Edward C. Chao, DO

Seasons change, but diabetes remains an intriguing year-round challenge. Here's a short quiz on diabetes treatment from Dr. Edward C. Chao, D.O.

1. Which of the following best describes what to do when you note hypoglycemia?

Test glucose, then consume 15 g of carbohydrate, and recheck 15 minutes later.
	

 Correct without first checking. It’s not important to know what the glucose reading is; besides, patients can usually guess their glucose.

The correct answer is (B). The 15/15 rule advises patients to first test their glucose level if they suspect they may be experiencing hypoglycemia (including if having symptoms, such as sweating, shaking, and irritable mood). Correct with 15 g of carbohydrate, such as 1/2 cup of fruit juice, or a handful of raisins. The fat in candy bars slows absorption of the sugar. Recheck 15 minutes after correcting, to ensure that the level has normalized.

2. Which is true of patients with diabetic kidney disease (DKD)?

 ACE-i or ARB are NOT recommended for preventing diabetic nephropathy.
	

 Test for microalbuminuria (MAU) every two years.
	

Blood pressure and glucose control do not help prevent progression of renal insufficiency.
	

Most patients who have DKD follow the usual path of progression from glomerular hyperfiltration, progressive albuminuria, decreasing eGFR, to ESRD.
	

 DKD affects a relatively small percentage of individuals with DM.

The correct answer is (A). Interestingly, there has been no evidence to support starting these agents for prevention of nephropathy.

Test for MAU annually. Many patients deviate from the classical progression to ESRD. DKD affects approximately 40% of patients with T2DM and about 30% of T1DM individuals in the U.S.


	Alicic RZ, Rooney MT, Tuttle KR. Diabetic kidney disease: Challenges, progress, and possibilities. Clin J Amer Soc Nephrol. 2017; 12(12): 2032-2045.

A) Only patients demonstrate this.
	B) It’s uncommon and not really an issue.
	C) Physicians and other health care professionals (HCP) can have this.
	D) Clinical inertia refers to the seemingly immovable bureaucracy when you’re trying to get insurance prior authorization.

The correct answer is (C). Both patients and HCP can be susceptible to clinical inertia, which is a lack of changing diabetes treatment, even in the face of suboptimal glycemic control. Patients may ask, “Can we not change anything for 6 months, and I’ll get back on track with my exercise and diet?”


	Okemah J, Peng J, Quinones M. Addressing clinical inertia in type 2 diabetes mellitus: a review. Adv Ther. 2018; 35(11): 1735-1745.

4. What is a commonly cited reason for suboptimally testing glucose?

A) Handling test strips
	B) Pain
	C) Obtrusive process
	D) Carrying equipment to perform self-monitoring of blood glucose (SMBG).
	E) All of the above.

The correct answer is (E). All are among the leading reasons in a study of 150 European patients with DM.

Wijsman I. Patient-reported barriers in diabetes management and areas of opportunity for healthcare professionals. Poster presentation at the 14th Annual Conference of the Federation of European Nurses in Diabetes (FEND); 2009 September 25-26; Vienna, Austria.

5. Which of the following is true of what’s on the horizon for diabetes care?

A) The artificial pancreas (or closed-loop system) will be an incremental improvement over what we currently have available.
	B) The implanted exenatide system being re-reviewed by the FDA can store 12 months of medication.
	C) AI (artificial intelligence) will replace us all within the next 5 years or less.
	D) A completely needleless means to measure glucose still eludes researchers.

The correct answer is (D). Contact lenses, wristwatches, and others have been designed and tested (the GlucoWatch had been withdrawn from the market in 2007; patients frequently cited skin irritation and a 3-hour warm-up time as reasons they discontinued use.

Articles

Seasons change, but diabetes remains an intriguing year-round challenge. Here's a short quiz on diabetes treatment from Dr. Edward Chao.

Diabetes Treatment Quiz

Where would be the last place you’d expect me to write this column? This month, it’s not from home, when it’s during nap time for my two daughters. I am currently in a jury assembly room at the San Diego County Courthouse where I’m being considered for jury duty. As I was taking the time to think, and to sketch out ideas for my next talk, the thought popped into my mind, “What about writing about something that is increasingly recognized in physicians and nurses?”  

Burnout is never far from the mind of a physician. But why? What are some of the key factors that lead to burnout? Here are my thoughts:

2. Appointment slots that are too brief. We know that 15 minutes is definitely not enough to help our patients who suboptimally adherent and not at glycemic goal.

3. _____________________________. I purposely left this one blank for you to share your thoughts. What drives your burnout? Better yet, how do you prevent yourself from getting burned out?

