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BNF > Chapter 6: Endocrine: Type 2 Diabetes > Flashcards

Chapter 6: Endocrine: Type 2 Diabetes Flashcards

1
Q

What is T2DM characterised by?

A

Insulin resistance

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2
Q

Also causing an increase in cardiovascular risk, what is T2DM associated with?

A
  1. Obesity
  2. Physical inactivity
  3. Raised blood pressure
  4. Dyslipidaemia
  5. Tendency to thrombosis
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3
Q

When does T2DM usually develop?

A

In later life

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4
Q

What is the first line intervention of T2DM?

A

Lifestyle measures

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5
Q

Which lifestyle measures can be used to manage T2DM? (3)

A
  1. Smoking cessation
  2. Weight loss
  3. Exercise
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6
Q

Metformin does not stimulate release of insulin, therefore it has no risk of causing which adverse event?

A

Hypoglycaemia

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7
Q

What is the starting dose of metformin?

A

500mg OD after one meal for 1 week
500mg BD after two meals for 1 week
500mg TDS with all three meals

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8
Q

Why is metformin titrated gradually?

A

To reduce gastro-intestinal effects

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9
Q

If patients find metformin intolerable, what can be offered?

A

Modified release preparation

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10
Q

Which 5 drugs are in the sulfonylureas class?

A
  1. Glibenclamide
  2. Gliclazide
  3. Glimepiride
  4. Glipizide
  5. Tolbutamide
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11
Q

Which adverse effect can sulfonyureas cause?

A

Hypoglycaemia

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12
Q

Which sulfonylureas is hypoglycaemia more likely with? and why?

A

Glibenclamide

Long acting

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13
Q

Which oral antidiabetic has the poorest anti-hyperglycaemic effect?

A

Arcabose

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14
Q

Meglitinides are less preferred compared with sulphonylureas. Give two examples (DVLA)

A
  1. Nateglinide

2. Repaglinide

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15
Q

Which oral antidiabetic drug is associated with several long term risks and has 2 MHRA alerts?

A

Pioglitazone

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16
Q

What are the 2 MHRA alerts concerning pioglitazone?

A
  1. Cardiovascular safety

2. Bladder cancer

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17
Q

Incidence of heart failure is increased when pioglitazone is combined with which other antidiabetic drug?

A

Insulin

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18
Q

What should happen if a patient on pioglitazone has deteriorating cardiac status?

A

Discontinue treatment

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19
Q

Can pioglitazone be used in patients with heart failure or those with a history of heart failure?

A

No

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20
Q

Although pioglitazone carries a risk of bladder cancer, why is it still used?

A

Benefits outweigh risks

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21
Q

Due to its risk of bladder cancer, in which patients should pioglitazone note be used?

A
  1. Active bladder cancer
  2. Past history of bladder cancer
  3. Uninvestigated haematouria
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22
Q

In which group of patients should pioglitazone be used with caution, due to the risk of bladder cancer?

A

Elderly

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23
Q

After how long should the safety and efficacy of pioglitazone be reviewed?

A

3-6 months

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24
Q

If there is an inadequate response to treatment with which T2DM drug should treatment be discontinued?

A

Pioglitazone

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25
Q

Due to its risk of bladder cancer, which signs should patients promptly report?

A
  1. Haematouria
  2. Dysuria
  3. Urinary urgency
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26
Q

Give 5 examples of DPP-4 inhibitors

A
  1. Sitagliptin
  2. Vidagliptin
  3. Alogliptin
  4. Linagliptin
  5. Saxagliptin
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27
Q

Can DPP-4 inhibitors (gliptins) cause weight gain?

A

No

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28
Q

Can DPP-4 inhibitors (gliptins) cause hypoglycaemia?

A

No

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29
Q

Give 5 exampled of GLP-1 mimetics

A
  1. Exanatide
  2. Liraglutide
  3. Albiglutide
  4. Lixisenatide
  5. Dalaglutide
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30
Q

Give 3 examples of SGT-2 inhibitors

A
  1. Canagliflozin
  2. Dapaglifloxin
  3. Empagliflozin
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31
Q

What do SGT-2 inhibitors (flozins) carry a risk of?

