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PR3152 Revision > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What are the 7 differences between type 1 and type 2 DM

A
  1. autoimmume mediated vs insulin resistance
  2. positive Ab vs negative Ab
  3. C-peptide absent vs present
  4. Age of onset below 30 vs above 40
  5. Onset abrupt vs gradual
  6. Physical appearance thin vs overweight
  7. DKA risk frequent vs uncommon
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2
Q

What are the risk factors for screening in asymptomatic adults? (screen if there are ≥ 1 risk factor for diabetes) (9)

A
  1. Obesity
  2. Ethnicity
  3. First degree relative with DM
  4. Women who have delivered babies ≥4kg or previously diagnosed w gestational DM
  5. HTN ≥ 140/90 or on medication
  6. High HDL-C or TG levels
  7. PCOS
  8. Impaired glucose tolerance or impaired fasting glucose on previous testing
  9. History of CVD
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3
Q

When should screening be started for in the general population in the absence of DM risk factors? (and subsequently how often)

A

40 years old, then every 3 years
or every year if IFG or IGT

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4
Q

What are the s/sx of hyperglycemia?

A

Extreme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, decreased healing

3 “P”s - polyuria, polydypsia, polyphagia

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5
Q

What are the s/sx of hypoglycemia?

A

Shaking, tachycardia, sweating, dizziness, anxiety, hunger, impaired vision, weakness, fatigue, headache, irritability

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6
Q

What are the 3 key parameters to measure DM?

A
  1. Fasting plasma glucose (no calorie intake for ≥ 8h)
  2. Postprandial plasma glucose (2h after a meal) (or 2hOGTT using 75-0g oral glucose)
  3. HbA1c (3 month average of FPG + PPG)
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7
Q

How often should BG be monitored for T1DM, pregnant women or insulin pump users?

A

≥4 times daily
before meals/snacks, at bedtime at 3am

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8
Q

How often should BG be monitored for T2DM patients on multiple insulin injections?

A

≥3 times daily

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9
Q

How should T2DM be diagnosed with HbA1c alone?

A

For HbA1c 6.0% and below → no diabetes, no further tests needed
For HbA1c 6.1-6.9% → proceed to FPG or OGTT
For HbA1c 7.0% and above → diabetes no further tests needed

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10
Q

What are the FPG guidelines for when HbA1c 6.1-6.9% ?

A

FPG ≤ 6.0 mmol/L no diabetes
FPG 6.1-6.9 mmol/L prediabetes
FPG ≥ 7.0 mmol/L diabetes

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11
Q

What are the 2hOGTT guidelines for when HbA1c 6.1-6.9% ?

A

2hOGTT ≤ 7.7 mmol.L no diabetes
2hOGTT 7.8-11.0 mmol/L prediabetes
2hOGTT ≥ 11.1 mmol/L diabetes

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12
Q

What are the microvascular complications of DM? (3)

A

retinopathy, nephropathy, neuropathy

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13
Q

What are local MOH goals for HbA1c, FBG and PPG?

A
  • HbA1c → ≤ 7%
  • Fasting blood glucose → 4.0 - 7.0 mmol/L
  • Postprandial glucose → < 10 mmol/L
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14
Q

In what patient groups can a more stringent goal of 6.0 to 6.5% be aimed for? (3)

A

patients with short disease duration, long life expectancy and no significant CV diseases

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15
Q

In what patient groups can a more lenient goal of 7.5 to 8.0% be aimed for? (5)

A

history of hypoglycemia
limited life expectancy
advanced complications
extensive comorbid conditions
lower target is difficult to attain despite intensive SMBG, repeated counselling and effective pharmacotherapy

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16
Q

How often should HbA1C be monitored?

A

3 months, 6 if stable

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17
Q

How often should lipid panel be monitored?

A

3-6 months, 12 if stable

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18
Q

How often should BP be monitored?

A

at every visit

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19
Q

How often should an eye exam be conducted?

A

6 months, 12 if stable

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20
Q

How often should renal function be monitored?

A

6 months, 12 if stable

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21
Q

How often should foot exam be conducted?

A

daily by patient, yearly by podiatrist

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22
Q

What are the 4 main NPM for diabetes

A
  1. quit smoking
  2. weight reduction (7% body weight)
  3. Exercise (150min/week moderate intensity)
  4. Diet modification
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23
Q

What is metformin’s MOA

A

Decreases hepatic glucose production

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24
Q

What is the maximum dose of metformin?

