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Question 1
Incorrect
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Karen is a 56-year-old woman with a past medical history of type 2 diabetes, hypertension and previous bladder cancer. She currently takes metformin at maximum dose and amlodipine.
Routine blood test results have returned showing a HbA1c of 59 mmol/mol. The previous HbA1c result 6 months ago was 51 mmol/mol. Urea and electrolytes are within normal limits.
Karen's body mass index is 36kg/m². What is the most appropriate next step in management?Your Answer: Commence liraglutide
Correct Answer: Commence empagliflozin
Explanation:Jeffrey’s HbA1c level of 59 mmol/mol indicates that his treatment needs to be intensified. According to NICE guidelines, if initial treatment for type 2 diabetes is ineffective, second-line treatment options should be considered as dual therapy with metformin. These options include metformin plus a gliptin, pioglitazone, sulfonylurea, or SGLT-2i.
When selecting the most appropriate management for Jeffrey, his BMI should be taken into account. SGLT-2 inhibitors, such as empagliflozin, are the most suitable option as they have the added benefit of weight loss in patients with T2DM. This is particularly relevant for Jeffrey.
GLP-1 mimetics, like liraglutide, also promote weight loss, but they are only considered when triple therapy with metformin and two other oral antidiabetic drugs is not effective. Since Jeffrey is currently on monotherapy and about to start dual therapy, liraglutide is not an option at this stage.
Gliclazide is a sulfonylurea that can be used in dual therapy with metformin. However, it can cause weight gain, making it less suitable for Jeffrey.
Pioglitazone is a thiazolidinedione that can also be used in dual therapy with metformin. However, it is contraindicated for Jeffrey due to his history of bladder cancer and can cause weight gain, making it a less appropriate option.
Understanding SGLT-2 Inhibitors
SGLT-2 inhibitors are medications that work by blocking the reabsorption of glucose in the kidneys, leading to increased excretion of glucose in the urine. This mechanism of action helps to lower blood sugar levels in patients with type 2 diabetes mellitus. Examples of SGLT-2 inhibitors include canagliflozin, dapagliflozin, and empagliflozin.
However, it is important to note that SGLT-2 inhibitors can also have adverse effects. Patients taking these medications may be at increased risk for urinary and genital infections due to the increased glucose in the urine. Fournier’s gangrene, a rare but serious bacterial infection of the genital area, has also been reported. Additionally, there is a risk of normoglycemic ketoacidosis, a condition where the body produces high levels of ketones even when blood sugar levels are normal. Finally, patients taking SGLT-2 inhibitors may be at increased risk for lower-limb amputations, so it is important to closely monitor the feet.
Despite these potential risks, SGLT-2 inhibitors can also have benefits. Patients taking these medications often experience weight loss, which can be beneficial for those with type 2 diabetes mellitus. Overall, it is important for patients to discuss the potential risks and benefits of SGLT-2 inhibitors with their healthcare provider before starting treatment.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 2
Incorrect
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A 54-year-old woman with established type 2 diabetes presents for her annual review. Her HbA1c has been stable on the maximal dose of metformin for the past few years and her BP has always been well controlled. She doesn't take any other regular medications. Her HbA1c result 1 year ago was 52 mmol/mol.
The results of her most recent review are as follows:
HbA1c 59 mmol/mol
eGFR 91 ml/min/1.73m² (>90 ml/min/1.73m²)
Urine albumin:creatinine ratio (ACR) 2 mg/mmol (<3 mg/mmol)
BMI 25 kg/m²
QRISK score 6.8%
According to NICE guidelines, what is the most appropriate next step in managing her diabetes?Your Answer: SGLT-2 inhibitor
Correct Answer: Sulfonylurea
Explanation:For a patient with T2DM on metformin whose HbA1c has increased to 58 mmol/mol, the appropriate second-line option would depend on the individual clinical scenario. In this case, the correct answer is sulfonylurea, which would be suitable for a patient with a normal BMI, no history of established cardiovascular disease or heart failure, and not at an increased risk of CVD based on their QRISK score.
