diabetes Management
I'll quiz you on the management of newly diagnosed Type 2 Diabetes Mellitus in adults. Here are progressive clinical scenarios:
Scenario 1: Initial Presentation
A 52-year-old obese man presents with polyuria, polydipsia, and a 15-pound unintentional weight loss over 2 months. His random blood glucose is 380 mg/dL and A1C is 10.4%. He has no history of cardiovascular disease.
Question 1A:
What is your immediate pharmacologic management?
Click for Answer
Start dual therapy immediately with metformin 500 mg once or twice daily with meals AND basal insulin at 10 units daily (or 0.1-0.2 units/kg/day). 1
Rationale:
- With A1C ≥9%, metformin monotherapy will only reduce A1C by 1-2%, leaving the patient well above goal 1
- The presence of catabolism (unintentional weight loss) and very high glucose levels (≥300 mg/dL) mandates insulin initiation regardless of disease stage 2
- Basal insulin analogues are preferred over NPH insulin due to reduced hypoglycemia risk 1
Titration plan:
Question 1B:
After 3 months, his A1C is 7.8% on metformin 2000 mg daily and basal insulin 28 units daily. What is your next step?
Click for Answer
Add a GLP-1 receptor agonist to the current regimen. 1
Rationale:
- A1C remains >7% despite optimized metformin plus basal insulin 1
- GLP-1 receptor agonists are preferred over adding prandial insulin due to lower risk of hypoglycemia and weight gain 1
- This patient would benefit from the weight loss effects of GLP-1 agonists given his obesity 2
Alternative consideration:
Scenario 2: Comorbidities Matter
A 68-year-old woman with newly diagnosed T2DM (A1C 8.2%) also has:
- Heart failure with reduced ejection fraction (HFrEF)
- Chronic kidney disease with eGFR 35 mL/min/1.73 m² and albuminuria
- BMI 32 kg/m²
Question 2A:
What glucose-lowering agent(s) should you prioritize and why?
Click for Answer
Start metformin AND an SGLT2 inhibitor immediately, with consideration for adding a GLP-1 receptor agonist. 2
Specific rationale for each agent:
SGLT2 inhibitor (MANDATORY):
- In adults with T2DM and heart failure (either reduced or preserved ejection fraction), an SGLT2 inhibitor is recommended for glycemic management AND prevention of HF hospitalizations 2
- With CKD (eGFR 20-60 mL/min/1.73 m² and albuminuria), SGLT2 inhibitors minimize CKD progression, reduce cardiovascular events, and reduce HF hospitalizations 2
- Note: Glycemic benefits are reduced at eGFR <45 mL/min/1.73 m², but cardiovascular and renal benefits persist 2
GLP-1 receptor agonist (STRONGLY CONSIDER):
- With advanced CKD (eGFR <30 would make this preferred), GLP-1 RAs are preferred for glycemic management due to lower hypoglycemia risk and cardiovascular event reduction 2
- At eGFR 35, this is approaching that threshold and would provide additional glycemic control and weight loss benefits 2
Metformin:
- Remains first-line unless contraindicated 1
- Safe at this eGFR level (contraindicated only at eGFR <30 mL/min/1.73 m²)
Question 2B:
What common pitfall should you avoid in this patient?
Click for Answer
Do not delay SGLT2 inhibitor initiation waiting to see if metformin alone achieves glycemic control. 2
Key points:
- The indication for SGLT2 inhibitors in this patient is NOT primarily glycemic control—it's for HF hospitalization prevention and CKD progression prevention 2
- These benefits are independent of A1C reduction 2
- A person-centered shared decision-making approach should guide choices, but cardiovascular and renal comorbidities take priority over glycemic targets alone 2
- Early combination therapy can be considered at treatment initiation to shorten time to individualized treatment goals 2
Scenario 3: Diagnostic Dilemma
A 28-year-old lean man (BMI 23 kg/m²) presents with:
- Random glucose 420 mg/dL, A1C 11.2%
- 15-pound weight loss over 6 weeks
- Mild ketonuria but no acidosis
- No family history of diabetes
Question 3:
How do you differentiate between Type 1 and Type 2 diabetes, and how does this change management?
