WBR1122

Author	[[PageAuthor::Mohamed Moubarak, M.D. [1]]]
Exam Type	USMLE Step 3
Main Category	Primary Care Office
Sub Category	Endocrine, Endocrine
Prompt	A 45 year-old female comes to your office for follow up after being diagnosed with type 2 diabetes mellitus 1 month ago. She has been following a diet and exercise to control her hyperglycemic state without medication, but so far it has no effect on her blood glucose level. Her recent laboratory test results are shown below: Hemoglobin 13 mg/dL Total blood cholesterol of 270mg/dL LDL of 190mg/dL HDL of 28 mg/dL Glucose 190 mg/dL HgbA1C 9.8% BUN 35 Creatinine 3.4 eGFR <30 mL/min ALT 15 IU/L AST 10 IU/L You decided to start a medical therapy to control her hyperglycemia. Which of the following is the best initial medical therapy for her condition?
Answer A	Metformin
Answer A Explanation	[[AnswerAExp::Incorrect Metformin is contraindicated in those with renal dysfunction.]]
Answer B	Sulfonylureas
Answer B Explanation	[[AnswerBExp::Correct Sulfonylureas are the oral hypoglycemic drug of choice in patients with renal dysfunction.]]
Answer C	Glitazones
Answer C Explanation	[[AnswerCExp::Incorrect Short acting sulfonylureas are the oral hypoglycemic drug of choice in patients with renal dysfunction.]]
Answer D	Insulin
Answer D Explanation	[[AnswerDExp::Incorrect If oral hypoglycemic drugs fail (or stop helping), insulin therapy may be necessary, usually in addition to oral medication therapy, to maintain normal glucose levels.]]
Answer E	Alpha glucosidase inhibitors
Answer E Explanation	Incorrect Short acting sulfonylureas are the oral hypoglycemic drug of choice in patients with renal dysfunction.
Right Answer	B
Explanation	[[Explanation::Metformin is contraindicated in those with renal dysfunction because it can accumulate and cause metabolic acidosis. It should not be used among chronic kidney disease(CKD) patients with eGFR <30 mL/min because of an increased risk of lactic acidosis. The 2012 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommended that metformin may be used among patients with an estimated GFR >45 mL/min. The oral agents that are thought to be relatively safe in patients with non-dialysis CKD include short-acting sulfonylureas (eg, glipizide) and repaglinide. Educational Objective: Metformin is contraindicated in those with renal dysfunction, the oral agents that are thought to be relatively safe in patients with non-dialysis CKD include short-acting sulfonylureas (eg, glipizide) and repaglinide. References: The 2012 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines.]]
Approved	No
Keyword	[[WBRKeyword::Diabetes mellitus type 2]]
Linked Question
Order in Linked Questions