Endocrinology Flashcards

Question

what is part of the annual diabetic review

Answer 1

``` Cardiovascular risk review Smoking? BMI BP ECG Blood lipids ``` ``` Assess for microvascular complications Eye check Feet Pain? Erectile dysfunction ? Neurovascular status Urine dip ``` ``` Assess diabetic control HBA1C Assess concordance to diet/lifestyle advice Assess for lifestyle events Hospitalisation Symptoms of hypoglycaemic episodes Medication side effects Injection site reactions ``` DrivinG? DVLA require informing? Depression/anxiety screen

Answer 2

Control blood pressure <140/80 <130/80 if there are any microvascular complications QRISK - Atorvostatin if >10% 10 year risk

Answer 3

Dietary advice General, stick to what is generally considered healthy Weight loss 5-10% aim Increase physical activity 30 min per day (low-medium intensity) Smoking cessation Alcohol advice Alcohol may exacerbate/prolong effects of hypoglycaemia and may make hypoglycaemic episodes unclear Limit intake and always have carbohydrates at the ready if alcohol is being consumed

Answer 4

1st line – metformin 500mg with breakfast 1st week, then with breakfast and dinner the next week, then after each of the 3 meals thereafter Alternative if contraindicated Gliptin (DPP4is) Thiazolidinedione/pioglitozone (PPARy activators) Sulphonylurea 2nd line Metformin + any of drugs mentioned above (Sulphonurea tends to be used more commonly) 3rd line Triple therapy Metformin + SU + gliptin/pioglitozone 4th line Insulin

Answer 5

Insulin therapy Basal bolus regime with long-acting insulin with mealtime short-acting insulin adjustments tends to be the best regime

Answer 6

Non-adherence Poor technique Non rotation of injection sites Innapropriate dose titration Psychosocial issues Organic causes

Answer 7

General Weight gain Insulin resistance ``` Local (injection site) Pain Redness Swelling Injection site abscess Lipohypertrophy ```

Answer 8

4x daily glucose monitoring at least 2x a week is the mimimum requirement Optimal targets are : Fasting glucose level of 5-7 on waking Plasma glucose level 4-7 before meals at any other time of the day Plasma glucose 5-9 90 mins after eating

Answer 9

Do not stop the insuin therapy Monitor blood glucose every 3-4 hours including overnight Consider checking blood/urine for ketones Maintain normal meal pattern where possible Drink at least 3L of fluid everyday Go to GP/hospital if there are serious indications of illness (can't drink fluid due to N+V, ketones in urine/blood, dangerously elevated glucose levels etc)

Answer 10

DVLA should be notified if: 2 episodes of severe hypoglycaemia in the last 12 months Reduced awareness of hypoglycaemic episodes Insulin therapy Must check BG every 2 hours of a long journey Must carry enough supplies to avert hypoglycaemic events

Answer 11

Decreased hepatic glucose production and increased peripheral insulin sensitivity

Answer 12

EGFR <30ml/min/1.73m2 (standard release) or 45 for modified release Alcohol addiction People at risk of lactic acidosis (DKA) People at risk of tissue hypoxia Cardiorespiratory failure

Answer 13

GI effects N+V Abdo pain Anorexia Lactic acidosis Rare but serious Caused by drug accumulation More common when combined with alcohol

Answer 14

tolbutamide (short acting) gliclazide (medium acting) glibenclamide (long acting)

Answer 15

increases insulin secretion

Answer 16

Insulin SUs + metglinides caution prescribing in elderly due to increased risk of hypoglycaemic events

Answer 17

insulin SUs Thiazolidinediones (PPAR-y activators)

Answer 18

PPAR-y activators increasing peripheral insulin sensitivtiy

Answer 19

increase post-prandial insulin release via DPP4 inhibition

Answer 20

cardio/hepatic/renal dysfunction

Answer 21

GI disturbance rarely Acute pancreatitis

Answer 22

Rarely used, only indication is replacing the pioglitazone/gliptins in triple therapy IF the patient: Has a BMI >35 or Has a BMI <35 AND Weight loss would be beneficial, Insulin therapy would have negative occupational impacts

Answer 23

GI disturbance Rarely acute pancreatitis

Answer 24

