endo3 Flashcards by M G

Pros and cons of insulin pumps?

Since the introduction of insulin pumps and continuous glucose monitoring, increasing numbers of individuals are using these systems; however, their use is limited by cost and individual factors. At last audit, only approximately 12% of individuals with type 1 diabetes in Australia were using insulin pump therapy; however, recent advances in technology have seen increased uptake of pumps. For individuals who continue on multiple daily injections, improvements in injectable insulins may be of benefit.

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Non urgent confirmatory tests for type 1 diabetes?

GAD and IA2 antibodies

C Peptide (level less than 0.2 supports dx of T1DM)

Also look for other autoimmune conditions

TSH, Coeliac antibodies

LFT, lipids and UEC

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What is a typical long term insulin regimen for someone with type 1 diabetes?

BASAL BOLUS REGIME

Typical initial dosage is 0.3 or 0.4Units/Kg daily

This dosage is divided in the following way:

BASAL long acting insulin (40% of dose) at night subcutaneously

BOLUS Rapid or short acting insuling (60% of dose given in three divided doses 15 (rapid)-30 (short) minutes before meals).

OTHER OPTION IS AN INSULIN PUMP

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What parameters are used to adjust a patients basal insulin

intended carb intake
Expected level of physical activity
Blood glucose concentration at the time - incorporating a correction dose if outside the agreed range

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How often should a patient with TYPE 1 DM check their BSL’s

4-6 times each day

Before and/or after meals

Before exercise

When a low BSL is suspected

Before critical activities such as driving

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When might more frequent BGL testing be required?

During periods of being unwell

after treatment of hypoglycaemia

times of increased activity

when changes to insulin regimen have been made

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When should a T1Diabetic check ketones?

During acute illness or stress

Whenever BGL is consistently above 15mmol/L
When any symptoms of ketoacidosis (vomiting, abdominal pain, nausea) are present

Blood Ketone above 0.6mmol are significant

BUT over 1.5mmol can indicate impending DKA and must be transferred urgently to hospital

A strong clinical suspicion with negative results - still warrants prompt intervention

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Exercise guidelines for T1DM?

Increase caloric intake

and/or decrease insulin dose in order to prevent hypoglycaemia during exercise

ADVICE:

take one carb exchange (15g carbs) every 30 or 45 minutes of exercise
decrease insulin dose in relation to anticipated intensity and duration of exercise
may need to adjust the subsequent overnight insulin dosea also to avoid overnight post exercise hypoglycaemia
An insulin pump may be a good option as it offers better control but needs RBS checking

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SGLT-2 Inhibitors and GLP1-RA’s and CV outcomes?

Both found to decrease CV related mortality

ESP - SGLT-2 Inhibitors

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Which Diabetic drugs are sensitisers to Insulin?

Metformin (biguanide) - reduces hepatic gluconeogenesis and muscle use of glucose
Thiazolidenediones - Pioglitazone (only one used now)

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Which diabetic drugs are insulin secretagogues?

Sulfonylureas (gliclazide etc)

Glinides (glitinides)

THEY INCREASE INSULIN SECRETION

Therefore can cause hypoglycaemia

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Which Diabetic meds are Incretin based?

DPP-4 inhibitors (eg vildagliptin etc)

(Increase the concentration of incretin hormones (GLP-1 and GIP) that are found in the gut after ingestion of food)

incretins -eg GLP-1 - increase the release of insulin and decrease glucagon secretion.

GLP-1 Receptor Agonists (Exenatide, liraglutide)

increase the release of insulin and decrease glucagon secretion.

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What kind of medicine/action is Acarbose?

Alpha Glucosidase inhibitor

Reduces breakdown of complex carbohydrate in the gut. Leads to less carb absorption and reduces insulin requirements.

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What is the mechanism of action of the SGLT-2 inhibitors?

They reduce the re-absorption of glucose by the kidneys

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Benefits of metformin? Risks? Perioperative?

