Diabetes

Question 1

How does a new diagnosis of T1DM often present

Answer 1

in DKA, may occur over a longer period of time

Question 2

Features of DKA

Answer 2

abdominal pain
polyuria, polydipsia, dehydration
Kussmaul respiration (deep hyperventilation)
acetone-smelling breath (‘pear drops’ smell)

Question 3

Investigations to perform in T1DM

Answer 3

urine dip - glucose and ketones
fasting glucose and random glucose
C-peptide levels are typically low in patients with T1DM
diabetes-specific autoantibodies are useful to distinguish between type 1 and type 2 diabetes

Question 4

Antibodies present in T1DM

Answer 4

1. anti-GAD (encourages the destruction of pancreatic cells which produce insulin)
2. Islet cell antibodies (ISA) - act on beta cells (primary source of insulin)
3. insulin autoantibodies (IAA)
4. Insulinoma-associated-2 autoantibodies (IA-2A)

First two mentioned are commonest

Question 5

Diagnostic criteria for T1DM

Answer 5

fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

Question 6

Signs of T1DM

Answer 6

ketosis
rapid weight loss
age of onset below 50 years
BMI below 25 kg/m²
personal and/or family history of autoimmune disease

Question 7

Why is C peptide low in T1DM

Answer 7

C peptide is also produced by the beta cells of the pancreas (same with insulin), hence, the destruction of these cells will not only demonstrate a high BM but a low level c peptide

Question 8

Once diagnoses T1DM, what blood test should be monitored?

Answer 8

HBA1C every 3-6 months
Target is less than 48 mmol

Question 9

Recommended monitoring daily for T1DM

Answer 9

4 times daily glucose and before and after meal times. Increase if hypos,, unwell, pregnancy, sport, breastfeeding.

Question 10

Blood glucose targets in AM and PM

Answer 10

5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day

Question 11

Should metformin be considered in T1DM

Answer 11

If BMI >25

Question 12

What is the recommended regime in T1DM re insulin

Answer 12

offer multiple daily injection basal–bolus insulin regimens with rapid acting at meal times

Question 13

Parameter for a diagnosis of pre-diabetes

Answer 13

fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk
OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Question 14

Mx of prediabetes

Answer 14

lifestyle modification: weight loss, increased exercise, change in diet
at least yearly follow-up with blood tests is recommended
NICE recommend metformin for adults at high risk ‘whose blood glucose measure (fasting plasma glucose or HbA1c) shows they are still progressing towards type 2 diabetes, despite their participation in an intensive lifestyle-change programme’

Question 15

Diabetes T2 and HTN target range

Answer 15

< 140/90 mmHg

Question 16

T1DM and HTN target range

Answer 16

Intervention levels for recommending blood pressure management should be 135/85 mmHg unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg

Question 17

Albuminuria is a sign fo what

Answer 17

KD

Question 18

What is metabolic syndrome

Answer 18

Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure (hypertension) and obesity. Anything that increases cardiovascular risk.

Question 19

Mx of choice white male with diabetes (age not relevant!) T1/T2DM

Answer 19

ACE inhibitors/or angiotensin-II receptor antagonist
Irrespective of age as deemed renoprotective

Question 20

Mx of choice in afrocaribean with diabetes

Answer 20

A2RBs

Question 21

you review a patient 6 months after starting metformin. His HbA1c is 51 mmol/mol (6.8%). He has no CVD risk factors. How do you titrate his medications?

Answer 21

increase metformin and titrate

Question 22

If metformin is causing GI upset, what should you do

Answer 22

swap to modified release

Question 23

If metformin is contraindicated and patient has CVD risks, what therapy would you choose to manage T2DM

Answer 23

SGLT-2

Question 24

If metformin is contraindicated and patient has NO CVD risks, what therapy would you choose to manage T2DM

Answer 24

DPP‑4 inhibitor or pioglitazone or a sulfonylurea

Question 25

If metformin is contraindicated and patient is already on a DPP-4 inhibitor and HBA1C >58 with no CVD RFs, what medication should you consider adding?

Answer 25

pioglitazone or a sulfonylurea

Question 26

When to consider adding a second/third line agent.

