16 - Diabetes

Question 1

What are some of the presenting symptoms of type 1 diabetes?

Answer 1

Children: sudden onset, polyuria, polydipsia, excessive tiredness, weight loss as fat broken down for energy

Adults: rapid weight loss, family history of autoimmune disease, ketosis (urine dip), age of onsrt <50, BMI<25

Onset of symptoms in a few days/weeks, needs immediate treatment with insulin

Question 2

What are some of the complications of type 1 diabetes?

Answer 2

- Microvascular: retinopathy, nephropathy, and neuropathy.

- Macrovascular: MI, stroke, and peripheral arterial disease.

- Metabolic: DKA and hypoglycaemia (glucose <3.5 mmol/L).

- Psychological: anxiety, depression, and eating disorders.

- Increased risk of other autoimmune conditions: thyroid disease, coeliac, Addisons, and pernicious anaemia. All often screened for on diagnosis

- Reduced quality of life and life expectancy

Question 3

What is the diagnostic criteria for type 1 diabetes?

Answer 3

• Symptoms + test

OR

• Asymptomatic + two positive tests on different days

- Random >11.1

- Fasting >7

- OGTT >11.1

Question 4

When diagnosing diabetes in children you should assume it is type 1 unless the child has risk factors for type 2. What are these risk factors?

Answer 4

• Strong family history of type 2 DM
• Obesity
• Black or Asian family origin.
• No insulin requirement, or insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase.
• Evidence of insulin resistance (for example acanthosis nigricans).

Question 5

When should you suspect DKA?

Answer 5

• Finger prick BM >11 mmol/L
• Increased thirst and urinary frequency.
• Weight loss.
• Inability to tolerate fluids.
• Persistent vomiting and/or diarrhoea.
• Abdominal pain.
• Visual disturbance.
• Lethargy and/or confusion.
• Fruity smell of acetone on the breath (pear drops)
• Acidotic breathing — deep sighing (Kussmaul) respiration

Question 6

What investigations should you do if you suspect a DKA?

Answer 6

- Assess for precipitating factors e.g infection, physiological stress, non-adherance to insulin treatment, drug treatment e.g steroids

- Test for ketones: in adults test urine and blood ketones even if blood glucose is ok. in children test blood ketones. Ketones high if 2+ in urine or >3mmol/L

Question 7

When should you suspect hypoglycaemia in type 1 diabetes? (levels below 3.5 mmol/L)

Answer 7

Question 8

What are normal BM ranges for people without diabetes and for people with diabetes?

Answer 8

Question 9

How is type 1 diabetes managed on initial presentation?

Answer 9

Immediate same day referral to the hospital to confirm diagnosis and start insulin

Question 10

How is type 1 diabetes managed for adults in primary care?

Answer 10

- Ensure individual care plan is in place. Review in a few weeks and then annually from then on

• Offer a structured education program like DAFNE within 6-12 months so pt takes responsibility
• Provide info on how to communicate with diabetes team
• Provide info on disability allowance

- Manage lifestyle issues like diet, exercise and alcohol intake

- Provide info on diabetes support groups like Diabetes UK and Living With Diabetes

Question 11

What things are included in an individual care plan for type 1 diabetes?

Answer 11

• A medical, environmental and cultural assessment are all undertaken with a general exam to form a care plan tailored to the patient

Question 12

What is the DAFNE programme?

Answer 12

Dos Adjustment For Normal Eating

Structured education programme for type 1 diabetics allowing them to lead as normal a life as possible. Helps them learn how to correct their sugars, carbohydrate counting etc

Question 13

How should blood glucose be monitored in type 1 diabetics?

Answer 13

HbA1c:

• Every 3-6 months aiming for below 6.5%

Self-Monitoring:

• Test at least 4 times a day: before breakfast, 2 hours after meals, during periods of illness, before driving, and if they feel hypoglycaemic
• May be offered Libre if more than 1 hypo a year, severe fwar of hypos, persistent hyperglycaemia despire 10xday testing
• Aim for 5-7 on waking, 4-7 before meals and 5-9 at least 90 minutes after eating

Question 14

What lifestyle advice should you give to adults with type 1 diabetes?