A

1g TDS (3g/day)

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25
Q

What are the main side effects of metformin (4)

A
  1. Diarrhea (take after food)
  2. anorexia
  3. metallic taste
  4. lactic acidosis (rare)
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26
Q

In which 2 patient groups is metformin contraindicated?

A

Patients in hypoxic state and severe renal impairment

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27
Q

What are the eGFR guidelines for metformin use

A
  • eGFR < 30 → stop metformin
  • eGFR 30-45 → titrate to half of the maximal dose (FDA says don’t start new patients, KDIGO says can)
  • eGFR 45-60 → can continue max dose, monitor every 3-6 months
  • eGFR ≥ 60 → can continue max dose, monitor annually
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28
Q

What are the DDIs for metformin? (3)

A
  1. alcohol consumotion
  2. iodinated contrast media (withhold for ≥ 48h after contrast administration)
  3. cationic drugs (compete for excretion)
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29
Q

What are SU’s (glipizide) effect?

A

Stimulates insulin secretion by b-cells

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30
Q

When should SUs be taken

A

15-30 mins before meals

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31
Q

What are the 3 main adverse effects of SUs?

A
  1. hypoglycemia (mainly in elderly)
  2. weight gain
  3. blood dyscrasias (rare)
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32
Q

What are the DDIs with SUs? (2)

A
  1. alcohol (disulfram-like rxn)
  2. Beta blockers (mask hypoglycemia)
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33
Q

What are TZD effects?

A

Promotes glucose uptake into cells

34
Q

What are the contraindications for TZDs (pioglitazone)? (2)

A

Black box warning for increased rish of CHF (CI in NYHA class III or IV HF) (stop if pt shows s/sx of HF)
CI in patients with active liver disease

35
Q

What are the adverse effects of TZDs? (6)

A
  1. Hepatotoxicity (don’t start or stop if ALT > 3x ULN)
  2. Edema
  3. Fractures
  4. Weight gain
  5. Bladder cancer
  6. Elevated LDLs
36
Q

How does acarbose work and which type of BG does it target?

A

delays glucose absorption and lowers postprandial glucose by competitively inhibiting brush border α-glucosidase enzymes required for the breakdown of complex carbohydrates

works on postprandial glucose

37
Q

What is the MAIN adverse effects of acarbose?

A

GI SE (flatulence, abdominal pain, diarrhea), until patients discontinue

38
Q

What are the DDIs with acarbose?

A

Intestinal adsorbants and digestive enzyme preparations like charcoal and yakult

39
Q

When should acarbose be taken?

A

With largest meal (or meal with the most carbs)

40
Q

What are adverse effects of GLP1-agonists (Liraglutide)?

A

nvd, acute pancreatitis
black box warning for thyroid C-cell tumour in animals (avoid in pts with thyroid disorders)

41
Q

What are the side effects of DPP4is?

A

Mild, some joint pain

42
Q

Which DPP4i is associated with acute pancreatitis?

A

Sitagliptin

43
Q

What are the side effects of SGLT2is? (7)

A
  1. hypotension
  2. hypoglycemia
  3. renal impairment
  4. increased LDL
  5. urinary urgency
  6. increased risk of GMI
  7. increased risk of euglycemic DKA
44
Q

Where is SGLT2i contraindicated in? (2)

A

ESRD
Pts on dialysis

45
Q

What are the KDIGO guidelines for SGLT2i?

A

Start in all patients with eGFR of ≥ 30 ml/min/1.73m2
Even if it falls below 30 after starting can continue because its an efficacy and not a safety issue

46
Q

What are the 3 main drugs for FBG?

A

Metformin
others (not so strong): GLP1-Agonists, TZD

47
Q

What are the 3 main drugs for PPG

A

SU, GLP-1 agonist, TZD

48
Q

How long can insulin vials be kept for?

A

If refrigerated, until expiry (if not, 28 days)
Once opened, 28 days

49
Q

Name the rapid-acting insulins

A

Glulisine
Aspart
Lispro

50
Q

Name the short-acting insulin

A

Regular

51
Q

Name the intermediate acting insulin

A

NPH

52
Q

Name the long acting insulins

A

Detemir
Glargine

53
Q

When should rapid and short acting insulins be taken?

A

Rapid - 15 mins before meals
Short - 30 mins before meals

54
Q

What are the 2 ultra fast acting insulins?

A

Insulin Aspart (vitamin B12 and L-arginine)
Insulin Lispro-aabc (treprostinil and citrate)

55
Q

When can ultra-fast acting insulins be given?

