Diabetes Management

Question 1

What is the mainstay and first line options of Type 1 treatment? [2]

Answer 1

Lifestyle changes and Insulin!

Question 2

How is insulin delivered? [2]

Why is it delivered any other route

Answer 2

By SC or IV

Because its a polypeptide inactivated by the GI tract so it doesnt work orally

Question 3

What are the types of insulin? [5]

Answer 3

• Rapid acting
• Short Acting
• Intermediate Acting
• Long acting
• Continuous SC insulin infusion (CSII)

Question 4

What changes the time insulin takes to take effect? [2]

Answer 4

Soluble insulin associates into hexamers in SC fat.

• It needs to dissociate into monomers in order to diffuse into capillaries.
• Altering the structure/solubility of insulin affects how long it takes to dissociate

Question 5

Describe a twice daily insulin regime [1]

Timings [2]

Answer 5

Mix of rapid and intermediate acting insulin 
Before breakfest (BB) & before tea (BT)

Question 6

Describe a thrice daily insulin regime? [1]

Timings [2]

Answer 6

Mix of rapid and intermediate BB

Rapid BT

Intermediate Bbed

Question 7

Describe a 4x daily insulin regime? [2]

Answer 7

Mix of: Short acting insulin BB, BL & BT

Then Intermediate Bbed or long acting insulin at a fixed time once per day

Question 8

How is Type 2 Diabetes treated?

Name drugs from 1st to 3rd line

Answer 8

Lifestyle modifications
1st line - Metformin (OHG)
2nd line - A Sulphonyurea (E.g. glimepiride)
3rd line - A thiazolidinedione (e.g. pioglitazone) (aka Glitazones)

Further 3rd line meds include:
DPP-IV inhibitors - SGLT-2 inhibitors - GLP-1 agonist - Insulin

Question 9

What does metformin do? [1]

Answer 9

It increases insulin sensitivity

Question 10

What aspects of hypoglycemia is it important to educate patients on? [4]

Answer 10

• How to test their blood sugar
• How to recognise the signs of a hypo
• How to treat it
• How to avoid it

Question 11

Treatment of hypoglycaemia
Give 3 options for non-hospital and hospital settings
Follow up [1]

Answer 11

Rapid acting carb e.g. 200ml of fruit juice
OR 1mg IM glucagon
OR if in hospital then 80ml 20% glucose

Follow up with a long acting carbohydrate

Question 12

How do patients avoid based on causes of hypoglycemia? [4]

Answer 12

• Blood glucose monitoring
• Rotate & check injection sites
• Review diet (carb counting)
• Maybe change the insulin regime

Question 13

What are the rules for driving and Hypos?

What are the contraindications for driving that the DVLA impose on diabetics [2]

Answer 13

Diabetics have to check their glucose within 2 hours of driving [1] and repeat on long journeys [1]
They should carry short acting carbs in the car
If they can’t recognise a hypo [1] or have >1 severe hypo a year they can’t drive [1]

Question 14

How would we advise a patient to deal with DKA at home? [6]

Answer 14

1) They think they’re getting symptoms
2) Test their ketones
3) +ve? Test Blood Glc
4) Elevated? Take an extra insulin dose
5) still high after 4 hours? Take another dose
6) Call diabetes team, notify them of possible DKA

Question 15

How do we treat DKA? [7]

Answer 15

Fluid replacement 0.9% NaCl 1L for 1st hour
- Once BM <15 mmol/l start 5% dextrose infusion
Insulin:
- IV infusion 0.1 unit/kg/hour
- Continue long acting insulin usual dose
- Stop short acting insulin
Correct hypokalaemia

Question 16

Management of DM complications

How do we manage diabetic nephropathy? [4]

Answer 16

• Glycaemic control
• BP control
• ACE inhibitor slows progression & treats BP
• CVD risk factor control

Question 17

Diarrhoea is a potential diabetic autonomic neuropathy, how do you treat it? [1]

Answer 17

Loperamide (i.e. imodium)

Question 18

Gastric stasis and vomiting is a potential diabetic autonomic neuropathy, how do you treat it?

Answer 18

Domperidone.

