Diabetes

Question 1

What are the HbA1c targets based on the management of T2DM ?

Answer 1

1. Lifestyle : 48mmol/mol (6.5%)
2. Lifestyle + metformin : 48mmol/mol
3. Any drygs that may cause hypoglycaemia : 53mmol / mol (7.0%)

Question 2

what is the HbA1c target for a patient already on one drug but HbA1c has risen to 58mmol/mol?

Answer 2

53mmol/mol

Question 3

First line treatment for T2DM?

Answer 3

Metformin

Question 4

First line management of T2DM if metformin causes GI upset

Answer 4

Modified release metformin trial

Question 5

When would an SGLT-2 ‘flozin’ inhibitor be added to metformin as first line treatment ?

Answer 5

• Patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
• Patient has established CVD
• Patient has chronic heart failure

Question 6

What is given first line for the management of T2DM if metformin is CI AND the pt is at risk of or has CVD / HF

Answer 6

SGLT-2 monotherapy (‘Floxin’)

Question 7

What is given first line for management of T2DM if metformin is CI but the pt is not at high risk of CVD / not in HF?

Answer 7

1. Pioglitazone : UNLESS bladder Ca, ketoacidosis, fracture risk, haematuria, HF
2. Sulfonylurea : UNLESS ketoacidosis / lorry drivert
3. DPP-4 inhibitor (e.g. linagliptin) : AVOID weight gain

Question 8

Mode of action and class of metformin

Answer 8

Improves insulin sensitivity
Biguanide

Question 9

SE of metformin

Answer 9

Nausea
Diarrhoea

Question 10

When is metformin CI ?

Answer 10

Creatinine : 150
eGFR <30

Question 11

Effect of metformin on weight

Answer 11

Neutral

Question 12

Action and example of DDP-4 inhibitor

Answer 12

• Linagliptin
• Increase leves of incretins which stimulate insulin release and inhibiting the release of glucagon

Question 13

Effect of DPP-4 inhibitor on weight

Answer 13

Neutral

Question 14

Action of Pioglitazone and class

Answer 14

• Improves insulin sensitivity and suppresses gluconeogenesis
• Thiazolidinedione

Question 15

SE of pioglitazone

Answer 15

Weight gain
HF
Bone fractures
Bladder cancer

Question 16

Effect of pioglitazone on weight

Answer 16

Increase

Question 17

Action of sulfonylurea and example

Answer 17

Enhances insulin secretion
Gliclazide

Question 18

two SE pf gliclazide

Answer 18

Hypoglycaemia
Cholestasis

Question 19

Effect of gliclazide on weight

Answer 19

Increase

Question 20

Action and example of SGLT-2 inhibitor

Answer 20

Empagliflozin
Reduces renal glucose reabsoprtion = increasing urinary glucose excretion

Question 21

SE of SGLT-2 inhibitors

Answer 21

Euglycaemic ketoacidosis
Increased risk of UTI and genital thrush
Fournier’s gangrene

Question 22

Effect of SGLT-2 inhibitors on weight

Answer 22

weight loss

Question 23

Example and action of GLP-1 analogue

Answer 23

• Exenatide, semaglutide
• Increase insulin secretion and inhibit glucagon secretion

Question 24

3 SE of GLP-1 analogues

Answer 24

Nausea
Diarrhoea
Pancreatitis

Question 25

Effect of GLP-1 analogues on weight

Answer 25

Decrease

Question 26

Example and action of a-glucosidase inhibitor

Answer 26

Acarbose Reduces glucose absorption

Question 27

3 SE of acarbose

Answer 27

Bloating Flatulence Diarrhoea

Question 28

First line management of DM if underweight

Answer 28

Glicliazide

Question 29

What is the earliest, clinically detectable manifestation of classic diabetic kidney disease

Answer 29

Microalbuminuria

Question 30

Screening for diabetic nephropathy

Answer 30

- Annual screening using urinary albumin:creatinine ratio (ACR) - Should be an early morning specimen - ACR > 2.5 in mend OR >3.5 in women = microalbuminuria

Question 31

Management of diabetic nephropathy

Answer 31

- BP control with ACEI or ARB to aim for <130/80 - Dietary protein restriction

Question 32

What is the best way to distinguish AKI from CKD

Answer 32

Renal USS -> most pts with CKD have bilateral small kidneys EXCEPCT - ADPKD - Diabetic nephropathy (early stages -> enlarged kidneys) - Amyloidosis - HIV- associated nephropathy

Question 33

- Small well defined deep ulcer on ventral aspect of the heel - Pale, dry with cracked skin

Answer 33

Arterial ulcer

Question 34

Sick day rules for pt with T1DM on inuslin

Answer 34

- CONTINUE NORMAL INSULIN REGIMEN - Check blood glucose more reg (every 1-2 hrs, including through night),

Question 35

T2DM sick day rules if on metformin

Answer 35

stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.