GLP-1 mimetic would not be a suitable second-line option but could be considered if triple therapy with metformin and two other oral hypoglycemic agents was not effective or tolerated, provided certain criteria are met.
Repaglinide is not the correct answer as it is a meglitinide that is typically used as initial treatment if metformin is contraindicated or not tolerated.
SGLT-2 inhibitor could be an appropriate option if certain NICE criteria are met. However, in the absence of established cardiovascular disease, heart failure, or an increased risk of CVD, a DPP-4 inhibitor, pioglitazone, or sulfonylurea can be offered as dual therapy with metformin in the first instance, as there is no indication that these would be inappropriate based on the patient’s history.
NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.
Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.
Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 3
Incorrect
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A 65-year old woman comes to your clinic concerned about the possibility of having diabetes. She is overweight and has a significant family history of type 2 diabetes. Due to her chronic kidney disease, you opt to conduct an oral glucose tolerance test instead of testing her HbA1c. What outcome would indicate that she has impaired glucose tolerance?
Your Answer: Fasting plasma glucose = 5.2mmol/L, two hour oral glucose tolerance test = 7.4mmol/L
Correct Answer: Fasting plasma glucose = 5.5mmol/L, two hour oral glucose tolerance test = 9.8mmol/L,
Explanation:Impaired glucose tolerance (IGT) is characterized by a fasting plasma glucose level below 7.0 mmol/l and an OGTT 2-hour value between 7.8 mmol/l and 11.1 mmol/l. Only option 4 meets these criteria. Options 1 and 2 indicate normal results with a fasting plasma glucose level below 5.5 mmol/l and a 2-hour plasma glucose level below 7.8 mmol/l. Options 3 and 5 indicate a diagnosis of diabetes mellitus with a fasting plasma glucose level above 7.0 mmol/l and a 2-hour plasma glucose level above 11.1 mmol/l.
The diagnosis of type 2 diabetes mellitus can be made through a plasma glucose or HbA1c sample. Diagnostic criteria vary depending on whether the patient is symptomatic or not. WHO released guidance on the use of HbA1c for diagnosis, with a value of 48 mmol/mol or higher being diagnostic of diabetes. Impaired fasting glucose and impaired glucose tolerance are also defined. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 4
Correct
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A 42-year-old woman presents with difficult-to-treat hypertension. She is on two agents and currently has a BP of 155/95 mmHg. She has noted that her face has become more rounded over the years and she is having increasing trouble with both acne and hirsutism. Fasting blood glucose testing has revealed impaired glucose tolerance. There has also been increasing trouble with abdominal obesity and she has noticed some purple stretch marks appearing around her abdomen.
What is the most likely diagnosis?Your Answer: Cushing syndrome
Explanation:Cushing Syndrome: Symptoms, Diagnosis, and Differential Diagnosis
Cushing syndrome is a rare disorder characterized by hypercortisolaemia, which leads to a variety of symptoms and signs. The most common features include a round, plethoric facial appearance, weight gain (especially truncal obesity, buffalo hump, and supraclavicular fat pads), skin fragility, proximal muscle weakness, mood disturbance, menstrual disturbance, and reduced libido. Hypertension is present in more than 50% of patients, impaired glucose tolerance in 30%, and osteopenia, osteoporosis, and premature vascular disease are common consequences if left untreated.
The annual incidence of Cushing syndrome is approximately two per million, and it is more common in women. The cause of the disease is hypercortisolaemia, and in 68% of cases, it is due to a pituitary adenoma producing adrenocorticotrophic hormone (ACTH). Ectopic ACTH production is the cause in 12% of cases (most commonly small-cell carcinoma of the lung and bronchial carcinoid tumours), adrenal adenoma in 10%, and adrenal carcinoma in 8%.
Diagnosis of Cushing syndrome is made based on the results of the 24-hour urinary free-cortisol assay or the 1 mg (low-dose) overnight dexamethasone suppression test.
