Diabetes

Question 1

What are the hormones secreted by the endocrine pancreas?

Answer 1

• b-cells produce and release insulin
o Stimulates glucose utilization and uptake

• a-cells produce and release glucagon
o Increases breakdown of glycogen and glucose release

Question 2

What is the role of insulin?

Answer 2

Decreases the plasma
o Glucose
o Amino Acids
o FFAs

Anabolic (glucose to glycogen)

Question 3

What is the role of glucagon?

Answer 3

Increases the plasma
o Glucose
o Ketones

Catabolic (glycogen to glucose)

Question 4

What fasting (8h) blood glucose characterises hyperglycaemia/diabetes?

Answer 4

Fasting (8h) blood glucose test - >7 mmol/L= diabetes

Oral glucose tolerance test

Glycosylated haemoglobin (HbA1c)

HbA1c
6.5% (48mmol/mol) < = T2DM
6-6.4% (42-47 mmol/mol) = high risk of developing diabetes

Urine analysis
Dipstick test

Question 5

Symptoms of type 1 diabetes?

Answer 5

Increased thirst
Increased urination
Weight loss (in spite of increased appetite)
Fatigue
Nausea, vomiting
Coma

Question 6

Symptoms of type 2 diabetes

Answer 6

Increased thirst
Increased urination
Increased appetite
Fatigue
Blurred vision
Slow-healing infections
Impotence in men

Question 7

What are the consequence insulin resistance?

Answer 7

Associated with POS
Inflammation of the liver

CVD RISK:
Hypertension (decreased eNOS signalling)
Atherosclerosis
Low HDL “good” cholesterol
Increase in fat stores (abdominal)
Elevated triglycerides

Fatigue & Changes in appetite

Hyperglycaemia

Question 8

What is the Basal Bolus injection regime?

Answer 8

Involves taking basal insulin for fasting period and separate injection of bolus insulin for each meal

Question 9

What is Basal injection?

Answer 9

For keeping blood glucose level at consistent levels during periods of fasting

Acts over a long period of time
Long acting or intermediate insulin

Question 10

How is blood sugar controlled?

Answer 10

Insulin is not secretes, blood sugar is not monitored
Injects synthesised insulin
Mimics the body to release insulin

Question 11

What is Bolus insulin?

Answer 11

Keeps blood glucose level under control 30 min before a meal

Acts quickly and over a short period of time

Question 12

Insulin need differs according to?

Answer 12

Amount of carbohydrates

Question 13

What monitoring is required during a Basal Bolus Regimen?

Answer 13

CV Risk inc. BP
HbA1c
eGFR
Optometry

Question 14

Example of Basal insulin?

Answer 14

Glargine (Lantus)
Detemir (Levemir)

Question 15

Example of Bolus insulin?

Answer 15

Novorapid,
Humalog,
Apidra

Question 16

Reasons for low blood glucose levels include:

Answer 16

missed or delayed meals
v not enough or no carbohydrate
(for example bread, pasta, rice, potato, cereal type foodstuffs) in meals
v too much insulin
v increased exercise, unexpected exercise
v alcohol
v problem with injection technique or sites for example lipodystrophy
(lumpy areas under injection sites)

Question 17

Example of biphasic insulin

Answer 17

Novomix (insulin aspart)
Humalog (insulin lispro)

Question 18

Example of long acting insulin?

Answer 18

Tresiba (Insulin degludec)
Levemir (detemir)
Lantus / Toujeo (glargine)

Question 19

Example of rapid acting and short acting

Answer 19

NovoRapid (aspart)
Apidra

Question 20

A middle-aged patient with type 2 diabetes mellitus comes for review. He also has chronic heart failure secondary to dilated cardiomyopathy (NYHA class II). His diabetes is currently diet-controlled but his HbA1c has risen to 64 mmol/mol (8.0%). Which one of the following medications is contraindicated?

• Metformin
• Pioglitazone
• Glipizide
• Exenatide
• Acarbose

Answer 20

The following medications may exacerbate heart failure:

Thiazolidinediones

• pioglitazone is contraindicated as it causes fluid retention

Verapamil

• negative inotropic effect

NSAIDs/glucocorticoids

• should be used with caution as they cause fluid retention
• low-dose aspirin is an exception - many patients will have coexistent cardiovascular disease and the benefits of taking aspirin easily outweigh the risks

class I antiarrhythmics

• flecainide (negative inotropic and proarrhythmic effect)

Question 21

A 30-year-old woman with type 1 diabetes mellitus is reviewed in clinic. She is currently using a ‘basal-bolus’ insulin regime consisting of three injections of a rapid-acting insulin analogue accompanied by intermediate-acting insulin once a day.

Select the two most appropriate investigations to assess how well controlled her diabetes is.

• A.HbA1c
• B.Fasting glucose
• C.Review her home blood glucose readings
• D.Random glucose
• E.Oral glucose tolerance test

Answer 21

Correct answer: A C

Glycosylated haemoglobin (HbA1c) is the most widely used measure of long-term glycaemic control in diabetes mellitus. HbA1c is generally thought to reflect the blood glucose over the previous ‘2-3 months’ although there is some evidence it is weighed more strongly to glucose levels of the past 2-4 weeks.

The home readings are also important as they not only reflect general control but may give a pointer to how the individual doses should be changed, for example if post-prandial sugars were high.

A random glucose simply gives a one-off reading of little significance. Patients on insulin should not be asked to fast!

The oral glucose tolerance test is used to diagnose diabetes, not monitor it.

Question 22

A 75-year-old man is admitted to the acute medical unit with an infective exacerbation of chronic obstructive pulmonary disease (COPD) which has failed to improve despite a course of amoxicillin and prednisolone.

Regular medications

• Aspirin 75mg od
• Simvastatin 40mg on
• Amlodipine 10mg od
• Metformin 500mg bd

His other past medical history of note includes type 2 diabetes mellitus and hypertension. His random blood glucose on admission is 12.3mmol/l. A HbA1c is requested:

• IFCC-HbA1c (mmol/mol)45
• HbA1c6.3%

What is the most appropriate course of action?

• Make no changes to diabetes medictions
• Increase metformin to 500mg tds
• Increase metformin to 1g bd
• Add glipizide 2.5mg od
• Reduce metformin to 500mg od

Answer 22

Make no changes to diabetes medictions

This HbA1c actually reflects good glycaemic control. Changes to diabetes medications should be based on the HbA1c which reflect average glucose levels over the past 2-3 months rather than one-off readings. In this particular scenario it is likely that the recent course of steroids has temporarily worsened glycaemic control.

Question 23

A 60-year-old man who has type 1 diabetes mellitus complains of reduced hypoglycaemic awareness. This has been a problem since he was discharged from hospital a few weeks ago. During his admission a number of new medications were started. Which one of the following is most likely to be responsible?

• Clopidogrel
• Bendroflumethiazide
• Atenolol
• Simvastatin
• Isosorbide mononitrate

Answer 23

Atenolol

Insulin therapy: side-effects

Hypoglycaemia

• patients should be taught the signs of hypoglycaemia: sweating, anxiety, blurred vision, confusion, aggression
• conscious patients should take 10-20g of a short-acting carbohydrate (e.g. a glass of Lucozade or non-diet drink, three or more glucose tablets, glucose gel)
• every person treated with insulin should have a glucagon kit for emergencies where the patient is not able to orally ingest a short-acting carbohydrate
• patients who have frequent hypoglycaemic episodes may develop reduced awareness. If this develops then allowing glycaemic control to slip for a period of time may restore their awareness
• beta-blockers reduce hypoglycaemic awareness

Lipodystrophy

• typically presents as atrophy/lumps of subcutaneous fat
• can be prevented by rotating the injection site
• may cause erractic insulin absorption

Question 24

A 20-year-old woman who has type 1 diabetes mellitus is found collapsed in the corridor. A nurse is already with her and has done a finger-prick glucose which is 1.8 mmol/l. On assessment you find that she is not responsive to voice, pulse 84/min. The nurse has already placed the patient in the recovery position. What is the most appropriate next step in management?

• Smear quick-acting carbohydrate gel on the gums
• Give rectal dextrose
• Give intramuscular protamine sulphate
• Give intramuscular glucagon
• Give intramuscular dextrose

Answer 24

Give intramuscular glucagon

It is potentially dangerous to place anything inside the mouth of an unconscious patient as they may not be protecting their airway properly.

Protamine sulphate is used in heparin overdose.

Question 25

A 78-year-old nursing home resident is admitted to the acute medical unit after being found collapsed in his room. A carer from the nursing home is present and reports that he has had regular ‘hypos’ recently. On admission he was drowsy and the blood glucose was 1.8 mmol/l. Following intravenous dextrose the patient’s condition significantly improved.

His medication on admission is as follows:

• Metformin 1g bd
• Gliclazide 160mg od
• Pioglitazone 45mg od
• Aspirin 75mg od
• Simvastatin 40mg on

What is the most appropriate action whilst awaiting review by the diabetes team?

• Stop metformin
• Stop pioglitazone
• Stop gliclazide
• Make no changes to the medication
• Stop all oral antidiabetic medications

Answer 25

Neither metformin nor pioglitazone cause hypoglycaemia. The gliclazide dose is therefore responsible and should be stopped whilst awaiting diabetes review.

Question 26

You are writing up the discharge medication for a 19-year-old man with type 1 diabetes mellitus who was admitted with appendicitis. He is now back on his regular insulin regime. This is a ‘basal-bolus’ regime with rapid-acting insulin before meals and a once daily long-acting insulin at night. Which one of the following types of insulin may be used to provide the rapid-acting bolus before meals?

• Insulin lispro
• Insulin determir
• Insulin glargine
• Protamine zinc insulin
• Isophane insulin

Answer 26

Insulin lispro

Question 27

During a consultant ward round one of your patients was started on gliclazide. He is a 66-year-old man who is recovering from an infective exacerbation of COPD. During the admission he was found to have very poor control of his type 2 diabetes mellitus. He currently takes metformin 1g bd for diabetes.

Select the two most important pieces of information to discuss with the patient regarding the new treatment:

• A.The patient should stop their existing metformin treatment
• B.Gliclazide should be taken three times a day before meals
• C.Gliclazide may cause blood sugars to fall too low
• D.Kidney and liver function tests are required every six months to check for side-effects
• E.Gliclazide often causes patients to gain weight

Question 28

During a consultant ward round one of your patients was started on gliclazide. He is a 66-year-old man who is recovering from an infective exacerbation of COPD. During the admission he was found to have very poor control of his type 2 diabetes mellitus. He currently takes metformin 1g bd for diabetes.