A

ketoacidosis

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32
Q

Besides T2DM, what other indication does metformin have? (specialist initiation - unlicensed)

A

Insulin sensitising drug in women with polycystic ovarian syndrome who are not planning on having children

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33
Q

Does metformin have a hypoglycaemic effect in those without diabetes?

A

No

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34
Q

What is the HbA1c target for T2DM patients using diet and lifestyle alone or taking a single oral antidiabetic NOT associated with hypoglycaemia?

A

Less than 48mmol/mol

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35
Q

What is the HbA1c target for T2DM patients taking a single oral antidiabetic associated with hypoglycaemia or TWO oral antidiabetics?

A

Less than 53mmol/mol

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36
Q

What are the options if a single oral antidiabetic is not controlling symptoms? (3)

A
  1. Check adherence
  2. Reinforce diet and lifestyle advice
  3. Intensify treatment by adding a second drug
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37
Q

What is the first line oral antidiabetic for all patients?

A

Metformin

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38
Q

What are the benefits of metformin? (3)

A
  1. Encourages weight loss
  2. Low incidence of hypoglycaemic events
  3. Lowers long term cardiovascular risk
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39
Q

If glycaemic control is not achieved with one oral antidiabetic, which others can be added? (3)

A
  1. DPP-4 Inhibitor (Gliptin)
  2. Sulfonylureas
  3. Pioglitazone
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40
Q

During first intensification of T2DM oral antidiabetic treatment, which drug is an option ONLY if sulfonylureas are contraindicated, not tolerated or there is a significant risk of hypoglycaemia?

A

SGT-2 inhibitor (Flozin)

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41
Q

Which drug might it be appropriate to start at the stage of second intensification? (3 drugs)

A

Insulin

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42
Q

As well as insulin-based treatment, which class of oral antidiabetic drug may it be appropriate to consider if second intensification (3 drugs) fails?

A

GLP-1 mimetics (TIDES)

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43
Q

In which patients would it be beneficial to use GLP-1 mimetics (TIDES) for T2DM?

A

BMI >35

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44
Q

After how long must treatment with GLP-1 mimetics for T2DM be reviewed?

A

6 months

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45
Q

What are the treatment options for T2DM if metformin is contradindicated?

A
  1. DPP-4 inhibitor (GLIPTINS)
  2. Pioglitazone
  3. Sulfonylureas
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46
Q

In the treatment of T2DM, can metformin be continued if the patient is started on insulin?

A

Yes

47
Q

In the treatment of T2DM, if a patient needs insulin-based treatment, metformin can be continued. What happens with the other oral antidiabetics?

A

They are reviewed then stopped if necessary

48
Q

What are the recommended insulin regimens for T2DM> (4)

A
  1. Human isophane insulin - once or twice daily
  2. Human isophane insulin + short-acting insulin
  3. Insulin determir or glargine (BASAL)
  4. Biphasic preparations
49
Q

As well as GI effects, what is another food-related side effect of metformin?

A

Taste disturbance

50
Q

In which patients are we worried about lactic acidosis with metformin?

A

Poor renal function

51
Q

At which renal function do we stop treatment with metformin?

A

Less than 30

52
Q

Which oral antidiabetics can cause weight gain? (2)

A
  1. Sulphonylureas

2. Pioglitazone

53
Q

Which oral antidiabetic can cause fluid retention?

A

Pioglitazone

54
Q

Which oral antidiabetic should not be used in the elderly?

A

Sulfonylureas

55
Q

Which oral antidiabetic can cause fractures?

A

Pioglitazone

56
Q

Which oral antidiabetic should be avoided in G6DP deficiency?

A

Sulfonylureas

57
Q

Which oral antidiabetic can cause flatulence?

A

Acarbose

58
Q

Which oral antidiabetic can cause acute pancreatitis?

A

DPP-4 inhibitors (gliptins)

59
Q

Which antidiabetic can lead to lower limb amputations?

A

SGT-2 inhibitors (FLOZIN)

60
Q

As well as a risk of hypoglycaemia, which antidiabetic can cause injection site itch?

A

SGT-2 inhibitos (FLOZIN)

61
Q

Diabetes carries a strong risk for which other disease?

