Integrated Diabetes Midterm 2026 HL

T/F: make decisions based on trends

T

use 3-4 days worth of data

What A1C level indicates diabetes?

> 6.5%

What FPG level indicates diabetes?

> 126mg/dL

What 75g OGTT 2 hour plasma level indicates DM?

> 200mg/dL

If S/S of hyperglycemia (3 Ps) are present, what random BG level indicates DM?

> 200mg/dL

When do we screen for DM in adults who are asymptomatic?

if they are overweight and have 1+ RF

What are RF for DM?

First-degree relative with DM

CVD hx

HTN (>130/80 or medicated)

HDL (< 35) or TG (> 250)

Physical inactivity

High-risk race or ethnicity

AA

Latino

Asian A.

Native A. 

Pacific islander 

What is the definition of overweight?

BMI > 25, or > 23 if Asian

How often should someone be screened for DM?

Normal Results → Q3Y

Abnormal Results → asap, 2+ abnormal screenings required for diagnosis 

T/F: all adults should be screened for DM at age 35

T regardless of RF

Which medications require screening for DM?

Steroids: Screen PPG or Random BG

Statins

Thiazide diuretics

Some HIV meds (protease inhibitors, NRTIs)

SGA (second gen antipsychotic): Screen at baseline, Q3-4M, and QY

What A1c level is pre-DM?

5.7-6.4%

What FPG level is pre-DM?

100 - 125mg/dL

What 2-hr OGTT level is pre-DM?

140 - 199mg/dL

What are critical time points when patients might be vulnerable to psychosocial issues?

At diagnosis

Annually/Routine Visits

Changes in disease status or tx

Changes in lifestyle

What psychosocial topics be screened routinely?

distress, depression, anxiety, burnout

What are the 5Cs in interventions for change?

Constructing a Problem Definition;

Collaborative Goal Setting;

Collaborative Problem Solving ;

Contracting for Change;

Continuing Support

What is the goal of constructing a problem defintion?

start with the patient's problem, be specific

What are questions to ask when constructing a problem definition?

What is your greatest concern about your DM?

What is the hardest part about managing your DM? Can you give an example?

What is causing you the most distress?

What is the goal of collaborative goal setting?

translate a patient's motivation and desired behavior into action, help patient identify first steps, make SMART goals

What are questions to ask when collaborating on goal setting?

What are your goals for changing your behavior?

What behavior would you like to change?

What is the goal of collaborative problem solving?

Identify barriers (i.e.,beliefs, emotions, social networks, resources, physical environment)

Formulate strategies to overcome barriers

Engage patient in this process

What are questions to ask when collaborating on problem solving?

What could prevent you from reaching your goal?

Why would that keep you from your goal?

What are some steps you could take to overcome these barriers?

What are some strategies you have used in the past to deal with an issue that were successful?

What is the goal of contracting for change?

commitment and strategies to achieve goals (i.e., start date, written agreement, tracking outcomes, re-evaluations, reward success)

What are questions to ask when contracting for a change?

How will you track your progress?

How will you reward your success?

How will you know when you are successful?

What is the goal of continuing support?

long-term interventions, plan for relapse, identify coping resources and emotional support

What are questions to ask when continuing support?

Everyone can occasionally get off track, what will you do when this happens?

What can you do to help prevent getting off track?

What can I do to help support you?

What are results of SDOH in DM?

Poor glycemic control

Medication nonadherence

Worse health outcomes

What screening tools are used in DM to address SDOH?

Incorporate and document screening

Track socio-demographic variables in the EMR

Team effort

Connect, refer, and f/u

Why are SDOH impairing care?

Patients may not confide in their healthcare team

What are + nutrition behaviors?

nonstarchy veggies,

whole fruit,

legumes,

high fiber (> 3g),

H2O,

lean protein,

herbs and spices,

vegetable oils,

meal prep

What are goals of MNT?

Promote healthy eating patterns, emphasizing variety of nutrient-dense food and portion control

Address individual nutrition needs

Maintain pleasure of eating by providing non-judgemental messages

Provide tools for developing healthy eating patterns

T/F: MNT can reduce A1c by 2-3%

F 1-2%

What is included in the MNT approach?

