Diabetes

Question 1

T1DM

Answer 1

Little to no secretion of insulin
Genetic disorder

Question 2

T1DM: Clinical Features

Answer 2

Polyurea - risk of UTI due to sugar excretion
Thirst
Weight loss
Hyperglycaemia
Diabetic Ketoacidosis - generation of fats leading to more keto bodies, ketones in urine due to increase burning of fats

Question 3

T1DM: Glucose monitoring

Ranges

Answer 3

Fasting - 5-7mmol/mol
Before meals - 4-7mmol/mol
After meals - 5-9mmol/mol
Driving - at least 5mmol/mol
HbA1C - 48mmol/mol or lower, every 3 months

Question 4

T1DM: Other monitoring

Answer 4

Urine testing
Urine ketones
Microalbuminurea - albumin creatinine ratio (ACR), diabetic nephropathy marker

Question 5

T1DM: Glucose Tolerance Test

What is it used for

Answer 5

Use for borderline cases
Diagnosis for gestational diabetes

Question 6

T1DM: Insulin Types

Answer 6

Short acting - soluble (used for emergencies e.g. ketoacidosis), rapid acting (human insulin analogues e.g. lispro, aspart)
Intermediate - works for people with regular lifestyle
Long-acting - offers basal insulin e.g. glargine, detemir, degludec

Question 7

T1DM: Basal-bolus regimen

Answer 7

Multiple injection of intermediate or long acting insulin + multiple injection of short acting insulin before meals

Question 8

T1DM: Biphasic

Answer 8

Multiple injection of short acting with intermediate acting - mixed together
Meals must match the injecting to avoid hypoglycaemia

Question 9

T2DM

Answer 9

Insulin resistance
Insuficient insulin production

Question 10

T2DM: Monitoring

Ranges

Answer 10

When managed by lifestyle alone or with 1 antidiabetic drug not associated with hypoglycaemia - 48mmol/mol
When managed by 1 antidiabetic drug associated with hypoglycaemia or prescribed with two or more antidiabetic drugs - 53mmol/mol
Drug treatment intensified + diet and lifestyle - 58mmol/mol and higher

Question 11

T2DM: Management

Answer 11

Lifestyle and diet - 1st line
Offer antidiabetic drugs if lifestyle and diet management failed after 3 months

Question 12

T2DM: Biguanides

Example, S/E, advantage, loading dose

Answer 12

Metformin
1st line
S/E - N+V, diarrhoea (give MR)
Advantage - weight loss
Loading dose - 500mg OD first week, 500mg BD second week, 500mg TDS third week

Question 13

T2DM: Sulphonylureas

Examples, S/E, where to avoid

Answer 13

Gliclazide, Glipzide, Glimepiride, Tolbutamide
S/E - hypoglycaemia, weight gain
Avoid in pregnancy, hepatic and renal impairment

Question 14

T2DM: Pioglitazone

S/E, increase risk in, contraindications

Answer 14

S/E - weight gain
Increase HF and bladder cancer risk
Contraindicated in hepatic impairment

Question 15

T2DM: DPP4 inhibitors

Examples, not associated with

Answer 15

Linagliptin, Sitagliptin, Vidagliptin
Not associated with weight gain
Less incidence of hypoglycaemia

Question 16

T2DM: SGLT2 inhibitors

Examples, associated with

Answer 16

Dapagliflozin, Empagliflozin
Canagliflozin - risk of amputation
Associated with - diabetic ketoacidosis, Fournier’s gangrene

Question 17

T2DM: GLP1 receptor agonists

Examples, associated with, preparation

Answer 17

Semaglutide, Dulaglutide, Liraglutide
Promotes weight loss and may improve cardiovascular outcomes (Liraglutide)
SC injection - once weekly
Semaglutide - oral
Associated with diabetic ketoacidosis

Question 18

T2DM: Step wise management 1st and 2nd line

Answer 18

Metformin - MR if GI disturbance
If contraindicated, consider - DPP4 inhibitor, Sulphonylurea, Pioglitazone
SGLT2 inhibitor - 2nd line

