Diabetes

Question 1

Diabetes diagnosis

Answer 1

if no symptoms, 2 screening tests (A1c, FBG, random glucose)

If symptoms, 1 screening test

A1c > 6.5% (6-6.4% - pre-DM)
FBG > 7.0 mmol/L (5.6-6.9 pre-DM)
Random glucose > 11.1 mmol/L

Question 2

Pre-diabetes diagnostic values

Answer 2

A1c 6.0-6.4%
FBG 5.6 - 6.9 mmol/L

Question 3

Normal fasting glucose and A1c

Answer 3

fasting glucose - <5.6

A1c - <6%

Question 4

Sick day rules

Answer 4

• If not eating well or hydrating, hold metformin (lactic acidosis) and sulfonylureas (hypos), SGLTS (DKA euglycemic)
• monitor BG q4hours
• eat 50g carbs every 3-4 hours
• encourage electrolyte fluid intake (1 cup fluid/hour)

for insulin, never stop taking insulin, continue basal dosing
- if BG > 14, check for urine or serum ketones (risk of DKA)

Question 5

Metformin pros cons

Answer 5

Biguanide, increases insulin sensitivity and reduces glucose liver production

pros: weight neutral, low risk of hypos

cons: GI upset, lactic acidosis in renal failure & dehydration (hold when sick)

Question 6

Sulfonylurea

Answer 6

Stimulates insulin release from pancreas

Glyburide, glicizide, glimepiride

pro: very effective
cons: weight gain, hypos (hold when sick)

Question 7

SGLT-inhibitors pros cons

Answer 7

Increases urinary glucose excretion

Empagliflozin

pro: cardiorenal protective (HF & CKD), weight loss
con: genital infections, euglycemic DKA, dehydration

Question 8

GLP-1 receptor agonists pros cons

Answer 8

Reduces appetite, slows gastric emptying, increases insulin

Ozempic (semiglutide), liraglutide

pros: weight loss, cardiovascular protection
cons: major GI side effects, injectable

Question 9

DPP-4 inhibitors

Answer 9

Increases endogenous GLP-1 levels

Sitagliptin, linagliptin

pros: weight neutral & low hypo risk
cons: not as potent

Question 10

Thiazolidinediones

Answer 10

Pioglitazone

Cons: weight gain, edema, risk of heart failure, bladder cancer concern?

Question 11

When to consider insulin?

Answer 11

A1c > 10%
significant hyperglycaemia
catabolic effects - weight loss, ketones
oral agents insufficient

Question 12

Oral vs. injectable diabetes medications

Answer 12

Oral:
- metformin
- SGLT-2 inhibitors
- DPP4-inhibitors
- semaglutide comes in an oral form (rebelsys)
- sulfonylureas

Injectibles:
- GLP-1 receptor agonists
- insulin

Question 13

rapid acting insulin

Answer 13

lispro (Humalog)
aspart (Novolog)
gluglisine (apidra)

onset 10-30mins, lasts 3-5 hours

use for correction doses and bolus insulin

Question 14

short acting insulin

Answer 14

regular insulin (humulin R, novolin R)

onset 30-60mins

can be used for meal coverage and corrections but used less often than rapid acting b/c longer onset

Question 15

intermediate acting insulin

Answer 15

NPH insulin (Humulin N, Novolin N)

onset 1-2 hours
duration 12-18 hours

typically used as basal plus rapid or short acting insulin
typically taken 2x a day

Question 16

long acting insulin

Answer 16

glargine (Lantus)
detemir (levemir)
degludec (tresiba)

onset 1-2 hours
no peak
duration 20-24 hours

Question 17

ultra long acting insulin

Answer 17

insulin degludec (Tresiba)
30-90 min onset
lasts up to 42 hours

Question 18

insulin dosing for T1DM

Answer 18

Basal plus rapid acting bolus before meals

Initial dosing:
- total daily dose (TDD) is 0.5-1units/kg/day
- 50% is given as basal, 50% given as bolus divided between meals

Question 19

insulin dosing for T2DM

Answer 19

if oral meds fail, will add on basal insulin at 10 units daily at bedtime or 0.1-0.2 units/kg/day –> adjust based on fasting glucose (every 1-3 days, add 1-2 units until in 4-7 fasting glucose range)

bolus insulin
- rapid acting for meal coverage if glucose spikes a lot after meals
- sliding scale used in hospital settings

Question 20

insulin admin

Answer 20

subcutaneous injection (injectable or insulin pen) in belly, arms, thighs (rotate sites)
- inject at 45-90 degree angle and hold for 10 seconds

Question 21

rule of 15 in hypoglycaemia

Answer 21

if blood sugar < 4 and having symptoms, give 15g of fast acting carbs and recheck BG in 15 minutes (if still low, treat again)

Question 22

symptoms of hypoglycemia

Answer 22

shaking, dizzy, sweating, confused, irritable, fatigue, LOC

Question 23

indications to start insulin right away

Answer 23

hyperglycaemic symptoms & A1c > 10%

Question 24

what else do you start with insulin right away?

