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yr3 revision > MET3 Revision: Diabetes I > Flashcards

MET3 Revision: Diabetes I Flashcards

1
Q

A patient is diagnosed with DMT1 after an admission for DKA.

What is the insulin regime you should start them on post-admission? [1]

A

Twice-daily basal insulin detemir (long acting), insulin aspart (short acting) bolus with meals

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2
Q

Name 4 complications associated with untreated diabetes

A

skin infections – staphylococcal skin abcesses, oral or genital candidiasis

foot problems – ulcers or neuropathic pain

retinopathy – perhaps found on routine eye test

acute myocardial infarct / stroke– diagnosed whilst in hospita

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3
Q

State 4 methods for diagnosing diabetes [4]

A

Fasting plasma glucose (FPG) (note NOT a capillary glucose [ie. a fingerprick test])

Random plasma glucose (RPG)

 75 gram oral glucose tolerance test (OGTT / 2hr PG)

 Haemoglobin A1c (HbA1c, glycated haemoglobin)

NOTE: One diagnostic test is enough to diagnose diabetes w/ symptom

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4
Q
A
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5
Q

Impaired glucose tolerance can only be diagnosed using which diagonostic test?
FPG
2 hr PG
RPG
HbA1c

A

Impaired glucose tolerance can only be diagnosed using which diagonostic test?
FPG
2 hr PG
RPG
HbA1c

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6
Q
A
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7
Q

Which HLA is associated with DMT1? [2]

A

HLA DR3 & DR4

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8
Q

Describe what pancreatic diabetes is [1]

Name 4 causes of pancreatic diabetes [4]

A

Pancreatic diabetes:
* Severe disease of pancreas causes damage to B cells

Causes:
 Acute / Chronic Pancreatitis
 Trauma / Pancreatectomy
 Neoplasia
 Cystic fibrosis
 Haemochromatosis / Thalassaemia – due to iron overload

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9
Q

Name 6 endocrine diseases known to cause diabetes [6]

A

Acromegaly (excess growth hormone)
Cushing’s syndrome (excess cortisol)
Glucagonoma (excess glucagon)
Phaechromocytoma (excess adrenaline)
Hyperthyroidism (excess thyroid hormone)
Conn’s syndrome (excess aldosterone hormone

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10
Q

State 5 causes of drug induced diabetes [5]

A

Glucocorticoids

b-blockers

Thiazide diuretics

Tacrolimus (used in transplantation – may cause “New Onset Diabetes after Transplantation” [NODAT])

 Atypical anti-psychotics – eg. olanzapine, risperidone, clozapine

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11
Q

Name two congenital viral infections that may cause diabetes [2]

A

 Congenital rubella
 Cytomegalovirus

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12
Q

DMT2 is caused by a combination of which two physiological factors? [2]

A

Insulin resistance AND B-cell failure

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13
Q

Insulin resistance AND B-cell failure are exacerbated by hyperglycaemia:
What is this concept called? [1]
Explain the pathophysiology [2]

A

Glucose toxicity:

 High levels of glucose lead to poorer b-cell function leading to reduced insulin secretion

 therefore lowering glucose may actually help b-cell function

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14
Q

Describe how alpha and beta cell mass changes in diabetic patients [2]

A

 b-cell mass is relatively preserved (50% at autopsies) - but function declines
 a-cell population increased

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15
Q

Which factors contribute to metabolic syndrome? [6]

A

BMI > 30 kg/m2 , or:
Abdominal Waist Circumference – ethnic specific
Low HDL Concentration
Blood pressure
Fasting glucose
Triglyceride

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16
Q

Label the treatment choices for the DM patients with multi-morbidities for patients already on metformin management and HbA1c remains above 53

A

CVD:
A: SGLT-inhibitor
B: GLP-1

Heart Failure:
C: SGLT-inhibitor
D: GLP-1

CKD
E: SGLT-inhibitor
F: GLP-1

High CV Risk:
G: SGLT-inhibitor
H: GLP-1

Frail / elderly:
I DPP-inhibitor (low hypoglycaemia risk)

Obesity
A: SGLT-inhibitor
B: GLP-1

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17
Q

Which drugs are contraindicated for patients with DMT2 who might also be suffering from:

Heart Failure [2]
CKD [1]
Frail / elderly [3]
Obesity [2]

A

Heart Failure:
- Pioglitazone: causes oedema as an AE
- Saxagliptin: increase risk of HF

CKD [2]
- Caution with SUs

Frail / elderly [3]
- SGLT2i (hypoglycaemia risk)
- GLPs (hypoglycaemia risk)
- Caution with SUs (hypoglycaemia risk)