Select the two most important pieces of information to discuss with the patient regarding the new treatment:

• A.The patient should stop their existing metformin treatment
• B.Gliclazide should be taken three times a day before meals
• C.Gliclazide may cause blood sugars to fall too low
• D.Kidney and liver function tests are required every six months to check for side-effects
• E.Gliclazide often causes patients to gain weight

Answer 28

Correct answer: C E

Sulfonylureas are commonly used second-line to metformin in type 2 diabetes mellitus. They are used in addition to metformin and hence there is no need to stop his current treatment. At standard (and starting) doses gliclazide is taken once a day.

Hypoglycaemia is by far the most important side-effect that patients should be made aware of. This is particular relevant if the patient drives or operates machinery.

No specific monitoring is required for patients taking sulfonylureas.

Question 29

A 56-year-old man presents to his GP for a diabetes review. He has a history of type 2 diabetes and is currently being treated with one diabetes drug (500mg metformin BD). He is tolerating this well with no side effects.

His recent retinopathy screening is normal. You take blood to check his HbA1c.

What should this man’s target HbA1c be?

• 42 mmol/mol
• 42-47 mmol/mol
• 48 mmol/mol
• 53 mmol/mol
• 58 mmol/mol

Answer 29

The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol

NICE guidelines suggest a standard target of 48mmol/mol for patients managed by lifestyle and/or a single antidiabetic drug.

The target may change to 53 mmol/mol if the patient is started on a second agent, or if they are receiving a medication that carries the risk of hypoglycaemia (e.g. sulphonylurea).

Remember that there is a difference between target HbA1c and the HbA1c threshold for changing medications.

Question 30

You are working in general practice reviewing a 54-year-old male who has come for a ‘check-up.’ He advises you that he feels perfectly well and is not suffering from any symptoms but would just like to be reviewed. During the consultation the patient mentions that he has a strong family history of type 2 diabetes mellitus and you advise him that, due to his large body habitus (his latest body mass index is recorded as 39 kg/m²), he is at further risk of developing the disease. He agrees to a check of his HbA1c levels to investigate his blood glucose control. This subsequently comes back as 54 mmol/mol.

What is required to diagnose type 2 diabetes in this patient?

• No further test required
• A further abnormal HbA1c
• A fasting glucose sample of below 5 mmol/litre
• A random glucose sample of less than 11 mmol/litre
• A random glucose sample between 7 mmol/litre and 11 mmol/litre

Answer 30

A further abnormal HbA1c.

Asymptomatic patients with an abnormal HbA1c or fasting glucose must be confirmed with a second abnormal reading before a diagnosis of type 2 diabetes is confirmed

This patient has presented to the GP with no symptoms of diabetes. NICE states that ‘in an asymptomatic person, the diagnosis of diabetes should never be based on a single abnormal HbA1c or fasting plasma glucose level; at least one additional abnormal HbA1c or plasma glucose level is essential. If the second test results are normal, it is prudent to arrange regular review of the person.’

As a result of the above NICE guidance, type 2 diabetes cannot be diagnosed in this patient with a single abnormal HbA1c. Therefore option 1 of no further testing can be ruled out.

A fasting sample of greater than 7 mmol/l would be indicative of type 2 diabetes so option 3 can be ruled out.

Random glucose levels of greater than 11mmol/l in patients that are symptomatic are indicative of type 2 diabetes mellitus and therefore both options 4 and 5 can be ruled out.

Question 31

A 30 year old type 2 diabetic presents to the diabetics clinic advising that she wishes to become pregnant. The patient normally has good glycaemic control and is currently being treated with metformin and gliclazide. What advice should you give her about potential changes to her medication during pregnancy?

• Patient may continue on metformin but gliclazide must be stopped
• Patient can continue on both medications
• Patient may continue on gliclazide but metformin must be stopped
• Both drugs must be stopped and the patient must be switched to insulin
• Both drugs must be stopped and the patient must be switched to liraglutide

Answer 31

The correct answer is that the patient may be continued on metformin but that the gliclazide must be stopped. In the management of type 2 diabetes in pregnancy ‘women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin’. While it is likely that the patient will be required to switch to insulin it is not an absolute requirement. Both gliclazide and liraglutide are contraindicated in pregnancy.

Source: BNF (https://www.evidence.nhs.uk/formulary/bnf/current/6-endocrine-system/61-drugs-used-in-diabetes/612-antidiabetic-drugs

Question 32

Theme: Side-effects of diabetes mellitus drugs

• A.Hypocalcaemia
• B.Diarrhoea
• C.Sinusitis
• D.Worsening of heart failure
• E.Headaches
• F.Hypoglycaemia

4. Metformin
5. Pioglitazone
6. Gliclazide

Answer 32

Diarrhoea

Worsening of heart failure

Hypoglycaemia

Overview of side effects:

Metformin:

• Gastrointestinal side-effects
• Lactic acidosis

Sulfonylureas

• Hypoglycaemic episodes
• Increased appetite and weight gain
• Syndrome of inappropriate ADH secretion
• Liver dysfunction (cholestatic)

Glitazones

• Weight gain
• Fluid retention
• Liver dysfunction
• Fractures

Gliptins

• Pancreatitis

Question 33

You are reviewing a 24-year-old man who has recently been diagnosed with type 1 diabetes mellitus. He has no comorbidities and works as an accountant. What HbA1c target should he aim for initially?

• 42 mmol/mol
• 45 mmol/mol
• 48 mmol/mol
• 50 mmol/mol
• 52 mmol/mol

Answer 33

In type 1 diabetics, a general HbA1c target of 48 mmol/mol (6.5%) should be used.

Overview:

HbA1c

• should be monitored every 3-6 months
• adults should have a target of HbA1c level of 48 mmol/mol (6.5%) or lower. NICE do however recommend taking into account factors such as the person’s daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia

Self-monitoring of blood glucose

• recommend testing at least 4 times a day, including before each meal and before bed.
• more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding

Blood glucose targets

• 5-7 mmol/l on waking and
• 4-7 mmol/l before meals at other times of the day

Type of insulin

• offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
• twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
• offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes

Metformin

• NICE recommend considering adding metformin if the BMI >= 25 kg/m²

Question 34

A 21-year-old female comes to see you to discuss her wish to begin driving. She suffers from type-1 diabetes and this is managed with insulin. She has a good underlying control of her diabetes and checks her blood sugars regularly. She last suffered from a hypoglycaemic episode 13 months ago. There are no underlying concerns about her vision. She wishes to learn to drive a car (group 1 vehicle) but is concerned that she will not be able to because of her condition.

Which of the following pieces of advice is correct?

• She may drive immediately. No need to inform the DVLA
• She should switch to tablets and can then drive. No need to inform the DVLA
• She may drive if she has adequate awareness of hypoglycaemia. No need to inform the DVLA
• She may drive if she has adequate awareness of hypoglycaemia. Must inform the DVLA
• She may not drive. Should not apply for a license

Answer 34

She may drive if she has adequate awareness of hypoglycaemia. Must inform the DVLA.

For group 1 vehicles, diabetic patients on insulin may drive if they have hypoglycaemic awareness

All patients with diabetes who are treated with insulin MUST inform the DVLA about their medical condition.

This patient has a well-controlled diabetes and there are no underlying concerns about her health. According to the DVLA she may drive if she has adequate awareness of hypoglycaemia.

She should NOT switch to tablets. This would be medically dangerous and would risk her having episodes of diabetic ketoacidosis. Although patients with well-controlled diabetes on tablets need not inform the DVLA this patient is on insulin and should stay on insulin.

OVERVIEW:

• Until recently people with diabetes who used insulin could not hold a HGV licence. The DVLA changed the rules in October 2011. The following standards need to be met (and also apply to patients using other hypoglycaemic inducing drugs such as sulfonylureas):
• there has not been any severe hypoglycaemic event in the previous 12 months
• the driver has full hypoglycaemic awareness
• the driver must show adequate control of the condition by regular blood glucose monitoring*, at least twice daily and at times relevant to driving
• the driver must demonstrate an understanding of the risks of hypoglycaemia
• here are no other debarring complications of diabetes
• From a practical point of view patients on insulin who want to apply for a Group 2 (HGV) licence need to complete a VDIAB1I form.
• Other specific points for group 1 drivers:
• if on insulin then patient can drive a car as long as they have hypoglycaemic awareness, not more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months and no relevant visual impairment. Drivers are normally contacted by DVLA
• if on tablets or exenatide no need to notify DVLA. If tablets may induce hypoglycaemia (e.g. sulfonylureas) then there must not have been more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months
• if diet controlled alone then no requirement to inform DVLA
• *to demonstrate adequate control, the Secretary of State’s Honorary Medical Advisory Panel on Diabetes Mellitus has recommended that applicants will need to have used blood glucose meters with a memory function to measure and record blood glucose levels for at least 3 months prior to submitting their application

Question 35

A 32-year-old woman comes to surgery for her blood results. She is 25 weeks pregnant and has had her glucose tolerance test.

The results are as follows:

• Fasting glucose7.1 mmol/L
• 2-hour glucose8.2 mmol/L

What would be the most appropriate next step?

• Dietary advice
• Gliclazide
• Insulin
• Metformin
• Repeat the test

Answer 35

Insulin

If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l immediate insulin (plus or minus metformin) should be started

This woman has gestational diabetes and should be started immediately on insulin (plus or minus metformin). Gestational diabetes is diagnosed with either a fasting plasma glucose level of > 5.6 mmol/L, or a 2-hour plasma glucose level of >/= 7.8 mmol/L. If at the time of diagnosis the fasting glucose is > or = 7 mmol/L, as in this case, then insulin should be started immediately.

Dietary advice is an important management step in any diagnosis of diabetes, but in this case the fasting glucose is greater than 7mmol/L and insulin needs to be started.

Gliclazide would not be the correct option. Sulfonylureas are avoided in pregnancy as there is a risk of neonatal hypoglycaemia.

Metformin may be started in gestational diabetes, but with a fasting glucose level >=7mmol/L insulin is the most appropriate next step. Insulin and metformin can be used together in the management of gestational diabetes.

The test results are conclusive for gestational diabetes as both the fasting glucose and the 2-hour glucose level are raised, there is no need to repeat the test.

Question 36

A 32-year-old Caucasian woman who is 25 weeks pregnant with her first child presents to antenatal clinic. She had been invited to attend screening for gestational diabetes on account of her booking BMI, which was 33kg/m². Prior to her pregnancy, she had been fit and well, and had no personal or family history of diabetes mellitus. She does not take any regular medications, and has no known allergies.

She undergoes an oral glucose tolerance test (OGTT), the results of which are as follows:

• Fasting glucose6.8mmol/L
• 2-hour glucose7.6mmol/L

An ultrasound scan does not show any fetal abnormalities or hydramnios. She is given advice about diet and exercise, and undergoes a repeat OGTT two weeks later, at which point she is started on metformin due to persistent impaired fasting glucose.

