Management of Diabetes

Question 1

What are the aims of management with regards to type 1 diabetes?

Answer 1

Prompt diagnosis
Encouragement of self management
Correction of acute metabolic upsets
Facilitate long term health and wellbeing

Question 2

Why is a prompt diagnosis important in type 1 diabetes?

Answer 2

DKA can develop and cause death if diabetes is left undiagnosed

Question 3

What steps can be taken to make an early diagnosis of type 1 diabetes?

Answer 3

Remember symptoms- thirsty, thinner, tired and more frequent toilet visits (4 Ts)
Test immediately- use a finger prick glucose test
Contact local team for a same day review

Question 4

What are some symptoms specific to children that may indicate type 1 diabetes?

Answer 4

A return to bed-wetting in a previously dry child
Heavier than usual nappies
Candidiasis
Constipation
Skin infections
Irritability/ behaviour change

Question 5

What are the symptoms of diabetic ketoacidosis?

Answer 5

Nausea & vomiting
Abdominal pain
Sweet smelling breath
Drowsiness
Rapid, deep respiration
Coma

Question 6

What steps should be taken in cases of diabetic ketoacidosis?

Answer 6

Test blood glucose with a finger prick test to confirm cause but DO NOT arrange for any laboratory tests
In children call a specialist for a same day review

Question 7

What are the current strategies to support people with type 1 diabetes?

Answer 7

Education- can be team based, structured or personal
Help with nutrition/lifestyle management
Skills training
Methods of receiving insulin

Question 8

When do type 1 diabetics need to be able to check their blood glucose levels?

Answer 8

To adjust insulin levels
Before driving
To tighten control of their diabetes

Question 9

What levels of ketones are considered normal, at risk of DKA and in DKA?

Answer 9

<0.6mmol/L-normal

0. 6-2.9 mmol/L- at risk of DKA
1. 0 or above- DKA

Question 10

What are the different kinds of insulin?

Answer 10

Rapid acting
Short acting
Intermediate acting
Long acting
Continuous acting

Question 11

What adjustments in lifestyle are necessary after a diabetes diagnosis?

Answer 11

Exercise
Diet
Driving
Smoking
Alcohol
Conception/contraception
Drugs
Holiday
Employment

Question 12

Under what blood glucose measurement is somebody considered hypoglycaemic?

Answer 12

> 4mmol/L

Question 13

What drugs put patients at risk of experiencing hypoglycaemic episodes?

Answer 13

Insulin and sulphonyureas

Question 14

What causes a hypoglycaemic episode?

Answer 14

An imbalance between nutrition, exercise and insulin

Question 15

What are the symptoms of a hypoglycaemic episode?

Answer 15

Sweating
Palpitations
Hunger
Shaking
Headache
Nausea
Confusion
Drowsiness 
Odd behaviours
Speech difficulty
Incoordination

Question 16

What volume of carbohydrate should be used to treat a hypo?

Answer 16

15-20g

Question 17

How can hypos be treated if the patient cannot take CHO orally?

Answer 17

Out of hospital- 1mg glucagon or Glucogel/Dextrogel

In hospital- 75-80ml 20% glucose or 25-50ml of 50% glucose

Question 18

How can hypos be avoided in insulin dependent diabetics?

Answer 18

Blood glucose monitoring
Site rotation and checking
Review diet
Consider change in insulin regimen
Deliver insulin before and after exercise

Question 19

What are the signs of DKA?

Answer 19

Dry mucus membranes
Sunken eyes
Tachycardia
Hypotension
Ketotic breath
Kussmaul resp.
Altered mental state
Hypothermia

Question 20

What are the possible complications of DKA?

Answer 20

Hyper/hypokalaemia
Hypoglycaemia
Cerebral oedema
Aspiration pneumonia
Arterial and venous thromboembolism
ARDS

Question 21

What measures may need to be taken in treating DKA?

Answer 21

Measure glucose, Us + Es, ketones, bicarbonate and arterial blood gases
Give IV saline
Give IV insulin
Give IV potassium in saline
May need antibiotics
Consider heparin and NG tube

Question 22

What factors help facilitate long term health and well being in cases of type 1 diabetes?

Answer 22

Optimal blood glucose (HbA1c to reduce microvascular disease)
Optimal blood pressure control (to reduce risk of nephropathy)
Manage cardiovascular risk factors
Screen for early detection of complications (feet, kidneys, eyes)

Question 23

What should patients with type 2 diabetes expect from their care?