A

At the first bite or during the meal (within 20 minutes)

56
Q

What are the 2 ultra-long acting insulins?

A

Insulin degludec and glargine (U-300)

57
Q

What are the benefits of ultra-long acting insulins?

A

Peakless, so lesser instances of hypoglycemia

58
Q

How are degludec and glargine (U-300) given

A

Degludec SC OD any time
Glargine (U-300) SC OD at the same time everyday

59
Q

What drugs can be continued when injectables are started?

A

Metformin, SGLT2i

60
Q

What drugs should be discontinued (or reduced by 50%) when injectables are started?

A

TZD - insulin sensitiser, high hypoG risk
SU - high risk of hypoG

DPP4i discontinue if patient is also on GLP1-agonist due to similar MOA

61
Q

What are the 4 main counselling points for SGLT2i?

A
  1. Increased risk of UTI/GMI
  2. Increased DKA risk (hold off 2-3d before surgery)
  3. Diuresis and natriuresis (vol depletion, stop taking in acute illness until 24-48h after)
  4. AKI (mild decrease in kidney function but recovers)
62
Q

What are the 3 target LDL levels?

A

super high risk < 1.4 mmol/L
very high risk < 2.1 mmol/L
high risk < 2.6 mmol/L

63
Q

When should dose be decreased when converting from different forms of insulin?

A

Decrease by 20% when switching from BD NPH to OD glargine/detemir

64
Q

What are the side effects of insulin? (4 main, 2 rare)

A
  1. Hypoglycemia (≤ 4.0 mmol/L, use 15-15-15 rule)
  2. Weight gain (usually w patients on SUs, counsel to exercise)
  3. Lipodystrophy
  4. Local allergic rxn
  5. Systemic allergic rxn
  6. Insulin resistance
65
Q

What are the first 2 drugs that can be started for course of treatment?

A

Metformin
SGLT2i for comorbidities (ASCVD, HF, CKD) independent of A1c

66
Q

Which drugs are good for ASCVD and CKD risk? (2)

A

GLP1A, SGLT2i

67
Q

Which drugs should be avoided in hypoglycemia risk? (2)

A

SU, insulin

68
Q

Which drugs have good weight loss benefits? (2)

A

GLP1A, SGLT2i

69
Q

When is insulin indicated? (3)

A
  1. ongoing catabolism (weight loss)
  2. sx of hyperglycemia
  3. A1c > 10% or BG > 16.7 mmol/L
70
Q

How should insulin be started?

A

Less than 10units before bedtime (glargine, detemir, degludec)

71
Q

How should insulin be uptitrated in inadequate response?

A

Increase by 2units every 3 days until at FPG goal
Increase by 4 units every 3 days if FPG consistently above 10mmol/L

72
Q

When should prandial cover be added?

A

When FPG still not at goal despite basal > 0.5IU/kg or FPG at goal

73
Q

How should prandial cover be added (dose and when to give)

What about when the patient is on bedtime NPH?

A

1 dose with largest meal (4IU or 10% of basal)

If patient on bedtime NPH, split to 2/3 in morning then 1/3 in evening

74
Q

What are the 4 characteristics of DKA?

A

Fruity breath
Ketones in blood and urine
Patient alert
BG > 14mmol/L

75
Q

What are the 4 characteristics of HHS?

A

no ketones
patient dehydrated
near unconscious
BG > 33mmol/L

76
Q

What is the somogyi effect caused by

A

Sharp decrease in BG (missing bedtime snack or too much insulin), causing body to overcompensate by releasing glucagon

77
Q

What is the Dawn phenomenon caused by

A

Release of cortisol (stress hormone) in the morning

78
Q

How to prevent complications in DM? (6)

A
  1. Smoking cessation
  2. Aspirin or clopidogrel administration
  3. BP control
  4. Lipid control
  5. Metabolic syndrome control
  6. Immunity (vaccinations)
79
Q

What are ASCVD risk factors for starting aspirin? (5)

A
  1. LDL ≥ 2.6 mmol/L
  2. High blood pressure
  3. Smoking
  4. CKD, albuminuria
  5. family history of premature ASCVD
80
Q

Who should not be started on aspirin therapy for CVD risk in DM?

A

elderly above 70yo, risk of falls

81
Q

How can medications be adjusted for Muslims fasting during Ramadan? (3)

A
  1. TDS meds change to BD
  2. Reduce medications w high hypoG risk (eg. SU, insulin)
  3. Evening dose potency higher than morning (bc break fast meal heavier)

PR3152 Revision (6 decks)

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