After taking metformin for two weeks, she undergoes another OGTT, with results shown below:

• Fasting glucose5.9mmol/L
• 2-hour glucose7.1mmol/L

Which of the following is the most appropriate next step in the management of her glycaemic control?

• No changes to current treatment
• Switch metformin to modified-release metformin
• Stop metformin, add insulin
• Add insulin
• Add a sulfonylurea

Answer 36

Add insulin

In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added

This patient fulfilled the criteria for a diagnosis of gestational diabetes on her original OGTT at 25 weeks, due to a fasting glucose > 5.6mmol/L. Her glycaemic control has been refractory to lifestyle modifications, and, most recently, the addition of metformin, as her fasting glucose has remained above 5.6mmol/L. At this stage, NICE advise that short-acting insulin should be added to her existing treatment.

Although the patient’s fasting glucose has improved slightly with the addition of metformin, her fasting glucose reading is still above the target range. As such, it would not be appropriate to continue with her current treatment, and risk the fetal and maternal complications of gestational diabetes.

Changing metformin to modified-release metformin can be helpful in patients who do not tolerate metformin due to side-effects such as gastrointestinal upset, but would not have a role in improving glycaemic control in this patient.

NICE advise that in the instance of persistent impaired glycaemic control, insulin should be added in conjunction with metformin, rather than substituted for it.

Sulfonylureas such as glibenclamide should only be offered for patients who cannot tolerate metformin, or as an adjunct for patients who decline insulin treatment, and would not be the most appropriate next drug for this patient.

Question 37

A 53-year-old man with a history of type 2 diabetes mellitus is reviewed in the diabetes clinic. Twelve months ago his HbA1c was 83 mmol/mol (9.7%) despite maximal oral hypoglycaemic therapy. Insulin was started and his most recent HbA1c is 66 mmol/mol (8.2%). He is considering applying for a HGV licence and asks for advice. What is the most appropriate advice?

• He cannot drive a heavy goods vehicle if he is taking insulin
• He may be able to apply for a HGV licence if he meets strict criteria relating to hypoglycaemia
• He should stop insulin and start meglitinide
• As under 55 years of age there is no requirement to inform the DVLA
• He needs to have been stable on insulin for at least 5 years before applying

Answer 37

He may be able to apply for a HGV licence if he meets strict criteria relating to hypoglycaemia.

Patients on insulin may now hold a HGV licence if they meet strict DVLA criteria

Question 38

You review a 67-year-old man with type 2 diabetes mellitus in the diabetes clinic. His blood pressure is currently 150/86 mmHg. His diabetes is well controlled and there is no evidence of end-organ damage. What should his target blood pressure be?

• < 140/80 mmHg
• < 125/75 mmHg
• < 140/85 mmHg
• < 130/80 mmHg
• < 140/90 mmHg

Answer 38

NICE recommend the following blood pressure target for type 2 diabetics: < 140/90 mmHg

Question 39

Bernard is a 62-year-old man who comes to see you with a 3 day history of sore throat, cough and muscle ache. He has a past medical history of type 2 diabetes and hypertension. He takes a twice daily insulin regimen.

After a full assessment, you explain to Bernard that he has likely got the flu and advise rest, regular paracetamol and plenty of fluids.

What is the most appropriate advice to give Bernard with regards to his insulin whilst he is unwell?

• Continue his normal insulin regime and check blood sugars frequently
• Double his normal dose of insulin whilst he is unwell
• Half his normal dose of insulin whilst he is unwell
• Stop insulin whilst unwell and re-start once he is feeling better
• Check blood sugars before each insulin dose whilst he is unwell and omit if blood sugar is <4mmol/L

Answer 39

Diabetes sick day rules: when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently.

Patients with insulin-dependent diabetes who become unwell should continue with their normal insulin regime and ensure they check their blood sugars frequently (at least four hourly during the day).

Stopping or reducing insulin whilst unwell would be very dangerous due to the risk of diabetic ketoacidosis.

Checking blood sugars before each insulin dose would not be appropriate as it would require the patient to be titrating each insulin dose very carefully and this would also depend on how much they would be eating. This would not be practical or safe in this situation for Bernard.

Doubling Bernard’s normal insulin dose would put him at a significantly increased risk of hypoglycaemia, particularly when he is likely to have a reduced oral intake due to feeling unwell.

Question 40

A 62-year-old male returns to your clinic for a review of his diabetes, which is poorly controlled, despite his multi-drug regime. Upon discussion with him, you decide to commence pioglitazone.

Which of the following is a classical side effect of this drug that he should be counselled about?

• Weight loss
• Increased risk of fractures
• Vomiting
• Lactic acidosis
• Injection-site reaction

Answer 40

Increased risk of fractures.

Glitazones - associated with fractures

Important for meLess important

Pioglitazone is a thiazolidinedione (also called the glitazones), which acts by reducing resistance to insulin, thus lowering blood glucose. It is a PPAR-γ agonist.

It’s classical side effects are: weight gain (rather than loss); fluid retention; liver dysfunction; and associated fractures.

It is metformin that has the classical risk of lactic acidosis and gastric disturbances (diarrhoea rather than vomiting most commonly).

Pioglitazone is not a subcutaneous medication, so would not have injection-site reactions.

Question 41

A 47-year-old-female presents to her normal diabetic outpatient appointment as part of her regular check up. She is a type two diabetic with a body mass index of 36kg/m². She is currently on full dose metformin monotherapy. Her HbA1c is 59mmol/mol. She reports that she is compliant with her medications. After discussion the patient feels there is not much more she can do with lifestyle modification or diet and is willing to add extra therapeutics to her management as needed. The patient reports she would be keen to avoid any medications that could cause weight gain if more medications are to be added.

With this in mind which of the following would be the most appropriate management options?

• Add a DPP-4 inhibitor
• Add a sulphonylurea
• Add pioglitazone (a thiazolidinedione)
• Continue with metformin monotherapy
• Start insulin therapy

Answer 41

DPP-4 inhibitors are useful in T2DM patients who are obese

• A DPP-4 inhibitor could be added at this stage as they are weight neutral. The other medical options suggested would cause weight gain.
• While a sulphonylurea would reasonable if it was just an elevated HbA1c, with her BMI there are better therapeutic options available. Sulphonylureas may also cause weight gain.
• Pioglitazone causes weight gain.
• With her HbA1c of 58mmol/mol and the patient reporting they feel they cannot modify their lifestyle more, continuing monotherapy is not advisable.
• Insulin therapy is not appropriate at this stage as there are more medical options available. Insulin also has a side effect of weight gain.

Question 42

A patient with type 2 diabetes mellitus is started on sitagliptin. What is the mechanism of action of sitagliptin?

• Incretin inhibitor
• Dipeptidyl peptidase-4 (DPP-4) inhibitor
• Alpha-glucosidase inhibitor
• Glucagon inhibitor
• Glucagon-like peptide-1 (GLP-1) mimetic

Answer 42

Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1

Question 43

You are seeing a 58-year-old male patient for his annual health review. He has hypertension and diet controlled diabetes. His blood tests show a HbA1c of 50 mmol/mol.

For this patient, what HbA1c target are you aiming for?

• 58 mmol/mol
• 53 mmol/mol
• 48 mmol/mol
• 43 mmol//mol
• 40 mmol/mol

Answer 43

The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol

Important for meLess important

Patients with type 2 diabetes should be offered diet and lifestyle advice to achieve and help maintain their HbA1c target.

For adults with type 2 diabetes managed either by lifestyle and diet (eg this patient) or by lifestyle and diet combined with a single drug not associated with hypoglycaemia (eg metformin), we should support the person to aim for an HbA1c level of 48 mmol/mol. Therefore, option 3 is correct.

In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol or higher the NICE guidelines suggest that we should:

Reinforce advice about diet, lifestyle and adherence to drug treatment

Support the person to aim for an HbA1c level of 53 mmol/mol

Intensify drug treatment.

For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol.

If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it.

Question 44

Which one of the following statements regarding dipeptidyl peptidase-4 inhibitors in the management of type 2 diabetes mellitus is correct?

• Metformin should always be co-prescribed
• Do not cause weight gain
• Is given via a subcutaneous injection
• An example is exenatide
• Patients should be warned that hypoglycaemia is the most common side-effect

Answer 44

Do not cause weight gain

Hypoglycaemia is rare in patients taking dipeptidyl peptidase-4 inhibitors.

Question 45

A 38-year-old female diabetic patient has called her general practitioner for some advice. She reports having diarrhoea and vomiting for the past 24 hours and has been unable to tolerate solid foods but is drinking without issue.

As she has not been eating, she is concerned about her insulin regime and wants to clarify if she should continue to take it.

What advice should be given to the patient?

• Withhold insulin until tolerating solid foods again
• Continue normal insulin regime
• Double the insulin dose throughout the illness
• Half the insulin dose throughout the illness
• Patient should be swapped from insulin to metformin for the duration of the illness

Answer 45

Continue normal insulin regime.

Diabetes sick day rules: when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently

Important for meLess important

Insulin administration on sick days should be continued due to the risk of diabetic ketoacidosis.

This patient is experiencing diarrhoea and vomiting and is at risk of electrolyte derangement, ketosis, and dehydration. It is important that she:

Maintains good fluid intake (minimum of 3 litres in 24 hours)

Consider taking sugary drinks to maintain carbohydrate intake as she is unable to tolerate solids

Monitor blood glucose at least every 4 hours

Ensure there are people in the house, patient has a mobile phone, or neighbours are aware that the patient is unwell in case of the patient becoming unconscious

If the patient is unable to keep fluids down, diarrhoea is persistent, or there is severe derangement in ketone and/or blood glucose levels then the patient may require admission to hospital.

Infection causes a stress response in the body with the increased release of cortisol and adrenaline which work against insulin, leading to increased glucose production in the body causing high blood glucose levels. As such, it is inappropriate to withhold insulin during illness. It would also be inappropriate to blindly double or half the insulin dose as this could cause hypoglycaemia.

Metformin should be stopped during illness - this is due to the increased risk of lactic acidosis with dehydration.

Question 46

A 54-year-old man attends for his diabetes review. He has type 2 diabetes and is currently taking gliclazide. He previously tried metformin but did not tolerate it. His HbA1c remains out of range after 5 months of this treatment and lifestyle changes. Therefore you discuss starting a third treatment, sitagliptin.

What is the action of the aforementioned drug?