Assess: evaluate current food, lifestyle, culture, and readiness to change

Education

Goal Setting: prioritize with patient, food diary, SMART goals

Evaluate & F/U: SMBG to evaluate impact of diet

What are obstacles to MNT?

Lack of interest/knowledge

Difficult resisting temptation

Eating out

FOMO mofo

Emotional eating

Temptation to relapse

Planning/priorities

Family support

$$

What are carbs?

Energy source

Sugars, starches, fibers

What is the glycemic response of carbs?

varies with amount, type, cooking, processing, and form

What is carb counting?

Total: 150-210g per day

45-60g per meal (3x per day)

15-30g per snack (1-2x per day)

What is the exchange system?

Total: 10-14 carb choices per day

3-4 choices per meal (3x per day)

1-2 choices per snack (1-2x per day)

Round to the nearest carb choice/serving

0-5g = 0

6-10g = ½ serving/choice

11-20g = 1 serving

21-25g = 1 ½ serving

26-35g = 2 servings

What is the DM plate method?

Use 9-in plate

½ vegetables

¼ protein

¼ carbs

+ 8 oz water (or another 0 calorie drink)

Who are candidates for advanced carb counting?

MDI or Pump Therapy

Flexible Insulin Regimen → educate on carb counting to determine mealtime doses (NOT really needed if fixed insulin doses, these ppl should choose consistency)

ICR improves glycemic management

What is the rule of 500?

500 / TDD = ICR

Example: 500 / 50 units = 10 → 1 unit of insulin : 10 g carbs

What is the individualized ratio?

Pre-meal glucose level

G of carbs eaten

Dose of pre-meal rapid/short acting insulin

2-hour PPG → if within target, divide g of carb eaten by pre-meal dose = ICR

Example: 122mg/dL is within goal → 60g  carbs eaten / 6 units = 10 → ICR 1:10

What is glycemic index?

system of ranking carbs according to their effect on postprandial sugars (glycemic effect of 50g of carbs from a single food is measured over 2hr period and compared to a reference food)

What is high, moderate, and low GI?

High > 70

Moderate 56-69

Low < 55

How much weight loss is recommended?

5-7%

What are + to weight loss?

Decreased insulin resistance

Prevent/delay onset of T2DM

Improve glucose, lipids, BP

Reduce risk of CVD

What are recommendations for physical activity?

150 min QW, spread over >3 days

Moderate-vigorous intensity aerobic exercise

Resistance training 2-3x per week

< 2 consecutive days without activity

Stand up every 30 minutes

What diabetes meds may cause weight gain?

Insulin

SUs

TZDs

What diabetes meds may cause weight loss?

GLP1

SGLTs (mod)

Metformin (mod/neutral)

What are considerations of hypoglycemia and physical activity?

Check BG before exercise

Eat carbs if < 90

Adjust insulin doses

Carry carbs

Monitor BG during and after

What is the rule of 15?

15 g of carb when low, wait 15 min, repeat

What are example of 15g of carbs?

3-4 glucose tablets

½ c OJ

½ c coke

1 c skim milk

What are A1c goals?

< 7 or < 8 (if frail)

can be more strict if healthy

How often should A1c be monitored?

Q3M if therapy changes or not at goal

Q6M if stable and controlled

What are BG targets/goals?

FPG 80-130

PPG < 180

What are C/I of metformin?

Renal impairment eGFR < 30

Metabolic acidosis (i.e., DKA)

What are precautions of metformin?

Hepatic impairment

Hypoxic states (ACHF, AMI)

Temporarily D/C at time of/before iodinated contrast imagine if eGFR 30-60

What are + of metformin?

Data

Efficacy

No hypoglycemia risk

No weight gain (mod weight loss)

Cheap

Reduction in CV events/death

What are ADEs and - of metformin?

GI

Lactic acidosis

What are monitoring parameters of metformin?

B12 Q2-3Y

eGFR baseline and QY

What is metformin dosing titration sched?

500mg QD x7 → increase by 500mg QW until 2000mg QD

What are + of SUs?

Low cost

Good A1c effect

What are ADEs and - of SUs?

Hypoglycemia

Weight gain (~2kg)

Beta cell exhaustion/treatment failure

What is a precaution with SUs?

decrease clearance in renal or hepatic impairment

What is a C/I of glyburide?

renal impairment

What are counseling points of SUs?

Take with breakfast or first main meal of day

What are meglitinides?