Answer 14

Diet

^{- Carbohydrate-counting training (matching carbs to insulin dose)}

^{- To prevent CVD diet low in fat, sugar, and salt, and contain at least 5 portions of fruit and vegetables a day}

^{- Avoid sugary drinks}

Alcohol

_{- Avoid drinking on empty stomach as will be absorbed faster}

_{- May prolong hypoglycaemic effect of insulin/nocturnal hypoglycaemia and may be more difficult to spot hypo signs}

_{- Wear medicalert bracelet or carry ID card when drinking as hypos can be confused with alcohol intoxication}

Exercise

_{- Encourage it because it lowers risk of CVD}

_{- Warn them it can lower blood sugars and you need to alter insulin doses for the next 24 hours}

^{<u><strong>Smoking Cessation</strong></u>}

Question 15

What are sick day rules for adults with type 1 diabetes?

Answer 15

• Never stop insulin, follow the rules from the specialist team about sick days and adjusting doses

- Check BM more frequently, every 1-2 hours, and through the night

• Check blood or urine ketones more frequently, and through the night
• Maintain normal eating pattern even if loss of appetite, could replace meals with milkshakes and drinks
• Aim to drink at least 3l of fluids to prevent dehydration
• Seek medical help if drowsy, violently sick or unable to keep fluids down

Question 16

How should cardiovascular risk factors be managed in type 1 diabetes?

Answer 16

Monitor the following:

• Lifestyle
• Waist circumference
• Albuminuria
• Full lipid profile
• Blood glucose control
• BP (target <135/85 with first line ACEi)
• Statins (don’t use Qrisk, offer 20mg atorvastatin for primary prevention, 80mg atorvastatin for secondary prevention)

Question 17

How should you monitor a type 1 diabetic for complications?

Answer 17

- Every appt: measure HbA1c, height, weight, waist circumference, check for depression, eating disorders like diabulimia, check smoking status

- Yearly: check injection sites, assess cardiovascular risk factors (lipid profile, bp, FHx, smoking status, blood glucose control), ensure screening for thyroid disease, ensure screening feet/eyes/kidneys

Question 18

How are the following complications assesed in type 1 diabetics:

• Retinopathy
• Neuropathy
• Nephropathy

Answer 18

• Retinopathy: annual review by local eye clinic. also if in GP and abnormal blood vessels on retina, referred to opthamologist

- Neuropathy: ask about ED and offer a PDE-5 inhibitor if so, ask about autonomic neuropathy, do diabetic foot checks with monofilament/looking for calluses/pulses

- Nephropathy: screen anually by bringing in first-morning urine and looking at creatinine:albumin ratio and eGFR (if below 60 diagnose CKD)

advise low protein diet and offer ACEi if nephropathy

Question 19

What are some signs of autonomic neuropathy in diabetics?

Answer 19

- Bladder emptying problems

- Unexplained diarrhoea particularly at night

- Gastroparesis (advise small particle diet if vomiting, referral to gastro for metoclopramide or continuous subcut insulin)

- Postural hypotension

- Excessive sweating

- Acute painful neuropathy of rapid improvement of blood glucose control (advise analgesics until resolved)

Question 20

What is the diagnostic criteria for gestational diabetes?

Answer 20

Question 21

What are the different insulin regimes for type 1 diabetics?

Answer 21

Offer multiple daily injection basal-bolus insulin regimens as 1st line

Offer twice-daily insulin detemir as the long-acting basal insulin and then a rapid-acting insulin analogue injected before meals

Question 22

What advice should be given to patients on insulin injection sites?