Click for Answer
This presentation strongly suggests Type 1 diabetes, but test islet autoantibodies (GADA, IA-2A, IAA, ZnT8A) to confirm. 3
Clinical features suggesting T1DM:
- Young age at diagnosis 3
- Lean body habitus 3
- Unintentional weight loss (evidence of catabolism) 3
- Ketosis/ketonuria 3
- Rapid onset of severe hyperglycemia 3
Diagnostic approach:
- Test for multiple autoantibodies—multiple positive autoantibodies strongly suggest T1DM 3
- Consider C-peptide measurement (measure fasting C-peptide when simultaneous fasting plasma glucose is ≤220 mg/dL for accuracy) 3
- Low C-peptide indicates T1DM; higher levels suggest T2DM 3
Management implications:
- If T1DM confirmed: Requires immediate multiple daily insulin injections (basal-bolus regimen), NOT just basal insulin alone 2
- Starting total daily requirement: 0.3-0.4 units/kg/day, with half as prandial coverage and half as long-acting basal 2
- Requires self-monitoring 4+ times daily or continuous glucose monitor 2
- Early endocrinology consultation is high priority 2
Critical pitfall:
- Long-acting insulin therapy alone is NOT sufficient for T1DM due to absence of pancreatic function after beta-cell destruction 2
Scenario 4: Treatment Failure
A 45-year-old man with T2DM for 2 years on metformin 2000 mg daily has A1C 8.9%. He works night shifts, has difficulty with medication adherence, and is concerned about injections.
Question 4:
What is your approach to intensifying therapy in this challenging patient?
Click for Answer
Add a once-weekly GLP-1 receptor agonist to improve adherence, or consider an SGLT2 inhibitor as an oral alternative. 2
Rationale for agent selection:
- Medication-taking behavior should be reevaluated and adjusted to incorporate specific factors that impact treatment choice 2
- Once-weekly GLP-1 agonists reduce injection burden compared to daily options
- SGLT2 inhibitors offer oral administration with cardiovascular benefits 2
- Both classes have low hypoglycemia risk, important for a shift worker 2
Person-centered approach:
- A shared decision-making approach should guide pharmacologic agent choice, considering effectiveness, hypoglycemia risk, impact on weight, cost and access, risk for adverse reactions and tolerability, and individual preferences 2
- Address adherence barriers: Consider once-weekly formulations, simplify regimen, assess cost/access issues 2
- Medication plan should be reevaluated at regular intervals (every 3-6 months) 2
What NOT to do:
Bonus Question: Special Population
An 82-year-old nursing home resident with advanced dementia and T2DM has A1C 9.2%. She has limited life expectancy and multiple comorbidities.
Question 5:
What are appropriate glycemic targets and treatment approach?
Click for Answer
Simplify the regimen to prevent hypoglycemia and hyperglycemia, with glucose targets aimed at keeping levels below the renal threshold (approximately <180-200 mg/dL) rather than aggressive A1C lowering. 2
Management approach for this "stable patient with advanced disease":
- Continue previous regimen with focus on preventing hypoglycemia and managing hyperglycemia 2
- Keep glucose levels below renal threshold to prevent osmotic diuresis and dehydration 2
- Very little role for A1C monitoring and lowering in this population 2
- Treatment interventions must be mindful of quality of life 2
Medication considerations:
- Oral agents may be used as first-line 2
- If insulin needed, use simplified basal insulin regimen without rapid-acting insulin 2
- Avoid agents causing gastrointestinal symptoms (nausea) or excess weight loss 2
- Agents that can cause hypoglycemia should be avoided or carefully titrated 2
Key principle:
How did you do? These scenarios cover the core principles of T2DM management: early combination therapy for elevated A1C, comorbidity-driven drug selection, diagnostic differentiation, adherence optimization, and individualized goals for special populations.