Diabetes Flashcards by Natalka K

What are the eight care processes assessed by the National Diabetes Audit (NDA) (as per the 2019 report covering 2017-2018)?

Measure HbA1c;
Measure BP;
Measure serum cholesterol;
Measure serum creatinine;
Measure urine albumin/creatinine ratio;
Foot risk surveillance;
Calculation of body mass index;
Record of smoking history;

(digital retinal screening is a ninth care process: NHS diabetic eye screening are responsible for this, rather than diabetic care providers)

How well did you know this?

Not at all

Perfectly

what does NICE recommend re: statin use for primary prevention of CVD in people with T1DM?

offer statin for primary prevention of CVD to all adults with T1DM who meet one of the following criteria:

older than 40, or

have had diabetes for over 10 years, or

have established nephropathy, or

have other CVD risk factors.

The recommended statin is atorvastatin 20mg.

How well did you know this?

Not at all

Perfectly

what dos NICE recommend re: statin use for primary prevention of CVD in people with T2DM?

atorvastatin 20mg for those with 10% or greater 10-year risk of developing CVD as calculated with QRISK2.

How well did you know this?

Not at all

Perfectly

what is the first line antihypertensive choice drug for adults with T2DM?

ACEi or ARB

How well did you know this?

Not at all

Perfectly

how often should HbA1c levels be measured in adults with T2DM?

every 3 to 6 months until HbA1c is stable on unchanging therapy at which point, at 6-monthly intervals.

How well did you know this?

Not at all

Perfectly

what is the NICE recommended HbA1c target level for adults with T2DM managed by lifestyle and diet?

48 mmol/mol (6.5%)

How well did you know this?

Not at all

Perfectly

what is the NICE recommended HbA1c target level for adults with T2DM managed by lifestyle and diet plus one drug not associated with hypoglycaemia?

48 mmol/mol (6.5%)

How well did you know this?

Not at all

Perfectly

what is the NICE recommended HbA1c target level for adults with T2DM managed with a drug associated with hypoglycaemia?

53 mmol/mol (7.0%)

How well did you know this?

Not at all

Perfectly

what is the NICE recommended HbA1c target level for adults with T2DM who require more than one drug for T2DM management?

53 mmol/mol (7.0%)

How well did you know this?

Not at all

Perfectly

for someone with T2DM and HbA1c above 48mmol/mol (6.5%) on lifestyle and diet treatment, what should the next treatment step be?

offer standard-release metformin, gradually increasing the dose over several weeks to minimise GI side effects (if pt experiences GI side effects, consider trial of modified-release metformin)

How well did you know this?

Not at all

Perfectly

for T2DM patients whose HbA1c levels rise to 58mmol/mol (7.5%) or higher on a single drug, what is the next treatment step?

intensify the drug treatment, consider dual therapy with metformin and one of the following:
DPP-4 inhibitor; or pioglitazone; or sulfonylurea; or SGLT-2 inhibitor.

AND reinforce diet/lifestyle/drug treatment adherence advice.

How well did you know this?

Not at all

Perfectly

what does DPP-4 stand for

dipeptidyl peptidase-4

How well did you know this?

Not at all

Perfectly

what does SGLT2 stand for?

sodium-glucose cotransporter 2

How well did you know this?

Not at all

Perfectly

for T2DM patients with HbA1c targets not met on dual therapy with metformin and another oral drug, what is the next stage of treatment?

intensify drug treatment: consider:

triple therapy with metformin and:
-a DPP-4 inhibitor and a sulfonylurea;
or
-pioglitazone and a sulfonylurea;
or
-(pioglitazone or sulfonylurea) and an SGLT2 inhibitor.

starting insulin-based treatment

If BMI above 35 kg/m2 and there are specific psychological or other medical problems ass’d with obesity, or BMI below 35 kg/m2 and insulin therapy would have significant occuplational implications or weight loss would benefit other significant obesity-related comorbidities, can consider:
triple therapy with metformin, sulfonylurea, and GLP-1

How well did you know this?

Not at all

Perfectly

what does GLP-1 stand for?

glucagon-like peptide-1

How well did you know this?

Not at all

Perfectly

what are the two incretins?

glucose-dependent insulinotropic peptide (GIP)

and

glucagon-like peptide-1 (GLP-1)

How well did you know this?

Not at all

Perfectly

what do incretins do?

stimulate insulin release and inhibit glucagon release, therefore lowering blood glucose

How well did you know this?

Not at all

Perfectly

how are incretins broken down?

by dipeptidyl peptidase-4 (DPP-4)

How well did you know this?

Not at all

Perfectly

what does dipeptidyl peptidase-4 do?

breaks down the incretins (GLP-1 and GIP)

How well did you know this?

Not at all

Perfectly

what does GIP stand for

glucose-dependent insulinotropic peptide

How well did you know this?

Not at all

Perfectly

what are the two incretin-based glucose lowering medications in clinical use?

GLP-1 agonists and DPP-4 inhibitors

How well did you know this?

Not at all

Perfectly

discuss the risk of hypoglycaemia using DPP-4 inhibitors

low risk of hypoglycaemia because the increase in insulin secretion by incretins is glucose-dependent
(increased risk of hypoglycaemia if using DPP-4 and sulfonylureas together)

How well did you know this?

Not at all

Perfectly

what class of drug are the “gliptins”?

DPP-4 inhibitors

How well did you know this?