I’m a relentless optimist, but I too face the challenges we all share. I try to be clear-eyed about difficulties, while searching for solutions. With these competing, but mutually crucial perspectives, I offer some vehicles to counter overload which, in some small way, may lead to fulfillment.

t.  Identify that one nuisance, task or pain point that presents a never-ending challenge. Perhaps a quality improvement project (such as refining a multidisciplinary approach to driving hemoglobin A1cs lower.) Or, maybe that one irritant that rises to the top involves streamlining clinic workflows. Or, perhaps consult approval and triaging. Pursue a passion outside of your usual comfort zone! But, don’t just tiptoe into a new passionâdevote yourself to becoming an expert.

, whether it be a medical student, resident, fellow or a colleague. There definitely is someone out there who can benefit from your experience and knowledge! The National Research Mentoring Network  offers various mentoring programs. Check these out online. I think you’ll find it worthwhile.

. Give a talk to an elementary or high school or a group of seniors. The Fleet Science Museum started a lecture series called, “Two Scientists Walk into a Bar.” The Fleet Center said in a news release: “Two Scientists Walk Into a Bar is helping to “put a face” on science and breaking down barriers between the STEM community and the general public. There are no presentations, no slides and no microphone-just two scientists sitting in a bar, engaging the public in casual conversation and making connections in a non-threatening atmosphere.”

I hope these suggestions have sparked your interest in seeking other ways to reduce stress, and enhance fulfillment. Beyond placing work into perspective, one or more of these could leave a lasting legacy to your community and your colleagues!


	Dr. Chao is an associate clinical professor of medicine at the University of California, San Diego, and the Veterans Administration San Diego Healthcare System.

What drives your burnout? Better yet, how do you prevent yourself from getting burned out? Dr. Chao raises this important issue in this month's physician column.

What drives your burnout?

Happy New Year! I hope you’ve had a rejuvenating holiday break, with family and friends. The holidays to me, also are a terrific time to reflect back on the year that has just past, and be grateful for all we get to do, not least of which is serving our patients.

As you dig in to the new challenges of a new year, try this short quiz on a range of topics that impact patient care. 

1. Which of the following best describes the current challenges of diabetes management?

 If current trends continue, the number of patients with diabetes in the US could reach 1 in 3 by 2050.
	
	

 Every 20 seconds, an American over the age of 20 is diagnosed with diabetes.
	
	

 Patients with diabetes tend to be receptive to starting insulin as the disease progresses.
	
	

 Recently, the numbers of new patients being diagnosed with has reached a plateau.
	
	

Please click here for answer and next question. 

Diabetes continues to be diagnosed at an alarmingly high rate. Currently, approximately 1 in 11 Americans has diabetes.

2. Which one of the following statements about SGLT-2 inhibitors (SGLT2i) is true?

SGLT2i act to increase glucouresis-the urinary excretion of glucose. 
	
	

SGLT2i have been not been shown to improve cardiovascular outcomes.
	
	

 SGLT2i are limited in clinical use by side effects such as severe hypoglycemia.
	
	

 SGLT2i act on the insulin secreting pathway.

Answer: A. SGLT2i act to induce glucouresis-the urinary excretion of glucose.

Similar to furosemide, SGLT2i cause diuresis, but of glucose, by lowering the renal threshold to excrete glucose in the urine.

3. Which one of the following phrases correctly completes this sentence: DPP-IV inhibitors…

 … result in significant weight loss in patients.
	
	

… carry a high risk for pancreatitis in humans.
	
	

… can cause nasopharyngitis and headache-the most common adverse effects.
	
	

… can be taken in conjunction with GLP-1 receptor agonists (GLP-1RA).

Answer: C. DPP-IV inhibitors (DPP-IVi)… can induce nasopharyngitis and headache-the most common adverse effects.

The DPP-IV inhibitors tend to be weight neutral, unlike GLP-1 RA, which have shown modest reductions in weight, so option A is not correct. This class has a not demonstrated a large number of cases of pancreatitis in human studies. DPP-IVi should not be prescribed concurrently with GLP-1RA, as they reduce degradation of the enzyme GLP-1, the other strategy to increase GLP-1RA. 

4. Which one of the following phrases correctly completes this sentence: GLP-1 receptor agonists…

. … are based on the mechanism that gut hormones stimulate glucose-dependent insulin secretion.
	
	

 … more potently stimulate insulin secretion than glucose-dependent insulinotropic peptide.
	
	

… lower A1c by approximately 0.5-1.5%.
	