Differential diagnosis includes multiple endocrine neoplasia, essential hypertension, phaeochromocytoma, and simple obesity. However, multiple endocrine neoplasia is less likely due to the rarity of the syndrome and lack of other features. Essential hypertension may respond to two agents but cannot explain the other symptoms and signs. Phaeochromocytoma is a rare tumour that secretes catecholamines and presents with headache, sweating, palpitations, tremor, and hypertension. Simple obesity is a differential diagnosis but cannot explain the other features.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 5
Incorrect
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A 38-year-old man presents to his General Practitioner for follow up; he recently suffered a myocardial infarction (MI). He is a non-smoker with no past medical history of note; he is not diabetic. His father died of a MI aged 43.
His total cholesterol is 10.2 mmol/l (normal range: 3.10–4.11 mmol/l). His triglycerides are just above the normal range, while his high-density lipoprotein (HDL) level is normal. He has a markedly raised non-HDL cholesterol.
What is the most likely cause of this patient’s raised cholesterol?
Your Answer:
Correct Answer: Heterozygous familial hypercholesterolaemia
Explanation:There are several types of genetic dyslipidaemia that can cause high levels of cholesterol and/or triglycerides in the blood, leading to an increased risk of cardiovascular disease. One such condition is heterozygous familial hypercholesterolaemia, which is caused by mutations in the LDLR gene or the gene for apolipoprotein B. This can result in extremely high levels of cholesterol and VLDL, and may lead to premature coronary heart disease. Familial combined hyperlipidaemia is another common genetic dyslipidaemia that can cause moderate-to-severe mixed hyperlipidaemia and may be polygenic in origin. Familial hypertriglyceridaemia is an autosomal-dominant condition that causes elevated triglyceride levels and is associated with premature coronary disease. Remnant hyperlipidaemia is an autosomal-recessive trait that can cause high levels of both cholesterol and triglycerides, and is often associated with obesity, glucose intolerance, and hyperuricaemia. Finally, there are several secondary causes of hyperlipidaemia, including certain medical conditions, medications, pregnancy, obesity, and alcohol abuse.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 6
Incorrect
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A 39-year-old woman comes in for her annual medication review. She was diagnosed with hypothyroidism a few years ago and is taking thyroxine. She recently had her thyroid function tested and her results show a free T4 level of 29 pmol/L (normal range 9.0-25) and a TSH level of 12 mU/L (0.5-6.0). What is the reason for her abnormal results?
Your Answer:
Correct Answer: Under-replacement of thyroxine
Explanation:Understanding Abnormal Thyroid Function Tests
In this case, a patient with hypothyroidism is prescribed thyroxine replacement, but her latest blood tests show elevated thyroid-stimulating hormone (TSH) and thyroxine (T4). Abnormal hormone binding due to pregnancy or drugs like amiodarone can cause raised T4 with normal TSH. Sick euthyroidism can cause low T4, T3, and TSH, but it should revert to normal after recovery from non-thyroidal illness. Subacute thyroiditis causes hyperthyroidism, painful goitre, and high ESR, but it is self-limiting. Under-replacement of thyroxine causes high TSH and low T4.
The correct answer in this case is medication non-compliance, which is the only option that can account for the test results. Patients may start taking their thyroxine again before testing to avoid showing irregular dosing. Erratic thyroxine dosing causes elevated TSH due to under-replacement, but recent use of thyroxine causes normal to high T4. Understanding the various causes of abnormal thyroid function tests can help diagnose and manage thyroid disorders effectively.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 7
Incorrect
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A 55-year-old woman, with type 2 diabetes, has been successful in controlling her HbA1c through diet alone. She has lost 5 kilograms in the past 6 months by making changes to her diet and exercising regularly. Despite her progress, she is aware that her BMI categorizes her as 'obese' and wants to continue losing weight. During her clinic visit, she inquired about foods she should avoid.