(shorter t1/2 secretagogues)

Options: Repaglinide, Nateglinide

What are + of meglitinides?

same as SU

Fewer side effects

What are ADEs and - of meglitinides?

same as SU

Dosed TID before meals

Less A1c effect than SUs

What are precautions and counseling points of meglitinides?

same as SU

What are + of TZDs?

QD +/- food

No hypoglycemia

Good A1c effect

Pioglitazone has decreased CVD events

Cheap

MASH benefit

What are ADEs and - of TZDs?

Weight gain

Edema

Increased HF risk BBW

Increased bone fracture risk

Increase bladder cancer risk

Fluid retention in renal impairment

What are precautions of TZDs?

HF/reduced LVEF

Acute liver disease (ALT 3x ULN)

CKD (due to fluid retention)

When are TZDs C/I?

Class III and IV HF

What should be monitored when taking TZDs?

LFTs at baseline

T/F: TZDs take 12 weeks for full benefit

T

What are + of DPP-4 inhibitors?

QD +/- food

Weight neutral

No hypoglycemia

Tolerated well

What are ADEs and - of DPP-4s?

Mid efficacy

Renal dose adjustment (EXCEPT linagliptin)

Saxagliptin: Increase HF hospitalizations, Metabolized by 3A4

D/C if pancreatitis

Reversible joint pain

Autoimmune blistering skin disease (reversible, rare, D/C)

What is a C/I of DPP-4?

GLP-1

What are possible dose adjustments needed for DPP-4?

Renal impairment

3A4 interactions

Lower SU dose if combination

What should you monitor on DPP-4?

SCr at baseline and routinely

What are + of GLP-1?

High A1c lowering

Weight loss: Sema > Dula > Lira > Exena > Lixisena

No hypoglycemia

Decreased PPG excursions

Improved beta cell fxn

CV benefit

HF benefit

CKD benefit

Semaglutide SQ MASH benefit

What are ADEs and - of GLP-1?

$

Injection (except Rybelsus) site reaction

Training/education

GI side effects

Renal impairment

Acute pancreatitis (D/C)

Ileus (rare)

What are C/I of GLP-1?

eGFR or CrCl < 30 (exena, lixisena) so monitor renal fxn

Gastroparesis

Thyroid C cell tumors

Biliary disease

Retinopathy (PO sema)

What are counseling points with GLP-1?

small meal size, stop eating when full, decrease high fat and spicy foods

Time and frequency

Instructions

Impacts absorption of PO contraceptives

D/C prior to surgery

PO take 30 min before first food of day

What are + of insulin-GLP1 combos?

Complementary MOA

Protections of beta cell mass

Benefits FPG and PPG

Weight sparing (compared to insulin alone)

Less GI ADEs

Less hypoglycemia (compared to insulin alone)

Improve adherence

Lower insulin doses

What are + of SGLT2?

Intermediate - high A1c lowering

Low risk of hypoglycemia

QD

Weight loss

CV benefit

Lowering BP

HF benefit

CKD benefit

What are ADEs and - of SGLT2?

DKA (rare in T2)

Polyuria

UTIs

Geneital mycotic infxns

Fluid-electrolyte imbalances

Less effective on A1c if eGFR < 45 (still start tho if > 20) for CKD benefits

Increase SCr

What are counseling points for SGLT2?

Sick day planning

D/C before surgery, critical illness, prolonged fasting

Euglycemia DKA

What is the MOA of metformin?

decreases hepatic glucose production

What is the MOA of SU (i.e., glipizide)?

stimulates pancreas to secrete insulin

TZD (pioglitazone) MOA?

increases peripheral insulin sensitivity

Sitagliptin (DPP-4) MOA?

inhibits DPP-4 activity, increasing incretin concentrations

Exenatide (GLP) MOA?

activates GLP-1 receptors

Canagliflozin (SGLT2) MOA?

blocks glucose reabsorption in kidney by inhibiting SGLT2, increases glucose urinary excretion

Acarbose MOA?

slows intestinal carbohydrate digestion and absorption

What is the route and freq of exenatide (byetta)?

BID 60 min before meals

SQ

What is the route and freq of lixisenatide (adlyxin)?

QD within 1 hour of first meal

SQ

What is the route and freq of liraglutide (victoza)?

QD SQ