Obesity
- SUs (weight gain)
- Pioglitzaone (weight gain)

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18
Q

When are the following useful / recommended as an additional step to DM patient medication? [3]

Sulfonylurea [1]
Pioglitazone [1]
Repaglinide [1]

A

Sulfonylurea: (gliclazide, glimepiride): if rapid glucose lowering needed and hypos are not a concern

Pioglitazone: can improve lipids, useful for insulin resistance if no C/Is

Repaglinide: can be useful in shift workers/ irregular meal patterns

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19
Q

Sick day rules:

During an acute dehydrating illness, patients with diabetes should be advised to stop the SADMAN drugs, and restart once they have been eating and drinking normally for 24-48 hours.

What do the SADMAN drugs refer to? [6]
State why need to stop each of the SADMAN drugs [6]

A

SGLT2 inhibitors: (risk of DKA)
ACE inhibitors: (risk of AKI)
Diuretics (risk of AKI)
Metformin (risk of lactic acidosis)
ARBs (risk of AKI)
NSAIDs (risk of AKI)

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20
Q

DPP4 inhibitors have a risk of causing which pathology? [1]

A

Pancreatitis

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21
Q

What BP in DM patients would indicate BP treatment? [1]
What BP for a diabetic patient would indicate BP treatment if they have kidney, eye or CV disease ? [1]

A

BP persistantly over 140 / 90 mmHG

BP persistantly over 130 / 80 mmHG & kidney, eye or CV disease

22
Q

What drug, dose and administration would you give to DMT2 patients with no CVD, but Qrisk score of greater than 10% to modify their lipid levels? [1]

What drug, dose and administration would you give to DMT2 patients with known CVD modify their lipid levels? [1]

If not achieving target, which drugs should be prescribed modify their lipid levels? [2]

A

Diabetic patients with no CVD, but Qrisk score of greater than 10%:
- Arvostatin, 20mg daily

Diabetic patients with known CVD:
- Arvostatin, 80mg daily

No response:
- Ezetimibe
- PCSK9 inhibitors

23
Q

When should you provide statins for DMT1 patients? [2]

A
  • Anyone who has has DMT1 for over 10 years
  • Statins for anyone with complications (eyes / neuro etc
24
Q

Describe the physiological effect for long term diabetic management of having tight glycaemic control [2]

A

Microvascular complications reduced

Macrovascular complications has no effect

25
Q

Which conditions are HbA1c may be invalid for when assessing diabetic conditions? [2]

A

May be invalid in haemoglobinopathy or anaemia (reduced red blood cell survival)

26
Q

How can patients using insulin therapy assess their glycaemic control? [1]
What are pre-prandial and post-prandial glucose level aims? [2]

A

Self monitoring of blood glucose (SMBG):
Pre-prandial aim: 4-7 mmol/L
Post-prandial aim: 5-9 mmol/L

27
Q

Name this [1]
Which Ptx populations can use it? [4]

A

Intermittently Scanned Continuous Glucose Monitoring (Freestyle Libre)
▪ Can be used in most people with T1D
▪ Consider in people with T2D if they are on
twice daily or more insulin therapy
▪ AND have recurrent hypos or severe hypos or hypo unawareness
▪ OrLearningdisability/Cognitiveimpairment

28
Q

DMT2 Management:
- MoA of Metformin? [3]

A
  • Acts by activation of the AMP-activated protein kinase (AMPK)
  • Increases insulin sensitivity / improving insulin resistance
  • Decreases hepatic gluconeogenesis
  • inhibits glucose absorption in the gut
29
Q

State 2 advantages of sulfonylureas
State 3 disadvantages of sulfonylureas

A

Advantage:
Oral
Cheap

Disadvantage
Hypoglycaemia

Weight gain
Testing glucose if driving

30
Q

Describe the MoA of Acarbose [2]

A

 Blocks disaccharidase in the GI tract
 Reduces absorption of glucose }

31
Q

Name 3 advantages of glitazones for diabetic control

A

Generally well tolerated
Oral / once daily
Cheap - ~ £2.00 per month

HbA1c reduction 10-15 mmol/mol

Little hypoglycaemia

32
Q

Name 4 disadvantages of glitazones (thiazolidinediones) [4]

A

Oedema (avoid in HF)
Weight gain 3-5 kg
Fractures in post menopausal women
Query around cause of bladder cancer

ELBOW
Edema
Liver failure
Bladder cancer
Osteoporosis
Weight gain

33
Q

Describe the physiological effect of GLP-1 [4]