Answer 22

- Pinch the skin to avoid injecting muscle. Don’t need to pinch if small needle or using buttocks

• Check injection sites regularly for lumps (lipohypertrophy) and rotate injection sites to prevent this and lipodystrophy
• Swtich from left to right side of body weekly

Question 23

What advice should be given on injection technique for type 1 diabetics?

Answer 23

• Leave insulin at room temp 30 mins before administering to prevent pain of the cold
• Check expiry date
• Ensure injection site is clean
• Inject needle quickly at 90 degrees, leaving in for 5-10 seconds to prevent leakage
• Do not rub the site after injection as will increase insulin absorption
• Keep insulin in fridge if not being used in next 28 days, keep away from radiators

Question 24

How should hypoglycaemia be managed?

Answer 24

- Promptly consume 10–20 g of a fast-acting form of carbohydrate, preferably in liquid form. (3-6 glucose tablets, 100ml of Lucozade energy, 2-4 teaspoons of sugar in water)

• Recheck blood glucose after 10-15 minutes and if no improvement repeat the oral intake
• At next meal increase the amount of carbohydrate
• If patient unconscious give IM 1g glucagon immediately or call 999

Question 25

What are some adverse effects of insulin?

Answer 25

**- Painful injections:** numb site with ice, use shorter needles - **Bruising/Bleeding:** apply pressure and shorter needle **- Lipohypertrophy:** rotate injection sites **- Insulin leakage:** keep needle in for 5-10 secs **- Altered vision:** on initiation, assure only temporary **- Acute painful neuropathy on rapid improvement of glucose control:** NSAIDs and reassure -

Question 26

What are some drugs that can enhance/antagonise the hypoglycaemic effect of insulin?

Answer 26

**_Enhance_** - Alcohol - Anabolic steroids - ACEi - Beta blockers (also can mask signs of hypoglycaemia) - Fibrates - MAOi **_Antagonise (more insulin needed)_** - Corticosteroids - Diuretics (loop and thiazides). - Glucagon - Growth hormone - Levothyroxine - Oral contraceptives. - Sympathomimetic drugs (such as adrenaline, salbutamol, and terbutaline)

Question 27

What are some of the presenting symptoms of type 2 diabetes?

Answer 27

**- Persistent hyperglycaemia** **- Risk factors for type 2 DM** (e.g FHx, obesity, black or asian origin, PCOS, drug treatments like diuretics/steroids, low birth weight) **- Evidence of insulin resistance** (e.g acanthosis nigricans) **- Characteristics** like thirst, recurrent infections, tiredness, blurred vision, weight loss are likely to be less severe than type 1 or absent

Question 28

What is the definition of diabetes, particularly type 2?

Answer 28

Group of metabolic disorders characterized by persistent hyperglycaemia (**HbA1c more than 48 mmol/mol [6.5%]** or **random plasma glucose more than 11 mmol/L**). Type 2 is a mixture of insulin resistance and insulin deficiency

Question 29

What is the diagnostic criteria for type 2 diabetes?

Answer 29

**Asymptomatic:** 2 abnormal HbA1c results \>6.5% or if CKD fasting plasma glucose \>7 **Symptomatic:** single abnormal HbA1c or fasting plasma glucose level No additional features of type 1 diabetes (such as rapid onset, often in childhood, insulin dependence, or ketoacidosis). If child and suspect type 2 should still do immediate referral

Question 30

When should HbA1c be used with caution to diagnose type 2 diabetes?

Answer 30

Sickle cell trait

Question 31

What initial care and support should be offered to a newly diagnosed adult with type 2 diabetes?

Answer 31

**- Individual care plan** inc things like polypharmacy **- Structured education programme** e.g DESMOND/Empower - Ensure the person/family knows how to contact the diabetes team - Provide info on **government disability benefits** **- Manage lifetstyle issues** **- Screen** for diabetic complications **- Signpost to Diabetes UK or** Leicester Diabetes Centre - Review in 3/12 to see if lifestyle changes have worked

Question 32

What are the treatment targets for adults with type 2 diabetes?

