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General Practice YR3 > Diabetes Pre-work > Flashcards

Diabetes Pre-work Flashcards

1
Q

Clinical features T2DM - symptoms

A
  • Polyuria
  • Polydipsia
  • Unexplained weight loss
  • Recurrent infections
  • Tiredness
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2
Q

Signs of T2DM

A
  • Acanthosis nigricans
  • Presence of risk factors?
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3
Q

Diagnostic criteria for T2DM

A
  • If symptoms, can have 1 hyperglycaemic reading
  • If no symptoms, needs repeat test to confirm
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4
Q

Values for diabetes diagnosis for readings

A
  • HbA1C of 48mmol/mol (6.5%) or more
  • Fasting glucose of 7mmol/L or more
  • Random blood glucose of 11.1mmol/L or more in presence of signs/symptoms
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5
Q

When should HbA1C not be used to confirm diabetes?

A
  • Children and young people under 18 - use fasting/random sample
  • Pregnant women or 2 months post partum
  • Symptoms for less than 2 months
  • High risk of diabetes who are acutely unwell
  • Taking medication that can cause hyperglycaemia (eg corticosteroids)
  • Acute pancreatic damage
  • End stage renal disease
  • HIV infection
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6
Q

When to interpret HbA1C with caution?

A
  • Abnormal Hb eg haemoglobinopathy
  • Severe anaemia (any cause)
  • Altered red cell lifespan (eg splenectomy)
  • Recent blood cell transfusion
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7
Q

Management T2 diabetes - general

A
  • Offer referral to structured education program eg DESMOND
  • Provide sources of information - Diabetes UK
  • Lifestyle advice - diet, exercise etc
  • Assess impact on mood - Diabetes and your emotions patient resource
  • Influenza and pnuemococcal vaccine
  • Wear or carry some form of Diabetes identification - bracelet, necklace, watch, card, wristband
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8
Q

Monitoring for T2DM

A
  • Measure HbA1C at 3-6 monthly intervals until stable on unchanging diabetic treatment
  • Then every 6 months after stable
  • Screening for complications
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9
Q

How often is screening for T2DM complications?

A
  • Eyes - at diagnosis and every 2 year for those low risk, annually for others
  • Diabetic foot check - at diagnosis and then once per year, more frequent if higher risk
  • Kidney - annual UACR (early morning sample) and eGFR
  • CVD risk assessed annually - smoking, BP, BG, albuminuria, lipids, FH, height weight and waist cicumference - calculate BMI
  • Neuropathy - screen for peripheral and autonomic
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10
Q

CKD management/urine microalbuminaemia with diabetes

A
  • CKD 3 - Offer atorvastatin
  • Offer ACEi - /ARB can have this at any level of CKD
  • Add Dapagliflozin (SGLT2) if eGFR 25-75ml/min or more
  • If still nor improving renal function, can offer Finerenone
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11
Q

Peripheral neuropathy screening

A

Ask about:
* Numbness
* Burning
* Shooting pain
* Tingling
* In hands and feet
* Typically at night
* Relieved by activity

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12
Q

Autonomic neuropathy symptoms/screening

A
  • Postural hypotension
  • Gastroparesis - vomitting, bloating
  • Urinary symptoms - hestitancy, reduced frequency, incomplete empyting
  • Erectile dysfunction
  • Unusual sweating - esp hands and feet
  • Impaired hypoglycaemia awareness
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13
Q

Managing CVD risk in someone with T2DM

A
  • Normal BP targets - stricter 130/80 target if ACR 70mg/mmol or more
  • Atorvastatin 20mg - if 84 years and below and QRISk 10% or more, if 85 and above take into account preferences, or if have CKD - aim for more than 40% reduction in non-HDL cholesterol
  • Do not routinely offer antiplatelet treatment
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14
Q

Lifestyle advice T2DM

A
  • High fibre, low glycaemic index carbs (eg fruit, veg, wholegrain, pulses)
  • Oily fish
  • Low fat dairy products
  • Control amounts of high saturated fats, sugary drinks, foods high in salt
  • Discourage diabetic marketed foods
  • Diabetes UK have good info on diet
  • Eat carbohydrate snack before and after alcohol - alcohol can prolong effects of hypoglycaemic treatment
  • Need to have regular oral check ups - increased risk peridontitis
  • Stop smoking if possible
  • Exercise
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15
Q

Sick day medication rules

A
  • On angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (AIIRAs), diuretics, or nonsteroidal anti-inflammatory drugs (NSAIDs) — stop treatment if there is a risk of dehydration, to reduce the risk of acute kidney injury (AKI).
  • On metformin — stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.
  • On sulfonylureas — may increase the risk of hypoglycaemia, particularly if dietary intake is reduced.
  • On 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.
  • On 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.
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16
Q

Diagnostic criteria of T1Dm

A

Random plasma glucose of 11.1mmol/L or more and usually (but not always) have associated symptom of one or more:
* Weight loss
* Ketones
* age onset under 50
* BMI less than 25
* Personal or FH of autoimmune disease

17
Q

Autoantibodies for T1DM?

