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Year 4 CCC conditions > Core Condition - Asthma & diabetes > Flashcards

Core Condition - Asthma & diabetes Flashcards

1
Q

what is high probability of asthma

A

1) recurrent episodes of symptoms
2) wheeze
3) historical record of reversible airflow obstruction
4) +ve Hx of atopy
5) no suggesting an alternative diagnosis

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2
Q

what is an intermedicate probability of asthma

A

1) some but not all presentation of asthma (those outlined in the high probability)
2) do not respond well with treatment

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3
Q

what is an low probability of asthma

A

no typical presentation of asthma at all
or
symptoms suggesting other diagnosis

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4
Q

what are some examples of SABA

A

salbutamol

terbutaline

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5
Q

exmaples of LABA

A

salmeterol

formoerol

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6
Q

pathology of asthma

A

Type I (IgE mediated) Hypersensitivity Reaction causing:
• Bronchoconstriction/bronchospasm
• Inflammation Caused by mast cells, eosinophils, dendritic cells and lymphocytes
• Increased mucous production
• Airway remodelling
• Loss of ciliated cells due to epithelial damage
• Increase in mucous-secreting goblet cells due to metaplasia in response to epithelial damage
• Thickened basement membrane due to deposition of repair collagens
• Smooth muscle hyperplasia causes more sustained contraction
• Nerves contribute to irritability of asthmatic airways

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7
Q

what are some of the aetiology of asthma

A

childhood exposure to allergens
maternal smoking
intestinal bacterial and childhood infections
growing up in a relatively clean environment
Fhx of asthma/atopic conditions

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8
Q

what are the other atopic conditions?

A

eczema, hayfever

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9
Q

what are some examples of acute trigger for asthma

A 
dust
animal furs 
vapours/fumes 
virl infection 
cold air 
exercise 
emotion

drugs - beta blocker, aspirin, NSAIDs

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10
Q

what are some clinical features of asthma

A 
bilateral expiratory polyphonic wheezes 
sputum - can appear pus-like due to white cell, can be hard to bring up
chest tightness 
SOB
diurnal variation 
cough - esp in the night/early morning
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11
Q

what is the investigation strategy of asthma in patient under 5?

A

can’t really test patient under 5 yrs old for asthma because their beta receptors are not developed fully

so treat symptoms based on observation and clinical judgment and review the child on a regular basis. Wait until 5 before objective investigations

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12
Q

what are the order of diagnostic test for asthma

A

FeNO followed by spirometry

carry out BDR if spirometry shows an obstruction

if diagnostic uncertainty after FeNo, spirometry and BDR, monitor peak flow for 2-4 weeks

if still uncertain after peak flow - refer for a histamine or methacholine direct bronchial challenge test

You will need 3/4 of the tests mentioned above to confirm diagnosis of asthma. FeNO has a more superior accuracy.

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13
Q

do you conduct a direct bronchodilator with histamine or methacholine in patients aged between 5 and 16?

A

No

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14
Q

how +ve tests do patient between 5 and 16 years old require to diagnose asthma

A

2 and FeNO does not have superior accuracy in children

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15
Q

how +ve tests do patient between 17 years old or older require to diagnose asthma

A

3

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16
Q

how does FeNO test work?

A

Fractional Exhaled nitric oxide

o During airway inflammation, inc level of NO are released from epithelial cells of bronchial wall

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17
Q

in what situation is FeNO test not accurate

A

smoker - can dec FeNO acutely and cumulatively

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18
Q

what value would you consider spirometry to be obstructive

A

FEV1/FVC < 70%

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19
Q

what is considered to be +ve for bronchodilator reversibility test?

A

improvement in FEV1 > 12% + >200ml inc in FEV1 = +ve test

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20
Q

What medication is used to conduct a bronchodilator reversibility test?

A

SABA

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21
Q

what would you do if a patient between 5 and 16 can not perform any objective testings

A

treat based on observation and clinical judgement
+
try doing the tests again ever 6-12 months

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22
Q

what is considered to be +ve for peak flow monitoring test

A

> 20% in variability

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23
Q

what is considered complete control of asthma

A

no daytime symptoms, no-night time awakening due to asthma, no need for rescue meds, no asthma attack, no limitation on activity including exercise, normal lung function (FEV1/FVC > 80%)

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24
Q

when will you consider up titrating management in asthma

A

when required to use 3 doses or more of SABA a weak

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25
Q

what is the first line regular preventer for patient < 5 yrs old

A

Leukotriene Receptor Antagonist - Montelukast

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26
Q

what is the first line initial add-on therapy for patient between 5 and 16

A

V. low dose ICS + inhaled LABA or LTRA

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27
Q

what is the first line initial add-on therapy for patient < 5

A

v.low dose ICS + LTRA

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28
Q

what is the first line initial additional controller therapies for patient between 5 and 16

A

increasing dose ICS to low dose +
LTRA +
LABA

if no response to LABA, consider stopping LABA

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29
Q

What happen if asthma is still not controlled in pt who are already on additional controller therapies

A

refer to specialist care

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30
Q

what is the first line regular preventer for patients > 17 yrs old

A

low dose ICS

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31
Q

what is the first line initial add-on therapy for patient > 17 yrs old

A

LABA

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32
Q

what is the first line initial additional controller therapies for patients > 17 yrs old

A

increasing ICS to medium dose +
LABA +
LTRA

if no response to LABA, considering stopping LABA

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33
Q

how would you move down the asthmatic management ladder

A

ICS should be maintained at lowest possible dose, reduction in dosages should be slow generally every 3 months and dec approx. 25-50% each