Not at all

Perfectly

name at least one DPP-4 inhibitor

Study These Flashcards

sitagliptin;
linagliptin; 
vildagliptin;
saxagliptin;
alogliptin.

which DPP-4 inhibitor does not require dose adjustment with impaired kidney function and why?

linagliptin because unlike the other DPP-4 inhibitors, linagliptin is predominantly metabolised in the liver

via what route are DPP-4 inhibitors mostly eliminated?

renal route (can be used at all stages of renal impairment with dose adjustment) - except for linagliptin which is metabolised in liver so doesn't need to have dose adjusted for renal impairment

is weight gain or loss associated with DPP-4 inhibitors?

Usually, DPP-4 inhibitors are weight neutral, some patients lose weight

Can DPP-4 inhibitors be used with insulin?

yes

There's been concern about what sort of cancer and DPP-4 inhibitors?

Some concerns of a link between DPP-4 inhibitors and pancreatic cancer, a study showed that DPP-4 inhibitors didn't confer an increased risk of pancreatic cancer compared to sulfonylureas.

What is a major risk of using DPP-4 inhibitors with a sulfonylurea?

50% increased risk of hypoglycaemia (so if used in combination, may need to decrease sulfonylurea dose)

Can GLP-1 agonists be used with insulin?

only with specialist care advise and consultant-led MDT support

how to GLP-1 agonists work?

mimic endogenous GLP-1 activity however are resistant to being deactivated by DPP-4 so have prolonged action

Discuss risk of hypoglycaemia with GLP-1 agonists?

minimal risk because incretin stimulation of insulin is glucose dependent. There is increased risk if use with a sulfonylurea (so may need to decrease or halve the dose of sulfonylurea if using in combination)

Name at least one short-acting GLP-1 agonist

twice per day exenatide or lixisenatide

name at least one long acting GLP-1 agonist

once per week exenatide, dulaglutide, or semaglutide

what class of drug is exenatide?

GLP-1 agonist

what class of drug is dulaglutide?

GLP-1 agonist

do GLP-1 agonists induce weight gain or loss?

induce weight loss

what are the main side effects of GLP-1 agonists?

GI: abdo bloating, N/V/D. Usually resolve within a few weeks so rarely require withdrawing therapy

which antidiabetic drug class is particularly associated with genitourinary infections?

SGLT-2 inhibitors

how do SGLT-2 inhibitors act?

reversibly inhibit the sodium-glucose co-transporter 2 (SGLT-2) in renal proximal convoluted tubule, reducing reabsorption of glucose therefore increasing urinary excretion of glucose

discuss risk of hypoglycaemia with SGLT-2 inhibitors

low risk because act independently of insulin (if used in combination with sulfonylureas there is an increased risk of hypoglycaemia so will need to reduce sulfonylurea dose)

do SGLT-2 inhibitors induce weight gain or loss?

weight loss

effect of SGLT-2 inhibitors on BP?

reduce BP

name at least one SGLT-2 inhibitor

canagliflozin; dapagliflozin; empagliflozin; ertugliflozin

what class of drug is ertugliflozin?

SGLT-2 inhibitor

do SGLT-2 inhibitors increase or decrease risk of CVD or heart failure?

emagliflozin, canagliflozin and dapagliflozin have shown decreased cardiovascular risk

Discuss the alert the European Medicines Agency (EMA) released in Feb 2017 regarding SGLT2 inhibitors, and how should this affect your practice?

canagliflozin vs placebo trials showed potential increased risk of lower limb amputation (esp of toe) with canagliflozin- so patients should be reminded to check feet regularly, follow advice on preventative foot care, and tell Dr if any wounds/discolouration/tenderness/pain on feet

Discuss the complications of SGLT2 inhibitors reported in 2018 and how should this affect your practice?

cases of necrotising fasciitis of perineum (Fournier's gangrene) in pts taking SGLT2 inhibitors, so should seek med attention if tenderness/redness/swelling of genitals or are from genitals back to rectum

what class of drug is pioglitazone?

thiazolidinediones

name a thiazolidinedione

pioglitazone

how do thiazolidinediones act?

improving insulin sensitivity in liver, fat, and muscle reducing fasting and postprandial plasma glucose

how long can thiazolidinediones take to achieve max effect?

up to 12 weeks

do thiazolidinediones cause weight gain or loss?

weight gain

pioglitazone shouldn't be used in patients with current or previous heart failure: why?

fluid retention is a side effect of pioglizatone and can precipitate heart failure in some patients

what are four reasons long-acting insulin anaglogues can be considered in place of NPH insulin for people with T2DM?

- if need for less frequent dosing because a healthcare assistant needs to visit to administer insulin; - no improvement in HbA1c due to significant hypoglycaemia; - significant hypoglycaemia regardless of Hb A1c; - pt can't use NPH delivery device.

what are 7 practical aspects of insulin therapy which should be discussed with patients starting insulin to educate them on self-management?

- self monitoring of blood glucose; - injection technique; - care of injection sites; - management of hypoglycaemia; - support and follow-up with diabetes specialist nurse or other trained health care professional; - advise on driving and occupational/hobbies/home life hazards; - pts must inform the DVLA that they're on insulin and may also need to contact their insurance providers.

c-peptide levels in pts with T1DM?

are typically low

what autoantibodies may be useful to distinguish between T1 and T2 DM?

antibodies to glutamic acid decarboxylase (anti-GAD) are present in around 80% of patients with T1DM; islet cell antibodies (ICA, against cytoplasmic proteins the beta cell) are present in around 70-80% pts with T1DM; insulin autoantibodies (IAA) in over 90% of young children w T1DM but only 60% of older pts with T1DM. Could also check insulinoma-associated-2 autoantibodies (IA-2A)

Diabetes Flashcards

(59 cards)