A

Glucose-dependently stimulates insulin secretion and decreases glucagon secretion:
 Delays gastric emptying
 Decreases food intake and induces satiety
 Stimulates B-cell function and preserves or increases B-cell mass in animal models (stimulating insulin release)

34
Q

Name a daily [1] & weekly [2] injectable GLP-1 drug

A

Liraglutide – daily injection
Dulaglutide – weekly injection
Semaglutide – weekly injection or oral tablet

35
Q

Name 4 advantages of GLP-1 analogues [3]

A

Weight loss
Reduce CV risk
HbA1c reduction 10 / 30 mmol/mol
One weekly injection

36
Q

Name 4 disadvantages of GLP-1 analogues [4]

A

Injection
Cost ~ £73.00 per month

Needs some nursing
GI side effects
?? Pancreatitis risk

37
Q

Name 4 disadvantages of using SGLT-2 inhibitors [4]

A

- UTIs / Thrush
- Euglycaemic DKA (rare) - get DKA but at normal glucose levels
- Care in acute illness
- £ 36

38
Q

Describe an overview of the drug pathway for glycaemic management of DMT2

A
  • HbA1c above 48 at diet and lifestyle alone: condiser Ptx CV risk or CV disease
  • If Ptx has low CV risk: metformin first line
  • If Ptx has high CV risk or CV disease: metformin AND gliflozin
  • If HbA1c continued not to be controlled: dual oral therapy
  • If HbA1c continued not to be controlled: triple oral therapy
39
Q

What is rescue therapy prescribed for symptomatic hyperglycaemia? [2]

A
  • Consider insulin or sulfonylurea
  • Review when glucose control achieved
40
Q

How do you chose between GLP-1 analogue versus insulin for DMT2 after triple oral therapy has not controlled HbA1c? [1]

A

GLP-1:
- BMI > 35

Insulin:
- BMI < 35

41
Q

Describe when insulin is released in a normal person [2]

A

Biphasic:
- Short-lived, rapidly generated meal-related insulin peaks
- Low, steady, basal insulin profile

42
Q

Name indications for insulin therapy for DMT2 patients [5]

A

▪ inadequate glycaemic control on tablets
▪ contraindications to tablets
▪ symptomatic hyperglycaemia
▪ pregnancy
▪ infection / foot ulcers
}

43
Q

State the three different types of insulin regimens

A

 Once-daily / twice-daily intermediate- or long-acting (basal) insulin
 Once-/ twice-/ three-times daily premixed insulin
 Basal–bolus therapy

44
Q

Describe the dosing regimen of twice daily insulin [2]

A

Two injections:

First injection (contains both):
- Short acting acts on breakfast
- Long acting works on lunch

Second injection:
- Short acting acts on dinner
- Long acting works in background

45
Q

Describe basal bolus therapy regime for insulin

A

3 injections of rapid acting, 1 injection of long acting: mimics normal physiology

46
Q

A man sees his GP for a review of his type 2 diabetes. He is on metformin at the maximum tolerated dose. His latest HbA1c is 64 mmol/mol.

His GP starts him on gliclazide and plans to repeat the HbA1c in 3 months’ time.

What is the patient’s new target HbA1c? [1]

A

The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol

47
Q

Pioglitazone is contraindicated in which type of cancer? [1]

A

Bladder cancer

48
Q

Name three anti-VEGF medications used to treat diabetic retinopathy [3]

A

ranibizumab, bevacizumab & Aflibercept

49
Q

Name two corticosteroids used to treat diabetic retinopathy [2]

Which

A

Triamcinolone
Dexamethasone implant can also be used, particularly in refractory DME

50
Q

Describe how you would treat mild-moderate hypokalaemia (2.5-3.4) and severe hypokalaemia (< 2.5) [2]

A

Mild to moderate hypokalaemia 2.5 - 3.4 mmol/l:
- oral potassium provided the patient is not symptomatic and there are no ECG changes.

Severe hypokalaemia (< 2.5mmol/l) or symptomatic hypokalaemia:
- should be managed with IV replacement.
- If there are no contraindications to fluid therapy (e.g. volume overload, heart failure) potassium should be diluted to low concentrations as higher concentrations can be phlebitic.
- The infusion rate should not exceed 20mmol/hr

51
Q

A second drug should be added in type 2 diabetes mellitus if the HbA1c is > [] mmol/mol

A

A second drug should be added in type 2 diabetes mellitus if the HbA1c is > 58 mmol/mol

52
Q
A

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