A

Cardiovascular disease

62
Q

Which non-antidiabetic drugs can be used in diabetes to reduce the risk of cardiovascular risk? (3)

A
  1. ACE inhibitor
  2. Low dose aspirin
  3. Lipid-regulating drug
63
Q

To manage the risk of diabetic nephropathy, regular review of diabetic patients should include which tests? (2)

A
  1. Urinary protein

2. Serum creatinine

64
Q

Even if blood pressure is normal, all diabetic patients with established microalbuminuria (3 positive tests) should be treated with which drug?

A

ACE inhibitor (or ARB)

65
Q

Which electrolyte disturbance are T2DM patients with nephropathy more susceptible to?

A

Hyperkalaemia

66
Q

Can an ACE inhibitor be combined with an ARB to treat diabetic nephropathy?

A

No - risk of hyperkalaemia

67
Q

When used with insulin and/or oral antidiabetic drugs, what can ACE inhibitors potentiate? Especially in the first few weeks of treatment, especially in patients with renal impairment

A

Hypoglycaemic effect

68
Q

Which drugs can be used to control mild-moderate diabetic neuropathic pain? (2)

A
  1. Paracetamol

2. Ibuprofen

69
Q

After paracetamol and ibuprofen, what is the first line treatment for diabetic neuropathy?

A

Duloxetine

70
Q

If duloxetine is not tolerated in diabetic neuropathy, what else can be tried?

A

Amitriptyline

71
Q

To manage the pain of diabetic neuropathy, if amitriptyline cannot be tolerated, which drug can be tried?

A

Nortriptyline

72
Q

To manage the pain of diabetic neuropathy, what is the next step if neither duloxetine or amitriptyline are effective? (2)

A
  1. Duloxetine + Pregabalin

2. Amitriptyline + Pregabalin

73
Q

To which class of analgesics can diabetic neuropathic pain be responsive to?

A

Opioids

74
Q

For the treatment of diabetic neuropathy, which drugs can be only initiated under specialist supervision?

A
  1. Oxycodone
  2. Morphine
  3. Tramadol
75
Q

As well as pregabalin, which other anti-epileptics can be used to treat diabetic neuropathic pain? (2)

A
  1. Gabapentin

2. Carbamazepine

76
Q

During pregnancy, which drug can women with pre-exiting diabetes be treated with? (unlicensed)

A

Metformin

77
Q

During pregnancy, can women with pre-exiting diabetes be treated with both metformin and insulin?

A

Yes

78
Q

What are the treatment options for gestational diabetes, after 11 weeks?

A
  1. Metformin
  2. Glibenclamide
  3. Glibenclamide with insulin
79
Q

How long after giving birth should antidiabetic treatment be carried on?

A

It should be stopped after giving birth

80
Q

True or false: All patients with diabetes should have emergency treatment for hypoglycamia written on their drug chart on admission

A

TRUE

81
Q

True or false: All patients undergoing any type of surgery should be put on a continuous variable rate insulin infusion

A

FALSE: patients going for minor surgery with good glycaemic control, HbA1c less than 69mmol/mol, can have their usual insulin the day before surgery. Long-acting once daily preparation to be reduced by 20%

82
Q

What should a continuous variable rate insulin infusion be administered with?

A

A glucose substrate

83
Q

On the day of surgery and throughout the intra-operative period, can patients receive their regular insulin if they do not need to be on a continuous variable rate insulin infusion?

A

No, basal only until eating and drinking

84
Q

After a patient has been on a a continuous variable rate insulin infusion, when can they be converted back to their regular insulin?

A

If they are eating and drinking without nausea or vomiting

85
Q

At which point does the patient start taking their regular insulin after they have been on a continuous variable rate insulin infusion?

A

With their first post-operative meal

86
Q

How long after the first dose of post-operative insulin after the patient’s first meal is the continuous variable rate insulin infusion continued?

A

30-60 minutes

87
Q

If a diabetic patients taking insulin requires emergency surgery; blood glucose, urinary ketones, serum electrolytes and serum bicarbonate should be checked before surgery. Which state, if present, can cause delay in treatment?

A

Ketoacidosis

88
Q

If a patient taking antidiabetic drugs requires insulin during surgery, can their regular drugs be continued?