Answer 23

Blood glucose levels
Blood pressure checked
Blood lipids
Eyes and feet screened
Kidney function tested
Weight management
Smoking cessation
An individual care plan
Structured education
Psychological/emotional support

Question 24

What are the aims of treatment of diabetes?

Answer 24

Relief of primary symptoms
Prevention of complications
Preservation of quality of life

Question 25

Describe the 5-step framework that should be considered when choosing a glucose lowering drug

Answer 25

1. Set a target HbA1c 2. Are there other risk factors that are more important? 3. Are the current treatments optimised? 4. What are the glucose lowering options? 5. Agree a review date and HbA1c target with the patient

Question 26

In what cases should you consider relaxing a HbA1c target?

Answer 26

``` People who are older or frail Adults with type 2 diabetes that have: -reduced life expectancy -high risk of hypoglycaemia -where intensive management not appropriate (eg multiple comorbities) ```

Question 27

What are the first line treatments of antihyperglycaemic therapy in type 2 diabetes and when is each recommended?

Answer 27

Metformin first line | Sulfonyureas if weight loss or osmotic symptoms are present

Question 28

What are the second line treatments of antihyperglycaemic therapy in type 2 diabetes and when is each recommended?

Answer 28

Sulfonyureas- if not already prescribed Thiazolidinedione- if hypos are a concern and no congestive heart failure DPP-IV inhibitor or SGLT-2 inhibitor- if hypos and weight gain are concerns

Question 29

What are the third line treatments of antihyperglycaemic therapy in type 2 diabetes and when is each recommended?

Answer 29

Add an additional one of the second line treatments Also can use injectable medications: GLP-1 agonist- if BMI >30 with a desire to lose weight Insulin- if osmotic symptoms/rising HbA1c

Question 30

``` Give examples of the following classes of medications: Sulfonyureas Thiazolidinedione DPP-IV inhibitor SGLT-2 inhibitor GLP-1 agonist ```

Answer 30

``` Sulfonyureas- glimepiride/gliclazide Thiazolidinedione- pioglitazone DPP-IV inhibitor- sitagliptin SGLT-2 inhibitor- empagliflozin GLP-1 agonist- lixisenatide ```

Question 31

Why is metformin the first choice in treating hyperglycaemia?

Answer 31

Improves outcomes Well tolerated Cheap

Question 32

What is the mechanism of metformin treating hyperglycaemia?

Answer 32

Affects glucose production and decreases fatty acid synthesis Improves receptor function Inhibits gluconeogenic pathways

Question 33

What are the disadvantages of metformin?

Answer 33

Risk of lactic acidosis GI side effects common Risk of vitamin B12 malabsorption

Question 34

Describe the mechanism of action of sulfonyureas

Answer 34

Bind to sulfonyurea receptors on functioning pancreatic beta-cells, closing the linked ATP-sensitive potassium channels. This causes a decreased potassium influx depolarisation of the cell membrane so voltage-gated calcium channels open and cause an influx of calcium. This causes translation and exocytosis of secretory granules of insulin into the cell

Question 35

What are the advantages of sulfonyureas?

Answer 35

``` Can be used with metformin Rapid improvement of control and systematic improvement Rapid titration Well tolerated Cheap ```

Question 36

What are the disadvantages of sulfonyureas?

Answer 36

Risk of hypoglycaemia Weight gain Caution needed in renal and hepatic disease Contraindicated in pregnancy and breast feeding Side effects include hypersensitivity and blood disorders

Question 37

Describe the mechanism of action of thiazolidinedione

Answer 37

Selectively stimulates the PPAR-gamma and modulates the transcription of insulin-sensitive genes involved in the control of glucose and lipid metabolism in muscle, adipose tissue and the liver. It reduces insulin resistance in the liver and peripheries, increases the expense of insulin-dependent glucose, decreases withdrawal of glucose from the liver and reduces quantity of glucose, insulin and glycated haemoglobin in the bloodstream

Question 38

What are the advantages of pioglitazione?

Answer 38

Helpful in cases where insulin resistance is significant Reduces HbA1c marginally Cheap Cardiovascular safety established

Question 39

What are the disadvantages of pioglitazione?

Answer 39

Increased risk of bladder cancer Fluid retention Weight gain Increases risk of fractures in females