	

 … can result in modest weight loss of ~1 to 4 kg.
	
	

Please click here for answer and next question

Answer: E. All of these describe this class of agents.

The most recent iterations of the GLP-1RA class of agents are once-weekly injections. This decreased dosing frequency may be more appealing to patients who are hesitant about adding an injectable medication to their regimen, or who are concerned about weight gain or hypoglycemia that could result from taking insulin.

5. Which one of the following is true of the new Freestyle Libre glucose monitoring system?

There is no warm-up period before glucose readings are available.
	
	

 It requires a 5-mm filament, and does not require calibration.
	
	

There has been a wealth of real-world experience with the Libre.
	
	

 The Libre requires fingerstick calibration.

Answer: C. It requires a 5-mm filament, and does not require calibration.

Though it does not use needles, this device is not wholly non-invasive, as it employs a fine filament. The Freestyle Libre does require a 1-hour warm up period, was FDA-approved in August 2018, and does not require fingerstick calibration.

Take 5 with a quick quiz on a variety of diabetes treatment topics.

DM Potpourri: A Short Quiz 

Managing hypertension can be like exploring an iceberg - deceivingly more complex than at first blush, especially for those patients whose blood pressures are stubbornly refractory to your recommendations of multiple medications, and lifestyle changes. Secondary causes of hypertension abound-and we must always keep these in mind. Pheochromocytomas (pheo) are very rare tumors of the adrenal glands that produce excess epinephrine and norepinephrine; they can increase risk of CVA, MI, and death.

Here are a few questions to consider about this intriguing endocrine disorder.

1. What is the classic clinical triad of pheochromocytoma?

. Hyperventilation, paresthesias, and headache



. Headache, chest pain, and diaphoresis



. Palpitations, dizziness, and jaw claudication



. Headache, diaphoresis, and palpitations

 The classic triad is headaches, diaphoresis, and palpitations though only ~40% of individuals present with these symptoms. Approximately 10% are diagnosed incidentally-when undergoing imaging for another reason.

2. Which of the following statements about hypertension in patients with pheo is true?

 All pheo patients have hypertension that is sustained and suboptimally controlled

 Some patients have paroxysmal hypertension



 Some patients do not have hypertension



Please click here for answer and next question.

Patients may also have protean presentations. While many patients have episodic hypertension, some have consistently high BP, and still other patients (~10%) are normotensive.

3. Which of the following should be included in your differential diagnosis for pheo?

 Hypoglycemia. You should keep hypoglycemia in mind, though a patient certainly can also have labile essential hypertension.

4. You’ve been consulted on a 46-year-old woman with suboptimally controlled hypertension, admitted for a heart failure (HF) exacerbation. The inpatient team ordered plasma metanephrines and the results are: 

Normetanephrine: 136 pg/mL (18 to 111 pg/mL)

Do not conduct these tests when a patient is admitted



Consult Endocrinology for further workup; the patient likely has a pheochromocytoma



Obtain urine catacholamines and metanephrines



Repeat plasma metanephrines as soon as possible

 Do not conduct these tests when a patient is admitted. The physical and mental/emotional stress of being acutely ill and hospitalized preclude testing for a pheo while a patient is inpatient because catecholamines may be slightly elevated. The test with the highest sensitivity for a pheo? Plasma metanephrines-with a sensitivity of 96% and specificity of 85%. A 24-hour urinary catecholamines and metanephrines has a sensitivity of 87.5% and a specificity of 99.7%.

5. Pheochromoctyomas are rare. Approximately _____ cases are diagnosed yearly in the US, and these account for approximately ______% of cases of hypertension per year.

1,000 and 0.2%. Pheos are extremely rare-we see about 2-8 cases per 1 million persons each year.

Bonus question: What are catecholamine-producing tumors found outside of the adrenal gland called, and where do they arise from?

This one probably had you reach back to your medical school and/or board exam-studying days! The organ was named after Dr. Emil Zuckerkandl. This Hungarian-Austrian anatomist in 1901 described a chromafin body at either the bifurcation of the aorta, or the origin of the inferior mesenteric artery.

What is the classic triad of symptoms that can be considered pathognomonic for pheochromocytoma? Answer and 4 more questions in this short test.

Pheochromocytoma Quiz: What's Your Pheo IQ?

She’s tried some more - to control her type 2 diabetes (T2DM).

Metformin, and ([insert your favorite oral agent] in combination with Metformin) - no longer are keeping her at goal. Neither are redoubled efforts at therapeutic lifestyle changes.

