Diabetes

Question 1

In what order should diabetes drugs be given (and step up treatment)

Answer 1

1. Metformin only
2. Metformin + sulphonylurea
3. Metformin + sulphonylurea + 3rd agent (PPPAR-gamma, GLP-1 mimetic, SGLT2 inhibitor)
4. Insulin (if not already used)

Question 2

Novorapid is a fast/ long acting insulin

Answer 2

Novorapid

Fast

Question 3

Glargine is a fast/ long acting insulin

Answer 3

Glargine

Long

Question 4

Determir is a fast/ long acting insulin

Answer 4

Determir

Long

Question 5

Humalog is a fast/ long acting insulin

Answer 5

Humalog

Fast

Question 6

Autonomic symptoms of hypoglycaemia

Answer 6

Sweating
Palpitations
Hunger

Question 7

Neuro symptoms of hypoglycaemia

Answer 7

Drowsiness
Confusion
Lack of coordination
Soeech difficulties

Question 8

Management of hypoglycaemia

Answer 8

IM glucagon

IV dextrose

Question 9

How to calculate anion gap

Answer 9

Anion gap = (Na+K) – (HCO3 + Cl)

= anions - cations

Question 10

Causes of high anion gap metabolic acidosis

Answer 10

CAT MUDPILES

• Congenital heart failure, cyanide, carbon monoxide
• Aminoglycosides
• Theophylline, Toluene (glue sniffing)
• Methanol, metformin
• Uraemia
• DKA (or alcoholic/ starvation ketoacidosis)
• Paracetamol, phenformin, paraldehyde
• Iron, isoniazid, inborn errors of metabolism
• Lactic acidosis
• Ethanol (due to lactic acidosis), Ethylene glycol
• Salicylates (Aspirin)

Question 11

How is the insulin regime changed when treating DKA

-in pt who normally takes long-acting insulin

Answer 11

Continue long acting insulin at usual dose and time

Question 12

How is the insulin regime changed when treating DKA

-in pt who normally takes 2x daily fixed mix insulin

Answer 12

Re-introduce at next meal (breakfast or evening)

Question 13

When to discontinue IV insulin in DKA patient

Answer 13

After meal.

Give fast-acting insulin with meal.

Stop IV insulin and IV fluids 30min later

Question 14

How does metformin work

Answer 14

Biguanide

Inhibits hepatic gluconeogenesis

Question 15

How does gliclizide work

Answer 15

Sulfonylurea

Increases insulin secretion from beta cells

Question 16

How does pioglitazone work

Answer 16

Thiazolidinedione

Improves sensitivity of beta cells to insulin

Question 17

How do SGLT2 inhibitors work

Answer 17

Inhibit sodium glucose transporter 2

Prevents renal glucose reabsorption

Question 18

How to Incretin (GLP-1 mimetics) work

Answer 18

Enhances glucose dependent insulin secretion

Question 19

How to DPP-IV inhibitors work

Answer 19

Prolongs half life of GLP-1

Question 20

Pre-operative changes to insulin regime in a T1DM pt

Answer 20

1. Give usual insulin on evening before surgery
2. Omit morning SC dose. Set up IV infusion

Infusion glucose and KCl at 100ml/h + insulin at 2 units/h

Question 21

Post-operative changes to insulin regime in a T1DM pt

Answer 21

1. Give SC insulin with 1st meal

2. Stop IV insulin 1h later

Question 22

Clinical features of hypoglycaemia

Answer 22

Reduced GCS
Clammy skin

(think of neuro and autonomic symptoms)

Question 23

Clinical features of DKA

including diagnostic triad

Answer 23

• Reduced GCS
• Abdominal pain

1. Ketonaemia (>3mmol/L)
2. Hyperglycaemia (>11mmol/L)
3. Acidaemia (pH <7.3 or Bicarb <15)

Question 24

How to treat hypoglycaemia

Answer 24

Depends on severity

MILD: sugar containing drink
MODERATE: buccal dextrose fel
SEVERE: IV dextrose 10% or 1mg glucagon IM/SC

Question 25

How to treat DKA

Answer 25

1. IV fluids
2. IV fast-acting insulin at 0.1units/kg/hour
3. IV KCl at 20mmol/h
   (or 40mmol/h if 3.5-5.5)

Reassess and monitor

Question 26

Side effect of pioglitazone

Answer 26

Pioglitazone causes fluid retention

Question 27

Which diabetic drug can cause thrush

Answer 27

Gliflozin

Due to excretion of glucose in urine