<\/p>\n
Diabetes Clinical Questions<\/p>\n
\n
Here are a few common clinical scenarios that you probably encounter several times a week.\u00a0 <\/span>Your job now is to say what you would do in these situations and why<\/strong>.\u00a0 <\/span>In extreme detail.<\/span>\u00a0 <\/span>Detail the parts of your recommendation which stand on a firm evidence base and the parts which stand on shaky or non-existent evidence.\u00a0\u00a0 Secondary sources such as the In the Clinic article attached here, UptoDate, The Hopkins module, and The Cochrane reviews are good places to start your research.\u00a0 However, your presentation should refer to important primary studies and not just quote recommendations or guidelines.\u00a0 <\/span><\/p>\n \n 1.\u00a0 <\/span>You have a patient, a 39 year-old Puerto Rican woman who weighs 200 pounds (BMI of 31) and has a family history of diabetes.\u00a0 <\/span>She has tried various diets and exercise regiments but has failed to lose weight.\u00a0 <\/span>She wants to know whether she has diabetes or not.\u00a0 <\/span>Random afternoon glucose (2 hours after lunch) is 170.\u00a0 <\/span>Hemoglobin A1c is 6.9%\u00a0 <\/span>What<\/span> would you recommend?<\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>-Can hemoglobin A1c<\/span> be used to \u201cdefine\u201d diabetes?<\/em><\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>-When should drug therapy for prevention be initiated?<\/em><\/p>\n \n 2. The patient is a 52 year-old Guyanese woman who had onset of polyuria<\/span> and polydypsia<\/span><\/span>\u00a0 <\/span>several<\/span> months ago.\u00a0 <\/span>Fasting glucose three days ago at urgent care was 178 mg\/dl, Hemoglobin A1c is 8.5%.\u00a0 <\/span>Her BMI is 25,<\/span> she has gained 4 lbs. in the last year.\u00a0 <\/span>Her husband also has diabetes; she has been following his diabetic diet with him.\u00a0 <\/span>His doctor has him on Actos<\/span> \u2013 the patient tried her husband\u2019s medication twice and says it was \u201ca good pill.\u201d\u00a0 <\/span>What would you recommend?\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span><\/p>\n -What evidence is there to support recommendations for a particular diabetic diet?<\/em><\/p>\n \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>-Is there evidence to support one oral therapy over another as initial therapy?<\/em><\/p>\n \n 3.\u00a0 <\/span>The patient is a 55 year-old mixed race Hispanic man who has had diabetes for eight years.\u00a0 <\/span>Initially he responded to recommendations for diet and exercise \u2013 he lost five pounds and his glucose normalized.\u00a0 <\/span>Then two years later, despite continued efforts, his glucose rose and he began taking metformin<\/span>.\u00a0 <\/span>After increasing the dose to 1000 mg bid, the glucose normalized again.\u00a0 <\/span>Then after two years, the glucose began to climb again.\u00a0 <\/span>Glyburide<\/span> 5 mg bid has been added and compliance with diet and exercise continues, but the patient\u2019s last two Hemoglobin A1c\u2019s<\/span> have been 8.3%.\u00a0 <\/span>He has gained four pounds over the last three years.\u00a0\u00a0<\/span>\u00a0<\/em><\/p>\n What evidence is there for combination oral therapy (including biguanide, sulfonylurea, TZD, alphaglucosidase inhibitor, DPPIV inhibitor, and glinides)?\u00a0 At what rate do oral therapies fail?<\/em><\/p>\n <\/p>\n \n 4. The patient is a 56 year-old woman with type 2 diabetes for five years and CAD.\u00a0 <\/span>She is on metformin<\/span> 1000 bid and NPH 50 U in the am, 30 U at bedtime.\u00a0 <\/span>Morning fasting fingersticks<\/span> are 55 to 150,<\/span> bedtime fingersticks<\/span> are 110 to 200.\u00a0 <\/span>Hemoglobin A1c<\/span> is 8%.\u00a0 <\/span>Attempts to increase her am NPH have caused sporadic hypoglycemic episodes, one of which resulted in syncope.\u00a0 <\/span>What changes would you recommend?<\/p>\n<\/div>\n a. When insulin is started, should the oral therapies be continued?\u00a0 Is there evidence supporting combinations of oral therapy and insulin?<\/em><\/p>\n b.\u00a0<\/span>When should a type 2 diabetic be switched to the newer insulins<\/span>, glargine<\/span> and lispro<\/span>?\u00a0 <\/span>Is there evidence of improved control with these<\/em>?<\/p>\n \n 5.\u00a0 <\/span>You have an 82 year-old man as your patient.\u00a0 <\/span>He has type 2 diabetes, hypertension, arthritis, and very mild dementia.\u00a0 <\/span>He has been injecting insulin twice a day for twenty years.\u00a0 <\/span>He has never had an MI, a stroke, PVD, or more than background retinopathy.\u00a0 <\/span>Creatinine<\/span> is 1.5.\u00a0 <\/span>BP is 130\/70, P 68. He has loss of protective sensation in his feet in all areas tested.\u00a0 <\/span>He does not perform glucometer<\/span> checks.\u00a0 <\/span>His random glucoses are always between 130 and 200 and his Hemoglobin A1c is always between 9% and 10%.\u00a0\u00a0 <\/span>His insurance is medicare<\/span> alone.\u00a0 <\/span>Medications are insulin glargine 40 U qd, monopril<\/span> 40, atenolol<\/span> 50, ASA 81 mg, Zocor<\/span><\/span> 20 mg and acetimenophen<\/span> prn<\/span>.\u00a0 <\/span>He lives at home with his wife who reminds him to take his medication.\u00a0 <\/span>He performs all his own ADLs<\/span>.\u00a0 <\/span>Would you recommend any changes in his regimen?<\/p>\n \n<\/div>\n","protected":false},"excerpt":{"rendered":" Diabetes Clinical Questions Here are a few common clinical scenarios that you probably encounter several times a week.\u00a0 Your job now is to say what you would do in these situations and why.\u00a0 In extreme detail.\u00a0 Detail the parts of your recommendation which stand on a firm evidence base and the parts which stand….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":901,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-904","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/904","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=904"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/904\/revisions"}],"predecessor-version":[{"id":908,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/904\/revisions\/908"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/901"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=904"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}