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Endocrine > Rx of DM > Flashcards

Rx of DM Flashcards

(92 cards)

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1
Q

What does type 1 always require

A

Insulin as no pancreatic tissue left

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2
Q

If on insulin what happens to BG control

A

Can be less strict due to risk of hypoglycaemia

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3
Q

How do you treat type II

A

Diet + exercise to restore insulin sensitivity
Oral meds
Metformin = 1st line
Can step up to insulin if still not controlled

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4
Q

How do you monitor DM

A

Self monitoring of BG only if risk of hypo
Trend in HbA1c = most important value every 3-6 months
If stable = then leave on drug
If rising = add in drug

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5
Q

What should target HbA1c be in type I

A

48

Depends on other factors / risk of hypo

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6
Q

How often should you monitor blood glucose on insulin

A

4x daily

Before each meal and before bed

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7
Q

What should target BG levels be

A

5-7 on waking

4-7 before meals

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8
Q

How do you treat type I

A

Insulin

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9
Q

What do you consider adding if high BMI >25

A

Metformin

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10
Q

What can you test for in type I

A

GAD Ab

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11
Q

How do you deliver insulin

A

SC
Insulin pump = continuous infusion + bolus at meals
IV insulin if acutely unwell

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12
Q

What is important in SC

A

Rotate sites to prevent lipodystrophy which will cause erratic absorption

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13
Q

What are SE of insulin

A

Hypoglycaemia
Lipodystrophy
Weight gain

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14
Q

What should people on insulin have

A

Glucagon kit for emergency

Education about signs of hypoglycaemia

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15
Q

What drug reduces hypo awareness / insulin sensitivity

A

Beta blocker

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16
Q

What sources of insulin is there

A

Analogue
Human sequence
Porcine

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17
Q

What duration of action of insulin is there

A

Rapid acting
Short acting ‘actarapid’ - use as basal bolus
Intermediate acting ‘isoprene’ - use in pre-mix with long acting
Long acting ‘determir’ - use once or 2x daily
Mixed

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18
Q

What is most common insulin regimen

A

2x daily insulin determir (LA)
+- rapid acting insulin analogue 30 mins before meal
Basal bolus - 4x B,L,T, B

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19
Q

What must patient work out

A

Insulin to CHO ratio

Initially 1 unit for 10g of carb

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20
Q

What is the future of type I

A

Full closed loop pump with internal glucose monitor
Donor transplant
Bionic pancreas

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21
Q

What does patient education encompass

A

Team based
DIANE - Diabetes Insulin Adjustment and Normal Eating
Online - DM UK / myDMmyway / carb counting apps
Group education
Sick day rules
Hypoglycaemia awareness
How to administer insulin
How to monitor glucose / ketones / finger prick glucose
CHO counting
Exercise advise

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22
Q

Who is involved in DM team

A 
Patient
DSN
Practice nurse
GP
Diabetes doctor
Podiatrist
Dietician
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23
Q

Lifestyle measures in DM

A 
High fibre, low glycemic index CHO 
Control fats
Weight loss 
Exercise
Stop smoking 
Manage CVS disease risk 
- High dose statin for cholesterol 
- BP meds 
Regular foot care 
Advise DVLA
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24
Q

