Diabetes Finals

Question 1

How often shoudl Hba1c be monitored in T1DM

What is the target in T1DM

Answer 1

HbA1c
should be monitored every 3-6 months

<48/6.5%

Question 2

How many times a day to monitor blood glucose in T1DM

Answer 2

recommend testing at least 4 times a day, including before each meal and before bed

NOTE: do more frequent if pregnant, sick or breastfeeding and sport

Question 3

Autoantibodies in T1DM

Answer 3

Anti-islet cell antibodies
Anti-GAD antibodies
Anti-insulin antibodies

Question 4

Mx of Type1DM

Answer 4

Basal Bolus Regime
or Insulin pumps

Question 5

Describe a Basal Bolus regime

Answer 5

SC
Basal - a long acting insulin once or twice daily:
Long-acting insulins in the background
insulin determir (Levemir): given once or twice daily
insulin glargine (Lantus): given once daily

Bolus
Short Acting/Rapid Insulin before meals
Actrapid (short)
Humulin S (S for short)

Rapid -
insulin aspart: NovoRapid
insulin lispro: Humalog

Question 6

Disadvantages of an Insulin Pump

Advantages

Answer 6

Difficulties learning to use the pump
Having it attached at all times
Blockages in the infusion set
A small risk of infection

Good:
better blood sugar control, more flexibility with eating and less injections.

Question 7

Dx of T2DM

Answer 7

If the patient is symptomatic:
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

When HbA1c is used for the diagnosis of diabetes:
a HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus ( NOTE - cannot use this in children, CKD, gestational diabetes, HIV, anaemia, people taking steroids)

If not:
If the patient is asymptomatic the above criteria apply but must be demonstrated on **two **separate occasions.

Question 8

Tx of Diabetic Neuropathy

Answer 8

Duloxetine

Question 9

Features of Diabetic neuropathy

Answer 9

Sensory ‘glove and stocking’ loss

Question 10

T2DM mx ladder

Answer 10

Lifestyle
Lifestyle + Metformin
Dual Therapy - Lifestyle+ Metformin and Another drug
ex:
metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea
metformin + SGLT-2 inhibitor (if high heart disease present)
**Triple Therapy: **
Lifestyle, Metformin + 2 other drugs
ex:
metformin + DPP-4 inhibitor + sulfonylurea
metformin + pioglitazone + sulfonylurea
(Or can have SGLT2 as one of them if requirements met)

Or INSTEAD - Insulin Based treatment as third line

If none of this works, consider adding GLP-1 mimetic
* *If a triple therapy line has failed consider switiching one of the drugs to a GLP-1 mimetic, especially if BMI>35**

Question 11

SGLT-2 inhibitor

Answer 11

Glycosuria (glucose in the urine)
Increased urine output and frequency
Genital and urinary tract infections (e.g., thrush)
Weight loss
Diabetic ketoacidosis

Question 12

Pioglitazone SE

Answer 12

Weight gain
Heart failure - CI in heart stuff
Increased risk of bone fractures
A small increase in the risk of bladder cancer

Question 13

DPP-4 inhibitors SE

Answer 13

Headaches
Low risk of acute pancreatitis

Question 14

DPP-4 inhibitor mechanism

examples

Answer 14

DPP-4 inhibitors block the action of DPP-4, allowing increased incretin activity.

sitagliptin and alogliptin.

Question 15

GLP-1 mimetics action

GLP-1 examples

Answer 15

GLP-1 mimetics imitate the action of GLP-1. Examples are exenatide and liraglutide.

Question 16

GLP-1 SE

Answer 16

Reduced appetite
Weight loss
Gastrointestinal symptoms, including discomfort, nausea and diarrhoea

Question 17

Hypersomalar Hyperglycaemic State features and mx

Answer 17

(hyperglycaemia) and the absence of ketones

IV fluids and careful monitoring.