A

No, all but GLP-1 mimetics (TIDES) need to be stopped

89
Q

Which oral antidiabetics should always be omitted on the day of surgery and until the patient is eating and drinking as normal again? (2)

A

Sulfonylureas

SGT-2 inhibitors

90
Q

Should metformin always omitted during surgery?

A

No, if they have an eGFR greater than 60mL/min and no contrast media is being used, may need to only omit the lunchtime dose if the patient is taking it TDS

91
Q

Which condition are SGT-2 inhibitors associated with during periods of dehydration, stress, surgery, trauma, and acute medical illness?

A

Diabetic ketoacidosis

92
Q

What does the management of diabetic ketoacidosis involve?

A
  1. Fluid and electrolyte replacement

2. Insulin

93
Q

At which blood pressure should we administer 500mL sodium chloride 0.9% over 10-15mins in diabetic ketoacidosis?

A

below 90mmHg

94
Q

Which electrolyte should be included in IV fluids when treating diabetic ketoacidosis?

A

Potassium chloride

95
Q

At which times should plasma potassium be monitored in diabetic ketoacidosis when administering potassium chloride? (3)

A
  1. At 60 minutes
  2. At 2 hours
  3. Every 2 hours
96
Q

Which preparation of insulin should be used in diabetic ketoacidosis

A

Soluble

97
Q

True or false: established treatment with long-acting insulin should be continued during diabetic ketoacidosis

A

TRUE

98
Q

With a small but significant effect on lowering blood glucose, what does arcabose delay?

A

Digestion and absorption of starch and sucrose

99
Q

What is the metformin mechanism of action? (2)

A
  1. Decreases gluconeogensis

2. Increases peripheral utilisation of glucose

100
Q

Can metformin be given to someone without any residual functioning pancreatic islet cells?

A

No, requires some endogenous insulin to work

101
Q

What must be determined before treatment is commenced with metformin and at least annually thereafter?

A

Renal function

102
Q

What are the symptoms of lactic acidosis that patients and carers taking metformin should be counselled on? (5)

A
  1. Dyspnoea
  2. Muscle cramps
  3. Abdominal pain
  4. Hypothermia
  5. Asthenia
103
Q

What is the mechanism of action of DPP-4 inhibitors (GLIPTINS)? (2)

A
  1. Increase insulin secretion

2. Lower glucagon secretion

104
Q

DPP-4 inhibitors can cause pancreatitis, what is the symptom of pancreatitis that patients should be made aware of?

A

Persistent, severe abdominal pain

105
Q

Which DPP-4 can cause hepatotoxicity?

A

Vidagliptin

106
Q

What is the mechnism of action of GLP-1 mimetics (TIDES)? (2)

A
  1. Augment glucose-dependent insulin secretion

2. Slow gastric emptying

107
Q

What is the dose of dulaglutide?

A

Once weekly

108
Q

As well as DPP-4 mimetics, which other class of antidiabetic drug can cause pancreatitis?

A

GLP-1 mimetics

109
Q

If a patient misses a dose of dulaglutide, what should they do?

A
  1. More than 3 days until next dose, take and take next as normal
  2. Less than 3 days until next dose, don’t take and take next as normal
110
Q

Women of child-bearing age should take contraception during treatment and 12 weeks after discontinuation when taking which GLP-1 mimetic?

A

Exenatide

111
Q

What are the MHRA alerts associated with Canagliflozin? (2)

A
  1. Lower limb amputation (mainly toes)

2. Diabetic ketoacidosis

112
Q

MHRA advice is to; consider stopping canagliflozin if a patient develops foot problems, monitor all patients with risk factors for diabetic foot problems and what else?

A

Ensure they stay well hydrated and monitor for signs of salt and water loss

113
Q

What are the signs and symptoms of diabetic ketoacidosis? (8)

A
  1. Fast, deep breathing
  2. Rapid weight loss
  3. Nausea and vomiting
  4. Abdominal pain
  5. Sleepiness
  6. Sweet smell to breath
  7. Sweet metallic taste in mouth
  8. Different odour/colour to urine
114
Q

If DKA is diagnosed or suspected in someone taking canagliflozin, what should happen to their treatment?

A

Discontinue

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