Answer 32

Should measure at 3 month intervals until HbA1c stable, then can be measured every 6 months ## Footnote **- Below 6.5%:** if managed by lifestyle/diet or if managed by lifestyle and one drug not associated with hypoglycaemia **- Below 7.0%:** if managed by one drug associated with hypoglycaemia e.g sulfonylurea or if on multiple drugs **- Individual target:** may be relaxed for elderly or frail who are unlikely to see long term benefits of lower blood sugars

Question 33

When should type 2 diabetics do self monitoring of their blood glucose?

Answer 33

**Not routinely advised (as does not help improve sugars at 6 months) unless:** - On insulin therapy - Evidence of hypoglycaemic episodes - Taking a drug that may increase risk of hypoglycaemia while driving or operating machinery (such as a sulfonylurea) - Pregnant or trying to concieve - Short term if starting corticosteroids

Question 34

What treatment is offered to type 2 diabetics first line?

Answer 34

**_High risk of cardiovascular disease_** * QRISK2 more than 10% in adults aged 40 and over or * an elevated lifetime risk of cardiovascular disease (defined as the presence of 1 or more cardiovascular risk factors in someone under 40) Cardiovascular disease risk factors: hypertension, dyslipidaemia, smoking, obesity, and family history (in a first-degree relative) of premature cardiovascular disease.

Question 35

If a patients HbA1c is not controlled by first line treatment, what should be done next?

Answer 35

SEE PASS MEDICINE!!!

Question 36

What immediate treatment is recommended for adults with type 2 diabetes who have symptomatic hyperglycaemia?

Answer 36

Insulin or sulfonylurea

Question 37

What advice on diet, weight and exercise can you give to a type 2 diabetic

Answer 37

- High fibre, low-glycaemic-index sources of carbohydrate (such as fruit, vegetables, wholegrain, and pulses), low-fat dairy products, and oily fish. - Control the intake of foods containing saturated and trans fatty acids - If overweight set target of 5-10% body weight loss and consider referral to dietician - Encourage 150 minutes of moderate exercise a week in bouts of at least 10 mins

Question 38

What equipment do diabetics need for 'sick days'?

Answer 38

Question 39

How should screening for diabetic complications be managed in primary care?

Answer 39

**Every appt:** check BMI, smoking status, neuropathy, depression and anxiety **Every 6 months:** HbA1c **Annually:** Retinopathy (starting at diagnosis) Diabetic foot problems (starting at diagnosis with monofilament) Nephropathy (albumin:creatinine ratio and eGFR) Cardiovascular risk factors (albuminaemia, lipid profile, age, waist circumference, blood pressure, family history) Autonomic neuropathy (postural hypertension) Injection sites if on insulin

Question 40

What statin should be given to diabetics? (use image)

Answer 40

**Primary prevention:** if QRISK \>10% give 20mg atorvastatin **Secondary prevention:** 80mg atorvastatin

Question 41

Which drugs do diabetics need to be careful taking when they have autonomic neuropathy?

Answer 41

TCA antidepressants and antihypertensives as they increase the risk of postural hypertension

Question 42

What is the following for Metformin (biguanide): - MOA - Benefits - Side effects - Contraindications - Drug interactions

Answer 42

**- MOA:** decreases gluconeogenesis and increases peripheral utilization of glucose. Only works if residual functioning pancreatic islet cells **- Benefits:** cardioprotective as lowers cholesterol and triglycerides, limits weight gain as lowers appetite, can be used in pregnancy, no hypoglycaemia **- Side effects:** GI disturbance (combat by increasing dose gradually or modified release), metallic taste, lactic acidosis, Vit B12 deficiency **- Cx:** eGFR\<30 (check renal function annually, review if \<45), people at risk of lactic acidosis (DKA), stop 48 hours before surgery **- Drug Interactions:** alcohol can increase risk of lactic acidosis, beta blockers as mask hypoglycaemia, corticosteroids/COCP/thiazides/loops may all antagonise

