Diabetes care - Hrudoy 2019

According to the ADA guidelines, diabetes is diagnosed if the HbA1c level is equal to or greater than 6.5% in at least 2 measurements. This means that if a person's HbA1c level is consistently 6.5% or higher in multiple tests, they can be diagnosed with diabetes.

Metformin is the first-line drug treatment for type 2 diabetes, especially in patients with a history of myocardial infarction. It is recommended as the initial therapy by various guidelines due to its efficacy in reducing blood glucose levels, its safety profile, and its potential cardiovascular benefits. Metformin works by decreasing glucose production in the liver, improving insulin sensitivity, and reducing glucose absorption in the gut. It is also associated with weight neutrality or even weight loss, which is beneficial for patients with diabetes and cardiovascular disease. Therefore, considering the patient's history and the recommended treatment guidelines, metformin is the appropriate first drug to be considered in this case.

Rosiglitazone is the correct answer because it raised serious concerns about cardiovascular safety, leading the FDA to issue guidance to evaluate cardiovascular risk in new therapies for treating type 2 diabetes in 2008. This indicates that the use of rosiglitazone may have adverse effects on the cardiovascular system, prompting regulatory action and increased scrutiny of cardiovascular risks associated with other medications used to treat type 2 diabetes.

Hypoglycemic episodes are associated with reduced health-related quality of life. This means that when patients with diabetes experience episodes of low blood sugar, it negatively impacts their overall well-being and quality of life. This can include physical symptoms such as weakness, dizziness, and confusion, as well as emotional and psychological effects. It is important to manage blood sugar levels effectively to minimize the occurrence of hypoglycemic episodes and improve the quality of life for patients with diabetes.

TZDs (thiazolidinediones) and Saxagliptin are not to be used in patients with type 2 diabetes (T2D) and congestive heart failure (CHF). Thiazolidinediones can cause fluid retention and worsen heart failure symptoms, while Saxagliptin has been associated with an increased risk of heart failure. Therefore, these drugs should be avoided in T2D patients with CHF to prevent exacerbation of their heart condition.

Testing for diabetes in asymptomatic individuals should be considered in overweight or obese individuals who have one or more of the following risk factors: first-degree relative with diabetes, hypertension (≥140/90 mmHg or therapy for hypertension), and women with polycystic ovary syndrome. However, being an active smoker is not a risk factor for diabetes in this context, so testing for diabetes is not recommended for active smokers who are overweight or obese.

SGLT2i stands for sodium-glucose co-transporter 2 inhibitors, which are a class of drugs used in the treatment of type 2 diabetes (T2D). Fournier's gangrene, also known as acute perineal necrotizing fasciitis, is a rare but serious complication that has been associated with the use of SGLT2i drugs. This condition is characterized by the rapid spread of infection and tissue death in the genital and perineal area. While the exact mechanism is not fully understood, it is believed that SGLT2i drugs may increase the risk of Fournier's gangrene by promoting genital infections and impairing the body's ability to fight off the infection.

The American Diabetes Association (ADA) has established criteria for the diagnosis of diabetes. These criteria include a fasting plasma glucose (FPG) level of greater than or equal to 126 mg/dL, a hemoglobin A1C (HbA1C) level of greater than or equal to 6.5%, a 2-hour plasma glucose (PG) level of greater than or equal to 200 mg/dL during an oral glucose tolerance test, or the presence of classical symptoms of hyperglycemia with a random PG level of greater than or equal to 200 mg/dL. The given answer, FPG ≥ 110 mg/dL, is not one of the criteria for the diagnosis of diabetes according to ADA.

Sulfonylureas and meglitinides are two classes of drugs that act by stimulating the pancreas to produce more insulin. Sulfonylureas work by increasing the release of insulin from the beta cells of the pancreas, while meglitinides stimulate insulin secretion by binding to a different receptor on the beta cells. Therefore, the correct answer is "a and b."

The UKPDS study found that a 0.9% reduction in A1C levels at 10 years was associated with a 25% reduction in microvascular endpoints. This means that for every 0.9% decrease in A1C levels, there was a 25% decrease in the risk of developing microvascular complications such as diabetic retinopathy, nephropathy, and neuropathy. This highlights the importance of achieving and maintaining good blood sugar control in order to prevent these complications.

