Diabetes

Question 1

What is type 1 diabetes?

Answer 1

• Cause: autoimmune destruction of pancreatic beta islet cells
• Treatment: insulin

Question 2

What is type 2 diabetes?

Answer 2

• Cause: unhealthy lifestyle (poor diet, high BO + cholesterol)
• Treatment: anti-diabetics + insulin

Question 3

What are the symptoms of diabetes?

Answer 3

• Hyperglycaemia
• Polyuria
• Polydipsia
• Poor wound healing
• Fatigue
• Weight loss
• Blurry vision

Question 4

What are the microvascular diabetic complications?

Answer 4

Diabetic retinopathy
- Treat HPT

Diabetic nephropathy
- Treat HPT
- Low dose ACEi/ARB

Peripheral neuropathy
- Neuropathic pain: analgesic, TCA + anti-epileptic
- Erectile dysfunction: sildenafil

Diabetic foot

Question 5

What are the macrovascular complications?

Answer 5

• Stroke
• Heart attack
• Atherosclerosis

Question 6

When would you offer low dose statin (primary)?

Answer 6

• 40+
• Type 1 >10 years
• Type 2 >20 years
• Target organ damage
• Significant elevated risk factor

Question 7

What are the risk factors of diabetic ketoacidosis?

Answer 7

• Stress
• Severe dehydration
• Not eating
• Surgery
• Intercurrent illness

Question 8

What are the symptoms of diabetic ketoacidosis?

Answer 8

• Inc ketones
• Blood glucose >11mmol/L
• Extreme thirst
• Polyuria
• Fruity breath
• Rapid weight loss

Question 9

What is the management of diabetic ketoacidosis?

Answer 9

Fluids?
Shock:
- Yes: restore circulating volume
- No: rehydrate + maintain

Potassium
- Don’t give anuric

Soluble insulin
- Continue LA insulin
- Add glucose when <14mmol/L
- Continue:
- Blood ketones <3mmol/L
- Blood pH >7.3: eat and drink
- Stop: 1H post SC fast acting insulin + meal

Question 10

What is the treatment for type 2 diabetes?

Answer 10

• First line: Metformin (GI disturbance: MR)
• CV status: HF, CVD, QRISK >10%: Metformin AND SGLT
• Additional therapy: SU, PIO, DPP
• Switch a drug for GLP-1 agonist or Tirzepatide (dual glucose dependent insulin tropic polypeptide + GLP-1 agonist)

Triple therapy: insulin therapy
- Continue Metformin
- Review/stop other drugs

If CVD develops during treatment: add/replace a drug w SGLT

Question 11

Type 2 diabetes + CKD: treatment

Answer 11

ACEi/ARB + SGLT

Question 12

Sick day rules: antidiabetic drugs

Answer 12

Temporarily stop -> AKI
- Metformin: INC risk of lactic acidosis
- SGLT inhibitor: volume depletion = dehydration is a significant risk factor

Question 13

Surgery (major procedure) + antidiabetic drugs

Answer 13

• Sliding scale insulin
• Stop antidiabetic (except GLP-1 agonist)

Question 14

Surgery (minor procedure) + antidiabetic drugs

Answer 14

Omit antidiabetic dose
- SGLTi: diabetic ketoacidosis
- Sulphonylureas: hypoglycaemia in fasted state
- Metformin: renal impairment = lactic acidosis

Pioglitazone, DPPi, GLP-1 agonist: continue as normal

Question 15

Pregnancy + diabetes: pregnancy planning

Answer 15

• HbA1c level: <48mmol/mol (6.5%)
• 5mg folic acid daily before conception until week 12

Question 16

Pregnancy + diabetes: STOP

Answer 16

• Oral antidiabetic drugs except metformin
• ACEi/ARB, statin - STOP

Question 17

Pregnancy + diabetes: treatment

Answer 17

First line: NPH, continue LA analogues (glargine, determir)

SC infusion: multiple injections AND don’t achieve blood glucose control without causing significant disabling hypo

Question 18

What is the treatment for gestational diabetes?

Answer 18

stop after birth

<7mmol/L
- First line: diet + exercise
- Metformin
- Alt: insulin (AND metformin if not effective alone)

> 7mmol/L (6-6.9 w hydamnios, macrosomia)
- First line: insulin +/- metformin

Question 19

What medication is given when breastfeeding?

Answer 19

• Insulin
• Metformin

Question 20

What are the signs and symptoms of hypoglycaemia?

Answer 20

• Slurred speech
• Blood glucose <4mmol/L
• Sweat + chills
• Blurred vision
• Tingling lips
• Palpitations
• Pale, clammy skin
• Drowsy + confused

Question 21

Which medication masks symptoms of hypoglycaemia?

Answer 21

Beta blockers

Question 22

What is the treatment for hypoglycemia?

Answer 22

> 4mmol/L small carbohydrate snack or next meal

<4mmol/L
15-20g fast acting sugar
- Repeat after 15min, max 3 times
- 150-200ml pure fruit juice (avoid orange juice in low potassium diet in CKD)

Long acting carb
- Two biscuits, one sliced bread

Do not omit insulin if due

Question 23

How is diabetes diagnosed?

Answer 23

HBA1c blood test - Glycaemic control in last 2-3M
- Diabetes: >6.4% (48mmol/mol)
- Prediabetes: 5.7-6.4%
- Normal: <5.7%

For: type 2 diabetes

Question 24

When would you not use HBA1c for a diagnostic tool?

Answer 24

• Type 1 diabetes
• Pregnancy, <2M postpartum
• Diabetes symptoms <2M
• Acutely ill
• Medication causes hyperglycaemia
• HIV infection, end stage CKD
• Acute pancreatitis damage

Question 25

When would you use oral glucose tolerance test to diagnose diabetes?

Answer 25

- Pre-diabetes - Gestational diabetes - Not suitable if severe hyperglycaemia symptoms

Question 26

How often do you monitor blood glucose levels?

Answer 26

Type 1 diabetes: 4x day - Before meals + before bed Not routinely for type 2: - Insulin or oral hypoglycaemic - Intercurrent illness - Medication changes - Driving

Question 27

What are the correct levels when testing for blood glucose?

Answer 27

- Waking (fasting) – 5-7 - Pre-prandial – 4-7 - Post-prandial (90min) – 5-9 - Driving – at least 5

Question 28

What are the correct levels when monitoring HBA1c in diabetic patients?

Answer 28

Type 1 diabetes: 6.5% (48mmol/mol) Type 2 diabetes: - Diet controlled, monotherapy: 6.5% (48mmol/mol) - Hypoglycaemic monotherapy + combination therapy: 7.0% (53mmol/mol) - Intensify monotherapy if HbA1c: >7.5% (58mmol/mol)

Question 29

What are the targets in diabetic patients with hypertension?

Answer 29

- Type 1: 140/90 - Type 2 under 80: <140/90 - Type 2 over 80: <150/90

Question 30

What are the targets in diabetic patients with high cholesterol?

Answer 30

- Normal patients <5mmol/L - High risk patient <4mmol/L

Question 31

Diabetes + driving

Answer 31

Notify DVLA: - Insulin Hypoglycaemia - 2+ severe episodes <12M - Impaired awareness - Disabling hypo while driving Group 2 vehicle Diabetic complication – retinopathy

Question 32

How often do you monitor blood glucose levels when driving?

Answer 32

Monitor 2H before + every 2H for long journey: insulin + group 2 vehicle - <5mmol/L: eat carb snack - <4mmol/L: do not drive Hypoglycaemia: stop vehicle in safe place + switch engine off, treatment, wait 45 minutes