So, after a bit of clinical inertia (ie, “Please, give me 6 more months to get back on track. I’ll get back to exercising more.” Or, “I’ll test more often”), or other changes promised, which will you recommend?

A glucagon-like peptide-1 receptor agonist (GLP-1 RA)? Insulin?

We can discuss the stats, and the need for better control. But, for some patients, the seemingly theoretical beta-cell burnout pales in the face of the daily reality and immediacy of sticking oneself.

This question, along with what patients select, has intrigued me. I’ve made some observations over the last several years. Why do many patients, the same ones who may decline insulin out of hand, appear to be more receptive to a GLP-1 RA?


Convenience seems to play a prominent role. Understandably, it’s easier to think of injecting yourself once per week, than 7, (or 28 or more times, if on a basal-bolus regimen).


Insulin’s potential for weight gain and hypoglycemia can lead both patients and their physicians to hold back. But, GLP-1 RAs can be more attractive due to their modest weight loss, also a very issue with which many T2DM patients struggle.




Many patients may have built up over time, more misconceptions and negative associations with insulin. “My grandmother started insulin, and not long after, she got toes amputated.”

Yet, sometimes, this kind of pattern doesn’t hold. I see a patient who’d for years, been asking for more time, yet his hemoglobin A1c remained largely unchanged. Oscillating between a rather narrow A1c range of approximately 11 to 13%, he faithfully followed up with me every 3 mos. Despite his disappointed mien when I informed him of his latest A1c, he just as reliably, flatly declined adding another medication, especially insulin. When I broached the subject of a GLP-1 RA, he seemed a bit more open, but was still hesitant about an injectable. Several 3-month follow-ups later, he agreed to see our pharmacist, so she could demonstrate injecting. They discussed details of using GLP-1 RAs.

To my surprise, when I read her note the next day, he opted for long-acting insulin.

The reason? He found reconstituting the GLP-1 RA too cumbersome. 

What have been your observations and experiences? I look forward to hearing from you!

A patient may resist the move to insulin in the face of even irrefutable evidence that it's time. A GLP-1 RA is often moe attractive. Why? Also, why not?

To Add an Injectable - or Not? 

We are surrounded by, indeed, bombarded by, negative feedback-all day, every day.  We see it in our clinics - patients who are not at goal for their diabetes, formulary restrictions, patients developing diabetes complications, and the list goes on.

What about pausing, for just a few seconds, to notice what’s going well with our patients, including those who are living with diabetes? Here are 3 thoughts on actively hitting “reset.”

1. Ask the patient, for a change, “What’s going well?”

This question is the flip side of the questions we tend to ask: “What bothers you about your diabetes?” or “What annoys you about your diabetes?” and that I’ve discussed in previous blogs. I find that eliciting the patient’s point of view on what is actually working in their self-care regimen can be encouraging and inspiring, both for the patient and for me. 

Diabetes can be demanding and frustrating. We counsel our patients to perform multiple self-management tasks, all in the service of a larger and critical (if distant) goal: reducing the risk of potential complications that may develop decades down the road. Performance of these tasks may for some run counter to human nature as well as the urgency of daily life-work, bills, children, and a hundred other worries. Since our patients, like us, can be their own toughest critics, asking what is going well can remind everyone that no matter what the current struggles are, there is at least one facet that is improving or that is better since the last follow-up. Sometimes, the responses can be surprising, funny, and thought-provoking.

Next: Point out the Positive, Look for Support

What if the patient responds with, “Nothing,” or “I can’t think of anything good?” Well, why not take the lead? You could remind the patient that his or her A1c is continuing to trend downward. Or, point out something seemingly small, such as noting the patient has consistently implemented a single change that was identified at the last visit. One of my patients, after expressing hesitation for a few visits, decided to start cutting out regular sodas. About 6 months later, building momentum from this one small tweak, he had lost 20 pounds!

This goes for both your patients and you! Just as you encourage your patients to develop a community of support-spouses or significant others, children, siblings, parents, friends, neighbors, or colleagues-you as the health care professional can also draw upon tremendous resources to help you hit your reset button and stay positive. Health care is a team sport, and we’re seeing more clinics embrace this formally.

None of us, in a brief office visit, can cram in all the discussions we feel are essential-proper injection technique, how to check feet, etc. The VA has dietitians, certified diabetes educators, nurses, and pharmacists working together to help patients and their physicians (or PAs, NPs) optimize their care.

It truly takes a village to stay positive. What are some tools that have worked for you and your team?

How can we help our diabetes patients break out of the negative feedback loop and find positivity? Edward C. Chao, DO, shares 3 simple steps. 