Diabetes

Question 1

How is diabetes defined using the WHO criteria?

Answer 1

Fasting plasma glucose >7.0mmol/l
Random plasma glucose >11.1 mmol/L
HbA1c >48mol/mol
One abnormal value + symptoms = diabetes
OR
Two abnormal values = diabetes

Question 2

In what cases of diabetes is an oral glucose tolerance test required for diagnosis?

Answer 2

Gestational diabetes mellitus

Question 3

Other than type one and two, what types of Diabetes Mellitus are there?

Answer 3

MODY
Gestational diabetes
Pancreatic diabetes mellitis
Latent autoimmune disease of adulthood

Question 4

What diagnostic investigations can be used to help different between different types of Diabetes Mellitus?

Answer 4

Ketone testing +/- bicarbonate
Pancreatic auto-antibodies
C peptide testing

Question 5

What autoantibodies are often found in type one Diabetes Mellitus?

Answer 5

Glutamic acid decarboxylase antibodies

Insulinoma associated antigen 2 antibodies

Question 6

Patients with type two Diabetes Mellitus can have islet autoantibodies. T/F?

Answer 6

True

Question 7

What substance is secreted in equimolar concentrations to insulin and is a useful marker of endogenous insulin secretion?

Answer 7

C-peptide

Question 8

At what point in the diagnosis of diabetes is the c-peptide test most useful?

Answer 8

3-5 years from diagnosis

Question 9

Describe the cause of type one diabetes?

Answer 9

Autoimmune destruction of the insulin producing beta cells in the islets of lagerhands.

Question 10

What environmental factors have been linked to an increased risk fo T1DM?

Answer 10

Viral infections (enterovirus)
Immunisations
Diet (early exposure to cow's milk)
High socioeconomic status
Obesity
Vitamin D deficiency
Perinatal factors - maternal age, history of preeclampsia, neonatal jaundice, low north weight (protective factor)

Question 11

A family history of diabetes is more significant in type one diabetes than type two. T/F?

Answer 11

False - the opposite is true

Question 12

What type of diabetes makes up the majority of cases?

Answer 12

Type two Diabetes Mellitus

Question 13

What can cause pancreatic diabetes?

Answer 13

Pancreatectomy
Pancreatitis
Haemochromatosis
Carcinoma
Cystic fibrosis

Question 14

Why is there a higher risk of hypoglycaemia in pancreatic diabetes than in type one diabetes?

Answer 14

Because pancreatic diabetes also results in loss of alpha cells which produce glucagon

Question 15

What are the main features of MODY?

Answer 15

<25 years at onset
C peptide not low
Pancreatic autoantibodies negative
Runs in families in AD pattern

Question 16

How is MODY managed?

Answer 16

By managing diet, oral hypoglycaemic agents and insulin

Question 17

What genes are. particularly associated with T1DM?

Answer 17

HLA DR3/4

Question 18

What endocrinopathies can cause diabetes?

Answer 18

Acromegaly, Cushing’s, phaechromocytoma

Question 19

What immunosuppressive agents can cause diabetes?

Answer 19

Clozapine

Olanzzipine

Question 20

What genetic syndrome can cause diabetes>

Answer 20

Down’s syndrome
Friedreich’s ataxia
Turner’s myotonic dystrophy
Kleinfelter’s syndrome

Question 21

How is T1DM managed?

Answer 21

Insulin replacement
Glucose/ketone monitoring
Carbohydrate counting
Structured education
Supported self management

Question 22

What insulin regimen are most T1DM patients on?

Answer 22

Basal bolus regimen

Question 23

A BD mix insulin regime requires less injections. What are the disadvantages of this regimen?

Answer 23

Requires regimented diet and eating time

Increased likelihood of hypos

Question 24

How can glucose monitoring be conducted?

Answer 24

Glucose/ketone meters

Flash glucose monitoring (freestyle libra)

Question 25

How can insulin be administered?

Answer 25

Insulin pen | Insulin pump

Question 26

What HbA1c target is aimed for in T1DM?

Answer 26

<53 mol/L

Question 27

What is the target blood sugar level before breakfast in T1DM?

Answer 27

5.5-7 mol/l

Question 28

What is the target blood sugar level before lunch and dinner in T1DM?

Answer 28

4.5-7.5 mol/l

Question 29

What is the target blood sugar level before bed in T1DM?

Answer 29

6.5-8 mol/l

Question 30

What factors need to be discussed when educating patients with T1DM?