• Act as glucagon-like peptide 1 agonists
• Increasing the peripheral breakdown of incretins
• Acting as incretin analogues
• Decreasing insulin sensitivity
• Reducing the peripheral breakdown of incretins

Answer 46

Reducing the peripheral breakdown of incretins

Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1

Reducing the peripheral breakdown of incretins such as glucagon-like peptide 1 is the correct answer. Sitagliptin belongs to dipeptidyl peptidase-4 inhibitors (DDP-4 inhibitors). They act by reducing the peripheral breakdown of incretins such as glucagon-like peptide 1. Incretins inhibit glucagon secretion, therefore increasing insulin secretion, subsequently reducing gastric emptying and reducing blood glucose levels.

Act as glucagon-like peptide 1 agonists is an incorrect answer, this describes the mechanism of action of glucagon-like peptide-1 mimetics. The medication named, sitagliptin, is a DDP-4 inhibitor. which reduces the breakdown of GLP-1 and other incretins, rather than mimicking them. Therefore both GLP-1 mimetics and DDP-4 inhibitors have the same overall effect of inhibiting glucagon secretion and increasing insulin secretion.

Act on ATP-sensitive K+ channels is incorrect. This describes the action of sulfonylureas, whereas the sitagliptin is a DDP-4 inhibitor. Sulfonylureas work by closing the ATP-sensitive K+ channel on pancreatic beta cells, depolarising the cell as potassium is unable to exit. This opens voltage-gated Ca2+ channels. The increase in intracellular calcium leads to insulin secretion. They can cause hypoglycemia and are associated with modest weight gain.

Increasing insulin sensitivity is incorrect, as this describes the mechanism of action of biguanides. However, the medication named, sitagliptin is a DDP-4 inhibitor.

Inhibiting sodium-glucose co-transport is incorrect, this describes the action of sodium-glucose co-transporter 2 inhibitors, whereas sitagliptin is a DDP-4 inhibitor.

Question 47

A 59-year-old man books a routine appointment with you following an appointment with your surgery’s diabetes nurse. He was diagnosed with type-2 diabetes three years ago and currently takes metformin. A blood pressure (BP) check with the nurse gave a BP of 158/82 mmHg. A subsequent home BP diary showed an average of 146/86 mmHg.

He has no other medical problems. He has never taken blood pressure medicines previously and has no known allergies. His most recent bloods showed an eGFR of 84 ml/min/1.73 m². He is of African-Caribbean ethnicity.

What is the most appropriate first line antihypertensive medication?

• Amlodipine
• Doxazosin
• Indapamide
• Losartan
• Ramipril

Answer 47

Losartan

An angiotensin II receptor blocker should be used first-line for black TD2M patients who are diagnosed with hypertension

Hypertension in patients with diabetes is treated slightly different to those without. NICE advises use of an angiotensin-converting enzyme (ACE) inhibitor such as ramipril or an angiotensin II receptor blockers (ARB) such as losartan as a first line in all patients with diabetes, regardless of age. NICE also recommends in patients of black African or African-Caribbean to use an ARB in preference to an ACE inhibitor, hence losartan is the correct answer.

Amlodipine is a calcium-channel blocker, it would be an appropriate first line medication in those of black African or African-Caribbean family origin without diabetes or those of other ethnic backgrounds aged over 55.

Doxazosin is an alpha blocker and generally used as a fourth line antihypertensive.

Indapamide is a thiazide diuretic and generally used as a third line antihypertensive.

Question 48

A 65-year-old woman has uncontrolled diabetes despite lifestyle changes and treatment with metformin. Her body mass index is 32 kg/m2. Her GP commences treatment with sitagliptin.

What is the main mechanism of action of this drug?

• Increases pancreatic insulin secretion
• Increases peripheral insulin sensitivity
• Reduces hepatic gluconeogenesis
• Reduces the peripheral breakdown of incretins
• Reduces the release of glucagon

Answer 48

Reduces the peripheral breakdown of incretins.

Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1

The correct answer is that sitagliptin reduces the peripheral break down of incretins. Sitagliptin is one of the Gliptins (DPP-4 inhibitors) which reduce the peripheral breakdown of incretins such as GLP-1.

Metformin increases peripheral insulin sensitivity and reduces hepatic gluconeogenesis.

Sulfonylureas augment pancreatic insulin secretion. Increased insulin secretion can lead to hypoglycaemia.

GLP mimetics, e.g. exenatide, augment pancreatic insulin secretion, suppress glucagon release, slow gastric emptying and promote satiety.

Question 49

A 62-year-old female presents to her general practitioner for a diabetic review. She has been suffering from type-two diabetes mellitus for a long time, but never fully controlled it. All the lifestyle changes have been implemented and she has been taking metformin and gliclazide. Today, she complains of polyuria and her Hba1c is 62 mmol/mol. Her past medical history comprises hypertension, controlled with amlodipine and recurrent urinary tract infections. She is keen on avoiding insulin as she is afraid of needles.

Which one of the following options is the most correct regarding her management?

• Add exenatide
• Add sitagliptin
• Stop all the drugs and start insulin therapy
• Stop gliclazide and prescribe sitagliptin
• Stop metformin and prescribe pioglitazone

Answer 49

Add sitagliptin.

TD2M already on 2 drugs - if HbA1c > 58 mmol/mol then triple therapy with one of the following combinations should be offered:

metformin + gliptin + sulfonylurea

metformin + pioglitazone + sulfonylurea

metformin + sulfonylurea + SGLT-2 inhibitor

metformin + pioglitazone + SGLT-2 inhibitor

OR insulin therapy should be considered

Important for meLess important

The correct answer is to add sitagliptin. The NICE guidelines suggest that patients with HbA1c > 58 mmol/mol already on two drugs should be either offered a third drug or insulin therapy should be considered. Given that she is afraid of needles, insulin therapy should be avoided if possible. Hence a third drug should be added, either an SGLT-2 inhibitor, a gliptin, or pioglitazone, given that she is already taking metformin and gliclazide (a sulfonylurea). Since she has a past medical history of recurrent urinary tract infections, SGLT-2 inhibitors should be avoided as they increase the chances of developing them. Pioglitazone is rarely prescribed, so the correct option is to add sitagliptin.

Adding exenatide is incorrect since this drug belongs to the class of GLP-1 mimetics. This class of drugs should be added only if the patient cannot tolerate triple therapy and they have a BMI greater than 35. In this case, none of these two conditions is true, making the option incorrect.

It is incorrect to stop all the drugs and start insulin. This patient clearly stated that she is afraid of needles, and since there are other options we should take into account the patient’s preference.

Stop gliclazide and prescribe sitagliptin is incorrect as the NICE guidelines suggest that drugs should not be stopped and substituted but added together to work synergically. You could potentially add a gliptin but you should not stop the other drugs.

Stop metformin and prescribe pioglitazone is incorrect as the NICE guidelines suggest that drugs should not be stopped and substituted but added together to work synergically. You could potentially add pioglitazone but you should not stop the other drugs.

Question 50

You go on a home visit to see Mr Bell, an elderly man who is suffering from an acute diarrhoeal illness he picked up from his grandchildren. His past medical history includes: ischaemic heart disease, type 2 diabetes, hypercholesterolaemia, and osteoarthritis. His medications are bisoprolol 2.5mg OD, ramipril 2.5mg OD, aspirin 75mg, lansoprazole 30mg OD, metformin 1g BD, atorvastatin 40mg ON, and paracetamol 1g PRN. His pulse is 92/min, blood pressure 152/82mmHg, oxygen saturations 97%, respiratory rate 16/min. His tongue looks a little dry, abdomen is soft and non-tender, with very active bowel sounds. After examining him, you feel he is well enough to stay at home, and you prescribe some rehydration sachets and arrange telephone review for the following day.

What else should you advise he change about his medication with immediate effect?

• Increase dose ramipril
• Double the dose of lansoprazole
• Suspend metformin
• Reduce dose paracetamol to 500mg
• Increase dose bisoprolol

Answer 50

Metformin increases the risk of lactic acidosis - suspend during intercurrent illness eg. diarrhoea and vomiting

Important for meLess important

Increase dose ramipril. Incorrect. Although his blood pressure is a little high today, it is not the priority and might increase risk of electrolyte disturbance whilst he is unwell - you may even consider suspending it. Blood pressure could be reviewed when he is feeling better.

Double the dose of lansoprazole. Incorrect, no indication for this.

Suspend ramipril. Incorrect. Blood pressure is a little high, and there is no evidence of acute electrolyte disturbance.

Suspend metformin. Correct answer - metformin is associated with an increased risk of lactic acidosis and therefore should be suspended when there is risk eg. dehydration, sepsis, CT with contrast, renal failure, heart failure; particularly if the patient is frail or elderly.

Reduce dose paracetamol to 500mg. Incorrect. Dose might be reduced when patient has a low body weight.

Increase dose bisoprolol. Incorrect. No indication for increasing bisoprolol here.

Question 51

You are reviewing a 31-year-old woman who has type 1 diabetes mellitus. Her control is currently good and she is well with no intercurrent illnesses. How often if it recommended that she monitors her blood glucose?

• At least 4 times a day, including before each meal and before bed
• At least 6 times a day, including before each meal and before bed
• At least 8 times a day, including before each meal and before bed
• On waking and after lunch and the evening meal
• On waking, before leaving the house and after lunch and the evening meal

Answer 51

At least 4 times a day, including before each meal and before bed

In type 1 diabetics, recommend monitoring blood glucose at least 4 times a day, including before each meal and before bed

Question 52

A 32-year-old multiparous female at 9 weeks gestation has presented to her general practitioner to book her pregnancy. Due to her previous history of gestational diabetes, she returns the following day for an oral glucose tolerance test. She has bloods which reveal:

• Fasting glucose7.2 mmol/L
• 2-hour glucose8.9 mmol/L

What is the appropriate management plan following these results?

• Patient to be started on insulin
• Patient to be started on insulin plus statin
• Patient to be started on metformin
• Patient to be started on metformin plus statin
• Patient to be started on sitagliptin

Answer 52

Patient to be started on insulin.

If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l immediate insulin (plus or minus metformin) should be started

Important for meLess important

This patient has a fasting glucose level ≥ 7.0 mmol/L - she needs to be started on insulin (plus or minus metformin).

If her fasting plasma glucose level was < 7.0 mmol/L, trial of diet and exercise with review in 1-2 weeks would be appropriate.

She must be seen in a joint antenatal and diabetic clinic within a week of diagnosis.

Statins are contraindicated during pregnancy. The British National Formulary (BNF) advises to stop taking statins 3 months before attempting to conceive as there have been incidents of congenital abnormality reported which may be attributed to reduced cholesterol synthesis possibly affecting foetal development.

Sitagliptin is not recommended for use during pregnancy and breast-feeding. It is a DPP-4 inhibitor (this is an enzyme which acts upon incretin).