Dopamine antagonist that acts as an antiemetic and progastrokinetic

Question 19

Postural Hypotension is a potential diabetic autonomic neuropathy, how do you treat it? [3]

Answer 19

Advice: avoid getting up to quickly

NSAIDS or Fludrocortisone

Question 20

Erectile dysfunction is a potential diabetic autonomic neuropathy, how do you treat it? [1]

Answer 20

Phosphodiesterase inhibitors e.g. Viagra

Question 21

Management of peripheral neuropathy

• Rx [2]
• Non pharmacological [3]

Answer 21

Pain relief:

• Capsaicin cream
• Amitriptyline

Protection of feet from ulceration:

• Fitted footwear
• Regular podiatry visits
• Foot screening and risk assessment

Question 22

How do we treat maculopathy? [3]

Answer 22

Grid laser therapy
Glc Control
BP control

Question 23

Treatment: proliferative retinopathy [2]
Describe rationale for each [4]
Natural progression if untreated [2]

Answer 23

We can do a vitrectomy if theres a vitreous haemorrhage

Laser photocoagulation destroys ischaemic retina [1] , reducing Endothelial Growth Factors [1] causing the new vessels to regress [1]

If untreated, scarring can occur which can lead to retinal detachment.

Question 24

CV risk reduction is an example of primary prevention [4]

Answer 24

Lifestyle mods
Control BP to <130/80
Smoking cessation services
Statin therapy - simvastatin for over 40 and in younger patients with significant complications

Question 25

Package of care for people with T2DM [11]

Answer 25

* Blood glucose levels (annually) * Blood Pressure (annually) * Blood Lipids (annually) * Eyes Screened (annually) * Feet checked (annually) * Kidney function (annually) * Weight * Smoking Cessation Support * Individual Care plan * Education Course * Emotional and psychological support

Question 26

Targets HBA1C depend on management: Lifestyle AND/OR metformin only Already on one drug, but HbA1c has risen to 58 mmol/mol (7.5%)

Answer 26

Lifestyle AND/OR metformin only: - Target for 48 Already on one drug, but HbA1c has risen to 58 mmol/mol (7.5%) - Target for 53

Question 27

Fluid replacement regime in DKA admission with systolic BP >90 mmHg (for 19 hours)

Answer 27

``` 1L over 1st hour 0.9% NaCl 1L over next 2h 0.9% NaCl with KCl - Another 1L over next 2h - Another 1L over next 4h - Another 1L over next 4h - Another 1L over next 6h ```

Question 28

``` Main complication of treating DKA in young people Specific age range Symptoms Onset Mx ```

Answer 28

Fluid therapy can cause cerebral edema so slower infusion is needed - 18-25yo - need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology etc - Usually occur 4-12h after commencement of treatment - CT head and senior review

Question 29

Goals of management of HHS | What NOT to do...

Answer 29

1. Normalise the osmolality (gradually) 2. Replace fluid and electrolyte losses 3. Normalise blood glucose (gradually) Don't use insulin in first instance, fluid replacement alone can facilitate a gradual decline in BM and plasma osmolarity. Because most patients with HHS are insulin sensitive (e.g. it usually occurs in T2DM), administration of insulin can result in a rapid decline of serum glucose and thus osmolarity.

Question 30

Fluid replacement in HHS [2] Aim? What is a safe rate of fall of plasma glucose? [2]

Answer 30

Intravenous (IV) 0.9% sodium chloride solution is the first line fluid for restoring total body fluid. 2nd line if unresponsive: 0.45% NaCl Aim: achieve positive balance of 3-6L by 12h, replace remaining losses within next 12h A safe rate of fall of plasma glucose of between 4 and 6 mmol/hr is recommended. The rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours.

Question 31

Complications of HHS treatment When can you expect total normalization? What target blood glucose is used?

Answer 31

Cardiovascular collapse Central pontine myelinolysis Complete normalisation of electrolytes and osmolality may take up to 72 hours. A target blood glucose of between 10 and 15 mmol/L is a reasonable goal.

Question 32

Why can insulin treatment cause cardiovascular collapse?

Answer 32

Insulin treatment prior to adequate fluid replacement may result in cardiovascular collapse as the water moves out of the intravascular space, with a resulting decline in intravascular volume.

Question 33

When would insulin be indicated in HHS? | What ROA and dose of insulin would be recommended?

Answer 33

If significant ketonaemia is present (3β-hydroxy butyrate is more than 1 mmol/L) this indicates relative hypoinsulinaemia and insulin should be started at time zero (e.g. mixed DKA / HHS picture). The recommended insulin dose is a fixed rate intravenous insulin infusion given at 0.05 units per kg per hour.

Question 34

Potassium in HHS

Answer 34

Patients with HHS are potassium deplete but less acidotic than those with DKA so potassium shifts are less pronounced Hyperkalaemia can be present with acute kidney injury Replace as required