Doesnt cause hypoglycaemia
Doesn’t cause weight gain (neutral weight)

Side effects

Gastrointestinal - nausea, vomiting ,diarrhoea

Renal impairment - dose reduce

Lactic acidosis - usually seen in setting of Liver failure, renal failure or heart failure

STOP 48 hours before surgery or contrast imaging - may need insulin in the interim period.

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Starting dosage metformin - immediate release vs modified release?

IR -

EGFR over 60 - 500mg twice daily

EGFR 30-60 - 500mg once daily

MR -

EGFR over 30 - 500mg once daily with evening meal

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What are drug side effects of Sulfonylurea meds?

Weight gain (less with gliclazide)

Severe hypoglycaemia

Blood dyscrasia

Rare - loss of appetite and diarrhoea

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Which sulfonylurea would be appropriate in an elderly patient? Which is NOT appropriate?

SHORT acting - gliclazide or glipizide, tolbutamide

less risk of hypo and ok on renal function as metabolised by the liver

CI in liver failure

LONG acting - glimepiride and gibenclamide (prolonged hypo risk) - dont use in elderly

also as its metaboilsed renally - dont use with CKD

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starting dose of sulfonylurea?

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Gliclazide 30mg daily modified release - once daily in the morning with food (max of 120mg)

Drug interactions of sulfonylureas?

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NSAIDs and MAOinhibitors - increase action of sulfonylurea - increased risk of hypo

Thiazides and steroids - decrease action

Disulfiram like reaction with Alcohol (nausea, vomiting, flushing, dizziness, chest and abdominal pain)

What are the contraindications for DPP4I and GLP1 (incretin based)

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History of pancreatitits

ADR of DPP 4 inhibitors? Benefits?

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Benefits - weight neutral

no hypos

CI’s - pancreatitis

Saxagliptin - ESRD

ADR - nasal congestion, URTI and headaches

LInagliptin 5mg orally daily

Starting dose of DPP 4 inhibitor?

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Linagliptin 5mg orally daily

Benefits and ADR of GLP1 receptor agonists?Example?

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May reduce weight
No hypos

CI- pancreatitis,

May have thyroid cancer causing??

ADR - profound effect on gastric emptying can initially cause nausea

Renal impairment - use carefully.

Liraglutide reduces CV risk in diabetics and can use until EGFR is 15

0.6 liraglutide s/c once daily for one week

Increase daily dose according to response by O.6mg at weekly intervals (Max 1.8mg daily)

When should thiazilodinediones be used?

Must have LFT first and expert commence after discussing risk/benefit ADR: MAcular odema, Osteoporosis, Liver damage (check lft initially and 3 monthly), Weight gain 4kg first year then stabalises, FLuid retention - can precipitate heart failure, Haemodilution leading to anaemia Pioglitazone - Bladder cancer Rosiglitazone - MI/Angina

Side effects of acarbose?

Manily GI - flatulence, bloating, nausea Hypos if combined with a SU or insulin

ADR of SGLT-2 inhibitors?

1. Severe liver diease (can use in mild) 2. Excreted via glomerulus - dont use if EGFR is less than 60 (dapagliflozin/forxiga) or 45 ( canagliflozin/empagliflozin) 3. Increases polyuria, nocturia, frequency - dont use if on loops or BPH 4. Symptomatic Hypotension in combo with ACEI and ARBS - use with caution in patients with other meds that predispose to renal injury 5. Genital infections are more common (Esp in post menopausal women) 6. Rarely - DKA can be euglycaemic (if patient with SGLT-2 is sick check for ketones)

When is SGLT-2 useful?

Empagliflozin - in patient with overt CVD or heart failure - not well controlled on metformin and lifestyle or patients with nephropathy or as a third line agent where others are not feasible

What therapeutic options for painful diabetic neuropathy?