Answer 30

``` Administration of insulin Glucose/ketone monitoring Sick day rules Hypoglycaemia Driving regulations Exercise and alcohol Pregnancy Targets Complications ```

Question 31

Carbohydrate counting is only used in which insulin regimen?

Answer 31

Basal bolus regimen

Question 32

What are the goals of therapy in T2DM?

Answer 32

Reduce rates of microvascular complications Minimise CVD risk Reduce rates of microvascular complications

Question 33

Give examples of microvascular complications of T2DM?

Answer 33

Retinopathy Nephropathy Foot disease

Question 34

Give examples of macrovascular complications of T2DM?

Answer 34

MI Stroke Heart failure Peripheral vascular disease

Question 35

What factor is most important in preventing microvascular disease in T2DM?

Answer 35

Good glycemic control

Question 36

What are the targets for the treatment of T2DM?

Answer 36

HbA1c of 7% BP <130/80mmHg Cholesterol. <5 once statins started Normal body weight

Question 37

At what age should patients with T2DM be started on statins?

Answer 37

>40 years

Question 38

What is the first line treatment of T2DM?

Answer 38

Metformin

Question 39

What drugs can be added to metformin in the second line treatment of T2DM?

Answer 39

Sulphonylureas SGLT-2 inhibitors DPP-4 inhibitors Glitazones

Question 40

Another second line agent can be added in the third line management of T2DM, alternatively an injectable medication can be used. Give examples of these injectable medications?

Answer 40

Insulin | GLP-1 agonists

Question 41

How does metformin act as a hypoglycaemic agent?

Answer 41

Suppresses hepatic gluconeogenesis to reduce glucose output from the liver Increases peripheral insulin sensitivity Increases glucose uptake and ultilisation Increases AMPK activity

Question 42

What effect does metformin have on weight?

Answer 42

Reduces weight

Question 43

What are the side effects of metformin?

Answer 43

GO side effects

Question 44

Why can metformin not be used if eGFR is <30?

Answer 44

Small risk of lactic acidosis

Question 45

What is the efficacy of metformin?

Answer 45

Moderate

Question 46

Which hypoglycaemic agents reduce weight?

Answer 46

Metformin SGLT2 inhibitors GLP-1 receptor agonists

Question 47

Which hypoglycaemic agents result in weight gain?

Answer 47

Sulphonylureas Thiazolidinediones Insulin

Question 48

Which hypoglycaemic agent is weight neutral?

Answer 48

DPP-4 inhibitors

Question 49

Which hypoglycaemic agent should be used at a rescued dose in CLD?

Answer 49

DPP-4 inhibitors

Question 50

Which hypoglycaemic agents can't be used in CKD?

Answer 50

Metformin (<30 eGFR) Caution use of sulphonylurea SGLT2 inhibitors

Question 51

What is the mechanism of action of sulphonylureas?

Answer 51

Bind to SUR1 receptor on cell membrane of pancreatic beta cells which results in closure of ATP-potassium channels which allows an influx of calcium which results in exocytosis of insulin

Question 52

What is the efficacy of sulphonylureas?

Answer 52

High efficacy

Question 53

What are the disadvantages of the use of sulphonylureas?

Answer 53

No CV benefit Weight gain High hypoglycaemic risk Caution use in CKD

Question 54

What is the mechanism of action of DPP-4 inhibitors?

Answer 54

Rapidly inactivate DPP-4 which prolongs the action fo endogenous incretins, enhancing the first phase insulin response.

Question 55

What is the efficacy of DPP-4 inhibitors?

Answer 55

Low/moderate efficacy

Question 56

There is a low risk of hypos with DPP-4 inhibitors. T/F?

Answer 56

True

Question 57

Which hypoglycaemic agents also have a CV benefit?

Answer 57

Metofmrin Thiazolidinedione (probably) SGLT-2 inhibitors GLP-1 receptor agonists

Question 58

What is the mechanism of action of SGLT2 inhibitors?

Answer 58

Inhibit SGLT2 glucose transporters in the proximal convoluted tubule of the kidney to decrease the renal reabsorption of glucose

Question 59

What is the efficacy of SGLT2 inhibitors?

Answer 59

Moderate efficacy

Question 60

What are the risks associated with the use of SGLT2 inhibitors?

Answer 60

GU infections | Small risk of hypovolaemia/DKA

Question 61

What is the mechanism of action of thiazolidinediones?

Answer 61

Increased insulin sensitivities by acting as. ligands for the nuclear hormone receptor PPARgamma to regulate its transcription activity. This reduces the availability of fatty acids as an energy source, thereby favouring the utilisation of glucose.

Question 62

What is the efficacy of thiazolidinidiones?

Answer 62

Moderate

Question 63

Why are thiazolidinidiones no longer commonly used?

Answer 63

Cause fluid retention | Fractures

Question 64

In addition to increasing the endogenous effects of icnretins, what are the effects of GLP-1 receptor agonists?

Answer 64

Increases satiety | Suppress appetite

Question 65

What is the efficacy of GLP-1 receptor agonists?

Answer 65

High efficacy

Question 66

Which hypoglycaemic agent has the highest hypoglycaemia risk?

Answer 66

Insulin

Question 67

What considerations need to be taken when prescribing hypoglycaemic agents in elderly patients?

Answer 67

Increased poly pharmacy which increases risk of drug interactions Increased likelihood of adverse reactions Likely to have decreased eGFR so some agents not suitable Increased risk fo hypoglycaemia Important to individualise therapy

Question 68

Can metofmrin be prescribe in heart failure?

Answer 68

It can be used in chronic heart failure but should be withheld with acute episodes of failure

Question 69

Can thiazolidinediones be used in heart failure?

Answer 69

No

Question 70

Which hypoglycaemic agent reduces hospitalisations for heart failure, with and without diabetes?

Answer 70

SGLT2 inhibitors