Discuss (3)Improve

Question 53

You receive the bloods tests which were requested by the practice nurse in advance of the annual diabetes review of Mr Perry, a 55-year-old patient. Mr Perry was diagnosed with type 2 diabetes about 5 years ago, and after 2 years of attempting to control it with lifestyle measures, he commenced metformin and is now prescribed 1g BD. His full blood count, renal profile and liver function tests are normal, his total cholesterol is 5.3mmol/L. His HbA1c is 60mmol/mol.

According to NICE, what action should be taken regarding his blood sugar control?

• Reinforce lifestyle and diet measures only
• Commence a second blood glucose lowering drug and reinforce lifestyle and diet measures
• Stop metformin and commence a more effective blood glucose lowering drug
• Change to modified-release metformin
• Increase dose of metformin

Answer 53

A second drug should be added in type 2 diabetes mellitus if the HbA1c is > 58 mmol/mol

Important for meLess important

Reinforce lifestyle measures. Incorrect answer, although lifestyle advice should be reinforced, NICE advises if HbA1c is 58mmol/mol or higher on a single drug, ‘intensify drug treatment.’

Commence a second blood glucose lowering drug and reinforce lifestyle and diet measures. Correct answer, NICE advises if HbA1c is 58mmol/mol or higher on a single drug, ‘intensify drug treatment, as well as revisiting lifestyle and dietary advice with the patient.

Stop metformin and commence a more effective blood glucose lowering drug. Incorrect answer, unless metformin is contraindicated or not tolerated, it should be continued.

Change to modified-release metformin. Incorrect answer, this can be done if a patient is experiencing gastrointestinal side effects on standard release metformin but will not improve blood sugar control.

Increase dose of metformin. Incorrect answer, he is already on the maximum dose (1g BD).

Question 54

A 19-year-old female arrives at your clinic with flu-like symptoms, she has recently been diagnosed with type 1 diabetes and has come for advice regarding her diabetes management whilst she is ill. Which of the following options is one of the ‘sick-day rules’ insulin-dependent diabetics should adhere to during illness?

• Reduce insulin doses
• Monitor their glucose as normal
• Substitute all main meals with sugar-containing foods
• Aim to drink at least 3L of fluid
• Check urinary ketones at the start of illness

Answer 54

Aim to drink at least 3L of fluid.

Option 4 is the correct answer as patients should be encouraged to drink at least 3L of fluid over 24 hours. Patients should continue their normal insulin regimen but check their blood glucose more regularly, therefore options 1 and 2 are wrong. Main meals should not be substituted for sugary foods, if a patient is struggling to eat then they may take sugary drinks. Ketones should also be measured, but more frequently than what is being proposed in option 5, for example, every 3-4 hours or even more frequently depending on the readings.

NICE Clinical Knowledge Summaries - Diabetes Type 1
https://cks.nice.org.uk/diabetes-type-1#!scenarioclarification:2

‘Candidates gave generally good responses to questions concerning management of type 2 diabetes. However, type 1 diabetes caused difficulty and candidates are reminded in particular to review the management of type 1 diabetes during intercurrent illness, and sick day rules.’

Question 55

Your next patient is a 74-year-old woman who is known to have type 2 diabetes mellitus. Her blood pressure has been borderline for a number of weeks now but you have decided she would would benefit from treatment. Her latest blood pressure is 146/88 mmHg, HbA1c is 58 mmol/mol and her BMI is 25 kg/m^2. What is the most appropriate drug to prescribe?

• Bisoprolol
• Bendroflumethiazide
• Amlodipine
• Ramipril
• Orlistat

Answer 55

ramipril

Hypertension in diabetics - ACE inhibitors/A2RBs are first-line regardless of age

Question 56

A 64-year-old man is reviewed in clinic. He has a history of ischaemic heart disease and was diagnosed with type 2 diabetes mellitus around 12 months ago. At this time of diagnosis his HbA1c was 7.6% (60 mmol/mol) and he was started on metformin which was titrated up to a dose of 1g bd. The most recent bloods show a HbA1c of 7.0% (53 mmol/mol). He has just retired from working in the IT industry and his body mass index (BMI) today is 25 kg/m². His other medication is as follows:

Atorvastatin 80mg on
Aspirin 75mg od
Bisoprolol 2.5 mg od
Ramipril 5mg od

What is the most appropriate next step?

• Add sitagliptin
• Make no changes to his medication
• Add glimepiride
• Add pioglitazone
• Add exenatide

Answer 56

No change

Since the publication of the 2015 guidelines, NICE recommend we only add another drug if the HbA1c has risen to >= 58 mmol/mol (7.5%) at this stage.

Question 57

A 24 year-old lady with type 1 diabetes presents to the maternity department at 25+3 weeks gestation with tightenings and a thin watery discharge. Her pregnancy so far has been uncomplicated and all scans have been normal. She has well controlled diabetes by using an insulin pump.

A speculum examination is performed and no fluid is noted, the cervical os is closed. A fetal fibronectin (fFN) test is performed which comes back as 300 (positive).

What is the most appropriate management?

• Discharge with 2 doses oral steroids
• Admit for 2 doses IM steroids, continue insulin therapy as usual
• Admit for 2 doses IM steroids and monitor BMs closely, adjusting pump accordingly
• Discharge and reassure
• Discharge with course of oral antibiotics

Answer 57

Admit for 2 doses IM steroids and monitor BMs closely, adjusting pump accordingly.

Fetal fibronectin (fFN) is a protein that is released from the gestational sac. Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN

Having a positive result means that the obstetric team can optimise everything, in case the lady does go into premature labour. This includes ensuring neonatal intensive care are aware, and administering steroids to help with neonatal lung maturity. As this lady is at high risk of premature labour, and is currently experiencing tightenings, it would be incorrect to discharge the patient without any further monitoring.

Giving antibiotics may be indicated if she had spontaneously ruptured her membranes, however this history of watery discharge but no fluid seen on speculum examination and a closed os is not enough to initiate antibiotic therapy at this stage. As infection can be a precipitating factor for premature labour, swabs and urine cultures should be obtained to screen for infection and treat as appropriate.

Administering steroids can cause hyperglycemia in diabetics, and therefore close attention should be paid to the blood glucose measurements. Hyperglycaemia in the mother can cause adverse outcomes for the fetus, which is why extra care must be taken. Hourly blood glucose measurements must be taken, and additional insulin given as required. If the blood glucose levels are hard to control in this way, a sliding scale should be started according to local protocol.

Question 58

A 39-year-old woman who has a history of type 1 diabetes mellitus phones for advice as she is worried about her blood sugar level. What is the target blood sugar level before meals at other times of the day (excluding first thing in the morning)?

• 5-9 mmol/l
• 4-7 mmol/l
• 4-6 mmol/l
• 6-8 mmol/l
• 5-7 mmol/l

Answer 58

4 -7 mmol/l

In type 1 diabetics, blood glucose targets:

5-7 mmol/l on waking and

4-7 mmol/l before meals at other times of the day

Question 59

A 62-year-old gentleman with a background of myocardial infarction, congestive heart failure and chronic obstructive pulmonary disease attends for a diabetes review at his GP. He has recently been diagnosed with type 2 diabetes mellitus and despite a trial of lifestyle modifications his HbA1c is 56 mmol/mol. His GP decides to commence drug treatment.

Which of the following drugs would be contraindicated for this patient?

• Metformin
• Sitagliptin
• Pioglitazone
• Insulin
• Gliclizide

Answer 59

Pioglitazone can cause fluid retention and is therefore contraindicated in patients with heart failure.

Question 60

Muhammad, a 45-year-old man with type 2 diabetes, organises a telephone consultation with you, his normal GP.

Muhammad complains of diarrhoea and vomiting, which started since returning from Saudi Arabia 3 days ago. He has been opening his bowels 4-5 times daily. He has a poor appetite and is struggling to eat and drink.

On questioning, he denies any PR bleeding. He reports a mild fever of 37.6ºC. He has a home blood pressure monitor and states his blood pressure is 109/69 mmHg, heart rate 94/min. His self-checked capillary blood sugar shortly before the phone call was 10.9 mmol/L.

He takes metformin 1g twice daily, atorvastatin 40mg once daily, and NovoMix 30 insulin 25 units twice daily. He has no other significant past medical history of note.

What advice should you give him?

• Increase Metformin
• Continue NovoMix 30 and check blood glucose every 2-4 hours
• Increase NovoMix 30 to three times daily
• Stop NovoMix 30 temporarily, and restart if blood sugars rise above 15 mmol/L
• Stop NovoMix 30, check blood glucose every 2-4 hours, and book review telephone consultation tomorrow to give further advice

Answer 60

Continue NovoMix 30 and check blood glucose every 2-4 hours

Diabetes sick day rules state that a patient must not stop their insulin due to the risk of ketoacidosis. Concurrent illness will often raise blood sugars and demand for insulin will often rise.

Most guidance suggests increasing the dose of mixed insulin by 2-4 units if blood sugars are above 10 mmol/L.

He is already taking maximum dose of metformin. Further, metformin should be stopped if there is severe infection or dehydration.

NovoMix is a biphasic insulin and so is not prescribed as a three times daily dose.

Discuss (4)Improve

Question 61

Theme: Side-effects of diabetes mellitus drugs

• A.Metformin
• B.Acarbose
• C.Glimepiride
• D.Nateglinide
• E.Pioglitazone
• F.Diazoxide
• G.Repaglinide

Select the drug most likely to cause each one of the following side-effects

20. Syndrome of inappropriate ADH secretion
21. Lactic acidosis
22. Fluid retention

Answer 61

Glimepiride

Metformin

Pioglitazone

Question 62

A 58-year-old man comes for review in the diabetes clinic. He was diagnosed as having type 2 diabetes mellitus (T2DM) around 10 years ago and currently only takes gliclazide and atorvastatin. Three years ago he was successfully treated for bladder cancer. A recent trial of metformin was unsuccessful due to gastrointestinal side-effects. He works as an accountant, is a non-smoker and his BMI is 31 kg/m². His annual bloods show the following:

• Na+138 mmol/l
• K+4.1 mmol/l
• Urea4.3 mmol/l
• Creatinine104 µmol/l
• HbA1c62 mmol/mol (7.8%)

What is the most appropriate next step in management?

• Add pioglitazone
• Add exenatide
• Add acarbose
• Add repaglinide
• Add sitagliptin

Answer 62

Add sitagliptin

Pioglitazone is contraindicated by his history of bladder cancer and may contribute to his obesity. A DPP-4 inhibitor such as sitagliptin is therefore the best option.

Exenatide generally causes weight loss and is therefore useful in obese diabetics but he does not meet the NICE body mass index criteria of 35 kg/m².

