5-question Diabetes Quiz for PCPs

Wild glucose readings, misconceptions about insulin, overwhelming symptoms, and treatment for diabetic nephropathy – these are a few of the 5 subjects covered in this short quiz for primary care physicians on key topics in diabetes.  

1. A frustrated patient of yours with a hemoglobin A1c (HbA1c) of 10.3 brings you her SMBG log. You see wildly variable readings. What should be your first thought?A. The patient is fabricating readings.

B. His/her glucometer is malfunctioning.

C. The pattern reflects dietary indiscretion.

D. The patient’s exercise patterns are the cause.

E. S/he needs insulin.

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Answer: C. Think about dietary indiscretion.

If a patient’s SMBG shows no discernible pattern - the readings fluctuate greatly, dietary indiscretion is most likely. Gently discuss food choices and exercise, and what might be causing the erratic behavior. Then, with the patient’s input, select 1 change to make before the next appointment, and offer a referral to a registered dietitian (RD) or certified diabetes educator (CDE).

2. Which of the following is a common patient misconception about diabetes and diabetes treatment?A. “I don’t want to start insulin, because when my aunt did, that led her toes to be amputated.”

B. “I can’t tell if my sugar is high or low just based on how I’m feeling.”

C. “I know I need to have my blood pressure under control, and not just my blood sugars.”

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Answer: A. “I don’t want to start insulin, because when my aunt did, that led her toes to be amputated.”

This statement reflects a common type of misconception about starting insulin that we should definitely begin this discussion with our patients early, before they actually require insulin. We certainly know there is no correlation between taking insulin and amputation. The aunt appears to have had advanced disease by the time insulin was initiated, and the family’s perception is that the treatment and the loss of toes were cause and effect. We must help our patients understand that, in fact, the opposite is true - more aggressive blood glucose control can prevent this very complication, and the other microvascular and macrovascular complications of diabetes.

Your patient is a 48-year-old male who noted an involuntary weight loss of ~65 lbs over 3 months, and increasing polydipsia and xerostomia. A friend with longstanding diabetes offered to test his glucose level with her meter. The reading was 600 mg/dL. His fingerstick glucose is 492 when he comes to you for evaluation of his symptoms.

3. What would you do next, and what medication would you recommend starting?A. Obtain a hemoglobin A1c, and do not start treatment pending results.

B. Obtain an A1c and glucose as part of the chemistry panel; start metformin only, pending results.

C. Recommend dietary changes only.

D. Begin an SGLT-2 inhibitor.

E. Start insulin.

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Answer: E. Start insulin.

Insulin can accomplish two crucial tasks at this time for this patient: 1) lower his/her glucose more rapidly than an oral agent, and 2) decrease the potential for glucotoxicity that accompanies such elevated glucose. Discuss with the patient that most of the time, it is possible to transition to oral medications after the glucose stabilizes. Obtain labs, and definitely strongly advise lifestyle changes.

4. Which of the following statements about treatment and management of type 2 diabetes (T2DM) is true? A. There is broad consensus that patients should NOT perform SMBG testing.

B. You can start screening for diabetic retinopathy at 5 years after diagnosis of T2DM.

C. Guidelines from the American Diabetes Association and American Association of Clinical Endocrinologists both state that there is evidence for a particular PO therapeutic agent to add to a patient’s regimen if metformin alone is no longer effective at maintaining glycemic control.

D. To date, only empagliflozin (Jardiance) and liraglutide (Victoza) have been shown in randomized, double-blind, placebo-controlled clinical studies to have favorable impact on cardiovascular outcomes.

E. None of the above.

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Answer: D. To date, only empagliflozin (Jardiance) and liraglutide (Victoza) have been shown in randomized, double-blind, placebo-controlled clinical studies to have favorable impact on cardiovascular outcomes.

Both have demonstrated such an effect, though the precise mechanism is uncertain.

5. An ACE (angiotensin-converting enzyme)-inhibitor or an ARB (angiotensin II receptor blocker) should be prescribed for all patients living with diabetes to prevent progression to diabetic nephropathy.A. True

B. False

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Answer: B. False

There is no evidence for prophylactic treatment to prevent nephropathy.