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Endocrine T2DM Flashcards

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1
Q

TYPE 2 DIABETES is characterised by…?

A

Insulin resistance, later in life

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2
Q

Prediabeties is what mmol/L?

A

42-47mmol/mol

Can try prevent diabetes with lifestyle advice

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3
Q

Diabetes HbA1c?

A

48mmol/mol

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4
Q

DIABETES TREATMENT- pts with LOW CVD RISK

What 3 do you need to assess first?

A

HbA1c
Kidney function
Cardiovascular risk

AIM FOR INDIVDUALLY AGREED THRESHOLDS!

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5
Q

DIABETES TREATMENT- LOW CVD RISK

1st LINE?

A

METFORMIN

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6
Q

DIABETES TREATMENT- LOW CVD RISK

Metformin not working and
HBA1C> individually agreed threshold, what meds to add?

A

DUAL THERAPY
ADD IN…
DPP-4i (gliptin)
OR
Pioglitazone (not in HF)
OR
SU (Sulphonylurea- glic, glim, tolb)
OR
SGLT-2i (Flozins)

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7
Q

DIABETES TREATMENT- LOW CVD RISK

DUAL THERAPY not working..
HBA1C> individually agreed threshold, how to treat?

A

TRIPLE THERAPY by…
adding/swapping class of anti-diabetic
NOTE: DAPAG with PIOG not recommended, OTHER SGLT-2is fine

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8
Q

DIABETES TREATMENT- HIGH CVD RISK

Which pts high risk?

A

Established atherosclerotic CVD
HF
QRISK2>10%

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9
Q

DIABETES TREATMENT- HIGH CVD RISK

1ST LINE?
ONCE TOLERATED?
IF NOT TOLERATED?

A

1ST LINE? METFORMIN

ONCE TOLERATED? ADD SLGT-2i

IF NOT TOLERATED? ALONE SLGT-2i

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10
Q

why is sglt2i good in diabetes with high cvd risk?

A

cardio protective

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11
Q

DIABETES TREATMENT- HIGH CVD RISK

what to do if HBA1C> individually agreed threshold?

A

SAME AS DUAL+TRIPLE THERAPY FLASHCARDS!

avoid pioglitazone due to cvd risk

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12
Q

Patient w/ diabetes develops high risk CVD at any point what to do?

A

Consider SLGT-2i first.

EU marketing agency, recent approval for flozins in HF, draining effect.

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13
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

Patient can’t tolerate metformin due to side-effects?

A

Use MR preparations

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14
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

Patient can’t tolerate metformin MR? Treat w/…

BUT
When high risk of CVD?

A

Treat w/ DPP-4I/Pioglitazone/SU/SLGLT-2I

BUT
When high risk of CVD? SGLT-2i

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15
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

HbA1c above individually agreed threshold& Monotherapy not working?
Treat w/…

A

Treat w/…
DPP-4i+Piogltiazone
OR
DPP-4i+SU
OR
Pioglitazone+SU

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16
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

HbA1c STILL not controlled..?

A

INSULIN THERAPY!

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17
Q

METFORMIN (biguanide)

MOA?

A

Decreases gluconeogenesis+increases peripheral utilisation of glucose

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18
Q

METFORMIN SIDE-EFFECTS? LGV

A

Lactic acidosis (avoid if eGFR<30)
GI side-effects (increase dose slowly/give MR prep)
Can reduce vitamin B12

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19
Q

why can metformin -> lactic acidosis?

A

metformin blocks pyruvated carboxylases -> enz involved in gluconeogenesis, thus leading to accumulation of lactic acid

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20
Q

sick day rules apply to which classes of drugs?

A

diuretics
acei/ arb
metformin
nsaids
aglt2i

(all act on kidneys)

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21
Q

what to do if PATIENT ON METFORMIN experiences acute AKI?

A

stop!
due to increased risk of lactic acidosis

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22
Q

SULPHONYLUREAS
MOA?

S for secretion!

