Diabetes Flashcards
(66 cards)
1
Q
What are the HbA1c targets based on the management of T2DM ?
A
- Lifestyle : 48mmol/mol (6.5%)
- Lifestyle + metformin : 48mmol/mol
- Any drygs that may cause hypoglycaemia : 53mmol / mol (7.0%)
2
Q
what is the HbA1c target for a patient already on one drug but HbA1c has risen to 58mmol/mol?
A
53mmol/mol
3
Q
First line treatment for T2DM?
A
Metformin
4
Q
First line management of T2DM if metformin causes GI upset
A
Modified release metformin trial
5
Q
When would an SGLT-2 ‘flozin’ inhibitor be added to metformin as first line treatment ?
A
- Patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
- Patient has established CVD
- Patient has chronic heart failure
6
Q
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
A
SGLT-2 monotherapy (‘Floxin’)
7
Q
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?
A
- Pioglitazone : UNLESS bladder Ca, ketoacidosis, fracture risk, haematuria, HF
- Sulfonylurea : UNLESS ketoacidosis / lorry drivert
- DPP-4 inhibitor (e.g. linagliptin) : AVOID weight gain
8
Q
Mode of action and class of metformin
A
Improves insulin sensitivity
Biguanide
9
Q
SE of metformin
A
Nausea
Diarrhoea
10
Q
When is metformin CI ?
A
Creatinine : 150
eGFR <30
11
Q
Effect of metformin on weight
A
Neutral
12
Q
Action and example of DDP-4 inhibitor
A
- Linagliptin
- Increase leves of incretins which stimulate insulin release and inhibiting the release of glucagon
13
Q
Effect of DPP-4 inhibitor on weight
A
Neutral
14
Q
Action of Pioglitazone and class
A
- Improves insulin sensitivity and suppresses gluconeogenesis
- Thiazolidinedione
15
Q
SE of pioglitazone
A
Weight gain
HF
Bone fractures
Bladder cancer
16
Q
Effect of pioglitazone on weight
A
Increase
17
Q
Action of sulfonylurea and example
A
Enhances insulin secretion
Gliclazide
18
Q
two SE pf gliclazide
A
Hypoglycaemia
Cholestasis
19
Q
Effect of gliclazide on weight
A
Increase
20
Q
Action and example of SGLT-2 inhibitor
A
Empagliflozin
Reduces renal glucose reabsoprtion = increasing urinary glucose excretion
21
Q
SE of SGLT-2 inhibitors
A
Euglycaemic ketoacidosis
Increased risk of UTI and genital thrush
Fournier’s gangrene
22
Q
Effect of SGLT-2 inhibitors on weight
A
weight loss
23
Q
Example and action of GLP-1 analogue
A
- Exenatide, semaglutide
- Increase insulin secretion and inhibit glucagon secretion
24
Q
3 SE of GLP-1 analogues
A
Nausea
Diarrhoea
Pancreatitis
25
Effect of GLP-1 analogues on weight
Decrease
26
Example and action of a-glucosidase inhibitor
Acarbose
Reduces glucose absorption
27
3 SE of acarbose
Bloating
Flatulence
Diarrhoea
28
First line management of DM if underweight
Glicliazide
29
What is the earliest, clinically detectable manifestation of classic diabetic kidney disease
Microalbuminuria
30
Screening for diabetic nephropathy
- 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
31
Management of diabetic nephropathy
- BP control with ACEI or ARB to aim for <130/80
- Dietary protein restriction
32
What is the best way to distinguish AKI from CKD
Renal USS -> most pts with CKD have bilateral small kidneys
EXCEPCT
- ADPKD
- Diabetic nephropathy (early stages -> enlarged kidneys)
- Amyloidosis
- HIV- associated nephropathy
33
- Small well defined deep ulcer on ventral aspect of the heel
- Pale, dry with cracked skin
Arterial ulcer
34
Sick day rules for pt with T1DM on inuslin
- CONTINUE NORMAL INSULIN REGIMEN
- Check blood glucose more reg (every 1-2 hrs, including through night),
35
T2DM sick day rules if on metformin
stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.
36
T2DM sick day rules if on sulfonylurea
may increase the risk of hypoglycaemia
37
T2DM sick day rules if on SGLT-2 inhibitor
check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA
38
T2DM sick day rules of GLP-1 receptor agonist
stop treatment if there is a risk of dehydration, to reduce the risk of AKI
39
Dangerous complication of fluid resuscitation in pts with DKA
Cerebral oedema -> reduced GCS, urine incontience, abnormal neurogenic respiratory and vomiting
40
When would NICE recommend adding metformin in the management of T1DM ?
BMI >=25
41
Important adverse SE of SGLT-2 inhibitors
- 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
42
Two ways of diagnosising T2DM
- Plasma glucose
- HbA1c
43
If symptomatic, how is DM diagnosed base on plasma glucose ?
- 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)
44
If asymptomatic, how is DM diagnosed based on plasma glucose
- 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
45
when is Hba1c diagnostic of T2DM
- HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus
- If asymptomatic, repeat to confirm diagnosis
46
HbA1c level suggestive of pre diabetes
42-47 mmol/mol (6.0-6.4%)
47
What can cause a falsely low HbA1c
Haemodialysis
48
Metformin rules with surgery
- If taken once or twice daily take as normal
- If taken 3 times, omit lunch time dose
49
Rules regarding sulfonylureas and morning surgery
- If taken OD in the morning , omit morning dose that dose
- If taken BD - omit morning dose
50
Rules regarding sulfonylureas and afternoon surgery
- If taken once daily in the morning -
omit the dose that day
- If taken twice daily - omit both doses that day
51
Rules regarding DDP-4 and GLP-1 analogues inhibitors and surgery
Take as normal
52
Rules regarding SGLT-2 inhibitors and surgery
Omit on the day
53
Rules regarding once daily insulins and surgery
- Reduced dose by 20% day prior
- Reduced dose by 20% on the day
54
Rules regarding BD biphasic or ultra long acting insulins
- No dose change day before
- Halve the usual morning dose and leave evening unchanged
55
what can be used to distinguish type 1 and type 2 DM
C peptide levels
Low in T1DM
56
Explain T1DM
- 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
57
Explain T2DM
Chronically high glucose levels leads to a peripheral resistance to insulin
58
Step wise management of T2DM if no CVD risk
1. Metformin
2. Sulfonylurea, pioglitazone, DPP-4 inhibitor
3. Triple therapy (metformin + 2 drugs)
59
When is GLP-1 mimetic considered
- 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.
60
What is the pathophysiology behind HHS?
Hyperglycaemia
Increased serum osmolality
Osmotic diueresis
Severe volume depletion
61
Presentation of HHS
- Clinical dehydration, polyuria, polydipsia
- N&V
- Altered consciousness
62
Management of HHS
- 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
63
If starting insulin in T2DM what is recommended
NICE recommend starting with human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need
64
when reviewing a pt on maximum dose metformin, when would anotehr drug be added ?
HbA1c = 58mmol/mol
65
BP target and first line meds for HTN
140/90
ACEI
ARB in afro-caribbean origin
66
