Endocrinology (diabetes, thyroid disorders) Practice Questions

Q: A 62-year-old man with type 2 diabetes mellitus on metformin and glipizide presents for routine follow-up. His HbA1c is 8.5% (goal <7%). He has a history of heart failure with reduced ejection fraction (EF 35%) and chronic kidney disease stage 3 (eGFR 45 mL/min/1.73m²). Which medication should be added to improve both glycemic control and cardiovascular outcomes?

Empagliflozin. ***Empagliflozin*** - **SGLT2 inhibitors** like empagliflozin are the drug of choice for patients with **Heart Failure with reduced Ejection Fraction (HFrEF)** as they significantly reduce heart failure hospitalizations and cardiovascular mortality. - In patients with **Chronic Kidney Disease (CKD)**, these agents provide **renoprotection** by reducing intraglomerular pressure and slowing the progression of renal decline. *Insulin glargine* - While effective for reaching **HbA1c goals**, basal insulin is associated with **weight gain** and a higher risk of **hypoglycemia**. - It does not offer the specific **cardiovascular or renal survival benefits** provided by SGLT2 inhibitors in the setting of heart failure. *Pioglitazone* - **Thiazolidinediones** are strictly **contraindicated** in patients with heart failure because they promote **fluid retention** and peripheral edema. - Use of this medication in a patient with an **EF of 35%** could lead to an acute exacerbation of congestive heart failure. *Sitagliptin* - **DPP-4 inhibitors** are generally **weight-neutral** and safe in CKD with dose adjustments, but they offer no proven **cardiovascular benefit**. - Specifically, some members of this class (like saxagliptin) are associated with an **increased risk of hospitalization** for heart failure. *NPH insulin* - NPH is an intermediate-acting insulin that carries a significant risk of **nocturnal hypoglycemia** compared to long-acting analogs. - Like other insulin formulations, it provides **no outcome-modifying benefits** for a patient's underlying heart failure or chronic kidney disease.

Q: A 45-year-old woman presents with heat intolerance, palpitations, and a 15-pound weight loss over 3 months. Physical examination reveals a diffusely enlarged, non-tender thyroid gland, fine tremor, and exophthalmos. TSH is 0.01 mIU/L (normal: 0.4-4.0), free T4 is 3.8 ng/dL (normal: 0.8-1.8), and thyroid-stimulating immunoglobulin is elevated. What is the most appropriate initial management?

Methimazole and propranolol. ***Methimazole and propranolol*** - **Methimazole** is the preferred **thionamide** for initial management of **Graves' disease** (confirmed by **TSI** and **exophthalmos**) as it inhibits **thyroid peroxidase** with a lower risk of hepatotoxicity than alternatives. - **Propranolol** is indicated for rapid control of **sympathetic symptoms** such as palpitations, tremors, and heat intolerance by blocking beta-adrenergic receptors. *Propylthiouracil alone* - PTU is primarily reserved for the **first trimester of pregnancy** or **thyroid storm** due to the associated risk of **severe liver failure**. - Using it alone without a **beta-blocker** would fail to provide immediate relief for the patient's symptomatic tachycardia and tremors. *Radioactive iodine ablation immediately* - This definitive treatment can acutely **worsen exophthalmos** due to the release of thyroid antigens and should not be used as the very first step before medical stabilization. - Patients are typically pre-treated with **thionamides** to achieve a euthyroid state to prevent a spike in thyroid hormone levels during treatment. *Thyroidectomy within 1 week* - Surgery is generally reserved for patients with **compressive symptoms**, large goiters, or suspected malignancy rather than as a standard initial step. - Operating on a severely hyperthyroid patient without first achieving a **euthyroid state** poses a significant risk of inducing a life-threatening **thyroid storm**. *Levothyroxine replacement* - Levothyroxine is a synthetic form of T4 used to treat **hypothyroidism**, which would be contraindicated and dangerous given this patient's already elevated **Free T4**. - Administering this medication would exacerbate the patient's **thyrotoxicosis** and increase the risk of cardiac arrhythmias.

Question 1

A 62-year-old man with type 2 diabetes mellitus on metformin and glipizide presents for routine follow-up. His HbA1c is 8.5% (goal <7%). He has a history of heart failure with reduced ejection fraction (EF 35%) and chronic kidney disease stage 3 (eGFR 45 mL/min/1.73m²). Which medication should be added to improve both glycemic control and cardiovascular outcomes?

Accepted Answer

Empagliflozin

Answer

Pioglitazone

Answer

Sitagliptin

Answer

Insulin glargine

Answer

NPH insulin

Question 2

A 45-year-old woman presents with heat intolerance, palpitations, and a 15-pound weight loss over 3 months. Physical examination reveals a diffusely enlarged, non-tender thyroid gland, fine tremor, and exophthalmos. TSH is 0.01 mIU/L (normal: 0.4-4.0), free T4 is 3.8 ng/dL (normal: 0.8-1.8), and thyroid-stimulating immunoglobulin is elevated. What is the most appropriate initial management?

Accepted Answer

Methimazole and propranolol

Answer

Propylthiouracil alone

Answer

Thyroidectomy within 1 week

Answer

Levothyroxine replacement

Answer

Radioactive iodine ablation immediately

Endocrinology (diabetes, thyroid disorders) — MCQs

Endocrinology (diabetes, thyroid disorders) — MCQs

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