Diabetes Education Certification Education Pathophysiology and Treatment 3 — Questions and Answers
Question 1: In a patient with gastroparesis and type 1 diabetes, which insulin timing strategy is most appropriate for mealtime bolus doses?
- Give rapid-acting insulin 15–30 minutes before eating
- Give rapid-acting insulin immediately before or even after eating (Correct answer)
- Give intermediate-acting insulin with each meal
- Discontinue mealtime insulin entirely
Correct answer: Give rapid-acting insulin immediately before or even after eating
Gastroparesis delays gastric emptying unpredictably, so administering rapid-acting insulin after eating (or immediately before) reduces the risk of hypoglycemia from a mismatch between insulin peak and glucose absorption.
Question 2: Which mechanism explains why hyperglycemia promotes cardiovascular disease in diabetes?
- Glucose directly damages cardiac muscle cells only
- Advanced glycation end-products (AGEs) promote vascular inflammation and endothelial dysfunction (Correct answer)
- Hyperglycemia reduces LDL cholesterol levels
- High glucose directly inhibits platelet aggregation
Correct answer: Advanced glycation end-products (AGEs) promote vascular inflammation and endothelial dysfunction
AGEs formed from non-enzymatic glycation of proteins cross-link vascular collagen, activate inflammatory pathways, and impair endothelial nitric oxide production, accelerating atherosclerosis.
Question 3: A patient with type 2 diabetes has an eGFR of 30 mL/min/1.73m². Which diabetes medication is CONTRAINDICATED?
- Insulin glargine
- Metformin (Correct answer)
- Sitagliptin (dose-adjusted)
- Insulin lispro
Correct answer: Metformin
Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² due to risk of lactic acidosis from reduced renal clearance of the drug.
Question 4: The pathophysiology of diabetic peripheral neuropathy involves which primary mechanism?
- Autoimmune destruction of Schwann cells
- Hyperglycemia-induced oxidative stress and polyol pathway activation damaging nerve fibers (Correct answer)
- Vitamin B12 deficiency caused by diabetes
- Direct compression of nerves by edema
Correct answer: Hyperglycemia-induced oxidative stress and polyol pathway activation damaging nerve fibers
Chronic hyperglycemia activates the polyol pathway, generating sorbitol and fructose, depleting NADPH and glutathione, causing oxidative stress that damages both myelin and axons of peripheral nerves.
Question 5: Which statement correctly describes the action of pramlintide (Symlin) in diabetes treatment?
- It is a GLP-1 receptor agonist that stimulates insulin secretion
- It is a synthetic amylin analogue that suppresses glucagon and slows gastric emptying (Correct answer)
- It stimulates PPAR-gamma receptors to improve insulin sensitivity
- It inhibits DPP-4 to increase endogenous GLP-1 levels
Correct answer: It is a synthetic amylin analogue that suppresses glucagon and slows gastric emptying
Pramlintide mimics amylin, a co-secreted beta cell hormone, suppressing post-meal glucagon release, slowing gastric emptying, and promoting satiety to reduce post-prandial hyperglycemia.
Question 6: In hyperglycemic hyperosmolar state (HHS), the primary distinguishing feature from DKA is:
- Blood glucose below 400 mg/dL
- Absence of significant ketoacidosis due to sufficient residual insulin to inhibit lipolysis (Correct answer)
- Presence of severe metabolic acidosis
- Onset within hours rather than days
Correct answer: Absence of significant ketoacidosis due to sufficient residual insulin to inhibit lipolysis
In HHS, residual insulin secretion (even if insufficient for glucose control) is enough to suppress hepatic ketogenesis and lipolysis, preventing significant ketonemia and acidosis.
Question 7: When teaching a patient about the dawn phenomenon, the diabetes educator should explain that morning hyperglycemia is caused by:
- Rebound from nocturnal hypoglycemia
- Physiologic overnight surge of growth hormone and cortisol that increases insulin resistance (Correct answer)
- Eating a large bedtime snack
- Insufficient basal insulin coverage throughout the day
Correct answer: Physiologic overnight surge of growth hormone and cortisol that increases insulin resistance
Growth hormone and cortisol, which peak in the early morning hours, increase hepatic glucose production and reduce insulin sensitivity, causing the dawn phenomenon in people with diabetes.
Diabetes Education Certification Education Pathophysiology and Treatment 3
In a patient with gastroparesis and type 1 diabetes, which insulin timing strategy is most appropriate for mealtime bolus doses?