Answer 26

If Hba1c >58

Question 27

What are the options for triple therapy for T2DM

Answer 27

metformin + DPP-4 inhibitor + sulfonylurea metformin + pioglitazone + sulfonylurea metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met Note SGLT-2 only in CVD risk and D+P never a combination Can also consider insulin at this point

Question 28

When to consider a GLP-1 in T2DM

Answer 28

BMI ≥ 35 kg/m² and specific psychological or other medical problems associated with obesity or BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months

Question 29

Do you continue metformin alongside a GLP-1

Answer 29

Yes

Question 30

What is the recommended insulin in T2DM

Answer 30

human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need

Question 31

you review an established type 2 diabetic on maximum dose metformin. Her HbA1c is 55 mmol/mol. What do you do?

Answer 31

Nothing as not at the 58mmol threshold for escalation

Question 32

a type 2 diabetic is found to have an HbA1c of 62 mmol/mol (7.8%) at annual review. They are currently on maximum dose metformin. What do you do?

Answer 32

DPP‑4 inhibitor or pioglitazone or a sulfonylurea

Question 33

in T2DM when should you offer a statin and what would you give ?

Answer 33

only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg on

Question 34

SGLT-2 examples

Answer 34

flozins e.g. empagliflozin

Question 35

Sitagliptin is an example of what

Answer 35

DPP-4

Question 36

exenatide is an example of what

Answer 36

GLP-1

Question 37

sulfonylurea examples

Answer 37

Glimperamide, gliclazide IDE

Question 38

Diagnostic thresholds for gestational diabetes on bloods

Answer 38

fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L

Question 39

Screening test of choice for gestational diabetes

Answer 39

OGTT Should do this on anyone who has previously had GD early on and at the 24 week mark. Do it at the 24 week mark for anyone with RFs such as FHx.

Question 40

If from fasting glucose, BM is >5.6 but below 7, how do you manage the pregnant patient

Answer 40

Diagnose GD and offer dietary and lifestyle adviceI

Question 41

If after a dx of GD and mx with diet and lifestyle, BM still not satisfactory e.g. fasting >5.6, what do you do?

Answer 41

if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started if glucose targets are still not met insulin should be added to diet/exercise/metformin gestational diabetes is treated with short-acting, not long-acting, insulin

Question 42

A pregnancy lady has a fasting BM of 8.5...what do you do?

Answer 42

start insulin any fasting BM>7 in a pregnant lady should be managed with insulin in the first instance

Question 43

if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, what do you do to mx the pregnant lady?

Answer 43

start insulin

Question 44

How should you manage a pregnant lady with pre-existing diabetes?

Answer 44

weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy

Question 45

A 25-year-old Asian woman who is 26 weeks pregnant has an oral glucose tolerance test (OGTT). This was requested due to a combination of her ethnicity and a background of obesity. A recent ultrasound shows that the fetus is large for dates. How do you manage her is her BM comes back high?

Answer 45

insulin as macrosomnia present in Hx

Question 46

A 71-year-old woman with type 2 diabetes attends her annual health review. She has a background of heart failure and stage 3 chronic kidney disease. It is noted that her HbA1c has risen from 57mmol/mol (7.4%) to 60mmol/mol (7.6%) over the last 12 months. She recently discontinued a trial of an SGLT2 inhibitor after developing euglycaemic diabetic ketoacidosis. Her current medications include metformin, losartan and bisoprolol.

Answer 46

Sitagliptin is correct. Her HbA1c is above the target range for metformin monotherapy (58mmol/mol, or 7.5%), and as she is on the maximum dose of metformin NICE guidelines recommend adding a second agent. As she has a background of heart failure and CKD4, the most appropriate option would be a DDP-4 inhibitor such as sitagliptin (prescribed at a reduced dose due to CKD4). Sulfonylureas should be avoided in significant renal impairment

Question 47

Maternal complications from diabetes when pregnant

Answer 47

polyhydramnios - 25%, possibly due to fetal polyuria preterm labour - 15%, associated with polyhydramnios

Question 48

Neonatal complications from diabetes when pregnant

Answer 48

macrosomia (although diabetes may also cause small for gestational age babies) hypoglycaemia (secondary to beta cell hyperplasia) respiratory distress syndrome: surfactant production is delayed polycythaemia: therefore more neonatal jaundice malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy) stillbirth hypomagnesaemia hypocalcaemia shoulder dystocia (may cause Erb's palsy)