Question 18

Sick Day Rules T1 DM

Answer 18

if a patient is on insulin, they **must not **stop it due to the risk of diabetic ketoacidosis, check blood glucose more frequently,

maintain normal meal pattern if possible - if LOA, try to at least eat carbohydrate-containing drinks (such as milk, milkshakes, fruit juices, and sugary drinks)

Question 19

Ramadan Rules

Answer 19

for patients taking metformin the expert consensus is that the dose should be split one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar)

expert consensus also recommends switching once-daily sulfonylureas to after sunset. For patients taking twice-daily preparations such as gliclazide it is recommended that a larger proportion of the dose is taken after after sunset
no adjustment is needed for patients taking pioglitazone

Question 20

Hypoglycaemia Mx

Answer 20

If awake: oral glucose 10-20g should be given in liquid, gel or tablet form

unconscious or unable to swallow: subcutaneous or intramuscular injection glucagon

Or if no response - intravenous 10% glucose solution

Question 21

DVLA rules

Answer 21

there has not been any severe hypoglycaemic event in the previous 12 months, they can drive

Question 22

SICK day Rules T2DM

Answer 22

STOP oral hypoglycaemics during acute illness

medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours

metformin: stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.

sulfonylureas: may increase the risk of hypoglycaemia - so stop

SGLT-2 inhibitors: check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA

GLP-1 receptor agonists: stop treatment if there is a risk of dehydration, to reduce the risk of AKI

if on insulin therapy, do not stop treatment, as above

Question 23

T2DM Morning Surgery Rules

Answer 23

Metformin - If taken once or twice a day - take
as normal. If taken three times per day, omit lunchtime dose

Sulfonylurea - If taken once daily in the morning - omit the dose that day If taken twice daily - omit the morning dose that day

SGLT-2 inhibitors (-flozins) - omit that day of surgery

DPP4/GLP-1 - Take as normal

Question 24

Gestational Diabetes RFs

Answer 24

BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Question 25

Gestational Diabetes Dx

Answer 25

oral glucose tolerance test (OGTT)
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

If women with prev GD, do this at booking scan and at 24-28 weeks

women with RFs at 24-28 weeks

Question 26

T2DM Day before surgery Rules

Answer 26

Metformin - NORMAL
Sulfonylurea - NORMAL
SGLT2 - NORMAL
DPP4/GLP-1 - NORMAL

Question 27

T2DM Afternoon Surgery

Answer 27

Metformin - If taken once or twice a day - take as normal If taken three times per day, omit lunchtime dose
Sulfonylurea - If taken once daily in the morning
omit the dose that day If taken twice daily - omit both doses that day
SGLT-2 - OMIT that day
DPP4/GLP1- take as normal

Question 28

GD mx

Answer 28

newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week

if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered**

If targets not met in 1-2 weeks, then do exercise + metformin

If targets STILL not met - then add SHORT-ACTING INSULIN

OR

if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started immediately

OR

If 6-6.9 mmol and evidence of complications (macrosomia ex) - START insulin

Question 29

DKA mx

Answer 29

F – Fluids – IV fluid resuscitation with normal saline (e.g., 1 litre in the first hour, followed by 1 litre every 2 hours)
I – Insulin – fixed rate insulin infusion (e.g., Actrapid at 0.1 units/kg/hour)
G – Glucose – closely monitor blood glucose and add a glucose infusion when it is** less than 14 mmol/L**
P – Potassium – add potassium to IV fluids and monitor closely (e.g., every hour initially - normally cannot exceed 10 mmol/hour, but in DKA up to 20mmol/hour)
I – Infection – treat underlying triggers such as infection
C – Chart fluid balance
K – Ketones – monitor blood ketones, pH and bicarbonate

Question 30

What is alcoholic Ketoacidosis?
Mx

Answer 30

Non-diabetic form of ketoacidosis, in people who drink a LOT.
Often alcoholics will not eat regularly and may vomit food that they do eat, leading to episodes of starvation. Body may break down ketones
Presents with a raised Anion Gap and Metabolic acidosis

Mx - Saline and Thiamine