What is HbA1c targets in DM II

A

Aim 48

Aim 53 if on drugs that cause hypo / frail / reduced LE

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25
What is 1st line oral drug in DM type II
Metformin | Titrate as high as patient tolerates or change to MR
26
When would you start sulphonyurea instead of metformin
If osmotic symptoms or present with weight loss or if metformin CI
27
When would you add another agent
If HbA1c >58 / trend increasing
28
What agents do you add
Any - look at SE | Not GLP-1
29
When do you add thiazodiole
If hypo a concern | No CCF
30
When do you add DDP-IV
If hypo / weight gain a concern
31
When do you add SGLT -2
If hypo or weight gain a concern
32
If HbA1c still >58
Add another agent OR | Consider insulin + metformin
33
If triple therapy not tolerated or not effective AND BMI >35
Metformin + sulphonyurea + GLP-1 - all 3 | Last resort
34
What is the action of metformin
Increases insulin sensitivity Decrease hepatic gluconeogenesis Increase peripheral utilisation of glucose
35
How do you take metformin
Oral
36
What are SE and when is it CI
``` Lactic acidosis CI in eGFR <30 Consider stopping if eGFR <45 Risk of b12 albsorption GI upset ``` CI CKD Recent MI / AKI / sepsis as may cause lactic acidosis as state of hypoxia Iodine containing contrast (stop 48 hours after) Alcohol abuse
37
What are advantages
Weight neutral No hypo risk Safe in pregnancy Improved CVS outcomes
38
What are examples of sulphonylurea drugs
Gliclazide | Glibenclamide
39
How do sulphonyurea drugs work
Augement insulin secretion by stimulating beta cells so increase insulin and C-peptide Useful in MODY
40
How do you take
Oral
41
What are SE
Risk of hypo so BG testing required - present nausea / sweaty / dizzy etc. Weight gain Increased appetite ``` Rare Hyponatraemia due to inapproriate ADH Hepatic failure / cholestasis Bone marrow suppression Neuropathy ```
42
What are advantages
Rapid onset
43
What do you avoid in
Pregnancy Breast feeding Hepatic failure
44
What are examples of thiazolidinediones (Glitazone)
Pioglitazone
45
What is the action
Reduce peripheral insulin resistance
46
How do you take
Oral
47
What are SE
``` Weight gain Fluid retention Anaemia Heart failure Osteoporosis / fractures Bladder cancer Liver impairment so monitor LFT before Rx and regularly ```
48
What are advantages
No hypo
49
Who do you avoid in
HF due to fluid retention | Bladder cancer
50
How do DDP-4 inhibitors work (siptagliptin)
Inhibit DDP-4 Increase insulin secretion Decreased glucagon secretion by increasing incretin
51
How do you take
Oral
52
What are SE
GI Sx Pancreatitis Careful in eGFR
53
What are advantages
Reduce hypo | Weight neutral
54
How do SGLT-2 inhibitors work
Inhibit SGL2 Reduce glucose reabsorption in kidney Increase kidney
55
How do you take
Oral
56
What are SE
``` Require eGFR of 60 Amputation Increased fungal and UTI due to glycosuria Can get normoglycemia ketoacdiosis Postural hypo due to diuresis Polyuria ```
57
When is it CI
EgFR <60 | Pregnancy
58
What are advantages
Weight loss as increased urine loss Decreased hypo CVS risk
59
What does GLP-1 agonist do
Activates GLP-1 in small intestine to increase insulin Suppress glucagon Slows gastric emptying
60
How do you take
SC injection
61
What are SE
N+V | Pancreatitis
62
When is it CI
eGFR <30
63
What are advantages
Weight loss HbA1c control Use with insulin
64
What are symptoms of uncontrolled
``` Increasing thirst and urination Blurred vision Fatigue Increased hunger Tingling / pain / numbness Slow healing of guts ```
65
How do you manage RF
BP Statin Lifestyle
66
Lifestylee
``` Diet Weight loss Physical activity Reduce alcohol Smoking cessation ```
67
What is target BP if no end organ damage and if end organ damage
140/80 = no damage | 130 / 80 if mage
68
What is 1st line in DM
ACEI as renoprotective
69
What should you be aware of
Autonomic neuropathy may lead to postural Sx | Avoid BB as cause insulin resistance
70
When do you offer statin
CVS risk >10%
71
When is this different
DM type I with see below CKD = offer to all Hx familial hyperlipidaemia
72
When do you consider statin in type 1
>40 DM >10 years Nephropathy Other CVD RF
73
How do you follow up statin
Full lipid profile
74
DM and work
Can't work in armed forces / police / fire
75
DM and Ramadan
Eat meals with long acting CHO Check BG if feel unwell Switch doses or times of meds
76
What are sick day rules
Increase BG monitoring to every 4 hours Drink 3L of fluid Drink sugary drinks if can't eat Continue oral meds / insulin even if can't eat due to risk of DKA as illness often requires extra insulin despite reduced food Corrective dose of insulin if sugar or ketones raised
77
What is exception to rule
Metformin | Should be stopped if dehydrated due to risk of renal impairment
78
Why do you continue meds if not eating
Stress = increased cortisol
79
When do you admit to hospital
``` Serious underlying illness Can't keep fluid down Persistent diarrhoea Significant ketones despite Rx BG >20 despite insulin Lack of support at home A child or pregnant ```
80
DVLA and type 1 /2
Can drive if no hypo in 12 months Still have awareness Regular BG monitoring No complications
81
Do you need to inform DVLA
Only if on insulin
82
Risks of surgery and DVLA
Increased risk of infection if poorly controlled
83
If poor control or on insulin what happens
Require variable rate IV insulin infusion + | K supplementation
84
If on oral med / diet controlled
Omit medication and monitor BG
85
What do you get when Dx with DM
``` BG measured BP and BMI measured Lipid measures Eye, foot and kidney screen annual Smoking cessation support Education Emotion and psych support ```
86
What do you do if on metfromin and having contrast CT
Stop for 48 hours after
87
Common errors insulin prescribing
Never omit dose Always use insulin unit and don't abbreviate Use insulin syringe Follow sick day rules
88
4 Rights to insulin prescribing
Right insulin Right dose Right time Right way
89
What are the 4 doses of insulin
100 = most common (100 units in 1ml) 200 300 500
90
What is important to remember
Any >100 must be given in device they are supplied with | NEVER draw out to be put into syringe
91
Where do you store insulin
Fridge
92
Cntrol
Tight needed in young to prevent complications | In elderly less tight as don't want to fall

Endocrine (17 decks)

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