Question 19

T2DM: Step wise management dual therapy

Combinations

Answer 19

Metformin - add DPP4 inhibitor or Sulphonylureas or Pioglitazone
If Metformin is contraindicated - either DPP4 inhibitor + Sulphonylurea or DPP4 inhibitor + Pioglitazone or Sulphonylurea + Pioglitazone

Question 20

T2DM: Step wise management triple therapy

Combinations, other considerations

Answer 20

Metformin + DPP4 inhibitor + Sulphonylurea
Metformin + Sulphonylurea + Pioglitazone
Metformin + Sulphonylurea + SGLT2 inhibitor
Metformin + Pioglitazone + SGLT2 inhibitor (Empa or Cana)
Metformin + DPP4 inhibitor + SGLT2 inhibitor (Ertu)
Consider insulin treatment - just insulin or with oral antidiabetic

Question 21

T2DM: Insulin

Answer 21

Intermediate
Intermediate + Short acting
Long acting

Question 22

T2DM: Long acting insulin considerations

Answer 22

Glargine or Detemir
Requires assistance injecting
Lifestyle is significanty restricted due to hypoglycaemia
Needs BD basal insulin injections + oral antidiabetic

Question 23

T2DM: Monitoring

Answer 23

HbA1c - every 3-6 months, once stable every 6 months

Question 24

Management of CVD risks

Answer 24

Addition of ACE / ARB and statins or other lipid regulating drugs

Question 25

Diabetes and HTN

Answer 25

Consider ACR - especially in T1DM Thiazides - risk of hyperglycaemia B-blockers - masks the symptoms of hypoglycaemia

Question 26

Hypoglycaemia

Answer 26

Main complication with insulin and sulphonylureas

Question 27

Hypoglycaemia Management: greater than 4mmol/mol but with symptoms

Answer 27

Small carb snack - bread Normal meal if due

Question 28

Hypoglycaemia Management: less than 4mmol/mol but conscious and can swallow

Answer 28

10-20g liquid or sugar lumps / granulated sugar Glucose tabs, gels, liquids, pure fruit juice Avoid orange juice in low potassium diet due to CKD Avoid chocolates and biscuits Repeat after 15 mins up to 3 times Once stable - long acting carb snack given e.g. sandwich, fruit, biscuits etc or normal meal if due

Question 29

Hypoglycaemia Management: not responding to 3 repeats

Answer 29

IM Glucagon or IV Glucose Alcoholic patients - give with Thiamine supplements to minimise risk of Wernicke's encephalopathy

Question 30

Hypoglycaemia Management: unconscious

Answer 30

IM Glucagon - initial Glucose - if Glucagon not suitable or unresponsive to Glucagon

Question 31

Diabetic Ketoacidosis: Clinical Features

Answer 31

Similar to hypoglycaemia Dehydration Hypotension Breath smell of ketones - specific marker Disturbances in consciousness Abdominal pain

Question 32

Diabetic Ketoacidosis: Investigations

Answer 32

Blood Glucose >20mmol/L Plasma ketones Urine stix testing - glycosuria and ketonuria Arterial blood gas Increase urea and creatinine Low serum bicarbonate

Question 33

Diabetic Ketoacidosis: Management

Answer 33

Insulin - IV infusion of soluble insulin Fluids Potassium

Question 34

Hyperosmolar Hyperglycaemic State (HHS)

Answer 34

Complication of T2DM Symptoms - dehydration, polyuria, weakness, weight loss, tachycardia, shock, dry mucus membrane, hypotension Characterised by - hyperglycaemia, hyperosmolality and volume depletion with not ketoacidosis Treatment - fluid and electrolytes correction and IV insulin

Question 35

Diabetic Nephropathy | What to give

Answer 35

Give ACE / ARB Nephropathy causing proteinuria or with microalbuminaemia

Question 36

Diabetic Neuropathy

Answer 36

Give pain management Paracetamol, NSAIDs, TCA, Pregabalin, Duloxetine, Carbamazepine, Gabapentin

Question 37

Diabetic Foot

Answer 37

Cellulitis - Fluclox (1st line), Clarithro or Erythro or Doxy (penicillin allergy) Cellulitis associated with an ulcer - Co amoxiclav (1st line), Doxy + Co-amox or Vanco + Co-amox (MRSA),