5. Diabetes Presentation and Management

Question 1

What are the main presenting complaints in someone with T2 DM

(hint glucose is an osmotic diuretic)

Answer 1

fatigue 
Polydipsia and polyuria (thirsty and urinating a lot)
unintentional weight loss
opportunistic infections 
slow healing 
glucose in urine

Question 2

for pre-diabetes what does impaired fasting glucose mean

Answer 2

their body struggles to get their blood glucose levels in to normal range, even after a prolonged period without eating carbs

Question 3

for pre-diabetes what does impaired glucose tolerance mean

Answer 3

their body struggles to cope with processing a carb meal

Question 4

diabetes can be diagnosed if a patient fits what criteria for;
HbA1c
random glucose
fasting glucose
OGTT2 hour result (fast and then have 75g glucose drink)

Answer 4

HbA1c: greater than 48 mmol/mol
random glucose greater than 11 mmol/l
fasting glucose greater than 7 mmol/l
OGTT 2 hour result greater than 11 mmol/l

Question 5

in men what is a common opportunistic infection of the penis

Answer 5

Candida balantis

Question 6

although rare, what its diabetes insipidus and what are the common PC

Answer 6

disorder of the posterior pituitary gland which causes inadequate ADH secretion therefore imbalance of fluids (ADH causes more aqua porin channels init the DCT

symptoms are, polyuria, dilute urine and polydipsia

Question 7

A differential for DM could be hypercalcaaemia, what are the common symptoms of this

Answer 7

loss of appetite 
nausea and vomitting
constipation and abdo pain 
tiredness/ weakness and muscle pain !!!!!
confusion/headaches

Question 8

weight loss even though you are eating more

is this a common T1 or T2 DM presentation

Answer 8

T1

Question 9

tingling, pain, or numbness in the hands/feet

is this a common T1 or T2 DM presentation

Answer 9

T2

Question 10

what is the main hyperglycaemic emergency in type ! DM and then type 2DM

Answer 10

T1 is diabetic ketoacidosis DKA

T2 is hyperosmolar hyperglycaemic state

Question 11

What are the main treatment goals in management of diabetes

Answer 11

minimise treatment side effects (hypoglycaemia and weight gain)
as near normal glucose as possible (to minimise complications)
cardiovascular risk management (optimise risk factors)

Question 12

In management of diet what things would you advise

Answer 12

eat vegetables and only fish
low glycemic, high fibre diet
low carb diet (not mainstream yet)

Question 13

What risk factors do you want to optimise and how would you advise this

Answer 13

exercise and weight loss
stop smoking
optimise treatment for other illnesses, eg hypertension, hyperlipidaemia and CVD

Question 14

what lifestyle changes cause the following;
improving islet function
reduces insulin resistance
improves insulin sensitivity

Answer 14

reduced calories improving islet function
weight loss reduces insulin resistance
Exercise improves insulin sensitivity with or without weight loss

Question 15

What is the first line treatment for T2 diabetes after lifestyle management and how does it work

Answer 15

metformin 500mg once daily

“biguanide” which increases insulin sensitivity and decreased liver production of glucose

Question 16

what are the main side effects of metformin

Answer 16

diarrhoea and abdo pain (lowering dose resolves symptoms)
Lactic acidosis
note that it does NOT typically cause hypoglycaemia

Question 17

What is the second line treatment for T2 DM

Answer 17

lifestyle changes +metformin + one of the following;
Sulfonylureas, pioglitazone, DPP-4 inhibitor, SGLT-2 inhibitor

based on individual factors and drug tolerance

Question 18

what is the third line treatment for T2 DM

Answer 18

triple therapy with metformin and two of the second line drugs combined or
metformin plus insulin

Question 19

SIGN guidelines suggest the use of which second line drugs in particular for pt with CVD

Answer 19

SGLT-2 inhibitors and GLP-1 inhibitors

Question 20

How does pioglitazone work

Answer 20

it is a thiazolidinedione which increases insulin sensitivity and decreases liver production of glucose

Question 21

How does Sulfonylureas work

Answer 21

it is a gliclazide. Stimulates insulin release from the pancreas

Question 22

How do incretins work

Answer 22

incretins are hormones produces by the GI tract in response to meals and act to reduce blood sugar by

• increasing insulin secretions
• inhibiting glucagon production
• slow absorption by the GI tract

the main incretin is GLP-1 and they are inhibited by an enzyme called DPP4

Question 23

how do DPP4 inhibitors work such as sitagliptin

Answer 23

inhibits the DPP-4 enzyme and therefore increases GLP-1 activity

Question 24

how do SGLT-2 inhibitor work (have the suffix -glifloziini)

Answer 24

SGLT-2 protein responsible for reabsorbing glucose from the urine ini to the blood in PCT
SGLT-2 inhibitors block the action of this protein and cause glucose to be excreted in the urine

Question 25

which kind of T2DM treatments have side effect of weight gain

Answer 25

Sulphonylurea Thiazolidinediones insulin

Question 26

which kind of T2DM treatments have side effect of hypoglycaemia

Answer 26

any that increase beta cell activity | insulin

Question 27

which kind of T2DM treatments have side effect of GI symptoms

Answer 27

Incretins (GLP-1) | sometimes metformin

Question 28

which kind of T2DM treatments have side effect of weight loss

Answer 28

metformin incretins/ GLP-1 agonist SGLT-2 inhibitors

Question 29

which T2 DM drug can cause osteoporosis and which can causes UTIs

Answer 29

osteoporosis is pioglitazone | UTI is SGLT-2 inhibitors

Question 30

what should be the ideal treatment target of HbA1c levels

Answer 30

48 mmol/mol for new T2 diabetics | 53 mmol/mol for diabetics that have moved beyond metformin alone

Question 31

Describe rapid acting insulins and give some examples

Answer 31

start to work after 10 mins and last around 4 hours | novorapid, Humalog, apidra

Question 32

describe short-acting insulins and give some examples

Answer 32

start to work in around 30 mins and last around 8 hours | act rapid, humbling S and inhuman rapid

Question 33

describe intermediate acting insulins and give some examples

Answer 33

start to work in around 1 hour and last around 16 hours | insulatard, humulin I, insuman basal

Question 34

describe long actin insulins and give some examples

Answer 34

start to work in an hour and last around 24 hours | Lantus, Levemir, Degludec (lasts over 40 hours)

Question 35

describe combinations insulins

Answer 35

``` contain a rapid acting and intermediate acting insulin Humalog 25 (25:75) Humalog 50 (50:50) novomix 30 (30:70) ```

Question 36

why is venous gases acceptable as routine use

Answer 36

less painful for patient similar Ph and bicarb to arterial values gives potassium and glucose levels too

Question 37

in what instances would an arterial blood gas be favoured over a venous one

Answer 37

if you are concerned about the patients respiration (or ventilation) as O2 and CO2 in venous samples are not useful clinically to guide treatment

Question 38

What would be a classic presentation to A&E which would suggest type 1 diabetic

Answer 38

``` high blood glucose ketones young age ethnicity (white) low weight ```

Question 39

what is the name of the structured education programme for type 1 diabetics that should be started 6-12 months after initial diagnosis

Answer 39

DAFNE - diabetes adjustment for normal eating

Question 40

What is the DVLA guidance regarding type 1 diabetics

Answer 40

they must take their blood sugars before driving

Question 41

before falling pregnant what is advised in pt with diabetes

Answer 41

low HbA1c levels and start taking folate supplements

Question 42

If anti-GAD are positive what is the diagnosis more likely to be

Answer 42

this would indicate type 1 diabetes