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EXAM Y4 > Diabetes > Flashcards

Diabetes Flashcards

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1
Q

Where is the absorption of insulin fastest when it is injected and what can also increase the rate of absorption?

A

Fastest at abdominal wall
Exercise and heat will increase rate

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1
Q

Name three short acting new human insulin analogues:

A

Insulin Aspart (NovoRapid)
Insulin Glulisine (Apidra)
Insulin Lispro (Humalog)

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2
Q

What is the onset of action, peak action and DoA time for Insulin Aspart?

A
  • Onset- 10-20mins
  • Peak action- 1-3 hours
  • DoA- 3-5 hours
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3
Q

What is the onset of action, peak action and DoA time for Insulin Glulisine?

A
  • Onset- 5-10mins
  • Peak action- 1 hour
  • DoA- 2-4 hours
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4
Q

What is the onset of action, peak action and DoA time for Insulin Lispro?

A
  • Onset- 10-20 mins
  • Peak action- 1-2 hours
  • DoA- 2-5 hours
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5
Q

Name three long acting new human insulin analogues:

A

Insulin Glargine (Lantus, Sanofi, Elililly)
Insulin Detemir (Levemir)
Insulin Degludec (Tresiba)

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6
Q

What is the onset of action, peak action and DoA time for Insulin Glargine?

A
  • Onset- 1 hour
  • Peak action- NO PEAK
  • DoA- 24 hours
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7
Q

What is the onset of action, peak action and DoA time for Insulin Determir?

A
  • Onset- 1 hour
  • Peak action- slight peak after 6 hours
  • DoA- 24 hours
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8
Q

What is the onset of action, peak action and DoA time for Insulin Degludec?

A
  • Onset- 30-90 mins
  • Peak action- NO PEAK
  • DoA- 24 hours
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9
Q

Name an intermediate acting insulin:

A

NPH insulin- Humulin N

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10
Q

What is the NICE guidance on insulin therapy for T1D?

A

1,2 or 3 injections per day, usually injections of short acting + intermediate acting (biphasic regimen)
No regiment suits all

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11
Q

What is the NICE guidance on insulin therapy for T2D?

A

NPH insulin, injected once or twice a day
NPH+ short acting insulin should be considered especially if pts HbA1c is 75mmol (9%) or more
Insulin detemir/glargine should be considered as an alternative to NPH

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12
Q

Describe rapid acting analogues of insulin:

A

Novorapid, Humalog
Injected 5-15 mins before eating or immediately after eating

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13
Q

Describe short acting insulin:

A

Actrapid, Humulin
Injected 15-30 mins before eating
Can act in the body for up to 8 hours

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14
Q

Describe medium acting insulin:

A

Insultard, Humulin I
Groups of insulin known as NPH
Injected usually at night and work up to 24 hours to keep blood glucose control between meals

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15
Q

Describe long acting insulin:

A

Levemir, Lantus
Injected usually at night and work up to 24 hours to keep blood glucose control between meals

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16
Q

Describe analogue mixture insulin:

A

Novomix 30
Injected 5-15 mins before eating or immediately after eating
They last 14-16 hours so usually injected 2x daily

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17
Q

Describe mixture insulin:

A

Humulin M3, Insuman Comb 15,25,50
Injected 20-30 mins before food
They last for 12 hours so injected 2x daily

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18
Q

Describe the vial and syringe for injecting insulin:

A

Syringes graduated in units
1ml=100units (for most)
Fixed needle, available in 1ml, 0.5ml and 0.3ml

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19
Q

When are insulin pumps prescribed on the NHS?

A

For uncontrolled hypos

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20
Q

Where would you administer insulin in the body and which is fastest?

A

Abdomen (fastest)
Thighs (slower)
Upper arms (medium fast)
Buttocks (slowest)

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21
Q

Why would you rotate the site of injection?

A

To avoid lipohypertrophy- where there is thickening/ hardening of the tissue so erratic insulin absorption

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22
Q

Describe how you would inject insulin:

A

Prime the insulin needle by pressing it facing up until a little insulin comes out, to remove air, using 2IU
Inject insulin into clean skin with clean hands, do not use alcohol wipes (more painful)
Inject into soft fat, not muscle, at a 90º angle
‘Pinch up’ if slim or injection site with little SC fat or use shorter needle
Push needle all the way in and leave for 5-10 seconds to avoid leakage

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23
Q

What is the multiple insulin regime?