Answer 24

metformin - works synergistically with insulin

Question 25

How should patients titrate their insulin based on fasting glucose?

Answer 25

Every 3 days, add 1-2 units until in 4-7 fasting glucose range

Question 26

When do you add a statin?

Answer 26

If LDL > 2.0 and age >40

Question 27

When do you add an ace-inhibitor?

Answer 27

If hypertensive or ACR > 3 (microalbuminuria)

Question 28

what dosing to add in bolus insulin?

Answer 28

either 4 units before the biggest meal of the day or 0.1units/kg or 10% of daily dose titrate by 1 unit every 3 days until 2hr postprandial is in target (<10)

Question 29

what is 2-hour postprandial BG target?

Answer 29

< 10 mmol/L

Question 30

what is insulin titration regimen for basal insulin

Answer 30

start at 10 units at bedtime, increase by 1 unit every 1-3 days until fasting glucose in target (4-7)

Question 31

what is insulin titration regimen for bolus insulin

Answer 31

start 4 units before biggest meal, increase by 1 unit every 1-3 days until 2-hour post prandial is in target (<10)

Question 32

What are the microvascular complications of DM?

Answer 32

Retinopathy Nephropathy Neuropathy

Question 33

What are the macrovascular complications?

Answer 33

Stroke/TIA CVD PAD

Question 34

How often are you going to check A1c and BP in DM patient?

Answer 34

Q3-6 months

Question 35

What are you going to check yearly?

Answer 35

Fasting lipids After 5 years of diagnosis for T1 or right away for T2: - retinopathy - ACR and Cr - monofilament and foot exam for peripheral neuropathy - Screen for depression, eating disorders, ED, NAFLD EKG every 3-5 years

Question 36

What is fasting and postprandial target for frail and dementia?

Answer 36

fasting - 6-9 post-prandial <14

Question 37

Type 1 DM self monitoring

Answer 37

- checking BG 3+ times a day - can try CGM - ketones if BG > 14 or sx of DKA

Question 38

Driving instructions for T1DM

Answer 38

check sugars before driving and every 2-4 hours while driving, keep quick acting sugars on you and do not drive if BG < 4

Question 39

Treatments for DM complications

Answer 39

Retinopathy - laser & vitrectomy, can give fenofibrate to slow down progression Nephropathy - statin, ezetimibe, consider ACE/ARB Neuropathy - pregabalin, gabapentin, amitryptiline, duloxetine, topical nitrate spray Diabetic foot infection ED - PDE5 inhibitor

Question 40

Alcohol guidance for diabetes

Answer 40

limit to 2 or less drinks because it can drop your glucose overnight

Question 41

total daily dose of insulin calculation

Answer 41

0.3-0.5units/kg/day divide 40% basal, 60% bolus divided TID

Question 42

basal insulin dosing

Answer 42

start 10 units per day and then increase 1 unit every 2-3 days until target is hit, monitor fasting glucose

Question 43

bolus insulin dosing

Answer 43

2-4 units or 10% of basal insulin dose add 1 unit every 3-4 days until 2hr pp is <8 (FM Notes Guidelines) or pre prandial is 4-7

Question 44

what meds should be considered in diabetics for vascular protection?

Answer 44

statin plus ezetimibe ACE/ARB Aspirin if secondary prevention

Question 45

levels of hypoglycaemia

Answer 45

level 1 - 3.0 - 3.9 with autonomic sx level 2 - <3 with neuroglycopenic sx level 3 - AMS level 1 & 2 - 15g carbs recheck 15 mins level 3 - 1mg glucagon subcutaneous

Question 46

symptoms of hyperglycaemia

Answer 46

polyuria polydipsia polyphagia weight loss fatigue blurred vision dry mouth paraesthesia arrhythmia coma *like an electrolyte disturbance

Question 47

when do you screen for diabetes

Answer 47

if over 40yo, every 3 years

Question 48

what percentage of pre diabetes will become diabetic in 5 years

Answer 48

100%

Question 49

remission of T2DM criteria

Answer 49

<6% or <6.4% (pre diabetes) without meds x 3 months

Question 50

prevention of pre diabetes into DM

Answer 50

lifestyle mods: - weigh loss >5% - exercise 150min/week - mediterranean or DASH diet consider metformin

Question 51

DM patient is <1.5% above A1c target. What do you do?

Answer 51

Initiate lifestyle mods and consider metformin. If not in target in 3 months, either start or increase metformin

Question 52

DM patient is >1.5% above target. Now what?

Answer 52

Start metformin and a second agent - consider SGLT2i and GLP1RA as they are cardio-renal protective

Question 53

Which DM drugs are weight NEUTRAL vs. weight gain vs. weight loss

Answer 53

metformin DPP4i loss: SGLT2 & GLP1RA gain: sulfonylurea and TZDs & insulin

Question 54

what do you need to supplement with when on metformin?

Answer 54

B12

Question 55

in acute illness, which diabetic meds to hold?

Answer 55

metformin, sulfonylureas and SGLT2is