Question 43

What is the following for gliptins: - MOA - Benefits - Side effects - Contraindications - Drug interactions

Answer 43

Sitagliptin, Saxagliptin, Vildagliptin, Linagliptin, and Alogliptin **MOA:** DPP4 inhibitor so increase GLP1 and GIP in the blood so increased insulin secretion and decreased glucagon secretion **Benefits:** no hypoglycaemia as only released on eating, weight neutral/loss as decreased appetite **Side effects**: GI symptoms (constipation, vomiting), acute pancreatitis, back pain, arthralgia, bullous pemphigoid, skin reactions, headaches, hepatic dysfunction **Contraindications:** hepatic or renal impairment (monitor renal annually and check both at start), pregnancy, ketoacidosis, heart failure **Drug Interactions:** beta blockers as masks hypos, ACEi can increase risk of angiooedema

Question 44

What are some adverse reactions specific to the following drugs: - Sitagliptin - Saxagliptin - Linagliptin

Answer 44

Black triangle drugs so intensely monitored and patients encouraged to report adverse reactions

Question 45

What is the following for Pioglitazone (thiazolidinediones): - MOA - Benefits - Side effects - Monitoring - Contraindications - Drug interactions

Answer 45

**MOA:** reduces peripheral insulin resistance in muscles and adipose tissue by activating PPAR-y receptors. Need insulin presence to work **Benefits:** no hyperglycaemia, can lower lipids **Side effects:** weight gain, bone fractures due to reduced mineralisation, risk of bladder cancer, risk of heart failure when used with insulin, decreased visual acuity, fluid retention **Monitoring:** before starting check ALT, FBC for anaemia, urine for blood and record weight. Monitor liver enzymes and for fluid retention after 3-6 months initiationt then regularly **Cx:** history of heart failure; previous or active bladder cancer; uninvestigated macroscopic haematuria, pregnancy **DDIs:** same as other antidiabetic drugs e.g beta blockers plus liver enzyme inducing drugs as metabolised by liver

Question 46

What is the following for Gliclazide/Tolbutamide/Glibenclamide (Sulfonylurea): - MOA - Benefits - Side effects - Monitoring - Contraindications - Drug interactions

Answer 46

**MOA:** stimulate pancreas to release insulin so only work if some residual function. Binds to ATP-K+ channels causing depolarisation **Benefits:** may reduce risk of microvascular complications, very potent, may shorten length of time until injectables needed **Side effects:** hypos, weight gain, abdominal pain and GI disturbance, disturbance in liver function, skin reactions **Cx:** pregnancy, ketoacidosis, _severe_ renal/hepatic impairment, acute porphyria, be careful in elderly and those with G6PD deficiency **Monitoring:** self monitoring of blood glucose **DDIs:** drugs that displace from protein bound site e.g NSAIDs and wafarin, fluconazole can increase amount in blood, any liver enzyme inducers/inhibitors as undergoes hepatic metabolism

Question 47

What is the following for GLP1 analogues: - MOA - Benefits - Side effects - Monitoring - Contraindications - Drug interactions

Answer 47

Exenatide, Liraglutide, and Lixisenatide **MOA:** activate GLP-1 receptor so insulin secretion, suppress glucagon secretion, and slow gastric emptying. Cannot be broken down by DPP4 **Benefits:** liraglutide has CVS benefit, weight loss by appetite decrease, low risk of hypos **Side effects:** GI disturbance (N+V, diarrhoea), GORD, painful to inject sc, headaches, alopecia, renal impairment **Monitoring:** after 6 months check for 3% weight loss and 1% HbA1c reduction **Cx:** ketoacidosis, renal impairment \<30 or \<50 with exenatide, severe gastrointestinal disease, gastroparesis, IBS **DDIs:** can affect absorption of drugs so take 1 hour before or 4 hours after injection e.g paracetamol, warfarin. Beta blockers.