Question 36

T2DM sick day rules if on sulfonylurea

Answer 36

may increase the risk of hypoglycaemia

Question 37

T2DM sick day rules if on SGLT-2 inhibitor

Answer 37

check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA

Question 38

T2DM sick day rules of GLP-1 receptor agonist

Answer 38

stop treatment if there is a risk of dehydration, to reduce the risk of AKI

Question 39

Dangerous complication of fluid resuscitation in pts with DKA

Answer 39

Cerebral oedema -> reduced GCS, urine incontience, abnormal neurogenic respiratory and vomiting

Question 40

When would NICE recommend adding metformin in the management of T1DM ?

Answer 40

BMI >=25

Question 41

Important adverse SE of SGLT-2 inhibitors

Answer 41

- Urinary and genital infection (secondary to glycosuria). - Fournier’s gangrene has also been reported - Normoglycaemic ketoacidosis - Increased risk of lower-limb amputation: feet should be closely monitored

Question 42

Two ways of diagnosising T2DM

Answer 42

- Plasma glucose - HbA1c

Question 43

If symptomatic, how is DM diagnosed base on plasma glucose ?

Answer 43

- 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 44

If asymptomatic, how is DM diagnosed based on plasma glucose

Answer 44

- 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) TWO SEPARATE OCCASIONS

Question 45

when is Hba1c diagnostic of T2DM

Answer 45

- HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus - If asymptomatic, repeat to confirm diagnosis

Question 46

HbA1c level suggestive of pre diabetes

Answer 46

42-47 mmol/mol (6.0-6.4%)

Question 47

What can cause a falsely low HbA1c

Answer 47

Haemodialysis

Question 48

Metformin rules with surgery

Answer 48

- If taken once or twice daily take as normal - If taken 3 times, omit lunch time dose

Question 49

Rules regarding sulfonylureas and morning surgery

Answer 49

- If taken OD in the morning , omit morning dose that dose - If taken BD - omit morning dose

Question 50

Rules regarding sulfonylureas and afternoon surgery

Answer 50

- If taken once daily in the morning - omit the dose that day - If taken twice daily - omit both doses that day

Question 51

Rules regarding DDP-4 and GLP-1 analogues inhibitors and surgery

Answer 51

Take as normal

Question 52

Rules regarding SGLT-2 inhibitors and surgery

Answer 52

Omit on the day

Question 53

Rules regarding once daily insulins and surgery

Answer 53

- Reduced dose by 20% day prior - Reduced dose by 20% on the day

Question 54

Rules regarding BD biphasic or ultra long acting insulins

Answer 54

- No dose change day before - Halve the usual morning dose and leave evening unchanged

Question 55

what can be used to distinguish type 1 and type 2 DM

Answer 55

C peptide levels Low in T1DM

Question 56

Explain T1DM

Answer 56

- Chronic autoimmune disorder in which insulin producing beta cells in the islets of langerhans in the pancreas are destroyed by immune system - Low insulin = high glucose levels

Question 57

Explain T2DM

Answer 57

Chronically high glucose levels leads to a peripheral resistance to insulin

Question 58

Step wise management of T2DM if no CVD risk

Answer 58

1. Metformin 2. Sulfonylurea, pioglitazone, DPP-4 inhibitor 3. Triple therapy (metformin + 2 drugs)

Question 59

When is GLP-1 mimetic considered

Answer 59

- When triple therapy fails and pt has a BMI above 35kg/m2 - Only continue if reduction of at least 11mmol/mol in in HbA1c and weight loss of at least 3% of initial body weight in 6mnths.

Question 60

What is the pathophysiology behind HHS?

Answer 60

Hyperglycaemia Increased serum osmolality Osmotic diueresis Severe volume depletion

Question 61

Presentation of HHS

Answer 61

- Clinical dehydration, polyuria, polydipsia - N&V - Altered consciousness

Question 62

Management of HHS

Answer 62

- FLUID : IV0.9% saline 0.5-1L/hr with potassium monitoring - Insulin only given if blood glucose stops falliing whilst giving IV fluid - VTE prophylaxis

Question 63

If starting insulin in T2DM what is recommended

Answer 63

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

Question 64

when reviewing a pt on maximum dose metformin, when would anotehr drug be added ?

Answer 64

HbA1c = 58mmol/mol

Question 65

BP target and first line meds for HTN

Answer 65

140/90 ACEI ARB in afro-caribbean origin