A

First line, most common
Intermediate/ long acting basal once daily at night+ short acting at meal times
e.g Lantus + Novorapid

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24
What are the advantages and disadvantage of the multiple insulin regime?
+ Flexible if need to delay meal/ adjust for exercise, suitable for shift workers/busy jobs - More injections, at least 4
25
What is the twice daily insulin regime?
Short+ intermediate acting premixed (rarely sometimes separated) e.g Novomix 30, Humulin M3
26
What are the advantages and disadvantages of the twice daily insulin regime?
+ Simple, good control, fewer injections (good when admin is by other people) - inflexible, fixed time, timed and constant food intake and lifestyle
27
What is the once daily regime?
Not for T1D Intermediate/ long acting basal once daily at night, often used in combo with oral hypoglycaemics where max oral therapy doesnt give control e.g Lantus
28
What is the sliding scale regime?
In hospital, given by IV Used for medical emergencies or peri-operatively, during labour or unstable diabetes Given by continuous IV infusion (with IV fluids) and rate of infusion adjusted according to blood glucose levels
29
What are the guidelines for the dosing routine for starting insulin?
Start with very low doses and very slowly to prevent hypos Often 'honeymoon' period when some recovery of endogenous insulin production Twice daily: 6-10 units BD Multiple: Short 60% and long 40% (4 IU TDS and 8IU at night) Patients can be taught to adjust dose according to pre-prandial BG
30
What are the rules for storing insulin?
Long term storage in fridge (loss of 5-10% potency at room temp over 2-3 months) Current use keep out of fridge- cold temp takes longer to be absorbed and stings Max 1 month out of fridge Avoid freezing as decreases activity- keep insulin in salad draws in fridge to avoid this
31
What are the sick day rules for both T1 and T2 diabetics?
Don't stop taking insulin or tablets Test blood more often- x4 daily more Test for ketones Drink plenty of fluids Replace normal meals with carb containing drinks if necessary
32
Name 4 classes of drug that increases insulin production from pancreatic B cells:
Sulphonylureas - gliclazide Meglitinides - nateglinide GLP-1 agonists - exenatide DPP-4 inhibitor - alogliptin
33
Name two classes of drugs which affect energy metabolism of cells?
Meformin -biguanides (only one that used) PPARgamma agonists - pioglitazone
34
Why does metformin not cause hypoglycaemia?
It doesn't involve an increase in insulin
35
Name the two classes of drugs which affect the absorption and reabsorption of glucose:
Sodium Glucose Co-transporter 2 SGLT2 inhibitors- dapagliflozin Alpha- glucosidase inhibitors -acarbose
36
What are common side effects of SGLT2 inhibitors and why?
Urinary disorders like UTIs or thrush This is due to an increase in glucose (glycosuria >50g day) being excreted out in the urine so an increase in glucose for bacteria to thrive in Tiredness, dehydration, weight loss due to reduced glucose
37
What is the main side effect of a-glucosidase inhibitors and why?
Diarrhoea and flatulence due to buildup of oligosaccharides in the colon and their bacterial digestion
38
What would be the initial treatment for T2D?
Lifestyle: -diet, weight, physical activity
39
What is a glucose tolerance test?
Give pt a significant amount of glucose and see how long the in vivo clearance takes
40
What are the side effects of Metformin and what can be done to reduce this?
GI side effects- change to MR formulation Lactic acidosis (rare)
41
Name 4 sulfonylureas:
Tolbutamide - 1st gen Glibenclamide (long acting)- 2nd gen Gliclazide (short acting) -2nd gen Glimepiride (long acting) -3rd gen
42
Name 2 meglitinides:
Nateglinide Repaglinide
43
What are the major side effects of sulphonylureas and why?
Hypoglycaemia and weight gain Hypo as directly effecting insulin release
44
What are the side effects of PPARg agonists and why doesn't it cause hypos?
Weight gain/ fluid retention Doesn't cause hypos as effect is independent of insulin secretion
45
Name 3 SGLT2 inhibitors:
Canagliflozin Dapagliflozin Empagliflozin
46
Do SGLT2 inhibitors cause hypos?
No- effect is independent from insulin
47
Name 2 irreversible DPP4 inhibitors and how are they irreversible?
Vildagliptin- steric shielding of amine, attach bulky group to amine Saxagliptin- add bulky group next to amine on carbon Both given orally
48
Name 3 reversible DPP4 inhibitors:
Sitagliptin Linagliptin Alogliptin
49
Describe GLP1 agonists and DPP4 inhibitors together as drugs:
Dual effect of promoting insulin production in B cells and inhibiting glucagon production in alpha cells Small chance of hypo GLP1 injectable DPP4 orally Small bit statistically sig risk of pancreatitis and pancreatic cancer
50
What are the guidelines when starting a T1D on long acting insulin?
Start with determir BD Alternative insulin glargine OD Insulin Decludec OD
51
What is the normal BG levels?
3.5-5.8mmol/L
52
What is metabolic syndrome?
Combination of medical disorders when occurring together increases risk of CVD and T2D e.g Increase in BP, BG, cholesterol, central abdominal obesity: -men ≥102cm -women ≥88cm
53
What are symptoms of DKA?
Hyperventilation, N&V, dehydration, weakness, ketone breath, reduced consciousness, potentially fatal
54
What does HHS stand for?
Hyperglycaemic hyperosmolar non-ketotic state
55
What is HSS?
Medical emergency Similar to DKA but no significant ketosis and no acidosis due to endogenous insulin level being sufficient to inhibit hepatic ketogenesis, but hepatic glycogenolysis and gluconeogenesis still occur