Question 63

A 36-year-old woman who is currently 32 weeks pregnant has been monitoring her capillary blood glucose (CBG) at home following a diagnosis of gestational diabetes mellitus (GDM) 4 weeks ago.

She has been given appropriate dietary and exercise advice, as well as review by a dietitian. She has also been taking metformin and has been on the maximum dose for the past 2 weeks.

Fetal growth scans have been normal with no signs of macrosomia or polyhydramnios.

She has brought her CBG diary today, which shows that her mean pre-meal CBG is 5.9 mmol/L and mean 1-hour postprandial CBG is 8.3 mmol/L.

What is the most appropriate management?

• Add gliclazide
• Add sitagliptin
• Commence insulin
• Stop metformin
• Continue current treatment and review in 2-3 weeks

Answer 63

Commence insulin.

In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added

Important for meLess important

Pregnant women with GDM should be advised to maintain their CBGs below the following target levels:

fasting: 5.3mmol/L

AND

1 hour postprandial: 7.8 mmol/L or

2 hours postprandial: 6.4 mmol/L

If these targets are not met with diet, exercise and metformin, then insulin should be offered as add-on therapy.

The only sulphonylurea that is advocated by the National Institute of Health and Clinical Excellence (NICE) is glibenclamide, which can be considered in women who decline insulin, or who cannot tolerate metformin initially, hence gliclazide is an incorrect option here. Note that the use of any sulphonylurea in GDM is an off-license indication.

There is insufficient evidence to advise the safe use of gliptins in pregnancy, hence it is currently not recommended in GDM management.

It would not be correct to continue the same management or de-escalate treatment by stopping metformin as the CBG readings are above target levels. Although fetal growth is currently normal, there are serious ongoing risks to both mother and fetus if glycaemic control is not achieved, including pre-eclampsia, pre-term labour, stillbirth and neonatal hypoglycaemia.

Question 64

A 65-year-old man who is prescribed metformin and gliclazide for type 2 diabetes mellitus has a HbA1c of 60 mmol/mol in a recent check-up. He has a history of bladder transitional cell carcinoma and is being treated for a foot ulcer.

What is the most appropriate management of this patient?

• Add acarbose
• Add canagliflozin
• Add pioglitazone
• Add sitagliptin
• Continue current regimen

Answer 64

Add sitagliptin

TD2M already on 2 drugs - if HbA1c > 58 mmol/mol then triple therapy with one of the following combinations should be offered:

metformin + gliptin + sulfonylurea

metformin + pioglitazone + sulfonylurea

metformin + sulfonylurea + SGLT-2 inhibitor

metformin + pioglitazone + SGLT-2 inhibitor

OR insulin therapy should be considered

Important for meLess important

As this patient has an HbA1c over 58 mmol/mol on two medications he requires triple therapy. The most suitable additional medication suggested in NICE guidance would be a gliptin such as sitagliptin as his medical history would contraindicate other options.

Acarbose is an inhibitor of intestinal alpha glucosidases which delays the digestion of starch and sucrose. It does not appear in NICE guidance due to significant gastrointestinal side-effects this medication causes.

Canagliflozin inhibits sodium-glucose co-transporter 2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion. It is contraindicated in active foot disease such as skin ulceration with a possible increased risk of toe amputation.

Pioglitazone is a thiazolidinedione that reduces peripheral insulin resistance and is contraindicated in patients with active or previous bladder cancer.

Question 65

A 54-year-old female has come to the GP diabetic clinic to review her medications and blood results. Up until now her HbA1c has been well controlled on metformin 1g twice-a-day. She has a past medical history of type 2 diabetes and heart failure. Today her HbA1c result is 59mmol/mol, so the GP reinforces the importance of lifestyle and dietary advice.

What is the most appropriate next step in this patient’s management?

• Increase dose of metformin
• Nothing else required
• Prescribe DPP-4 inhibitor
• Prescribe a thiazolidinedione
• Start insulin regimen

Answer 65

Prescribe DPP-4 inhibitor

A second drug should be added in type 2 diabetes mellitus if the HbA1c is > 58 mmol/mol

Important for meLess important

The patient’s HbA1c result shows that her glucose levels are not well controlled anymore, this could be due to tolerance, adherence or lifestyle issues. The next step would be to prescribe a second medication, be it a DPP-4 inhibitor, sulfonylurea or a SGLT-2 inhibitor, based on the patients needs and weighing up the risks and benefits of each.

The standard dose of metformin is 500g daily which can be increased up to a maximum of 2g daily, divided into separate doses. She is already on 2g so cannot have her dose increased further.

Thiazolidinediones such as pioglitazone should not be used in heart failure and are rarely used as first or second-line therapies.

As her HbA1c levels exceed 58mmol/mol, another intervention is needed, in conjunction with reinforcing lifestyle and dietary advice.

Insulin is retained for patients who do not respond to double or triple therapy.

Question 66

A 23-year-old woman who is 28 weeks pregnant attends the joint antenatal and diabetes clinic, for a review of her gestational diabetes.

She was found to have gestational diabetes at 24 weeks gestation after glucose was found on a routine urine dipstick. She had 2 week trial of lifestyle modifications, which did not lead to any improvement. After this, she was then started on metformin for the past 2 weeks, which has equally not improved her daily glucose measurements.

On examination, her symphysio-fundal height is 28 cm and foetal heart rate is present.

What is the most appropriate next step in her management?

• Prescribe glibenclamide
• Prescribe gliclazide
• Prescribe gliclazide and glibenclamide
• Prescribe short-acting and long-acting insulin
• Prescribe short-acting insulin only

Answer 66

Prescribe short-acting insulin only

Gestational diabetes is treated with short-acting, but not longer-acting SC insulin.

This woman has been trialled on both lifestyle modifications for 2 weeks, and then metformin for 2 weeks, and neither of these has led to improvement of her gestational diabetes. The next step in her treatment should be to offer short-acting insulin, alongside education on how to dose insulin in accordance with meals.

Glibenclamide is an oral hypoglycaemic agent which is a second-generation sulfonylurea. It decreases blood glucose by increasing insulin secretion. It may be associated with increased birth weight, macrosomia, and neonatal hypoglycemia when compared with insulin. For that reason, it is only given if insulin fails to offer adequate glycaemic control, or if insulin is refused or contraindicated. Therefore, in this scenario, it is not the correct answer.

Gliclazide is an oral hypoglycaemic agent which is not recommended for use in pregnancy. It is unsure or not whether it may cross the placenta, and there is a risk of neonatal hypoglycemia. Therefore, it is not the correct answer.

Gliclazide and glibenclamide together is not the correct answer. Gliclazide is not recommended in pregnancy, and glibenclamide should only be offered as the next step after insulin management has failed. Both of these drugs together may also precipitate maternal hypoglycaemia.

Prescribing short-acting and long-acting insulin is not the correct answer. Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia. Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman.

Question 67

You are asked to see a 29-year-old patient in a joint medical/obstetric clinic who has recently been diagnosed with gestational diabetes. Her pregnancy has been complicated by a diagnosis of gestational diabetes through routine screening and she now takes metformin 500mg three times a day.

She is 24 weeks pregnant and she has just had a scan revealing an estimated foetal weight of 850g (97.5th percentile).

She feels well and she has been tolerating the metformin without issue. A fasting blood glucose level is taken at the clinic and it is compared to her previous result:

• 6 weeks ago6.2mmol/L
• 4 weeks ago6.3mmol/L
• Today7.1mmol/L

Given the above, what change would you make to the management of this patient?

• Continue metformin and add gliclazide
• Continue metformin and add insulin
• Increase metformin dose
• Stop metformin and commence insulin
• Take high dose folic acid daily

Answer 67

Continue metformin and add insulin.

In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added

Important for meLess important

This question is assessing your knowledge of the management of gestational diabetes.

This patient would have been trialled with exercise and dietary changes over a 2-week period as her initial fasting blood glucose was below 7mmol/L. It is apparent that she has failed this trail and she has been started on metformin monotherapy. Insulin therapy was not previously started as her fasting blood glucose was below 7mmol/L.

NICE guidelines advise that in the event targets aren’t met on metformin monotherapy, then insulin should be commenced and lifestyle changes reiterated. This means that continuing metformin and adding insulin to this patients management is the correct answer.

Continuing metformin and adding gliclazide is in an incorrect answer as it is preferable to avoid the use of gliclazide during pregnancy.

Increasing the dose of metformin is an incorrect answer as her fasting blood glucose levels are now >7mmol/L and the commencement of insulin therapy is required.

Stopping metformin and commencing insulin is an incorrect answer as it would go against current NICE guidance which recommends continuing metformin if tolerated. The patient in this scenario has no tolerance issues with metformin.

High dose folic acid is an incorrect answer. High dose folic acid may reduce the risks of foetal spinal cord defects but it will not improve her diabetic control.

Question 68

A 59-year-old woman attends for her annual diabetes review. She has had a diagnosis of type two diabetes for the last 2 years, and currently takes metformin 500mg tds. She is experiencing no side effects and is concordant with medication advice. There is no other significant past medical history.

Her most recent HbA1c was recorded as 55 mmol/mol. You consider altering her current medication.

What is the target HbA1c for this patient?

• 42 mmol/mol
• 46 mmol/mol
• 48 mmol/mol
• 52 mmol/mol
• 53 mmol/mol

Answer 68

The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol

Important for meLess important

The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol for those taking a signal drug not associated with hypoglycaemia (in this case metformin).

For those taking more than one medication or a single medication associated with hypoglycemia then the target would be 53 mmol/mol.

Question 69

Theme: Diabetic drugs

• A.No change in treatment
• B.Refer to secondary care
• C.Start a gliclazide
• D.Start a gliptin
• E.Start a glucagon-like peptide-1 (GLP-1) receptor agonist
• F.Start a sodium-glucose transport protein 2 (SGLT2) inhibitor
• G.Start insulin
• H.Start metformin
• I.Start metformin modified release
• J.Start pioglitazone

In the following scenarios, chose the most appropriate management from the list above.

33.You are reviewing a 54-year-old man with type 2 diabetes that was started on metformin earlier this year. He is currently taken 500mg metformin three times daily. Prior to this, he had not tried any other medications.

Unfortunately, he tells you that since starting the metformin, he has developed watery diarrhoea and finds he is passing 5-6 watery stools per day. There is some intermittent crampy abdominal pain. He is otherwise well.

You agree that the symptoms are likely secondary to the metformin and unlikely due to another cause. You decide to stop the metformin. What should you do next?

34.You are seeing a 62-year-old lorry driver with poorly controlled type 2 diabetes. He is on the maximum tolerated dose of metformin and you are thinking about adding in a second drug.