TCA Venlafaxine duloxetine

Which diabetic drugs cause weight gain?

Insulin, SU, Thiazolinediones

Which diabetic drugs are weight neutral?

Metformin, Acarbose, DPP4 inhibitors

Which diabetic drugs cause weight loss?

GLP1 agonists, SGLT 2 inhibitors

How would you screen for Diabetic complications?

1. **CV risk stratification** and managment of CV risk factors 2. **2 yearly retinopathy** screening in adults and adolescents. (Kids from _age of 9 or 5 years after dx_ - once commenced do it every 2 years) 3. **Yearly NEUROPATHY** screening for everyone 4. **Yearly Nephropathy** screening - Kids from _age of 9 or 5 years after dx_ - once commenced do it annually) 5. **Lipids - yearly in adults** (Kids - at diagnosis if Fhx - otherwise start at 12years of age and do it annually) 6. **BP at diagnosis and then 6 monthly** 7. **Macrovasc Cx - yearly in adults** (not kids)

Screening history questions to assess DM control (esp poor control)

1. Sx of hyperglycaemia - Polyuria, polydipsia, weight loss 2. Fatigue 3. Blurring of vision. If symptoms of poor control - then recheck with HBA1c

What are some potential reasons for poor diabetic control?

1. Check current therapies and consider which ones are not improving blood glucose. 2. Check adherence to therapy and any potential barriers - eg, Poor understanding of risks of complications or importance of daily medications. 3. Review comorbidities and other therapies which may adversely affect diabetic control - **Potentially refer to pharmacist for a home medicines review and to a diabetic educator.**

Complications of myocarditis?

Acute: Arrhythmia, Cardiac failure Cardiogenic shock Chronic: Dilated cardiomyopathy

What are the clinical features of myocarditis?

**RISE IN BIOMARKERS! No ischaemia.** Often young and sick/ FEVER.

Post partum GDM testing when contemplating pregnancy - (after initial postpartum OGTT)

Women contemplating another pregnancy should have an oral glucose tolerance test annually Women who have had gestational diabetes have a 40% risk of a recurrence of gestational diabetes mellitus in a subsequent pregnancy and an increased risk of developing type 2 diabetes within their lifetime. These women should receive education about lifestyle changes to reduce their risk of diabetes. They should undertake a 2 hour 75g oral glucose tolerance test at 6 – 12 weeks post-partum, as well as HbA1c or fasting glucose every 3 years life long. Women contemplating another pregnancy should have an OGTT annually.

Cause of an isolated elevated calcium? What test would you order?

Most commonly Primary Parahyperthyroidism CHECK PTH (Sometimes can be familial Hypercalciuric hypercalcaemia - needs 24 urine) Drug induced - lithium, thiazide diuretics Hypercalcaemia of Malignancy

Difference between primary and secondary hyperparathyroidism?

Clinical features of hypercalcaemia?

Increased risk of **Stones**, Increased fracture risk -**bones,** abdominal cramping, constipation and nausea - **moans**, psychosis, depressed mood, lethargy -**psychic groans**

What is the most common cause of primary Hyperparathyroidism?

Parathyroid adenoma. Definitive therapy is surgery, which cures 95% of cases and has low morbidity.

Which one of the following foods is best for reversing hypoglycaemia? aChocolate bApple juice cOrange juice dJelly beans

Jelly beans

What is an ultra long basal insulin example?

Degludec is an ultra–long acting basal insulin with a half-life of 24 hours.

Which one of the following is a rapid-acting insulin analog? aGlargine bAspart Correct. cDetemir dDegludec Submit

Aspart

When starting an insulin pump how does insulin dose change?

As a result of enhanced absorption, insulin doses are reduced by 20–30% when an individual commences pump therapy.

Out of pocket cost for full time continuous glucose monitoring

The out-of-pocket cost for full-time continuous glucose monitoring is approximately $3000–$5000 per year.

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