56
What are the symptoms of HHS?
Same as DKA but no ketone breath or air hunger: N&V, dehydration, weakness, reduced consciousness (not always), potentially fatal
57
What is the value for the random venous plasma glucose that indicates diabetes with symptoms:
More than 11.1mmol/L
58
What is the value for the fasting venous plasma glucose that indicates diabetes with symptoms:
More than 7mmol/L
59
What is the glucose tolerance test and why is it used?
If greater than 11.1mmol/L after 75g of anhydrous glucose from an oral administration Only used for borderline cases and diagnosis of gestational diabetes
60
What should occur if the patient has no symptoms but has a high glucose value:
Two separate measurements of either random or fasting or two hours post GTT If fasting or random non diagnostic, the GTT value should be used
61
How can an official diagnosis be made for diabetes?
A venous blood sample in the lab
62
What is the HbA1c value for a diagnosis of T2D?
more than 48mmol/mol (6.5%)
63
What is the BG value which indicates hypoglycaemia?
Less than 4mmol/L
64
What is the treatment for mild hypoglycaemia?
15-20g of rapidly absorbed sugar e.g 2 teaspoons of sugar, Glucogel, 120ml lucozade If necessary repeat after 10-15 mins After snack or next meal of sustained carbs
65
What is the treatment for moderate hypoglycaemia?
1.5-2 tubes of GlucoGel (oral) or 1mg glucagon (IM)
66
What is the treatment for severe hypoglycaemia?
1mg Glucagon (IM) or 10-15 mins of 10% IV glucose (150ml)
67
Name and describe the two major categories of diabetic complications:
Microvascular: small BV damage -retinopathy (eyes) -nephropathy (kidneys) -neuropathy (nerves) Macrovascular: large BV damage -hypertension (BP) -hyperlipidaemia (blood lipids)
68
What is the most common macrovascular and microvascular complication in T2D?
Micro= retinopathy Macro=hypertension
69
What are some types of diabetic eye disease?
*retinopathy Blurred vision (diplopia = double vision) Cataracts at an earlier age than usual Glucoma (increase pressure of fluid inside eye) which is resistance treatment
70
How can you prevent diabetic retinopathy?
Good glycaemic control Effective management of hypertension Avoidance of smoking Regular screening (annually) Laser treatment to seal off the leaking blood vessels
71
Describe proteinuria in nephropathy:
Presence of protein (mainly albumin) in urine Common signs of renal disease Presents detected using urine dipsticks Repeated positive needs a 24 hour urine collection and quantify how much protein in it
72
Describe microalbuminuria in nephropathy:
Presence of small amount of albumin in urine Detected with specialist dipsticks Early indicator of diabetic nephropathy Check albumin:creatinine ratio (ACR) Need treatment to prevent progression, ACE inhibitor
73
What is the ACR value which indicates treatment is needed in nephropathy?
Men > 2.5mg/mmol Women > 3.5mg/mmol
74
What is the treatment for nephropathy in both types of diabetics?
Improve control of diabetes Aim for HbA1c of less than 7%, target 6% Aggressive control of BP T1D= less than 130/80 T2D= less than 140/90, 150/90 (if 80+) Also treat any other CV risk factors like smoking cessation
75
What is the treatment for hypertension in patients with diabetes?
Start with an ACE inhibitor regardless of age/ethnicity as renoprotective If target BP not achieved add other drugs If using CCB use amlodipine or felodipine as additional renoprotective action (additive effect with ACEi) Restrict dietary sodium intake to 100mmol per day
76
What are the symptoms of diabetic neuropathy?
Numbness occurs in both legs Pain may/may not be present Accompanied by unusual feelings without any obvious causes e.g tingling, itching Impaired sense of position leading to pt being unsteady on their feet
77
What are the symptoms in motor neuropathy?
Neuropathy in the autonomic nerves leads to: ED in men Low BP when pt is standing- orthostatic hypotenstion Delayed emptying of the stomach causing bloating, occasional N&V- gastroporesis Diabetic diarrhoea
78
What is the treatment in motor neuropathy?
Optimise control of BG- possible worsening of symptoms initially but then improvement Pain modifying agents: -simple analgesics like paracetamol -analgesics for nerve pain e.g amitriptyline, gabapentin
79
Describe the management of diabetic foot:
Wound management, cleaning/dressings Reduce the risk of recurrence: -check foot wear -no products containing acids E.g. salicylic acid, don't use OTC foot treatment -no abrasive products designed to remove hard skin
80
What should be given to diabetic patients to reduce CV risk? (over 40)
All patients aged over 40 with diabetes are considered at high CV risk and receive a statin Atorvastatin 20mg
81
What should be given to a patient with diabetes to reduce CV? (under 40)
If they have one of the following risk factors then they should have atorvastatin 20mg: -retinopathy -nephropathy -Persistent poor glycemic control (HbA1c >9%) -Elevated BP needing antihypertensives -Total serum cholesterol <6mmol/L -Premature CVD in first degree relative -Features of metabolic syndrome
82
What should be the aim for HbA1c value for type 1 and how often should it be measured?
48mmol (6.5%) or lower Every 3-6 months
83
What BG level should T1D achieve when waking?
5-7mmol/L
84
What BG level should T1D achieve at other times?
4-7mmol/L

EXAM Y4 (19 decks)

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