USMLE/COMLEX 3 - Diabetes Mellitus Treatments

Here are key facts for USMLE Step 3 & COMLEX-USA Level 3 from the Diabetes Mellitus - Pathophysiology tutorial, as well as points of interest at the end of this document that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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1. Patient-specific dosing: "Give lower doses of insulin when a patient's estimated GFR is low." 2. Type 1 management: "Insulin is a required treatment and must be taken regularly throughout the day, with special considerations given to infection and surgery." 3. Treatment intensification: "These patients may not need insulin if their glucose levels are controlled by other medications and/or changes in diet and exercise. However, when glucose targets are not met by these measures, patients will need insulin." 4. Administration options: "Insulin is often administered into subcutaneous tissues via injections or continuously via an insulin pump; an inhaled version with rapid action can be used before meals." 5. Access considerations: "In the US, especially, the price of insulin is an impediment to proper diabetes management." 1. First-line rationale: "Metformin is first-line therapy in patients with Type 2 diabetes." 2. Safety monitoring: "Metformin doesn't seem to affect the development of chronic kidney disease, but is contraindicated in patients with low estimated GFR (eGFR < 30 mL/min/1.73m²)." 3. Side effect management: "Side effects include gastrointestinal issues (nausea, vomiting), and there is potential for vitamin B12 deficiency." 4. Cardiovascular benefit: "Metformin seems to have beneficial effects on cardiovascular outcomes, though more conclusive studies are needed." 1. Perioperative management: "SGLT-2 inhibitors should be discontinued prior to surgery to avoid diabetic ketoacidosis." 2. Cardiovascular indications: "Empagliflozin, canagliflozin and dapagliflozin have beneficial effects on ASCVD, Heart Failure, and diabetic kidney disease." 3. Renal protection mechanisms: "It is also thought that SGLT-2 inhibitors protect the kidneys via reductions in renal blood flow, glomerular hyperfiltration, and intra-glomerular pressure." 4. Cardioprotective mechanisms: "Cardioprotective effects include reducing blood pressure, producing osmotic diuresis, and improving cardiac energy metabolism, among others." 5. Safety monitoring: "Side effects: Weight loss, bone fractures, urogenital infections, volume depletion and hypotension, increases in LDL levels, and increased risk of Fournier's gangrene and necrosis of the lower limb leading to foot and leg amputation." 1. Indications beyond glycemic control: "Dulaglutide, liraglutide, and semaglutide have protective effects against ASCVD and diabetic kidney disease." 2. Multiple benefits: "They also aid with appetite control and inhibition of glucagon secretion." 3. Administration options: "Administration can be subcutaneous injection or orally." 4. Adverse event monitoring: "These drugs are associated with increased risk of acute pancreatitis."

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1. Cost considerations: "Cost varies by type of insulin and route of administration; for simplicity, indicate that human insulin costs less than analog insulin." 2. Side effect management: "Weight gain is a common side effect of insulin use." 3. Formulation selection: "Rapid, regular (or "short"), intermediate, and long-acting versions of insulin that are given in different patient scenarios." 4. Risk assessment: "Insulin has potential hypoglycemic effects; the risk is higher when human insulin is used." 1. Mechanism relevant to complications: "They increase insulin secretion via beta cell stimulation. They do this by interacting with the sulfonylurea receptors, which reduce cellular potassium release; this depolarizes the cell and triggers insulin release." 2. Risk-benefit analysis: "These drugs can cause weight gain (like insulin does), and, despite being the second most prescribed drug for diabetes treatment, these drugs are associated with increased risk of cardiovascular event and mortality." 3. Affordability advantage: "Cost is relatively low." 4. Hypoglycemia management: "Because sulfonylureas increase insulin release, they can cause hypoglycemia." 5. Cardiovascular considerations: "They have neutral effects on ASCVD, heart failure, and diabetic kidney disease." 1. Mechanism for patient education: "These drugs increase incretin levels, which increases insulin secretion. DPP-4 is an enzyme that otherwise breaks down incretins." 2. Safety advantage: "No hypoglycemic effects." 3. Heart failure risk: "Saxagliptin is associated with an increased risk of heart failure." 4. Patient monitoring: "Associated with Pancreatitis." 5. Practical considerations: "Indicate that administration is orally, and cost is high." 1. Mechanism for clinical correlation: "Highly effective drugs that improve insulin sensitivity, increase fatty acid uptake, and promote adipogenesis." 2. Contraindications: "They are associated with increased risk of heart failure, and can cause fluid retention; thus, do not give to patients with renal impairment." 3. Comprehensive side effect monitoring: "These drugs are associated with weight gain, bone fractures, bladder cancer, increased LDL, and, as mentioned fluid retention." 4. Administration and cost: "Oral administration. Relatively low."

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1. Patient-centered care: Consideration of comorbidities, cost, side effect profile, and patient preferences in medication selection. 2. Deintensification: Recognizing when to reduce medication burden in elderly or vulnerable populations. 3. Treatment algorithms: Understanding ADA/EASD consensus guidelines for treatment sequence based on clinical characteristics. 1. Perioperative glycemic management: Protocols for insulin management during surgical procedures. 2. Inpatient hyperglycemia: Management strategies for critically and non-critically ill hospitalized patients. 3. Diabetic emergencies: Recognition and treatment of DKA, HHS, and severe hypoglycemia. 1. Pregnancy: Medication safety in gestational diabetes and preexisting diabetes during pregnancy. 2. Elderly patients: Adjusted glycemic targets and medication selection to minimize hypoglycemia. 3. Renal impairment: Dose adjustments and contraindications across the spectrum of kidney disease. 1. Continuous glucose monitoring (CGM): Interpretation of data patterns and therapeutic adjustments. 2. Insulin pumps: Programming considerations including basal rates, carbohydrate ratios, and correction factors. 3. Hybrid closed-loop systems: Understanding algorithms and interventions for artificial pancreas systems. 1. Multidisciplinary approach: Coordination with educators, nutritionists, and specialists. 2. Complication screening: Evidence-based protocols for detecting microvascular and macrovascular complications. 3. Quality measures: Understanding metrics for evaluating diabetes care quality in practice.