WBR0264
| Author | PageAuthor::Vendhan Ramanujam |
|---|---|
| Exam Type | ExamType::USMLE Step 3 |
| Main Category | MainCategory::Community Medical Health Center, MainCategory::Primary Care Office, MainCategory::Inpatient Facilities |
| Sub Category | SubCategory::Endocrine, SubCategory::Endocrine |
| Prompt | [[Prompt::A 26 year old Caucasian male comes to his physicians office for his regular checkup. He is a known type 1 diabetes mellitus patient for the past four years who was on NPH insulin, 30 U each morning and 15 U every night. But following a persistent morning glycosuria that did not improve, the evening dose was increased to 20 U during his last visit. He strictly adheres to his diet schedule. His following lab tests reveal worsening of his morning glycosuria with moderate ketones in his urine. Several consecutive nights glucose monitoring did not reveal any hypoglycemia. The next step in management of this patient will be]] |
| Answer A | AnswerA::Increasing the evening dose of NPH insulin further |
| Answer A Explanation | AnswerAExp::'''Incorrect'''-Increasing the evening dose of NPH insulin further might not be helpful since a previous attempt did not turn out to be useful |
| Answer B | AnswerB::Switching from NPH to glargine during evening |
| Answer B Explanation | [[AnswerBExp::Correct-Early morning hyperglycemia without nocturnal hypoglycemia in diabetes mellitus patients who are on insulin is called as Dawn phenomenon. This is due to the increased body production of certain hormones (growth hormones, cortisol, catecholamines, glucagon and epinephrine) between 4 a.m. and 8 a.m., which suppress the activity of insulin and trigger the glucose release from liver. In non-diabetic people, the body responds to the excess glucose that accumulates as a result of this process by producing insulin. The insulin then moves the excess glucose into the cells. However, people with diabetes either fail to produce insulin or cannot properly use the insulin that is available. As a result, glucose continues to rise to abnormally high levels (hyperglycemia). The first step will be to monitor nocturnal blood glucose on several consecutive days, to rule out hypoglycemia that occurs due to Somogyi effect. After confirming, the next step in managing Dawn phenomenon will depend on the case. When the patient is not responding to adjusted dosage of evening medication (increased evening NPH insulin dose), the next best step will be to switching over to a longer acting insulin (glargine) during the evening.]] |
| Answer C | AnswerC::Increasing the morning dose of NPH insulin |
| Answer C Explanation | AnswerCExp::'''Incorrect'''-Only increasing the evening dose of insulin will be helpful in treating Dawn phenomenon and not the morning dose. |
| Answer D | AnswerD::Advising the patient not to eat late in the night |
| Answer D Explanation | AnswerDExp::'''Incorrect'''-The patient already adheres to his strict diet schedule, which will include avoidance of late night eating. |
| Answer E | AnswerE::Add metformin |
| Answer E Explanation | AnswerEExp::'''Incorrect'''-Metformin inhibits liver glucose production and is effective in treating Dawn phenomenon. This will be the next step if including longer acting insulin to the evening dose did not help. |
| Right Answer | RightAnswer::B |
| Explanation | [[Explanation::Early morning hyperglycemia without nocturnal hypoglycemia in diabetes mellitus patients who are on insulin is called as Dawn phenomenon. This is due to the increased body production of certain hormones (growth hormone, cortisol, catecholamines, glucagon and epinephrine) between 4 a.m. and 8 a.m., which suppress the activity of insulin and trigger the glucose release from liver. In non-diabetic people, the body responds to the excess glucose that accumulates as a result of this process by producing insulin. The insulin then moves the excess glucose into the cells. However, people with diabetes either fail to produce insulin or cannot properly use the insulin that is available. As a result, glucose continues to rise to abnormally high levels (hyperglycemia). The first step will be to monitor nocturnal blood glucose on several consecutive days, to rule out hypoglycemia that occurs due to Somogyi effect. After confirming, the next step in managing Dawn phenomenon will depend on the case. When the patient is not responding to adjusted dosage of evening medication (increased evening NPH insulin dose), the next best step will be to switching over to a longer acting insulin (glargine) during the evening.
Educational objective: Early morning hyperglycemia without nocturnal hypoglycemia in diabetes mellitus patients who are on insulin is called as Dawn phenomenon. The first step will be to rule out Somogyi effect by monitoring nocturnal blood glucose levels. The following management like adjusting the pre-bedtime diet, exercise plan, oral medication or insulin therapy will depend upon the case. Adjusting medication dosage: Physicians may recommend that patients take more medication in the evening or schedule their dosages of long-acting insulin later in the evening so peak action occurs when glucose starts rising. Eating a snack before bedtime: Some patients may be advised not to eat late at night. However, some cases of dawn phenomenon are a response to lower glucose that occurred earlier. Their physicians may advise such patients to smooth these glucose roller coasters by eating a snack before bedtime. They may recommend a small snack that contains protein or fat and is low in carbohydrates, such as nuts or cheese. Exercising earlier in the day: Strenuous physical activity at night can cause lows at night, which may trigger rebound highs. Taking metformin: This oral medication curbs glucose production by the liver,
and has been used effectively to treat people with dawn phenomenon if adjustment of evening doses fail. |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Dawn phenomenon |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |