Chapter 6: Endocrine system Flashcards

Question

What is the most appropriate form of insulin to use in diabetic emergencies e.g. DKA

Answer 1

Soluble insulin IV Give Na/K 0.9% iv infusion if Bp low Monitor blood glucose and ketones ever hour Continue long acting insulin analogues (detemir and glargine) during treatment of DKA

Answer 2

Insulin Glulisine Insulin Aspart Insulin Lispro

Answer 3

5-15 mins before food

Answer 4

Rapid acting insulins (aspart and lispro) are better than soluble acting because there are fewer episodes of Hypo

Answer 5

Intermediate - designed to mimic the effect of endogenous basal insulin

Answer 6

Pre-mixed insulin preparations containing various combinations of short-acting insulin (soluble insulin or rapid-acting analogue insulin) and an intermediate-acting insulin.

Answer 7

Insulin detemir (levemir) OD/BD Insulin glargine (Lantas/toujeo/abasaglar) OD Insulin degludec (Tresiba) OD Rarely prescribed: Protamine zinc insulin Insulin zinc suspension

Answer 8

Modified release metformin By mouth using modified-release medicines Initially 500 mg OD, then increased if necessary up to 2 g OD, dose increased gradually, every 10–15 days, dose to be taken with evening meal, alternatively increased to 1 g BD, dose to be taken with meals, alternative dose only to be used if control not achieved with once daily dose regimen.

Answer 9

Glibenclamide Gliclazide Glimeprimide Glipizide Tolbutamide

Answer 10

Nateglinide Repaglinide Drivers need to be particularly careful to avoid hypoglycaemia and should be warned of the problems.

Answer 11

Alogliptin Linagliptin Sitagliptin Saxagliptin Vildagliptin

Answer 12

Not associated with weight gain and have less incidence of hypoglycaemia

Answer 13

Canaglifozin Dapaglifozin Empaglifozin

Answer 14

Dulaglutide Exenatide Liraglutide Lixisenatide

Answer 15

48 mmol/mol

Answer 16

53 mmol/mol

Answer 17

58 mmol/mol or higher

Answer 18

53 mmol/mol

Answer 19

Metformin- No effect on weight -Reduced risk of hypoglycaemia -Long term cardiovascular benefits

Answer 20

Elderly and Renally impaired are at particular risk of hypoglycaemia Use Short acting e.g. gliclazide or tolbutamide

Answer 21

Option 1) Metformin + dpp 4i /pioglitazone/ sulfonylurea / SGLT2 Option 2) or switch to another drug Use SGLT2 if patient has CVD risk or disease

Answer 22

Dapagliflozin + Pioglitazone Both Dapagliflozin and Pioglitazone can increase the risk of hypoglycaemia.

Answer 23

Switch or add Dpp4 inhibitor (gliptin) / pioglitazone / sulfonylurea (gliclazide) SGLT2 I (dapagliflozin) may also be an option in dual therapy if CVD

Answer 24

If triple therapy with metformin hydrochloride and two other oral drugs is tried and is not effective, or is not tolerated or contra-indicated, a glucagon-like peptide-1 (GLP-1) receptor agonist may be considered as part of a triple therapy regimen by switching one of the other drugs for a GLP-1 receptor agonist. These should only be considered for patients who have a BMI of 35 kg/m2 or above (adjusted for ethnicity) and who also have specific psychological or medical problems associated with obesity; or for those who have a BMI lower than 35 kg/m2 and for whom insulin therapy would have significant occupational implications or if the weight loss associated with GLP-1 receptor agonists would benefit other significant obesity-related comorbidities.

Answer 25

After 6 months, the GLP-1 receptor agonist should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight).

Answer 26

If metformin is contra-indicated or not tolerated, SGLT2 inhibitor (canaglifozin) with proven cardiovascular benefit should be offered as first-line treatment for patients who have chronic heart failure or established atherosclerotic cardiovascular disease. An SGLT2 inhibitor should also be considered for patients who are at high risk of developing cardiovascular disease. For all other patients, consider a dipeptidylpeptidase-4 (DDP-4) inhibitor (gliptin), or pioglitazone, or a sulfonylurea (glipizide) as first-line drug treatment if metformin is contra-indicated or not tolerated. An SGLT2 inhibitor may be considered as an alternative option to a DDP-4 inhibitor, if neither a sulfonylurea or pioglitazone are appropriate.

Answer 27

Repaglinide is also an effective alternative option for single therapy, but it has a limited role in treatment because, should an intensification of treatment be required, it is not licensed to be used in any combination other than with metformin hydrochloride; it would therefore require a complete change of treatment in those patients who have started it due to intolerance or contra-indication to metformin.

Answer 28

liraglutide should be considered in patients with established cardiovascular disease.

Answer 29

- Isophane OD/BD -Isophane + short acting (either separate or pre-mixed) - particularly appropriate if HbA1c is 75 or higher -Insulin detemir or glargine can be an alternative to isophane

Answer 30

75 or higher

Answer 31

If require OD dosing, if recurrent hypo restricting lifestyle, if require BD isophane plus oral antidiabetics

Answer 32

Bedtime basal insulin should be initiated and the dose titrated against fasting glucose in the morning

Answer 33

Blood pressure should be reduced to the lowest achievable level to reduce the glomerular filtration rate. ARB or ACEi to be started even if the blood pressure is normal

Answer 34

Can potentiate the hypoglycaemic effect More likely in the first few weeks of combined treatment and in patients with renal impairment

Answer 35

Replacement of fluid and electrolytes, potassium chloride in the fluids unless anuria (lack of urine production) is suspected Administration of SOLUBLE Insulin in sodium chloride 0.1 units/kg/hr Long acting insulin (basal) should be continued in the background If blood glucose falls below 14, give glucose 10% Monitor ketones and glucose hourly Monitor BP Blood pH

Answer 36

Continue insulin infusion until patient is able to eat and drink; ideally give s/c fast-acting insulin and a meal, and stop the insulin infusion 1 hour after meal

Answer 37

Lower rates usually required

Answer 38

0.1 units/kg/hr

Answer 39

Below 48 if possible without causing any problematic hypoglycaemia

Answer 40

High dose - 5mg daily as classed in the high risk group of neural tube defects

Answer 41

All antidiabetic drugs APART from metformin should be stopped and substituted with insulin therapy For breastfeeding, the options are:- Insulin continued- Metformin continued- Glibenclamide is fine to restart if originally on it However, all other antidiabetic agents should be avoided during breastfeeding

Answer 42

Isophane insulin However in women who have good blood-glucose control before pregnancy with the long-acting insulin analogues (insulin detemir or insulin glargine), it may be appropriate to continue using them throughout pregnancy.

Answer 43

Should be aware of the risk of hypoglycaemia and should always carry a fast-acting form of glucose

Answer 44

Hypoglycaemia during the postnatal period Should reduce their insulin immediately after birth and blood glucose levels monitored

Answer 45

ACEi or ARB should be discontinued and an alternative antihypertensive suitable in pregnancy should be used(Preferably before conception if pregnancy is planned)

Answer 46

Discontinue the statin during pregnancy (Preferably before conception if pregnancy is planned)

Answer 47

False - should discontinue hypoglycaemic treatment immediately after giving birth

Answer 48

On the day before surgery, give the usual insulin dose However, once daily long acting insulins should be given at 80% of normal dose Then their usual insulin regimen can be adjusted accordingly during the operative period

Answer 49

Long acting insulin You give 80% of normal dose

Answer 50

VRII - Continued until the patient is eating/drinking and stabilised on their previous diabetes medication Day before surgery - Give normal insulin dose (Apart from once daily long acting insulin is given at 80% usual dose) Day of surgery and during the operative period:- Once daily insulin given at 80% usual dose. All of the other patient's insulin should be stopped until the patient is eating and drinking again- Start IV infusion of potassium chloride with glucose and sodium chloride AND a variable rate insulin infusion of soluble human insulin in 0.9% sodium chloride Blood glucose monitored hourly for at least the first 12 hours

Answer 51

<6 - Give IV glucose 20% and check blood glucose hourly <4 - Give IV glucose 20% and check blood glucose every 15 mins

Answer 52

They are eating/drinking without nausea or vomiting Note- their insulin dose may need adjusting due to altered food intake/post-op stress/infection

Answer 53

Should be restarted when the first post-op meal is due Give the first short-acting insulin first and then stop VRII 30-60 mins after Note- the long acting insulin is continued in the background of VRII at 80% dose - should continue at that dose until the patient leaves hospital

Answer 54

Should be restarted before breakfast or evening meal (not at any other time) Stop VRII 30-60 mins after

Answer 55

- When the fasting period requires more than one missed meal - major elective surgery - Patients with poor glycaemic control- Risk of renal injury- If on insulin as part of their treatment anyway -

Answer 56

- Acarbose- Sulfonylureas- DPP-4 inhibitors- Pioglitazone- Meglitinides- SGLT-2 inhibitors Should not be restarted until the patient is eating and drinking normally

Answer 57

If it requires a short fasting period (one missed meal), it may be possible to adjust antidiabetic drugs to avoid a switch to VRII

Answer 58

Dehydration, stress, surgery, trauma, acute medical illness or any other catabolic state

Answer 59

Standard release- 2g/day Initially 500 mg once daily for at least 1 week, dose to be taken with breakfast, then 500 mg twice daily for at least 1 week, dose to be taken with breakfast and evening meal, then 500 mg 3 times a day, dose to be taken with breakfast, lunch and evening meal; maximum 2 g per day.

Answer 60

Gastrointestinal side-effects are most frequent during treatment initiation and usually resolve spontaneously. A slow increase in dose may improve tolerability. lactic acidosis (discontinue) symptoms include dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia occur. skin reactions, taste altered vitamin B12 deficiency especially in those receiving a higher dose or longer treatment duration and in those with risk factors for vitamin B12 deficiency. Patients should continue taking metformin unless they are advised to stop.

Answer 61

Chronic heart failure Concomitant use of drugs that acutely impair renal function

Answer 62

Should be informed of the risk of lactic acidosis and told to seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia (weakness/lack of energy) occur Take with meals

Answer 63

30mg MR = 80mg standard release

Answer 64

Sulphonylurea: IDE Weight gain Hypoglycaemia

Answer 65

heart failure bladder cancer Patients should be advised to report promptly any haematuria, dysuria, or urinary urgency during treatment. Bone fracture weight increased discontinue if jaundice occurs DKA

Answer 66

Risk of DKA Inform patients to be aware of signs e.g. rapid weight loss, sweet smell to breath, different odour in urine/sweat Reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum Canagliflozin - risk of lower-limb amputation

Answer 67

Risk of lower-limb amputation

Answer 68

DPP-4 inhibitors (gliptins) GLP1 receptor agonists (Exenatide)

Answer 69

SGLT2 inhibitors, flozins

Answer 70

No - only with metformin

Answer 71

Acarbose Contra-indications Disorders of digestion or absorption; hernia (condition may deteriorate); inflammatory bowel disease; predisposition to intestinal obstruction

Answer 72

Once Weekly= semaglutide, duaglatide + MR exenatide

Answer 73

Insulin should not be extracted from insulin pen devices.The strength of insulin in pen devices can vary by multiples of 100 units/mL. Insulin syringes have graduations only suitable for calculating doses of standard 100 units/mL. If insulin extracted from a pen or cartridge is of a higher strength, and that is not considered in determining the volume required, it can lead to a significant and potentially fatal overdose.

Answer 74

Fiasp (aspart)

Answer 75

Humulin S Actrapid Insuman rapid Hypurin neutral (povine/porcine)

Answer 76

Soluble insulin Humulin S Actrapid

Answer 77

No- it is a short acting insulin

Answer 78

Apidra (glulisine) Novorapid (aspart) Humalog (lispro)

Answer 79

Insulatard Humulin I (isophane) Insuman basal Hypurin isophane Isophane can be otherwise known as NPH

Answer 80

Levemir (detemir) Lantus/Absalgar (glargine) Tresiba (degludec) Toujeo (glargine)

Answer 81

Novomix 30 Humalog Mix 25 or 50 Humulin M3 Insuman Combo 15 or 25 or 30

Answer 82

The suspension contains rapid-acting and intermediate-acting insulin aspart in the ratio 30/70

Answer 83

Treat with fast acting carbohydrate by Fast-acting carbohydrates include Lift® glucose liquid (previously Glucojuice®), glucose tablets, glucose 40% gels (e.g. Glucogel®, Dextrogel®, or Rapilose®), pure fruit juice, and sugar (sucrose) dissolved in an appropriate volume of water. Oral glucose formulations are preferred as absorption occurs more quickly. Orange juice should not be given to patients following a low-potassium diet due to chronic kidney disease, and sugar dissolved in water is not effective for patients taking acarbose which prevents the breakdown of sucrose to glucose. Chocolates and biscuits should be avoided if possible, as they have a lower sugar content and their high fat content may delay stomach emptying. If necessary, repeat treatment after 15 minutes, up to a maximum of 3 treatments in total. Once blood-glucose concentration is above 4 mmol/litre and the patient has recovered, a snack providing a long-acting carbohydrate should be given to prevent blood glucose from falling again (e.g. two biscuits, one slice of bread, 200–300 mL of milk (not soya or other forms of 'alternative' milk, e.g. almond or coconut), or a normal carbohydrate-containing meal if due). Insulin should not be omitted if due, but the dose regimen may need review.

Answer 84

IM Glucagon is given by family if unsuitable or no response after 10 mins then give IV glucose 20% or glucose 10% intravenous infusion needs to be given

Answer 85

Desmopressin or vasopressin

Answer 86

Desmopressin is more potent and has a longer duration of action Desmopressin is an analogue of vasopressin Has no vasoconstrictor effect compared to vasopressin

Answer 87

Diabetes insipidus Initial control of oesophageal variceal bleeding

Answer 88

Treatment of hyponatraemia resulting from inappropriate secretion of antidiuretic hormone (if fluid restriction does not work)

Answer 89

Treatment of hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion

Answer 90

Fludrocortisone

Answer 91

High-dose corticosteroids should be avoided for the management of septic shock. However, there is evidence that administration of lower doses of hydrocortisone and fludrocortisone acetate is of benefit in adrenal insufficiency resulting from septic shock.

Answer 92

MHRA/CHM advice: Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration Patients should report any blurred vision/visual disturbances

Answer 93

Fludrocortisone HYPERtension Na retention + H2O retention K loss +Ca loss

Answer 94

psychiatric reactions may occur

Answer 95

Hydrocortisone and fludrocortisone Hydrocortisone alone is not sufficient as it does not provide sufficient activity

Answer 96

Hydrocortisone This is given in 2 doses, the larger in the morning and the smaller in the evening, mimicking the normal diurnal rhythm of cortisol secretion.

Answer 97

IV hydrocortisone

Answer 98

7.5mg daily

Answer 99

- Received more than 40 mg prednisolone (or equivalent) daily for more than 1 week or 2 mg/kg daily for 1 week or 1 mg/kg daily for 1 month- Been given repeat doses in the evening- Received more than 3 weeks’ treatment- Recently received repeated courses (particularly if taken for longer than 3 weeks)-Taken a short course within 1 year of stopping long-term therapy- Other possible causes of adrenal suppression.

Answer 100

750 micrograms

Answer 101

750 micrograms

Answer 102

Prednisolone

Answer 103

Contains lactose- not suitable for those with a cow's milk allergy

Answer 104

Starting at 0.5 units/kg/day So 30 units Half basal and half bolus 15 units basal e.g. Lantus And split the other 15 into 3 for meal times, so 5 units TDS of rapid acting insulin

Answer 105

First line = Oral bisphosphonates: alendronic acid or risedronate as they have a broad spectrum of anti-fracture efficacy 2. IV bisphosphonate (Ibandronic acid, zolendronic acid) Denosumab, Raloxifene

Answer 106

Reserved for postmenopausal women with severe osteoporosis at very high risk for vertebral fractures. Its duration of treatment is limited to 24 months.

Answer 107

1. First line Oral bisphosphonates- alendronic acid or risedronate sodium Alternatives- IV zolendronic acid or denosumab, teripartide

Answer 108

Fractures Fracture risk should be assessed at the start of therapy

Answer 109

1. Oral bisphosphonates- alendronic acid or risedronate sodium Alendronic acid 10mg daily Swallow whole and oral solution swallowed as single 100mg dose Take with plenty of water sitting or standing Take on empty stomach at least 30mins before breakfast / other oral meds Stand/ sit upright for at least 30 minutes after administration Or By mouth Adult (male) 35 mg once weekly risedronate Alt: IV zolendronic acid or denosumab

Answer 110

5 years of treatment of alendronic acid, risedronate sodium or ibandronic acid 3 years of treatment with zolendronic acid

Answer 111

Patients over 75 years of age, or with a history of previous hip or vertebral fracture, or patients who have had one or more fragility fractures during treatment, or who are taking long-term glucocorticoid therapy

Answer 112

1. Risk of atypical femoral fractures report any thigh/hip/groin pain Review treatment after 5 years 2. Risk of osteonecrosis of the jaw Dental check up and any necessary work is needed before therapy report non-healing sores, swelling, pain If the patient wears dentures, need to ensure they fit properly before starting therapy 3. Risk of osteonecrosis of external auditory canal, report ear infections, ear discharge, ear pain 4. Severe oesophageal reactions (oesophagitis, oesophageal ulcers, oesophageal stricture and oesophageal erosions) have been reported; patients should be advised to stop taking the tablets and to seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain

Answer 113

- Anaemia - Severe oesophageal reactions (ulcers, strictures, erosions) - Risk of atypical fracture- Osteonecrosis of jaw or auditory canal - Altered taste -Joint swelling - Hypophosphatemia NB- absorption is affected by other meds e.g. iron, so needs to be taken 30 mins before food and other meds

Answer 114

Progesterone to reduce the risk of hyperplasia of endometrium and cancer

Answer 115

Venous thromboembolism, stroke, endometrial cancer (reduced by a progestogen), breast cancer, ovarian cancer; there is an increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause.

Answer 116

HYPERthyroidism skinny needs Carbs Carbimazole Propylthiouracil

Answer 117

The MHRA/CHM advice: Carbimazole: increased risk of congenital malformations; females of childbearing potential should use effective contraception during treatment. Neutropenia and agranulocytosis recognise bone marrow suppression induced by carbimazole and the need to stop treatment promptly. Report symptoms and signs suggestive of infection, especially sore throat. A white blood cell count should be performed if there is any clinical evidence of infection. Carbimazole should be stopped promptly if there is clinical or laboratory evidence of neutropenia. Carbimazole is associated with an increased risk of congenital malformations when used during pregnancy, especially in the first trimester and at high doses (daily dose of 15 mg or more). MHRA/CHM advice: Carbimazole: risk of acute pancreatitis (February 2019) acute pancreatitis reported during treatment with carbimazole. It should be stopped immediately and permanently if acute pancreatitis occurs. Carbimazole should not be used in patients with a history of acute pancreatitis associated with previous treatment—re-exposure may result in life-threatening acute pancreatitis with a decreased time to onset.

Answer 118

Severe hepatic reactions have been reported Recognise signs of liver disorder seek prompt medical attention if symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, or pruritus develop.

Answer 119

Emergency situation: IV fluids propranolol hydrocortisone oral iodine /carbimazole/propylthiouracil

Answer 120

Levothyroxine Liothyronine

Answer 121

Dose to be taken preferably at least 30 minutes before breakfast, caffeine-containing liquids (e.g. coffee, tea), or other medication

Answer 122

For women Short term treatment of oestrogen deficiency Osteoporosis prophylaxis

Answer 123

Progesterone

Answer 124

Take it as soon as you rememberHowever if it is not taken within 3 hours of the normal time of taking the pill- additional precautions should be used and for 2 days after

Answer 125

If vomiting occurs within 2 hours of taking an oral progestogen-only contraceptive, another pill should be taken as soon as possible. If a replacement pill is not taken within 3 hours of the normal time for taking the progestogen-only pill, or in cases of persistent vomiting or very severe diarrhoea, additional precautions should be used during illness and for 2 days after recovery (but still keep taking the pill as usual)

Answer 126

True If delayed longer than 3 hours, then the contraceptive effect may be lost

Answer 127

Should ideally start taking on day 1 of the cycle Additional contraceptive precautions are not required if norethisterone is started up to and including day 5 of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days.

Answer 128

Start on the day following completion of the combined oral contraceptive course without a break (or in the case of ED tablets omitting the inactive ones)

Answer 129

Can be started up to and including day 21 postpartum without the need for additional contraceptive precautions. If started more than 21 days postpartum, additional contraceptive precautions are required for 2 days.

Answer 130

If one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours late and unprotected intercourse has occurred before 2 further tablets (2 days worth) have been correctly taken.

Answer 131

1) diet and exercise 2) metformin 3) add insulin if metformin ineffective

Answer 132

Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise

Answer 133

Hydramnios- a condition in which excess amniotic fluid accumulates during pregnancy Macrosomia- larger than normal baby

Answer 134

Discontinue Ace/ARB and replace with methyldopa or labetalol in pregnancy Discontinue statin

Answer 135

Can lead to nephrotoxicity If patient's eGFR >60 and only missing one meal, then there is no need to stop metformin If eGFR < 60:Metformin should be discontinued prior to, or at the time of the imaging procedure and not restarted until at least 48 hours after, provided that renal function has been re-evaluated and found to be stable

Answer 136

Stop all anti diabetic drugs once insulin infusion is commenced (Acarbose/sulfonylureas/ pioglitazone/ meglintinide/ SGLT2/ Gliptins) Continue metformin and GLP-1 agonists once infusion insulin is commenced

Answer 137

No, only give VRII if their usual metformin dose is more than once daily OR if their blood glucose is >12 on 2 consecutive occasions

Answer 138

Renal impairment may lead to accumulation and lactic acidosis

Answer 139

Sulfonylureas are associated with hypoglycaemia in the fasted state and therefore should always be omitted on the day of surgery until the patient is eating and drinking again. Monitor blood glucose and give insulin if necessary

Answer 140

Pioglitazone, dipeptidylpeptidase-4 inhibitors (gliptins) and glucagon-like peptide-1 receptor agonists can be taken as normal during the whole peri-operative period.Metformin- depends on AKI risk, eGFR, how many doses they are missing

Answer 141

Sulphonylureas

Answer 142

Those with suspected type 1 diabetes, in children, during pregnancy, or in women who are up to two months postpartum Also should not be used in the following:- Symptoms for less than 2 months - Treatment with medication that may cause hyperglycaemia - Acute pancreatic damage - HIV - End stage CKD

Answer 143

Women of child bearing potential

Answer 144

Hypothyroidism

Answer 145

HYPERthyroidism

Answer 146

Carbimazole is associated with congenital defects, including aplasia cutis of the neonate, therefore propylthiouracil = first trimester of pregnancy. Second trimester= carbimazole because of the potential risk of hepatotoxicity with propylthiouracil

Answer 147

Over treatment with anti thyroid drugs may cause hyperthyroidism combination of carbimazole + levothyroxine sodium daily, may be used in a blocking-replacement regimen; therapy is usually given for 18 months. The blocking-replacement regimen is not suitable during pregnancy

Answer 148

Can cause serious CNS effects and demyelination of neurones

Answer 149

Can cause hypokalaemia

Answer 150

Seek urgent medical attention as they are immunocompromised Passive immunisation with varicella zoster immunoglobulin is important

Answer 151

Taking long term steroids > 3 weeks High dose ICS

Answer 152

Type 1 if >40 years TYpe 2 if QRISK >10%

Answer 153

Diet and exercise If blood glucose targets are not met within 1-2 weeks, metformin can be prescribed (if not, insulin)

Answer 154

Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise

Answer 155

Should be considered for immediate insulin treatment, with or without metformin

Answer 156

Larger than average foetus- usually a complication for pregnant women with diabetes

Answer 157

Stop vehicle in safe place Switch off engine, remove keys, move from drivers seat >4 then eat/drink suitable source of sugar (bread/normal meal if due) <4 glucose tablets, glucose 40% gel (glucogel, dextrogel, rapilose) pure fruit and sugar dissolved in water Wait 45 mins Once blood glucose returned normal after 45 mins= continue journey

Answer 158

SGLT2 inhibitors

Answer 159

Continuous oestrogen

Answer 160

Progesterone cyclically and oestrogen Or continuous progesterone and oestrogen (avoids withdrawal bleed) ii) Continuous combined HRT is unsuitable for peri-menopausal or <12 months after last period as it can cause irregular bleeding so you would use cyclic

Answer 161

Endometrial cancer

Answer 162

Coronary heart disease

Answer 163

Severe pancreatitis DPPi - gliptins (linagliptin… Alogliptin)

Answer 164

Prevention of osteoporosis in female 5 mg risedronate daily Treatment of postmenopausal osteoporosis to reduce risk of vertebral or hip fractures By mouth Adult (female) 5 mg daily, alternatively 35 mg once weekly. Treatment of osteoporosis in men =35 mg risedronate once weekly Treatment of postmenopausal osteoporosis female 10 mg daily, or 70 mg once weekly alendronic acid Treatment of osteoporosis in men 10 mg alendronic acid daily

Answer 165

Iron can decrease the absorption of levothyroxine, so separate administration by at least 4 hours

Answer 166

Norethisteron 5 mg 3 times a day, to be started 3 days before expected onset (menstruation occurs 2–3 days after stopping).

Answer 167

Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension or death Withdrawal can also be associated with fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and weight loss.

Answer 168

statins (HMGCoA Reductase inhibitors) which inhibit endogenous production of LDL Cholesterol and up-regulate its uptake by the liver. The only other therapy in routine use and suggested by NICE is Ezetimibe. Other medication includes; Fibrates (especially if triglycerides are >10mmol/l), Omacor and Bile acid sequestrants but are not for routine use.

Answer 169

Insulin Glulisine Apidra® Insulin Aspart Novorapid® Insulin Lispro Humalog® That GAL is RAPID!

Answer 170

Insulin Aspart Rapid-acting

Answer 171

0- 15 mins before food

Answer 172

2 - 5 hours

Answer 173

300 units/3ml pens containing 100 units/ ml

Answer 174

Less at risk of hypoglyceamia as it is only in body for a few hours and is used with meals

Answer 175

soluble Insulin

Answer 176

15 - 30 mins before food Must eat food within 30 mins of injecting to avoid hypoglycaemia They start working after 30 mins

Answer 177

They usually need to be injected twice daily, sometime once daily in eldery No need to inject with meals They have a peak action at 4 - 12 hour and last for around 21 hours

Answer 178

Insulin Detemir Levemir ® Insulin Glargine Lantus ® Insulin Degludec Tresiba®

Answer 179

Degludec tresiba

Answer 180

Soluble insulin

Answer 181

These are basically pre-mixed preparations of a rapid or short acting insulin plus a intermediate acting insulin (either the protamine or isophane insulin They are to be injected twice daily, and are good for patients who don't like multiple injecting regimens ( also called basal bolus- where people have to inject short acting with meals plus a long acting insulin Disadvantages of these are that there may be less control as proportions are fixed- if unwell and need to boost their insulin they cannot use these and would need a rapid or short acting insulin for this

Answer 182

Insulin aspart rapid acting Insulin aspart protamine (long acting) Together it becomes intermediate acting- injected twice daily

Answer 183

Cloudy Need to be resuspended before use- tell patient this- by rolling in their hands (not shaking)

Answer 184

Novomix 30 (insulin aspart+ aspart protamine) Humalog Mix 25 Humalog Mix 50 (Insulin Lispro + lispro protamine) Humulin M3 (soluble insulin + isophane insulin) Insuman Comb 50 (soluble insulin + isophane insulin)

Answer 185

HypoKaleamia

Answer 186

Think about what each one contains: short or rapid acting! The ones containing rapid acting (NovoMix 30, Humalog Mix) should be injected 0-15 mins before a meal Containing soluble (Humulin M3, Insuman Comb) inject 15 - 30 mins before a meal

Answer 187

These will now have a 28 day expiry, as not-in-use pens need to be in the fridge to be used by their original expiry date (i.e. now follow the same rules that In-use pens have)

Answer 188

Over 11 mmol/L

Answer 189

Fasting= over 7 mmol/L

Answer 190

Two hour post food/ glucose: Over 11 mmol/L

Answer 191

HbA1c of over 48 mmol/mol 6.5%

Answer 192

Children/ young adults Suspected Type 1 diabetes Symptoms less than 2 months Medication related glucose effects e.g. steroids, antipsychotics Pancreas damage Pregnancy Acutely unwell in hospital

Answer 193

Intermediate acting (Isophane) Biphasic preparations- Novomix, Humulin M3, Humalog Mix, Insuman Comb

Answer 194

Within 2 hours of starting their journey Every 2 hours whilst driving If a hypo occurs: stop, pull over, get out of drivers seat, eat sugar, wait 45 mins after BG have returned to normal to continue driving

Answer 195

Within 2 hours of starting to drive, every 2 hours whilst driving at least twice daily when not driving

Answer 196

Fat hypertrophy at injection site Local reactions at injection, the injection site should be rotated to prevent lipodystrophy and cutaneous amyloidosis oedema Hypoglycaemia

Answer 197

Just because the patient is ill and not eating does not mean they should stop injecting their insulin infection= stress hormones/ steroids released steroids increase blood glucose stay well hydrated to avoid DKA patient should monitor their BG and urine ketones more frequently and be prepared to inject accordingly

Answer 198

For all insulin preparations, except rapid and soluble insulin and insulin glargine (Lantus), the vial or pen should be gently rolled in the palms of the hands (or shaken gently) to resuspend the insulin.

Answer 199

Intermediate acting: Human isophane insulin

Answer 200

Onset of action of 10-20 mins Peak acivity of 1-4 hours

Answer 201

It is the first insulin to be available in two different strengths: 100 units/ml, 200 units/ml

Answer 202

Increase insulin secretion from the pancreas

Answer 203

Short acting Gliclazide, Glipizide, Tolbutamide Longer acting: Glimepramide Glibenclamide (longest acting)

Answer 204

Glibencamide (longest acting) Avoid use in the elderly

Answer 205

Weight gain

Answer 206

No, causes weight gain

Answer 207

Weight gain GI disturbance: Diarrhoea, dyspepsia, nausea, vomitting Allergic dermatitis (usually in first 6- 8 weeks) Jaundice (avoid in severe liver impairment)

Answer 208

It is a Biguanide: Decreases gluconeogenesis (production of new glucose) and increases peripheral utilisation of glucose Remember: metformin produce normoglycemia rather than hypoglycaemia It does not increase insulin secretion like other oral antidiabetics, therefore it does not cause weight gain!

Answer 209

GI upset- take with food, use MR if intolerable Taste disturbance Lactic acidosis

Answer 210

risk factors such as renal dysfunction (as metformin accumulates), liver disease, heavy alcohol, IV contrast media- reduces renal function therefore lactic acidosis risk Poor tissue perfusion/ poor renal function= risk of lactic acidosis

Answer 211

Cobalamin Vitamin B12, Can lead to vitamin B12 deficient aneamia: symptoms= increased tirednes, weakness, mouth ulcers, pins and needles, disturbed vision, sore red tongue, depression/ confusion

Answer 212

eGFR falls below 30 ml/min/ 1.73m2 In moderate impairment (eGFR under 45) a dose reduction is needed

Answer 213

Alpha glucosidase inhibitor- (Acarbose stops the break down of starch and disaccharides to glucose, thereby delaying the digestion and absorption of starch and sucrose- small but significant effect in lowering blood glucose.

Answer 214

FLATULENCE- advise this will decrease with time Diarrhoea/ Soft stools (as poo becomes sugary due to limited glucose absorption). Other GI effects To counteract possible hypoglycaemia, patients receiving insulin or a sulfonylurea as well as acarbose need to carry GLUCOSE (not sucrose—acarbose interferes with sucrose absorption).

Answer 215

Manufacturer advises tablets should be chewed with first mouthful of food or swallowed whole with a little liquid immediately before food. Antacids containing magnesium and aluminium salts unlikely to be beneficial for treating side effects.

Answer 216

Interaction:Renal function deteriorates rapidly can then increase risk of Lactic acidosis

Answer 217

Inhibit an enzyme called Dipeptidylpeptidase-4. This enzyme breaks down incretins, incretins trigger insulin secretion and lower glucagon secretion, therefore they are good at helping control glucose, so by inhibiting the enzyme that breaks them down, gliptins increase incretin levels.Gliptins.. incretins... gliptins.... incretins!

Answer 218

Discontinue if symptoms of acute pancreatitis occur such as persistent, severe abdominal pain Abdominal pain; gastrooesophageal reflux disease; headache; increased risk of infection; skin reactions

Answer 219

Vildagliptin Report symptoms of liver disease: nausea, vomitting, abdominal pain, fatigue, dark urine discontinue if jaundice or other signs of liver dysfunction occur Pancreatitis Discontinue if symptoms of acute pancreatitis occur, such as persistent severe abdominal pain.

Answer 220

Dipeptidylpeptidase-4 inhibitors (gliptins- sitagliptin, Linagliptin etc) Glucagon-like peptide-1 receptor agonists (Exenatide, Liraglutide, Lixisenatide) Exenatide especially can cause SEVERE PANCREATITIS Symptoms: Persistent and severe abdominal pain, Nausea and vomitting

Answer 221

Reduces peripheral insulin resistance

Answer 222

Pioglitazone:Incidence of HF increased when pioglitazone is combined with insulin Also small risk of BLADDER cancer Signs of bladder cancer: blood in urine, pain on urination, urinary urgency

Answer 223

Yes- alot of them cause a headache, particularly pioglitazone and the DDPi gliptins

Answer 224

Nateglinide Repaglinide Stimulate insulin secretion Take 30 minutes before meal

Answer 225

Pioglitazone DDP4i - Vidagliptin

Answer 226

Glucagon-like peptide-1 receptor agonists Examples: Exenatide Liraglutide Lixisenatide These are given by SUBCUTANEOUS INJECTION- not oral (apart from semaglutide). These work by binding to the GLP-1 receptor causing: Increase in insulin secretion suppression of glucagon secretion (glucagon gets converted in glucose usually) Slow gastric emptying If given with sulfonylureas or insulin, their dose may need to be reduced as increased risk of hypoglyceamia!

Answer 227

(GLP-1 agonist) These are symptoms of pancreatitis- exanatide can cause severe pancreatitis- discontinue permanently Also DDP4i gliptins can cause pancreatitis

Answer 228

If a dose of the immediate-release injection is missed, treatment should be continued with the next scheduled dose—do not administer after a meal. If a dose of the modified-release injection is missed, it should be administered as soon as practical, provided the next regularly scheduled dose is due in 3 days or more; thereafter, patients can resume their usual once weekly dosing schedule. Some oral med's need to be given 1 hour before or 4 hours after this drug

Answer 229

Sodium Glucose Co-transporter 2 inhibitors, Gliflozins Examples:Canagliflozin, Dapagliflozin, Empagliflozin The sodium glucose transporter is found in the kidneys: by inhibiting this they stop glucose being re-absorbed in the renal tubule and therefore more glucose is excreted

Answer 230

Volume depletion Think floz= flow Think: these are inhibiting glucose reabsorption into the renal tubules. Water usually follows the glucose- less reabsorbed= less water follows= more weeing etc Patients need to report signs of this: Dizzy, postural hypotension Side effects: Thirst Constipation (less water in stools) Increased risk: things that also decrease fluid volume Antihypertensives Elderly diarrhoea

Answer 231

0.5 percentage

Answer 232

SGLT2 inhibitors: Dapagliflozin

Answer 233

Poylcystic ovary syndrome It helps to normalise the menstrual cycle on ovulation

Answer 234

Symptoms of bladder cancer: heamatruria, dysuria, urinary urgency. signs of liver toxicity: nausea, vomiting, abdominal pain, fatigue and dark urine develop. discontinue if jaundice occurs HF

Answer 235

For all SULFONYLUREAS: Presence of ketoacidosis For GLICLAZIDE: Avoid where possible in Acute porphyrias Metformin in pic incorrect- weight neutral

Answer 236

In general, manufacturers advise avoid in severe impairment (increased risk of hypoglycaemia). Reduce the dose- sulfonylureas metabolised hepatically- they will accumulate and cause hypoglyceamia

Answer 237

Chewed with first mouthful of food/ with a bit of water immediately before food

Answer 238

Diazoxide (remember diuretics can cause hyperglyceamia)

Answer 239

A sulfonylurea- Gliclazide

Answer 240

Exenatide This is a NICE recommendation

Answer 241

Strontium ranelate Severe allergic reaction: Symptoms known as DRESS 'Drug rash with eosinophilia and systemic symptoms' Starts with: fever, rash, swollen glands, high WCC

Answer 242

Osteonecrosis of the Jaw The risk is higher with IV therapy for cancer treatment than it is with oral. Patients have a dental check up before starting and need to maintain good oral hygiene and attend regular check ups. They should report any oral symptoms: Pain, inflammation, difficulty swallowing

Answer 243

Stop taking and Report it- may be an oesophageal reaction: can be serious

Answer 244

Hyponatreamic convulsions mentioned in the BNF. This can be minimised by sticking to the recommended start dose and avoiding drugs that increase secretion of vasopressin such as TCA's.

Answer 245

Not for more than 6 cyclesIncreased risk of ovarian cancer with clomifene use.

Answer 246

Carbimazole Used for Hyperthyroidism Used in the 18 month blocking-replacement regimen together with levothyroxine.

Answer 247

Baseline ECG- this is because we want to check we haven't mistaken hypothyroidism with ischaemia/ cardiovascular disease.

Answer 248

Propylthiouracil Liver function- severe hepatic reactions have taken place.

Answer 249

Beta blockers- propranolol IV fluids hydrocortisone

Answer 250

Rashes and pruritis- don't say 'discontinue' in exam cause you've mistaken it for neutropenia/agranulocytosis

Answer 251

Double dose for 2 days

Answer 252

Double dose until symptoms improve

Answer 253

Hydrocortisone emergency injection may be needed from GP

Answer 254

Addisons is a deficiency of ACTH- (adrenocorticotropic hormone) because the immune system has turned against the adrenal glands. Symptoms: anorexia, Nausea and vomiting, weightloss- treat with glucocorticoids Cushings- too much ACTH, caused by long term glucocorticoid therapy or tumour. Moon face, buffalo hump, mood swings, weight gain. Treatment- withdraw the steroid

Answer 255

Rapid weight loss Abdominal pain Nausea and vomiting Rapid and deep breathing? Sweet smelling breath Altered odour of urine/sweat Sleepiness

Answer 256

Adult:Dose may be reduced rapidly down to physiological dose (equivalent to 7.5mg prednisolone daily) and then reduced more slowlyChild:Dose may be reduced rapidly down to physiological dose (equivalent to 2-2.5 mg/m2 prednisolone daily) and then reduced more slowly

Answer 257

When disease is unlikely to relapse and those who have received less than 3-weeks treatment

Answer 258

1 year or more

Answer 259

Long duration of action Makes it good for suppression of corticotrophin secretion (e.g. congenital adrenal hyperplasia)

Answer 260

Fludrocortisone acetate Can be used to treat postural hypotension

Answer 261

Betamethasone and Dexamethasone

Answer 262

HYDROCORTISONE

Answer 263

Glucocorticoids

Answer 264

Derived from prednisolone Has high glucocorticoid activity

Answer 265

88% is inactivated

Answer 266

Avoid in acute or chronic impairment Do not initiate the drug if liver enzymes are greater than 2X the normal upper limit

Answer 267

Fatigue Anorexia Nausea and vomiting Hypotension Hyponatraemia Hypoglycaemia Hyperkalaemia

Answer 268

1. Deficient insulin secretion 2. Resistance to actions of insulin

Answer 269

1. Pancreatic damage2. Hepatitis3. Endocrine disease

Answer 270

Hypoglycaemia

Answer 271

1. Glucose meter 2. Test strips

Answer 272

Every two hours - more frequent if recent activity that may increase risk of hypo

Answer 273

Have a fast-acting carbohydrate Glucose tablets, glucose drinks, full-sugar soft drinks or squashes, jellies (not diet), sweets.

Answer 274

1. Stop driving 2. Switch off the engine, remove keys and move from driver's seat 3. Consume source of sugar

Answer 275

45 minutes after it has returned to normal

Answer 276

If hypoglycaemia awareness has been lost

Answer 277

1. Sulphonylureas 2. Nateglinide 3. Repaglinide

Answer 278

No, they must drink in moderation and with food

Answer 279

Oral Glucose Tolerance Test

Answer 280

Gestational diabetes

Answer 281

Plasma glucose is measured after fasting for 8 hours.Patient drinks glucose drink. Plasma glucose is measured 2 hours after

Answer 282

The amount of glycated haemoglobin

Answer 283

The last 3 months

Answer 284

1. Type 1 diagnosis 2. Children 3. Pregnancy 4. Up to 2 months post-partum 5. Symptoms of diabetes less than 2 months 6. High risk diabetes or critically ill 7. Treatment with medication that causes hyperglycaemia 8. Acute pancreatic damage 9. End stage CKD 10. HIV

Answer 285

every 3-6months

Answer 286

every 3-6 months and once stable every 6 months

Answer 287

1. Disturbed erythrocyte turnover 2. Lack of/abnormal haemoglobin

Answer 288

1. Quality controlled blood glucose profiles2. Total glycated haemoglobin estimation3. Fructosamine estimation

Answer 289

Glycated concentration of ALL plasma proteins over 14-21 days

Answer 290

No (little to none)

Answer 291

Destruction of insulin-producing pancreatic beta cells

Answer 292

Auto-immune basis

Answer 293

Before adulthood

Answer 294

1. Nephropathy 2. Neuropathy 3. Retinopathy

Answer 295

1. Stroke 2. Cardiovascular disease (MI) 3. Peripheral arterial disease

Answer 296

Over 11mmol/L

Answer 297

Less than 25kg/m2

Answer 298

Less than 50

Answer 299

1. Rapid weight loss 2. Ketosis 3. (Family) history of autoimmune disease

Answer 300

1. Achieve blood glucose control 2. Reduce frequency of hypoglycaemic episodes 3. Minimise the risk of microvascular and macrovascular complications

Answer 301

Less than 48mmol/mol

Answer 302

at least 4 times daily - before each meal and before bed

Answer 303

1. Hypertension 2. Blood lipids

Answer 304

BMI over 25 (over 23 S. Asian)

Answer 305

1. Improve blood glucose 2. Minimise insulin dose

Answer 306

Carbohydrate-counting training

Answer 307

No, specilist initiation and management

Answer 308

1. Multiple daily BASAL-BOLUS regimens2. Mixed (BIPHASIC) regimens3. Continuous subcutaneous insulin infusion

Answer 309

Long acting

Answer 310

Short acting

Answer 311

Short acting + intermediate acting

Answer 312

Basal-bolus

Answer 313

1. Insulin detemir2. Insulin glargine

Answer 314

Before meals

Answer 315

Continuous subcutaneous insulin infusion

Answer 316

1. Adherence issues 2. Poor injection technique 3. Injection site issues 4. Poor blood-glucose monitoring skills 5. Lifestyle (diet/exercise/alcohol) 6. Psychological issues 7. Organic disease

Answer 317

1. Renal disease2. Thyroid disorder3. Coeliac disease4. Addison's disease5. Gastroparesis

Answer 318

1. Infection2. Stress3. Accidental/Surgical trauma

Answer 319

1. Physical activity2. Intercurrent illness3. Reduced food intake4. Impaired renal function5. Endocrine disorders

Answer 320

1. Palour2. Tingling lips3. Sweating4.Palpitations5. Fatigue6. Hunger7. Shaking/Trembling8.Irritable

Answer 321

1. Weakness2. Blurred vision3. Difficulty concentrating4. Slurred speech5. Confusion6. Sleepiness7. Seizures8. Coma

Answer 322

Hypoglycaemia

Answer 323

1. Ability to recognise symptoms is lost2. Symptoms are blunted / no longer present

Answer 324

Gold/Clarke score

Answer 325

Increased frequency of hypoglycaemia episodes

Answer 326

less than 3mmol/L

Answer 327

Beta blockers

Answer 328

Yellow sharps bin

Answer 329

Taken from the patient by the local authority

Answer 330

1. Increase glucose uptake by adipose tissue and muscles2. Suppress hepatic glucose release

Answer 331

Basal-bolus

Answer 332

Subcutaneous

Answer 333

1. Abdomen2. Outer thighs3. Buttocks

Answer 334

1. Local tissue reactions2. Injection site3. Depth of injection4. Changes in insulin sensitivity5. Blood flow6. Amount injected

Answer 335

Lipohypertrophy

Answer 336

The insulin released by the body in response to a meal

Answer 337

1. Insulin glulisine 2. Insulin aspart 3. Insulin lispro

Answer 338

Immediately

Answer 339

1. Poorer glucose control2. Hypoglycemia

Answer 340

Isophane insulin

Answer 341

Endogenous basal insulin continuously secreted in response to glucose production by liver

Answer 342

11-24hours

Answer 343

1. One or more daily injections of intermediate insulin + short-acting insulins at meal times2. Mixed (biphasic) insulin injections

Answer 344

1. Insulin detemir2. Insulin glargine3. Insulin degludec

Answer 345

Insulin detemir

Answer 346

Risk of severe harm and death due to withdrawing insulin from pen devices - Insulin should not be extracted from pen devices

Answer 347

Between 4 and 10mmol/L

Answer 348

Show them the container to confirm the expected version is dispensed

Answer 349

10-20g glucose by mouth

Answer 350

A carbohydrate snack

Answer 351

If it cause unconsciousness

Answer 352

Glucagon - increases the plasma-glucose concentration by mobilising glucagon stored in the liver

Answer 353

Glucose 20% IV Infusion into a large vein

Answer 354

1. High risk of extravasation2. Difficult to administer

Answer 355

Initially 500 mg OD for at least 1 week, dose to be taken with breakfast, then 500 mg twice daily for at least 1 week, dose to be taken with breakfast and evening meal, then 500 mg 3 times a day, dose to be taken with breakfast, lunch and evening meal; maximum 2 g per day.

Answer 356

Aspart Lispro

Answer 357

Isophane insulin High risk of hypo with insulin especially in 1st trimester Patient should carry glucose/dextrose/glucose drink Prescribe glucagon for use when needed for type 1 diabetic patients

Answer 358

True insulin causes HYPOkalaemia

Answer 359

Infection stress accidental or surgical trauma can all increase insulin requirement. Physical activity, inter current illness, reduced food intake, impaired renal function = decreased insulin requirement

Answer 360

135/85 130/80

Answer 361

HYPOglycaemia (may lower blood glucose; increased risk of hyperkalaemia)

Answer 362

Micro- affects eyes kidneys and nerves Macro- affects heart brain blood vessels

Answer 363

The dose of insulin generally needs to be increased in the second and third trimesters of pregnancy

Answer 364

Intermediate insulin- containing insulin and protamine

Answer 365

HRT is restricted to younger postmenopausal women due to CVD and cancer in older postmenopausal women on long term HRT

Answer 366

BPH -5mg daily Alopecia 1mg daily

Answer 367

The MHRA has received reports of depression and, in rare cases, suicidal thoughts in men taking finasteride (Propecia®) for male pattern hair loss; depression is also associated with Proscar® for benign prostatic hyperplasia. Patients should be advised to stop finasteride immediately and inform a healthcare professional if they develop depression. Cases of male breast cancer have been reported. Patients or their carers should be told to promptly report to their doctor any changes in breast tissue such as lumps, pain, or nipple discharge.

Answer 368

Finasteride is excreted in semen and use of a condom is recommended if sexual partner is pregnant or likely to become pregnant.

Answer 369

Avoid handling crushed/broken tablets and capsules

Answer 370

Impotence Decreased libido Ejaculation disorders Breast tenderness and enlargement

Answer 371

Vaginal bleeding Investigate for endometrial cancer if bleeding continues beyond 6 months or after stopping treatment. Reasons to withdraw treatment Withdraw treatment if signs of thromboembolic disease, abnormal liver function tests, or signs of cholestatic jaundice.

Answer 372

Sulphonylureas SGLT2 DPP4i ????

Answer 373

Illness. When you get sick, you may not be able to eat or drink as much as usual, which can make blood sugar levels hard to manage. Missing insulin shots, a clogged insulin pump, or the wrong insulin dose.

Answer 374

DKA develops when your body doesn’t have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body.

Answer 375

SGLT2 - Flozins