His past medication includes heart failure, eczema and hayfever.

His latest renal function was normal.

35.You are asked to do a follow up on a 59-year-old man with known type 2 diabetes. He was taking metformin and gliclazide for a number of years, but despite this, his HbA1c has been steadily climbing.

As such the diabetic nurse has started him on Dapagliflozin, a sodium-glucose transport protein 2 (SGLT2) inhibitor. Unfortunately, he has had a number of hypoglycaemic episodes and it has not made a significant difference to his HbA1c, so you decide to stop it again.

He has a history of heart failure following an NSTEMI 3 years previously, obesity with a BMI of 43 and as a result has developed some arthritis in his knees.

What would be the most appropriate next step in treatment?

Answer 69

Start metformin modified release

Gastrointestinal side effects are common with metformin and can occur in up to 20% of patients.

As such we should start at a low dose of 500mg once daily and up titrate the dose slowly whilst monitoring for side effects. In this case, it appears the patient has been struggling with the symptoms ever since starting the medication (rather than when the dose was increased).

The modified release variant of metformin appears to have a better gastrointestinal side effect profile and is recommended in patients experiencing those side effects as a second-line treatment.

As he is taking the metformin three times daily we can assume he is on the immediate-release formulation. The modified release variant is usually given once daily (rarely twice daily).

As such he should be switched to the modified-release formulation of metformin, before trying anything else.

The correct answer is: Start a sodium-glucose transport protein 2 (SGLT2) inhibitor27%

At first glance there may be more than one correct answer - this is something you will come across in the exam where multiple answers may appear correct, but you are asked to select the most appropriate one.

He is on the maximum dose of metformin. Second-line options are a combination of metformin with another oral treatment.

Insulin and the GLP-1 injectables, as well as pioglitazone, are usually reserved for those not controlled with the other treatment options. Also know that pioglitazone should not be used in heart failure.

Whilst gliclazide is probably one of the most effective oral agents, it also carries the greatest risk of hypoglycaemia - something you really want to avoid in a lorry driver!

Gliptins may be another option but are probably the least effective drug and should only be used if there is no better alternative.

This only leaves a sodium-glucose transport protein 2 (SGLT2) inhibitor (the ‘gliflozins’).

The added benefit is that they appear to improve cardiovascular outcomes and reduce the admission rates for patients with heart failure - an extra benefit in this case. They do carry a small hypoglycaemia risk, but much less so than gliclazide.

We should also warn patients about the small risk of DKA even at relatively low blood sugar levels. They should be used with caution in patients with renal impairment and the elderly.

The correct answer is: Start a glucagon-like peptide-1 (GLP-1) receptor agonist

Again, this question appears to have more than one correct answer at first glance.

You may consider starting/adding a gliptin, insulin, a GLP-1 receptor agonist or pioglitazone as the next step.

NICE recommends the following step wise approach to managing type 2 diabetes:

Start with lifestyle modifications, then add metformin

Add second oral drug to metformin

If this fails, NICE recommends triple therapy with either

Metformin + gliclazide + gliptin/glifozin/pioglitazone or

Metformin + pioglitazone + glifozin or

Insulin +/- other drug

If triple therapy fails, we may consider a GLP-1 receptor agonist like Exenatide (GLP-1 receptor agonist should be limited for people with obesity).

As we can see, this man was already on triple therapy. Replacing Dapagliflozin with a gliptin would unlikely improve his HbA1c significantly (remember that gliptins are one of the least effective drugs).

He has heart failure, so pioglitazone is contraindicated.

He is significantly overweight and has already struggled with hypos. As such we should really hold off giving him insulin at this stage.

Starting him on a GLP-1 receptor antagonist like Exenatide would be the best option here - it carries almost no risk for hypoglycaemia, may result in weight loss and is recommended by NICE.

Currently, this class of drug is one of the most expensive diabetic drugs on the market. He would need to achieve an 11 mmol/mol (1%) reduction in HbA1c AND 3% weight loss in the first 6 months in order for it to be continued.

Question 70

A 32-year-old woman presents to the obstetric clinic at 30 weeks gestation. She has been diagnosed with gestational diabetes and was started on metformin two weeks previously. Despite a well controlled diet and maximum dose metformin, her blood glucose levels remain too high.

What is the next most appropriate step to control blood glucose in this woman?

• Add on a sulfonylurea and review in two weeks
• Stop metformin as start insulin therapy
• Add on an sodium-glucose co-transporter-2 (SGLT-2) antagonist and review in one week
• Add on insulin therapy
• Continue metformin and review in two weeks

Answer 70

Add on insulin therapy.

In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added

Important for meLess important

This woman has gestational diabetes and hyperglycaemia associated with this can result in macrosomia, premature birth and stillbirth. It is therefore vital that glucose levels are brought under control as quickly as possible. NICE state that ‘if blood glucose targets are not met with diet and exercise changes plus metformin, offer insulin as well’.1 Adding on insulin therapy is therefore the most appropriate thing to do.

Sulfonylureas are not as effective as the metformin and insulin combination in pregnancy.² In addition, they have been shown to be teratogenic in animals. They are therefore not indicated in gestational diabetes.

Stopping metformin would not be ideal as it increases sensitivity to insulin, something which is lacking during pregnancy. Instead, it is safe to continue metformin while adding insulin therapy.

Sodium-glucose co-transporter-2 (SGLT-2) antagonists are also associated with teratogenic effects in animals. They are a very useful option for diabetes management in patients with congestive heart failure due to their diuretic effects.

Continuing metformin alone for a further two weeks in spite of persistently high blood glucose will increase the risk of complications. Insulin should be added at this stage.

1 NICE (2015). Diabetes in pregnancy: management from preconception to the postnatal period
² BMJ (2015). Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis.

Question 71

A 26-year-old pregnant woman with type 1 diabetes asks you how often she should test blood glucose levels throughout her pregnancy?

• Daily fasting test
• Daily bedtime test
• Daily 1-hour post meal test
• Daily fasting, pre-meal, 1-hour post-meal and bedtime tests.
• Daily pre-meal test

Answer 71

Daily fasting, pre-meal, 1-hour post-meal and bedtime tests.

Pregnant patients with type 1 diabetes should monitor their blood glucose levels closely. They should test their levels multiple times during the day. NICE NG3

Question 72

A 34-year-old female comes to see you in clinic in the third trimester as her foetus is large for gestational age. She has pre-existing type 2 diabetes and usually takes oral hypoglycaemics to control her blood glucose. She would like some advice about which tablets she can take when she breastfeeds. Which of the following oral hypoglycaemics is safe when breastfeeding?

• Gliclazide
• Metformin
• Exenatide
• Liraglutide
• Sitagliptin

Answer 72

METFORMIN

Sulfonylureas (gliclazide) should be avoided when breastfeeding due to theoretical risk of neonatal hypoglycaemia.

Exenatide, liraglutide, and sitagliptin should be avoided when breast feeding.

Metformin is safe to use when breast feeding.

Question 73

What is target blood pressure for a 56-year-old man with type 2 diabetes mellitus who has no end-organ damage, if using a clinic blood pressure reading?

• < 125/75 mmHg
• < 130/75 mmHg
• < 130/80 mmHg
• < 140/80 mmHg
• < 140/90 mmHg

Answer 73

< 140/90 mmHg

• T2DM blood pressure targets are the same as non-T2DM. If < 80 years:
• clinic reading: < 140 / 90
• ABPM / HBPM: < 135 / 85
• Important for meLess important
• The target blood pressure for patients with type 2 diabetes mellitus are no different from those without diabetes, regardless of whether they have end-organ damage.

Question 74

A 32-year-old man is prescribed a 5-day course of amoxicillin following a diagnosis of community acquired pneumonia (CURB-65 score of 1). He has a past medical history of type 1 diabetes mellitus, which is well controlled with an insulin basal-bolus regime.

What action should be taken with regards to this patients insulin therapy?

• Admit the patient for sliding insulin scale
• Decrease the dose of insulin to lower the risk of hypoglycemia
• Increase the dose of insulin and advise regular checking of blood sugar levels
• Increase the dose of insulin to lower the risk of diabetic ketoacidosis
• No change in dose of insulin

Answer 74

No change in dose of insulin

Diabetes sick day rules: when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently.

Admitting a patient to the hospital would only be indicated in a CURB score of 2 or greater.

The dose of insulin should not be decreased as this would increase the risk of diabetic ketoacidosis.

The dose of insulin should not be increased as this puts the patient at risk of hypoglycaemia.

The dose of insulin should not be changed, but the patient should be advised to keep hydrated and frequently check their blood sugar levels.

Question 75

You are doing the annual review for a 67-year-old man who has type 2 diabetes. His glycaemic control is reasonable with metformin therapy; the latest HbA1c is 54 mmol/mol (7.1%). A few weeks ago he was noted to have a clinic blood pressure reading of 152/90 mmHg. A 24 hour blood pressure monitor was requested. The report shows his average blood pressure was 142/88 mmHg. What is the most appropriate course of action?

• Do nothing for now, monitor his blood pressure regularly
• Start an ACE inhibitor
• Start a calcium channel blocker
• Repeat the 24 hour blood pressure monitor in 4-8 weeks time
• Request an ultrasound of his kidneys

Answer 75

Start an ACE inhibitor.

Hypertension in diabetics - ACE inhibitors/A2RBs are first-line regardless of age.

This patient has stage 1 hypertension as defined by NICE. He should however be treated because he has underlying diabetes.

The first-line treatment for a patient aged > 55 years is a calcium channel blocker. However, in patients with diabetes ACE inhibitors are used first-line due to their renoprotective effect.

Question 76

A 25-year-old primigravida presents to her General Practitioner at 25-week gestation following a referral from her midwife who found glucose present during a routine urinalysis. The following results are noted:

Blood pressure129/89 mmHg

Fundal height25.5 cm

Fasting plasma glucose6.8 mmol/L

What intervention should be offered to this patient?

• Commence insulin
• Commence metformin
• Aim for 1-2kg weight loss within next 1-2 weeks
• Trial of diet and exercise for 1-2 weeks
• Home monitoring of blood glucose for 2 weeks

Answer 76

Trial of diet and exercise for 1-2 weeks.

Gestational diabetes: if the fasting plasma glucose is < 7 mmol/l a trial of diet and exercise should be offered for 1-2 weeks

Important for meLess important

This patient is presenting with elevated fasting plasma glucose (6.8 mmol/L) and may have gestational diabetes. The most appropriate management for this is a trial of diet and exercise to attempt to control blood glucose without pharmacological intervention. The patient should be advised to eat a high fibre diet with minimal foods containing refined sugars. During this period, the patient will be asked to check their blood glucose regularly as there are significant risks to the foetus with gestational diabetes and the patient should contact their team if ongoing elevated readings despite lifestyle interventions.