Weight gain – redistibutes ectopically stored lipids Fluid retention – avoid in CCF Liver dysfunction – monitor LFTs Linked to bladder cancer – assess risk factors

Answer 25

high insulin levels but low C-peptide levels c-peptide is produced with endogenous insulin but not in exogenous insulin

Answer 26

A to E 1L 0.9% sodium chloride over 1 hour if SBP >90 500ml bolus over 10 mins if SBP <90, reassess and repeat if poor response Start IV infusion of insulin 50 units human soluble rapid acting insulin added to 60ml 0.9% NaCl giving 1 unit/ml solution Start in syringe driver at 0.1units/hour

Answer 27

Severe DKA (pH <7.1) Drowsy Pregnant Sats <94% on 40% O2 Persistent hypotension (<90SBP) after 2L of NaCl

Answer 28

Continue fixed rate insulin at 0.1units/kg/hour and continue normal long acting insulin Aim for blood glucose to fall 3mmol/L/hour until <14mmol/L If glucose not falling check dosage, pump operation, patient weight, reassess concominant illness Increase rate by 1 unit/hour if necessary ``` Continue IV 0.9% NaCl 1L over 1 hour Then 1L over 2 hours 3rd bag = 1L over 2 hours 4th bag = 1L over 3 hours ``` When glucose is <14mmol/L add 10% glucose at 125ml per hour Adjust to keep blood glucose between 8-14mmol/L Potassium If potassium <5.4 add 40mmol KCL per litre NaCl Consider after first liter either way Reassess hourly for the first 4-6 hours Regular lab monitoring of glucose, ketones, potassium and bicarbonate

Answer 29

Transfer to SC insulin once the patient is able to eat and drink normally, and venous pH is >7.3 Stop the IV infusion 1 hour after the next SC injection of insulin Refer all patients to the diabetes team prior to discharge

Answer 30

Aggressive IV fluids 1L 0.9% NaCl over one hour Aim for positive balance of 3-6L over 12 hours There may be an initial rise in Na this is not concerning if osmolality is declining Low dose fixed dose IV insulin infusion Ketones = treat as DKA and treat immediately No ketones = add insulin once fall in glucose is <5mmol/L hr 0.05 units/kg/hour, may not be required Consider potassium replacement 3.5-5.5, add 40mmol/L if >5.5, seek senior help Give prophylactic LMWH Very high risk of thrombosis Regular monitoring of vitals, fluid balance, glucose, osmolality, U+E hourly for the first 6 hours Complete normalisation of fluid/electrolytes may take 72 hours Transfer to SC insulin when eating and drinking and normally and biochemistry has normalised Stop the IV infusion 1 hour after starting SC insulin Refer to diabetes team

Answer 31

Promptly consume 10-20g fast acting carbohydrate preferable in liquid form Avoid chocolates/biscuits as sugar content lower, and fats may delay stomach emptying Recheck blood glucose levels after 10-15 mins Hypoglycaemia should be reversed in about 10 mins Improvements in signs and symptoms may lag behind improvement in blood glucose If inadequate response repeat as above and recheck again When symptoms improve, the patient should eat some long-acting carbohydrate

Answer 32

if available Administer IM glucagon immediately <8yrs 500mcg >8yrs 1mg Glucagon not available, alcohol has been consumed, or patient does not respond to glucagon within 10 mins call 999 for emergency hospital transfer as Glucagon doesn't work is alcohol has been consumed If the patient responds to glucagon, advise intake of long acting carbohydrates when able Vomiting is common during recovery which can precipitate further episodes of hypoglycaemia If episodes recur the patient may require hospital admission for IV treatment

Answer 33

Within hospital 100ml 20% glucose can be used as an alternative to glucagon and this can be repeated 3 times If IV access is not available, administer IM glucagon whilst gaining access (<8yrs 500mcg, >8yrs 1mg) Following recovery never omit insulin In patients with T1DM

Answer 34

Pan-retinal photocoagulation Aim is to burn off the new developing vessels Vitrectomy if there is persistent haemorrhage

Answer 35

Focal laser treatment Mixed maculopathies require more complex treatments

Answer 36

any diabetic patient with microalbuminurea should be started on an ACE inhibitor regardless of symptoms

Endocrinology Flashcards

(61 cards)