Ep #166: Diabetes Review for NP Boards: What to Focus On

Anna: Welcome to the Real Deal Nurse Practitioner Club, the podcast for nurses who are ready to pass their boards and thrive in their careers as real deal nurse practitioners. I’m Anna and I’m the Director of Nursing Content at Blueprint Test Prep. Whether you’re deep in exam prep or stepping into practice, I’ve got you. It is time to become the confident, knowledgeable NP that you’re meant to be. Let’s dive in. 

Hey, hey there. Welcome back to The Real Deal Nurse Practitioner Club podcast. I’m Anna, and I have Alex with me today. And we are going to cover a pretty big topic for NP boards, and that’s diabetes.

Alex: Hey everyone. I’m so excited to be here again with you today.

Anna: All right, I want to give a quick note before we dive in. This is not a full, deep dive into every diabetes medication or every clinical nuance. And this isn’t even going to be a full review of everything you know for boards, because we could talk for a while. But we are just doing a quick episode, and we’re going to focus on some areas where you should focus your studying efforts.

Alex: Yes, studying diabetes can very, very quickly turn into a 50 or, you know, 100-page outline if you’re not sure where to focus your efforts. But we’ve got you covered. We’ll hit some highlights today, and if you are looking for a deeper dive into diabetes, definitely be sure to check out our courses.

Anna: Yeah, we cover everything you need to know and not the things you don’t need to know. We cut out all that fluff. But we’re going to cover everything you need to know for your boards in our courses. But let’s do our overview. Now, is type one or type two diabetes characterized by an absolute insulin deficiency? That key word there is absolute insulin deficiency, and the answer to that is going to be type one.

In type one, there isn’t enough insulin to move glucose into cells, and the body starts using alternative fuel sources, which can lead to ketone production, and then diabetes-related ketoacidosis or DKA. And this is why patients with type one diabetes require insulin treatment, right? They can’t use all of these oral medications we have. And make sure to know those basic ranges for onset, peak, and duration for the key types of insulin, like regular or NPH.

Alex: Yes, and another key exam point here is recognizing the classic presentation. So think about those three Ps. Polyuria, polydipsia, and polyphagia, along with weight loss, fatigue, and even blurry vision. So type one can present pretty dramatically, especially in younger patients. And sometimes the very first presentation you’ll see is DKA.

Anna: Yeah, and here’s a quick little board pearl. If a patient with type one diabetes says that they’ve been sick and they’ve stopped checking their glucose or they’ve reduced their insulin, well, that’s immediately a red flag. Because illness can actually increase insulin needs. So the safe answer usually involves reinforcing monitoring, sick day planning, and then escalating care if needed.

But now let’s switch to type two diabetes, and this one is much more commonly tested on. This is primarily a combination of insulin resistance and then, over time, a declining production of insulin. Early on, the body compensates, but eventually it just can’t keep up.

Alex: Yes, and clinically, this is why type two diabetes can be asymptomatic for a while, sometimes a long while. Which is why screening for diabetes is so important. But when symptoms do show up, you might still see those three Ps, along with fatigue, blurry vision, or even slow wound healing and recurrent infections. And if you see dark, velvety patches around the neck or the axilla, that also points towards insulin resistance. Do you remember the term for this? That’s going to be acanthosis nigricans.

Anna: Yeah, definitely remember that one for boards. Now, for diagnosis, the key is recognizing normal versus pre-diabetes versus diabetes ranges and remembering that if a patient is asymptomatic, you usually need confirmation before making the diagnosis. So what’s that A1C diagnostic cutoff for diabetes? 6.5 or higher. Now, there are, of course, other labs that we use, but right now we’re just going to focus on that A1C.

All right, let’s move into type two diabetes treatment. Lifestyle modifications are always, always essential. But what’s that classic first medication you’ll see in most board questions? Well, that’s metformin. Metformin is one of those drugs the exam loves to ask about.

Alex: Yes, and it’s commonly used because it’s effective, it’s inexpensive, and importantly, it doesn’t cause hypoglycemia when used alone. That is a huge safety point to know.

Anna: Yeah, I think metformin is actually one of the most commonly prescribed medications in primary care, which is why it is tested on so much. And boards also love testing side effects and monitoring, so let’s just run through a few rapid-fire questions in that domain. All right, Alex, what is the classic side effect of metformin?

Alex: That’s going to be GI upset, and it usually gets better with time.

Anna: Yeah, and some people find like taking it with food helps a little bit. And what lab do we absolutely need to monitor with metformin?

Alex: That’s going to be kidney function. And so if the question gives you a clue in the scenario about a patient’s kidney lab results, you really need to think about whether metformin is still appropriate for that patient.

Anna: Absolutely. And a little teaser, we’re going to be doing a GFR episode soon, which is really that main kidney lab we’re looking at. All right, what oral diabetes medication class has a high, high risk of hypoglycemia?

Alex: That’s going to be sulfonylureas, like glipizide. So extra caution here for older adults as they are at a much higher risk. The Beers Criteria actually recommend avoiding this drug class in older adults due to all the risks associated. This class is also commonly associated with weight gain.

Anna: Yeah, and it’s typically not given if then the patient also needs insulin. We’ll usually switch them to something else if they need dual therapy. All right, now there is a medication class that causes fluid retention. Do you know what that one is?

Alex: So a big example here is pioglitazone, and this is the TZD class. This is why this drug class for type two diabetes is a no-go, especially for patients with heart failure.

Anna: Absolutely. All right, another concept boards love is diabetes medications with all these extra benefits built in. So some diabetes medication classes have cardiovascular or kidney benefits, for example. And you’ll often see these tied to clinical scenarios with patients with specific risk factors. All right, let’s touch on complications.

Microvascular complications affect those small blood vessels. Remember we said microvascular. And really there are three that you should know and recognize how to monitor for. Those are going to be our neuropathy, retinopathy, and nephropathy. The macrovascular complications, those are the larger cardiovascular ones.

Alex: Yeah, definitely know the difference and how to monitor for these complications, but it is really straightforward. So, for example, we’re going to want to make sure the patient receives routine eye exams to catch on to that retinopathy early.

Anna: Yeah, and we already talked about the GFR and monitoring the kidney. We’re going to be monitoring albumin in the urine, all of those things. Again, I don’t want to get into the nitty-gritties here because it’s hard to listen to all of the nitty-gritties in the podcast form.

But if you want more about diabetes, we cover everything extensively for the boards within our courses. We have some YouTube videos, but that’s going to be all for this episode so we don’t overwhelm you. Again, make sure to check out our QBank and our courses for a deeper dive. But if you want more about GFR labs, we’re going to be continuing our little mini-lab series next week. Then in a couple weeks, we’ll be back to talk about just evolving trends for NPs in general. And of course, follow us on Instagram for more free content @SMNPReviewsOfficial. See you next time.

Thanks for listening to another episode of the Real Deal Nurse Practitioner Club. If you want more information about the different types of support that we offer to students and new nurse practitioners, you can visit npreviews, with an S, dot com. We’ll see you next week.