What foods should this patient steer clear of?Your Answer:
Correct Answer: Foods marketed specifically for diabetics
Explanation:NICE doesn’t recommend diabetic foods for individuals with diabetes. Instead, it is important to prioritize a healthy and balanced diet that includes high-fibre, low-glycaemic-index sources of carbohydrates (such as fruits, vegetables, whole grains, and pulses), low-fat dairy products, and oily fish. It is also advised to limit the consumption of foods that contain saturated and trans fatty acids. Additionally, the use of foods marketed specifically for individuals with diabetes should be discouraged.
NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.
Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.
Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient doesn’t achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 8
Incorrect
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You are evaluating a middle-aged diabetic woman who is experiencing painful neuropathic symptoms in her feet.
The patient has been receiving routine monitoring at the clinic due to her poorly controlled diabetes, high blood pressure, and renal dysfunction.
She reports that she was prescribed amitriptyline a few weeks ago, which provided significant relief for her symptoms. However, she had to discontinue its use due to bothersome adverse effects.
What would be the most suitable medication to consider next for managing her symptoms?Your Answer:
Correct Answer: Carbamazepine
Explanation:NICE Guidelines for Neuropathic Pain Management
The National Institute for Health and Care Excellence (NICE) has released guidelines for the pharmacological management of neuropathic pain in non-specialist settings. The recommended drugs for painful neuropathy are amitriptyline, duloxetine, gabapentin, and pregabalin. If one of these drugs fails due to poor tolerance or effectiveness, then one of the other three should be tried. Phenytoin and valproate were previously used but are not currently recommended. Carbamazepine is only used for trigeminal neuralgia. Nortriptyline is not included in the latest guidelines. These guidelines aim to provide healthcare professionals with evidence-based recommendations for the management of neuropathic pain.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 9
Incorrect
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A 76-year-old woman is found to have osteoporosis following a Colles fracture. Which medication she is taking is most likely to have played a role in causing her osteoporosis?
Your Answer:
Correct Answer: Lansoprazole
Explanation:Reduced bone mineral density is linked to the prolonged use of proton pump inhibitors.
Osteoporosis is a condition that is more prevalent in women and increases with age. However, there are many other risk factors and secondary causes of osteoporosis. Some of the most significant risk factors include a history of glucocorticoid use, rheumatoid arthritis, alcohol excess, parental hip fracture history, low body mass index, and current smoking. Other risk factors include a sedentary lifestyle, premature menopause, certain ethnicities, endocrine disorders, gastrointestinal disorders, chronic kidney disease, and certain genetic disorders. Additionally, certain medications such as SSRIs, antiepileptics, and proton pump inhibitors may worsen osteoporosis.
If a patient is diagnosed with osteoporosis or has a fragility fracture, further investigations may be necessary to identify the cause of osteoporosis and assess the risk of subsequent fractures. Recommended investigations include a history and physical examination, blood tests such as a full blood count, urea and electrolytes, liver function tests, bone profile, CRP, and thyroid function tests. Other procedures may include bone densitometry, lateral radiographs, protein immunoelectrophoresis, and urinary Bence-Jones proteins. Additionally, markers of bone turnover and urinary calcium excretion may be assessed. By identifying the cause of osteoporosis and contributory factors, healthcare providers can select the most appropriate form of treatment.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 10
Incorrect
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A 42-year-old man presents to the clinic with a medical history of type 1 diabetes for the past 30 years. His blood pressure is 122/72, and his most recent HbA1c level is 53 mmol/mol. Upon examination, he is diagnosed with microalbuminuria.
What can be said about the man's condition?Your Answer:
Correct Answer: Underlying nephropathy can be reversed by tight BP control
Explanation:Diabetic Nephropathy and Microalbuminuria
Death in young diabetics is often caused by end stage diabetic nephropathy, which can lead to ESRF within 10 years if proteinuria has developed. However, interventions can help prevent this outcome. One of the earliest signs of diabetic nephropathy is microalbuminuria, which is characterized by an albumin excretion of 30-300 micrograms per day. It is important to note that microalbuminuria doesn’t mean that the albumin is smaller. Tight control of both blood pressure and glucose levels can help reduce the progression of microalbuminuria and renal failure. Even if blood pressure is normal, ACE inhibition is still important in managing diabetic nephropathy.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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