Question 48

What is the following for SGLT2 inhibitors: - MOA - Benefits - Side effects - Monitoring - Contraindications - Drug interactions

Answer 48

**Canagliflozin, Dapagliflozin,** and **Empagliflozin** **MOA:** reversibly inhibit SGLT2 in the PCT to reduce glucose reabsorption and increase urinary glucose excretion. Can be used first line if metformin not tolerated **Benefits:** Cana and Empa can be beneficial to CVS, low risk of hypos Monitoring: **Side effects:** polyuria, UTIs, thrush, Fournier's gangrene, constipation, balanoposthitis, dyslipidaemia/raised lipids, dehydration, thirst, risk of toe amputation with canagliflozin, risk of DKA **Cx:** ketoacidosis, eGFR\<60, lactose intolerance, increased risk of volume depletion, foot ulcers due to risk of amputation **DDIs:** thiazides/loops can volume deplete, enzyme inducers, digoxin toxicitiy

Question 49

What are the other classes of drugs you may consider giving to diabetics to manage their vascular risk factors?

Answer 49

- Statins - Antihypertensives with ACEi first line - Stop smoking

Question 50

What is the aetiology behind micro and macrovascular complications in diabetes?

Answer 50

**- Nephropathy** and **neuropathy** due to small vessel damage by atherosclerosis **- Neuropathy** due to ischaemia from small vessel damage and direct damage due to hyperglycaemia

Question 51

What is LADA?

Answer 51

**Latent Autoimmune Diabetes of Adulthood** Type 1 diabetes that develops in adulthood

Question 52

When are people with diabetes prescribed aspirin or antiplatelet therapies?

Answer 52

- Do not give to diabetics who have no cardiovascular disease for primary prevention. Bleeding risk outweighs benefits - ?beneficial to give to hypertensive diabetics

Question 53

If a patient comes in on a Fridy afternoon with polyuria and thirst, how do you decide whether or not this is diabetes and if they are safe to be left for the weekend?

Answer 53

- Assess clinical picture e.g risk factors - Urine dipstick for ketones to rule out DKA - Random glucose - Obs: RR, temp, sats, BP **- DKA red flags:** N+V, high temp, abdominal pain, pear drop breath - If suspect type 1 then immediate referral

Question 54

What are some factors that can affect the accuracy of HbA1c results?

Answer 54

Question 55

What are some of the signs of hypoglycaemia?

Answer 55

Question 56

What are some signs a diabetic has autonomic neuropathy?

Answer 56

- If have hypo unawareness do not use drug with risk of hypos

Question 57

What is reactive hypoglycaemia?

Answer 57

- Low blood sugar that occurs after a meal — usually within four hours after eating - Can be an early sign of diabetes as pancreas producing too much insulin

Question 58

What should you offer to someone if their HbA1c levels are between 6.1 and 6.4?

Answer 58

National diabetes prevention programme

Question 59

What are some factors that affect the accuracy of HbA1c?

Answer 59

- Haemoglobinopathies e.g Sickle Cell - Type 1 Diabetes - Pregnancy - Children - HIV - Splenectomy

Question 60

What are some of the macrovascular complications of Diabetes?

Answer 60

- Cerebrovascular disease - Peripheral Vascular disease - Coronary Heart disease

Question 61

If a type 2 diabetic needs to be started on insulin as they are not hitting their targets, what insulin should be prescribed?

Answer 61

* Metformin should be continued * Start with human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need

Question 62

# Fill in this table for the following: * DPP4 inhibitors * Metformin * Pioglitazone * SGLT2 Inhibitors * Sulfonylurea

Answer 62

Question 63

What criteria needs to be met when on Liraglutide or a GLP1 analogue to continue NHS funding?

Answer 63

\> 11 mmol/mol (1%) reduction in HbA1c and 3% weight loss after 6 months **Major adverse effects:** N+V, Pancreatitis