A

Do not routinely measure C-peptide and/or diabetes-specific autoantibody titres to confirm the diagnosis of type 1 diabetes
May be done in secondary care if atypical symptoms

18
Q

T1DM management - general

A
  • Offer structured education program eg DAFNE (dose adjusted for normal eating)
  • Provide Diabetes UK source for information
  • Individual care plan
  • Target 48mmol/mol HbA1C - measure every 3-6 months
  • CGM - but need to double check with capillary blood glucose, if just CBG monitor 4x per day at least
19
Q

Targets for CBG readings for T1DM

A
  • Fasting plasma glucose level of 5–7 mmol/L on waking.
  • Plasma glucose level of 4–7 mmol/L before meals at other times of the day.
  • For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating.
20
Q

Diet/lifestyle information T1Dm

A
  • Do not advise low glycaemic index of carbohydrates
  • Process of matching insulin dose to carbohydrates in grams
  • Low in fat, sugar and salt and contain at least 5 portions of fruit and veg
  • Have carbohydrate snack before and after drinking alcohol
  • Regular oral check ups for higher risk of peridontitis
  • Stop smoking
21
Q

Sick day rules T1DM

A
  • Never omit insulin
  • Check CBG every 1-2hrs so more regularly
  • Checking blood/urine ketones regulalry
  • Maintain normal eating pattern if possible
  • Drink at least 3L of fluids per day
22
Q

Assessing CVD risk in T1DM

A
  • do not use risk assessment tool
  • Consider in all T1DM for primary prevention esp if over 40, more than 10yrs with diabetes, other CVD risk factors, established neuropathy
23
Q

Treatment targets T2DM

A
  • 48 mmol/mol for new type 2 diabetics
  • 53 mmol/mol for patients requiring more than one antidiabetic medication
24
Q

Medical management T2DM

A

First-line
* Metformin
* Once settled on metformin, add an SGLT-2 inhibitor (e.g., dapagliflozin) if the patient has existing cardiovascular disease or heart failure. NICE suggest considering an SGLT-2 inhibitor in patients with a QRISK score above 10%.

Second-line
* Add a sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor.

Third-line options are:
Triple therapy with:
* metformin and two of the second-line drugs
* Insulin therapy (initiated by the specialist diabetic nurses)

When triple therapy fails, and BMI is 35kg/m2 or more can offer GLP-1 mimetic.

25
Q

Management complications of T2DM

A
  • ACE inhibitors are used first-line to manage hypertension in patients of any age with type 2 diabetes.
  • ACE inhibitors are started in type 2 diabetics with chronic kidney disease when the albumin-to-creatinine ratio (ACR) is above 3 mg/mmol (as opposed to 30 mg/mmol in patients without diabetes).
  • SGLT-2 inhibitors are started in type 2 diabetics with chronic kidney disease when the albumin-to-creatinine ratio (ACR) is above 30 mg/mmol (in addition to the ACE inhibitor).
  • Phosphodiesterase‑5 inhibitors (e.g., sildenafil or tadalafil) may be used for erectile dysfunction.
  • Prokinetic drugs (e.g., domperidone or metoclopramide) may be used for gastroparesis (slow emptying of the stomach). These medications are used with caution due to cardiac side effects.
26
Q

Neuropathic pain management

A
  • Amitriptyline – a tricyclic antidepressant
  • Duloxetine – an SNRI antidepressant
  • Gabapentin – an anticonvulsant
  • Pregabalin – an anticonvulsant
27
Q

DKA management

A

FIGPICK
* 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)
* I – Infection – treat underlying triggers such as infection
* C – Chart fluid balance
* K – Ketones – monitor blood ketones, pH and bicarbonate

28
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28
Q

Diabetes drugs

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29
Q
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General Practice YR3 (31 decks)

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