If this patient had initial fasting plasma glucose of 7 mmol/L or more, insulin should be started. The vignette shows a patient with initial fasting glucose lower than this (6.8 mmol/L), however, if her blood glucose is not controlled by diet or metformin, she will need insulin.

If there is no improvement (or improvement is not to an adequate level) within 1-2 weeks, the patient should be started on metformin. If metformin is inadequate, the patient will then be started on insulin too.

Women who are pregnant should not be aiming to lose weight. Women are advised to maintain a balanced diet, high in fruit, vegetables, and unrefined foods. This option is also incorrect as gestational diabetes is caused by insulin insensitivity which affects women across the BMI spectrum.

It is inappropriate to advise the patient to only monitor blood glucose at home for 2 weeks without any interventions (such as diet and exercise). The patient has been flagged to have elevated blood glucose and this is unlikely to change without any lifestyle intervention. While it is part of the management, it is not an exclusive intervention that should be offered.

Question 77

You review a 68-year-old man who has type 2 diabetes mellitus. He was noted during recent retinal screening to have pre-proliferative changes in his right eye but is otherwise well with no history of cardiovascular disease. What should his target blood pressure be, if using home blood pressure monitoring?

• < 140 / 90 mmHg
• < 125 / 70 mmHg
• < 125 / 75 mmHg
• < 130 / 75 mmHg
• < 135 / 85 mmHg

Answer 77

< 135 / 85 mmHg

T2DM blood pressure targets are the same as non-T2DM. If < 80 years:

clinic reading: < 140 / 90

ABPM / HBPM: < 135 / 85

The target blood pressure for patients with type 2 diabetes mellitus are no different from those without diabetes, regardless of whether they have end-organ damage.

Question 78

A 32-year-old woman is referred to the joint antenatal and diabetic clinic after being diagnosed with gestational diabetes mellitus. She is currently 25 weeks pregnant and this is her first pregnancy. There is no history of any pregnancy-related problems in her family but her father has type 1 diabetes mellitus. The examination is normal, other than a raised BMI of 32 kg/m².

Which of the following would be diagnostic for this woman’s condition?

• 2-hour glucose level >= 5.6 mmol/L
• Fasting plasma glucose >= 5.6 mmol/L
• Glucose >= 6.4 mmol/L 2-hours after mealtime
• Glucose >=7.8 mmol/L 1-hour after mealtime
• Random plasma glucose >= 7.8 mmol/L

Answer 78

Fasting plasma glucose >= 5.6 mmol/L

Gestational diabetes can be diagnosed by either a:

fasting glucose is >= 5.6 mmol/L, or

2-hour glucose level of >= 7.8 mmol/L

‘5678’

Important for meLess important

This patient has been diagnosed with gestational diabetes mellitus in her first pregnancy - she was at an increased risk of this due to her raised BMI and the presence of a first-degree relative with diabetes mellitus. Women with risk factors and no previous history of gestational diabetes mellitus undergo an oral glucose tolerance test at around 24 weeks. Gestational diabetes mellitus is diagnosed if the patient has fasting glucose above 5.6 mmol/L or 2-hour glucose above 7.8 mmol/L on either of these occasions. The correct answer is therefore fasting plasma glucose of above 5.6 mmol/L.

A 2-hour glucose level above 5.6 mmol/L would not be diagnostic of gestational diabetes mellitus. The 2-hour glucose level needs to be above 7.8 mmol/L for diagnosis.

Glucose of 6.4 mmol/L 2-hours after mealtime is one of the glucose targets for women with gestational diabetes mellitus so this answer is not correct.

Glucose of 7.8 mmol/L 1-hour after mealtime is another glucose target for women with gestational diabetes mellitus so this is not the correct answer.

Random plasma glucose tests are not part of the diagnostic process for gestational diabetes mellitus.

Question 79

A 54-year-old man has a routine medical for work. He is asymptomatic and clinical examination is unremarkable. Which of the following results establishes a diagnosis of impaired fasting glucose?

• Fasting glucose 7.1 mmol/L on one occasion
• Fasting glucose 6.8 mmol/L on two occasions
• Glycosuria ++
• 75g oral glucose tolerance test 2 hour value of 8.4 mmol/L
• HbA1c of 6.7%

Answer 79

Fasting glucose 6.8 mmol/L on two occasions

A 75g oral glucose tolerance test 2 hour value of 8.4 mmol/L would imply impaired glucose tolerance rather than impaired fasting glucose

Question 80

A 35-year-old asymptomatic woman presents to hospital for an oral glucose tolerance test (OGTT). She is 14 weeks pregnant with her second child. Her first pregnancy was complicated by gestational diabetes and foetal macrosomia. She has a body mass index of 36 kg/m2 but is otherwise healthy.

Her results are as follows:

Fasting glucose8.2 mmol/L(<5.6 mmol/L)

2 hour glucose12.5 mmol/L(<7.8 mmol/L)

How should this be managed?

• Lifestyle modifications
• Metformin
• Insulin plus or minus metformin
• Glibenclamide
• Pioglitazone

Answer 80

Insulin plus or minus metformin

If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l immediate insulin (plus or minus metformin) should be started

Important for meLess important

Insulin plus or minus metformin should be offered immediately to women with gestational diabetes mellitus (GDM) who have a fasting plasma glucose level of ≥7.0mmol/L at diagnosis.

Lifestyle modification (diet and exercise) should be offered to women with GDM who have a fasting plasma glucose level <7 mmol/L at diagnosis.

Metformin should be offered to women with GDM if blood glucose targets are not met after 1-2 weeks using lifestyle modification.

Glibenclamide should be offered to women with GDM who fail to achieve their blood glucose targets with metformin, or in those who decline insulin therapy.

According to the BNF pioglitazone should be avoided in pregnancy. Animal studies suggested that pioglitazone was toxic in pregnancy.

Question 81

A 53-year-old man with type 2 diabetes attends his GP for his annual diabetic check. He is currently taking Metformin 1g modified release twice daily with no issues. He has no other medical history. On examination he has a pulse rate of 67 bpm, a blood pressure of 141/83 mmHg and his body mass index is 53 kg/m². His most recent HbA1c is shown below:

HbA1c69 mmol/mol (29-42 mmol/mol)

Which of the following medications is most suitable to start next to control this man’s diabetes?

• Pioglitazone
• Sitagliptin
• Acarbose
• Insulin
• Gliclazide

Answer 81

Sitagliptin

DPP-4 inhibitors are useful in T2DM patients who are obese

Important for meLess important

This questions is essentially asking about which drug to use in the second intensification of oral therapy in type 2 diabetes. The NICE guidelines state that in this case the next step would be a choice between a sulfonylurea (in this case gliclazide), pioglitazone or a DPP-4 inhibitor (in this case sitagliptin). The reason a choice is offered is to allow clinicians to apply the guidelines in the most appropriate way to tailor the drug choice to the patient and it is this skill that the question is testing. This man is morbidly obese, with a BMI over 50 m/kg², which would make you want to start a therapy which is less likely to cause weight gain. The only one of the three choices which is appropriate is sitagliptin in this respect as gliclazide would cause significant weight gain by increasing the levels of insulin present and pioglitazone acts to change glucose and lipid metabolism in such a way that an increase in peripheral adipose tissue is always expected. Sitagliptin works by essentially increasing satiety and the insulin response to high-glucose content foods and so is more helpful in patients who overeat.

The best choice for a second intensification in non-obese patients would be a sulfonylurea such as gliclazide or glibenclamide as these are the most effective at reducing blood glucose, although they do come with the side-effect of hypoglycaemia which can be prolonged and quite severe. Therefore if the patient needs to avoid this, such as a professional driver, a different drug would be more appropriate. Additionally, an important contraindication to Pioglitazone is heart failure and for this reason it is rarely used now as some degree of heart failure is expected in those with ischaemic heart disease and this is a very common co-morbidity in type 2 diabetics.

Question 82

A 23-year-old man is diagnosed as having type 1 diabetes mellitus after presenting with diabetic ketoacidosis. His blood sugars are now stable and he is well. What is the first-line insulin regime he should be offered?

• Twice‑daily mixed insulin
• Once-daily mixed insulin
• Basal–bolus insulin regimen with twice-daily insulin detemir
• Basal–bolus insulin regimen with once-daily insulin glargine
• Rapid‑acting insulin analogue before each meal with no longer acting insulin

Answer 82

Basal–bolus insulin regimen with twice-daily insulin detemir

In newly diagnosed adults with type 1 diabetes, the first-line insulin regime should be a basal–bolus using twice‑daily insulin detemir

Question 83

A 46-year-old man comes to see you complaining of feeling more tired than usual. He is worried that he may have developed diabetes like his father. You order a set of blood which show a HbA1c of 45 mmol/mol.

Which one of the following is the best course of action?

• Discuss diet and exercise
• Start metformin 1g BD
• Start metformin 500mg BD
• Reassure and advise repeat in 6 weeks
• Refer to endocrinologist

Answer 83

Discuss diet and exercise

A HbA1c between of 42-47 mmol/mol is indicative of prediabetes.

Patients with prediabetes should be actively encouraged to increase physical activity and lose weight and improve diet by increasing dietary fibre intake and reducing fat intake. Metformin can also be considered in patients with prediabetes, however, this would be started at 500mg OD.

Patients diagnosed with prediabetes should have their HbA1c repeated at regular intervals as they are at high risk of developing diabetes.

Question 84

A 32-year-old pregnant woman of South Asian origin is 10+0 weeks into her second pregnancy. She has had one natural delivery at 39 weeks to a healthy child, and no other previous pregnancies. Since she has a strong family history of type 2 diabetes mellitus, she is offered a fasting glucose test at her booking visit. Her fasting glucose level is 7.2 mmol/L.

What is the most appropriate initial management given her fasting glucose level?

• Advice on diet and exercise
• Advice on diet and exercise plus daily blood glucose monitoring
• Gliclazide
• Insulin
• Metformin

Answer 84

Insulin.

If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l immediate insulin (plus or minus metformin) should be started

Important for meLess important

When fasting glucose is >7 mmol/L at the diagnosis of gestational diabetes insulin should be started immediately. This makes insulin the correct answer here.

Advice on diet and exercise alone would be inappropriate here due to her high fasting glucose level. Advice should be given alongside insulin therapy. Although regular glucose monitoring is key to the management of gestational diabetes when fasting glucose >7 mmol/L at diagnosis insulin should be started.

Sulfonylureas such as gliclazide are contraindicated in pregnancy due to increased risk of fetal macrosomia.

Metformin may be given alongside insulin in this case, but not as monotherapy.