A

Stimulates insulin secretion from pancreatic beta cell

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23
Q

2 TYPES OF SULPHONYLUREAS? and examples pls

A

SHORT-ACTING- GT- gliclazide, tolbutamide, glipizide

LONG-ACTING- GG- glibenclamide, glimepiride

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24
Q

What are LONG-ACTING sulphonylureas associated with?

A

prolonged/sometimes fatal cases of hypoglycaemia
AVOID IN ELDERLY

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25
SULPHONYLUREAS- SIDE-EFFECTS?
High risk of hypoglycaemia AVOID in: Acute porphyria Hepatic/Renal failure (sulpHonyluRea)
26
PIOGLITAZONE MOA? P for less peripheral!
Reduces peripheral insulin resistance
27
PIOGLITAZONE AVOID IN which pts?
history of HF
28
PIOGLITAZONE There’s an increase risk of Bladder cancer therefore report what..?
review safety+efficacy after 3-6months stop treatment if patient responds inadequately REPORT… Haematuria (blood in urine) Dysuria (painful urination) Urinary urgency
29
increased risk what 3 with Pioglitazone?
bladder cancer bone fractures liver toxicity
30
inc risk of liver tox with pioglitazone so report what?
nausea vom abdominal pain fatigue dark urine develop
31
DPP-4i MOA? increases one, decreases the other
Increases insulin secretion+lowers glucagon secretion
32
DPP-4i Can cause..?
Pancreatitis Discontinue if symptoms of acute pancreatitis occur… - persistent, severe abdominal pain
33
DPP-4i EXAMPLES?
ALIOGLIPTIN LINAGLIPTIN SAXAGLIPTIN SITAGLIPTIN VILDAGLIPTIN (hepatotoxic)
34
SLGT-2iS MOA?
Inhibits SLGT2 in renal proximal convoluted tubule (more urine, glucose, infection)
35
SGLT-2iS MHRA WARNINGS? DKAKFaGLLA MONITOR RENAL FUNCTION!
- DIABETIC KETOACIDOSIS MONITOR KETONES if treatment interrupted-> surgery/illness - FOURNIER’S GANGRENE - CANAGLIFLOZIN only: risk of lower-limb amputation (mainly toes)
36
SGLT-2iS what causes volume depletion and how to correct?
Due to lots of urination, loss of water Correct hypovolaemia (reduced volume of circulating blood in body) before starting treatment
37
what to monitor with SGLT-2i?
renal function
38
SGLT-2iS EXAMPLES?
CANAGLIFLOZIN DAPAGLIFLOZIN EMPAGLIFLOZIN
39
GLP-1 AGONIST MOA? GLP-1 receptor
BINDS TO GLP-1 RECEPTOR Increases insulin secretion, suppresses glucagon secretion slows gastric emptying
40
GLP-1 AGONIST EXAMPLES? -tides
DULAGLUTIDE EXENATIDE LIRAGLUTIDE LIXISENATIDE
41
GLP-1 AGONIST SIDE-EFFECTS?
SEMAGLUTIDE!!! ozempic ACUTE PANCREATITIS (same as DPP4i)- persistent, severe abdominal pain DEHYDRATION- risk, due to GI SEs, take precautions to avoid fluid depletion
42
OTHER ANTIDIABETICS ACARBOSE?
Delays digestion+absorption of starch+sucrose high risk of GI side-effects- reduce dose?
43
OTHER ANTIDIABETICS MEGLITIDES (Nataglinide/Repaglinide)?
Stimulates insulin secretion Stressed? Change to treatment w insulin to maintain glycaemia control
44
which of the following SEs NOT associated w pioglitazone HF bladder cancer bone frax liver tox pancreatitis
pancreatitis
45
which antidiabetics assoc with: weight gain
Pioglitazone+Sulphonylureas (gliclazide)+Insulin