Glimepride is a sulfonylurea drug used to treat type 2 diabetes. One of the common side effects of sulfonylureas is hypoglycemia, which is a condition characterized by low blood sugar levels. Therefore, it is likely that hypoglycemia is more common with Glimepride compared to the other drugs listed (Dapagliflozin and Linagliptin).

The answer suggests that patients with diabetes (DM) but no coronary heart disease (CHD) have a similar rate of myocardial infarction (MI) as patients without diabetes but with CHD. This means that the presence of diabetes alone does not significantly increase the risk of MI compared to having CHD without diabetes.

SGLT2 inhibitors and long-acting GLP-1 agonists have shown cardiovascular benefits by decreasing MACE (Major Adverse Cardiovascular Events). These drugs work by different mechanisms to improve cardiovascular outcomes. SGLT2 inhibitors reduce the reabsorption of glucose in the kidneys, leading to decreased blood glucose levels and improved cardiovascular function. Long-acting GLP-1 agonists increase insulin secretion, decrease glucagon secretion, and slow down gastric emptying, resulting in improved glycemic control and cardiovascular health. The combination of these two drugs has been found to be effective in reducing MACE and improving cardiovascular outcomes in patients.

Linagliptin is the correct answer because it is a dipeptidyl peptidase-4 (DPP-4) inhibitor that is not renally excreted. This means that it does not require dose adjustments or pose a risk of accumulation in patients with chronic kidney disease (CKD) and an estimated glomerular filtration rate (eGFR) of less than 30 ml/min. Metformin is contraindicated in patients with an eGFR below 30 ml/min due to the risk of lactic acidosis. Glibenclamide and empagliflozin also require dose adjustments or are contraindicated in patients with CKD.

Acarbose is an antidiabetic drug that is associated with the rare condition of multiple gas containing cysts in the sub mucosal or subserosal layer of the intestine, known as pneumatosis. This condition can be seen in various gastrointestinal conditions such as bowel gangrene and inflammatory bowel disease, as well as in rare cases associated with mechanical ventilation and endoscopic procedures.

Empagliflozin requires the least number of patients to prevent one cardiovascular (CV) death in patients with type 2 diabetes (T2D). This suggests that empagliflozin has a higher efficacy in preventing CV death compared to the other options listed (statins, antihypertensives, and aspirin). The NNT (number needed to treat) is a measure of the effectiveness of a treatment, and a lower NNT indicates a more effective treatment. Therefore, empagliflozin is the most effective option for preventing CV death in T2D patients.

The combination of DPP-4 inhibitors and GLP-1 agonists is not recommended in the treatment of T2D according to ADA guidelines. This is because both of these medications work to increase the levels of GLP-1, which can lead to an increased risk of hypoglycemia. Additionally, there may be an increased risk of gastrointestinal side effects when these two medications are used together. Therefore, it is advised to avoid this combination in the treatment of T2D.

Dapagliflozin has shown significant cardiovascular benefit in patients with type 2 diabetes (T2D) who have a high risk of cardiovascular disease (CVD). This drug belongs to a class of medications called sodium-glucose co-transporter 2 (SGLT2) inhibitors, which work by blocking the reabsorption of glucose in the kidneys, leading to increased glucose excretion in the urine. In addition to its glucose-lowering effects, dapagliflozin has been shown to reduce the risk of major adverse cardiovascular events, including heart attack, stroke, and cardiovascular death, in patients with T2D and high CVD risk.

In elderly patients with long-standing diabetes and comorbidities, the HbA1C goal is set at 7.5-8%. This higher range is chosen to avoid the risk of hypoglycemia, which can be particularly dangerous for older individuals. Additionally, elderly patients may have other health conditions that make it difficult to achieve tight glycemic control. Therefore, a slightly higher HbA1C target is considered more appropriate in this population to balance glycemic control with the potential risks.

According to a meta-analysis of intensive glucose-lowering trials, the intervention that results in better reduction of CV events is the reduction of systolic BP (4 mmHg). This means that lowering systolic blood pressure by 4 mmHg has a greater impact on reducing cardiovascular events compared to reducing HbA1C levels or LDL cholesterol levels.