Diabetes

Question 1

Threshold values for diabetes diagnosis

Answer 1

Fasting blood glucose >7 mmol/L

Random/post-load glucose >11.1 mmol/L

HbA1c >48mmol/mol (6.5%)

Question 2

How many measurements of HbA1c are needed to diagnose diabetes?

Answer 2

Symptomatic -> 1 hyperglycaemic measurement

Asymptomatic –> 2 hyperglycaemic measurements 2-3 months apart

Question 3

When can HbA1c not be used for diagnosis of diabetes?

Answer 3

Pregnant/post-partum

Acute illness

Recent onset (<3mo) diabetes

Type 1 diabetes

Renal failure

HIV

Pancreatic disease/surgery

Antipsychotics or steroids <2mo

Question 4

HbA1c targets in T2DM

Answer 4

First-line: <48mmol/mol (6.5%)

Second-line and beyond: <53 mmol/mol (7.5%)

Question 5

Microvascular complications of diabetes

Answer 5

Retinopathy, glaucoma, cataracts - annual screening

Nephropathy - blood pressure, fluid retention, microalbuminuria

Neuropathy - sensory and autonomic

Question 6

Symptoms of diabetes

Answer 6

Tiredness

Blurred vision (intermittent)

Polydipsia, polyuria

Autonomic neuropathy symptoms

Infections (Esp UTIs)

Question 7

Features of autonomic neuropathy in diabetes

Answer 7

Gastroparesis

Diarrhoea/constipation

ED

Postural hypotension

Bladder dysfunction

Question 8

Macrovascular complications of diabetes

Answer 8

Infections (immunosuppression)

PVD - ulcers/poor healing

IHD

CVA

Question 9

Management of macrovascular complications of T2DM

Answer 9

BP control and lipid regulation

Question 10

Frequency of HbA1c monitoring in T2DM

Answer 10

3-6 monthly until stable

6-monthly when stable

Annual retinal, renal, BP, lipid screening

Question 11

Antihypertensive treatments in T2DM

Answer 11

ACE-I as first-line

Don’t switch on diagnosis unless evidence of poor control

Question 12

Normal lipid profile

Answer 12

Total cholesterol <5

HDL >1

LDL <3

Triglycerides <2.3

Question 13

Indications for statins in diabetes

Answer 13

>40yo

QRISK >10.0%

20mg atorvastatin

Question 14

Indications for increasing statin dose in diabetes

Answer 14

total cholesterol >4

LDL >2

Question 15

Screening for diabetics

Answer 15

Annually:

Retinal/cataract screen

Foot care

Nephropathy: early am alb:creatinine ratio

CVD: BP and lipids

Erectile dysfunction

Question 16

Dietary adice for diabetes

Answer 16

Encourage low-glycaemic-index foods (complex carbs)

Reduce energy intake - 5-10% weight loss target

Increase fruit and veg, wholegrains, fish (Mediterranean)

Reduce fat

Reduce salt (BP control)

Question 17

Lifestyle advice for diabetes

Answer 17

Smoking

Alcohol

Weight loss

Exercise

Question 18

DVLA criteria for group 1 license, non-insulin

Answer 18

No need to notify if:

<=1 severe hypo in past 12mo AND >=3mo since last episode

Under regular review

Question 19

DVLA criteria for group 1 license, insulin-treatment

Answer 19

Must notify DVLA

<=1 severe hypo in past 12mo and >=3mo since last episode

Adequate awareness of hypoglycaemia (warning signs)

Question 20

DVLA criteria for group 2 license, insulin-treated

Answer 20

Must notify DVLA

No severe hypos in past 12 months

Regular glucose monitring with reader with >=3mo memory

Full awareness of hypoglycaemia

Question 21

DVLA criteria for group 2 license, non-insulin therapy

Answer 21

Must notify

No severe hypos in past 12months

Regular monitoring (eery 2 hours while driving)

Full awareness of hypoglycaemia

Question 22

Options for drug management of T2DM

Answer 22

Metformin (biguanide)

Sulphonylureas (Gliclazide)

DPP-4 inhibitors (gliPtins)

GLP-1 mimetics (e.g. exenatide)

Pioglitazone

SGLT-2 inhibitors (Gliflozins)

Question 23

Metformin doses

Answer 23

500mg - 2.4 g/day over 2-3 doses

Question 24

Contra-indications for metformin

Answer 24

Increased risk of lactic acidosis:

Impaired renal f(x) - check eGFR

CCF

Liver disease

Chronic alcoholism

Acute illness (e.g. sepsis, shock)

Question 25

Contraindications to glitazones

Answer 25

PMHx/risk of bladder cancer (incl. uninvestigated frank haematuria) Fracutres Heart failure or risk of

Question 26

When to consider insulin treatment

Answer 26

Third-line (when considering triple drug therapy)

Question 27

Criteria for use of GLP-1 mimetic

Answer 27

Tolerance to self-injecting BMI \>35 and weight-related co-morbidity BMI \<35 AND insulin has occupational implications or weight loss would improve physical/psychological wellbeing

Question 28

Risk factors for T2DM

Answer 28

Age \>65 Obesity FHx of T2DM South Asian/Afro-Caribbean Gestational diabetes or baby \>4kg

Question 29

Pre-diabetes diagnostic criteria

Answer 29

fbg \>6.1 HbA1c 42-47 mmol/mol Follow up annually with aggressive treatment of CVD risk factors

Question 30

Diabetes therapy in renal failure

Answer 30

Linagliptin (DPP-4 inhibitor) - excreted via gall bladder

Question 31

Main SE of metformin

Answer 31

GI upset (diarrhoea)

Question 32

Main SEs for sulphonyureas (e.g. gliclazide)

Answer 32

Weight gain High risk of hypos (take before meals) Not in renal impairment

Question 33

Weight-neutral antihyperglycaemic

Answer 33

DPP-4 inhibitors (gliptins)

Question 34

Pioglitazone SEs

Answer 34

Safe in renal impairment Low hypo risk Weight gain HF Bladder cancer

Question 35

GLP-1 mimetic SEs

Answer 35

Pancreatitis Injection needed High cost

Question 36

Gliptin SEs

Answer 36

DPP4 inhibitors Heart failure Pancreatitis

Question 37

Weight loss antiglycaemics

Answer 37

Metformin GLP-1 mimetics gliflozins