46
which antidiabetics are weight neutral
metformin DPP4i (gliptins)
47
which antidiabetics asociated w weight loss
GLP-1+SGLT-2i glutides
48
4 diabetic complications
CV disease diabetic nephropathy diabetic neuropathy visual impairment
49
WHAT DRUG IS CONSIDERED IN ALL TYPE 1 PATIENTS to prevent treat CVD?
Low-dose atorvastatin, offer to: 40+years diabetic 10+years nephropathy/other CVD factors
50
what drug class REDUCES CVD risk
ACEi regardless of age or ARB in afro-carribean
51
what is diabetic nephropathy
deterioration of kidney func
52
DIABETIC COMPLICATIONS pts with DIABETIC NEPHROPATHY causing proteinuria (protein in urine) TREATMENT?
ACE-i/ARB
53
WHAT DRUG CAN POTENTIATE HYPOGLYCAEMIA EFFECT OF ANTIDIABETIC DRUGS/INSULIN?
ACE-i (risk of HYPERkalaemia) can affect clearance of drugs thus inc risk
54
diabetic complications PAINFUL PERIPHERAL NEUROPATHY treated with what what about diabetic foot?
antidepressants/gabapentin/pregabalin Diabetic foot? treat pain+manage infection
55
how is AUTONOMIC NEUROPATHY with diabetes tx?
treat diarrhoea w/ codeine/tetracyclines
56
how is NEUROPATHIC POSTURAL HYPOTENSION w diabetes tx?
increase salt intake/fludrocortisone (mineralocorticoid causes fluid retention)
57
how is GUSTATORY SWEATING w diabetes tx?
antimuscarinic- propantheline bromide
58
how is ERECTILE DYSFUNCTION w diabetes tx
Sildenafil
59
how is VISUAL IMPAIRMENT w diabetes tx
Yearly eye tests
60
DIABETEIC KETOACIDOSIS- SEVERE HYPERGLYCAEMIA SYMPTOMS? PTP(B)DLC
Polyurea Thirsty Pear drop breath smells (ketones) - key giveaway. other symptoms overlap w drunk (B) Deep/ fast breathing Lethargic Confusion
61
DKA- checking blood sugar levels What do you do if… PATIENT DISPLAYS SYMPTOMS OF DKA? BLOOD SUGAR LEVELS >11mol/L?
PATIENT DISPLAYS SYMPTOMS OF DKA? Check blood sugar levels BLOOD SUGAR LEVELS >11mol/L? Check ketone levels (urine/ blood)
62
DKA- ketone levels 0.6-1.5mmol? 1.6-2.9mmol? 3mmol?
0.6-1.5mmol? slight risk (retest in 2hrs) 1.6-2.9mmol? increased risk (contact GP) 3mmol? medical emergency
63
DKA- TREATMENT systolic BP<90? Once BP>90? Give what
BP<90? RESTORE VOLUME W/ 500ml IV NaCl 0.9% Once BP>90? GIVE MAINTENANCE IV NaCl 0.9%
64
in DKA, Start IV insulin mixed w/ NaCl, administer at a rate so that ketone conc. falls at? blood glucose conc. falls at?
ketone conc: 0.5mmol/L/hr Blood glucose conc: 3mmol/L/hr
65
DKA- TREATMENT What do you do when blood glucose <14mmol/L?
Give IV glucose 10% as were trying to keep BG from falling too much while trying to lower ketone levels
66
DKA- TREATMENT blood glucose <14mmol/L. Continue insulin till.. ketone< ph>?
Continue insulin till.. ketone <3 mmol/L & pH>7.3 When patient is able to eat, give fast-acting insulin w/ meal Finally, stop treatment 1hr after food
67
INSULIN DURING SURGERY ELECTIVE (minor w/ good glycaemic control) day before what changes to make?
Reduce OD long-acting dose by 20%, rest as usual
68
INSULIN DURING SURGERY ELECTIVE (major/poor glycaemia control) DAY BEFORE? ON THE DAY?
DAY BEFORE? Reduce long-acting dose by 20%- rest as usual ON THE DAY? Reduce long-acting dose by 20%- stop other insulin till patient eating IV infusion of KCL+Glucose+NaCl Variable rate IV insulin (soluble human) in NaCl 0.9 given via pump
69
elective major surgery/ poor glycaemic control, how often bg measurements taken and what to give if bg drops belwo 6mmol/L
Hourly blood glucose measurements for first 12hrs Give IV glucose 20% if blood glucose dips <6mmol/L
70
INSULIN- POST SURGERY When do you convert back to SC insulin?
when patient can eat/drink
71
INSULIN- POST SURGERY when to restart BASAL-BOLUS REGIMEN?
with the first meal- IV insulin infusions carried on till 30-60mins after first meal-time short-acting insulin admin
72
INSULIN- POST SURGERY LONG-ACTING REGIMEN carries on at 20% reduced dose until when
pt leaves hospital
73
INSULIN- POST SURGERY BD REGIMEN when restarted?
Restart before breakfast/evening meal- IV insulin infusion carried on for 30-60mins after first SC insulin dose
74
SICK DAY RULES - SUGAR LEVELS? - INSULIN? - CARBOHYDRATES? - KETONES?
SUGAR LEVELS? Check regularly (every 2-3hrs if needed) INSULIN? Carry on taking, else -> DKA CARBOHYDRATES? Keep eating+stay hydrated KETONES? Check regularly, 4 hrly
75
DIABETES- PREGNANCY/BREASTFEEDING Risks to woman+foetus, risk reduced by ?
effective blood-glucose control
76
DIABETES- PREGNANCY/BREASTFEEDING PLANNING FOR PREGNANCY - what to aim for?
hba1c < 48mmol/L take folic acid 5mg
77
FOLIC ACID HIGH RISK OF NEURAL TUBULE DEFECTS?
diabetes, antiepileptics, previous child, smoking is just at risk factor 5MG OD BEFORE CONCEPTION+TILL WEEK 12 PREGNANCY
78
FOLIC ACID LOW RISK OF NEURAL TUBULE DEFECTS?
400MCG OD BEFORE CONEPTION+TILL WEEK 12 PREGNANCY
79
WOMEN TAKING INSULIN MUST BE AWARE OF..?
HYPOGLYCAEMIA RISK + ALWAYS CARRY FAST-ACTING GLUCOSE
80
DIABETES- PREGNANCY/BREASTFEEDING x3 MEDICATION KEY POINTS?
Stop all antidiabetics, except metformin, replace w insulin 1st line long-acting insulin: isophane insulin* Statins/ACE-i/ARBs-> discontinue *Good blood glucose control before pregnancy w/ long-acting insulin analogues (detemir/glargine) calm to continue
81
what is GESTATIONAL DIABETES
Developed during pregnancy, STOP treatment after birth
82
GESTATIONAL DIABETES Fasting BG<7mmol/L?
1. Diet+Exercise. 2. Metformin (unlicensed) 3. Insulin IF REQUIREMENTS NOT MET IN 1-2 WEEKS!
83
GESTATIONAL DIABETES Fasting BG>7mmol/L?
diet, exercise, insulin!! +/- metformin
84
GESTATIONAL DIABETES Fasting BG 6-6.9mmol/L w/ complications? macrosomia
Insulin +/- Metformin
85
HYPOGLYCAEMIA- mmol/L?
<4mmol/L
86
HYPOGLYCAEMIA- SYMPTOMS?
SWEATING LETHARGIC DIZZINESS HUNGER TREMOR TINGLING LIPS PALPITATIONS EXTREME MOODS PALE
87
HYPOGLYCAEMIA- TREATMENT (conscious+can swallow) with/without symptoms! What 3 things could you give?
FAST-ACTING CARBS: 4-5 glucose tablets 3-4 heaped teaspoonfuls of sugar 150-200mL fruit juice Repeat/ 15mins for 3 cycles
88
HYPOGLYCAEMIA- TREATMENT (patient unconscious/swallow L) What do you do now?
IM glucagon unresponsive after 10mins? IV glucose
89
Why be careful with b-blockers?
Can mask the effects of hypoglycaemia

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