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34
Q

what are some of the symptoms for T1DM

A 
polyuria 
polydipsia 
unexplained weight loss 
lethargy 
hyperglycaemia despite diet and meds 
ketosis
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35
Q

what are some of the symptoms for T2DM

A

polyuria
polydipsia
recurrent infection eg thrush
lethargy

36
Q

what are some symptoms of DKA

A 
polyuria 
polydipsia 
weight loss 
inability to tolerate fluids 
persistent diarrhoea/vomiting 
abdo pain 
lethargy/confusion 
fruity smell of acetone on the breath 
acidotic breathing - kusmaul breathing 
urine dip shows ketons 
signs of dehydration
37
Q

what are some symptoms of hypoglycaemia

A 
BM <3.5 
hunger 
anxiety/irritability 
palpitations 
sweating 
tingling lips 
weakness/lethargy 
impaired vision 
confusion 
irrational behaviour 
seizures 
LOC
coma
38
Q

what are other names for T1DM

A

insulin dependent diabetes

Juvenille onset diabetes

39
Q

what is the diagnostic pathway for T1DM

A

• refer children and young people with suspected T1DM (same day referral) to MDT paediatric diabetes team

1st line - Random plasma glucose > 11 mmol/L or fasting > 6.9

2-hour plasma glucose (plasma glucose 2 hours after75g oral glucose)  > 11 = +ve

plasma or urine ketones  +ve when present

HbA1c = indicates severity but not diagnostic

only test C-peptide and diabetic specific autoantibodies if uncertain diagnosis

40
Q

treatment for T1DM

A

immediate (same day) referral to specialist
immediate start of insulin to prevent ketoacidosis
- see separate card for treatment regimen

41
Q

how often do you need to check HbA1c level of T1DM

A

every 3-6 months

42
Q

what is the HbA1c target for T1DM

A

< 48

43
Q

what is the blood glucose level for T1DM

A

fasting - 5-7
before meals 4-7
90mins after meal 5-9

44
Q

what is the 1st line insulin regimen for T1DM

A

basal-bolus

45
Q

what is the 2nd and 3rd line insulin regimen for T1DM

A

2nd line - twice daily long -acting insulin detemir (if not tolerating 1st line)

3rd line - once daily insulin glargine

46
Q

when will you offer metformin for T1DM

A

if BMI > 25 and want better control of blood glucose

47
Q

when will you refer a T1DM for islet or pancreas transplant

A

recurrent severe hypoglycaemia that has not responded to other treatment/suboptimal control

48
Q

what medications will you prescribe for secondary prevention of CVD in T1DM

A

aspirin 75mg, clopidogrel if contra

atorvastatin 20mg if no CVD risk , 80mg if CVD risk

anti-hypertensie - ACEi/ARB (aim for 135/85 if no signs of albuminuria or metabolic syndrome. but 130/80 if there is)

49
Q

what is the BP target for T1Dm if no albuminuria or metabolic syndrome

A

135/85

50
Q

what is the BP target for T1Dm if there are signs of albuminuria or metabolic syndrome

A

130/80

51
Q

what is the blood glucose level of pre-T2diabetes

A

fasting 5.6 - 6.9

HbA1c of 39-46

52
Q

what is the blood glucose level of T2diabetes

A

fasting > 6.9

HbA1c > 48

53
Q

what is diagnostic criteria for T2DM

A

1 of 4 diagnostic test to confirm diagnosis

1) fasting plasma glucose > 6.9 or Random plasma glucose > 11 + diabetes symptoms
2) if asymptomatic with abnor plasma glucose, 2 fasting venous plasma glucose > 7 is required
3) 2 hour post- load glucose > 11.1 (75 g oral glucose tolerance test)
4) HbA1c > 48

54
Q

what are some investigations required after diagnosis of T2DM

A

lipid profiles

urinary ketones

random C-peptide (not routine done but can help to differentiate between T1 and T2 DM, +ve in T1DM)

ACR to confirm the presence of end organ damages, kidney

creatinine + EGFR –> assess kidney function

BP - DM often related with HTN

55
Q

what are some of the differentiates for T2Dm

A

T1DM
Latent autoimmune diabetes in adults (LADA)
gestational diabetes

56
Q

what is the treatment regimen for T2DM

A
  • 1st step  lifestyle + aim for HbA1c of < 48
  • 2nd step  metformin if HbA1c > 48 + aim for < 48
•	3rd step/1st intensification  if HbA1c > 58  dual therapy &amp; aim for HbA1c < 53 
o	metformin +  DPP-4i 
o	metformin + pioglitazone 
o	metformin + SU 
o	metformin + SGLT-2i

• 4th step/2nd intensification  if HbA1c > 58  triple therapy & aim for HbA1c < 53
o metformin + SU + DDP-4i or pioglitazone or SGLT-2i
o metformin + SU + GLP-1
 if not tolerate the above combination and have BMI > 35 and specific psychological and other medical problems associated with obesity
 BMI >35 and insulin would not be suitable
 BMI < 30 and South Asian

• 5th step/3rd intensification  Insulin (refer for this)

57
Q

how does metformin work

A

dec gluconeogenesis

inc peripheral utilisation of glucose

58
Q

what are good advantage for use of metformin

A

do not make you gain weight

cardioprotective

59
Q

SE of metformin

A

GI upset - reduced when given modified released

can not be given if eGFR < 30

take about a month to work - therefore, if patient is symptomatic then not useful as 1st line

60
Q

what is the 1st line treatment if the patient is symptomatic hyperglycaemic

A

insulin or

SU

61
Q

what other medication can one use if metformin is contra-indicated?

A

SGLT2 inhibitors eg empagliflozin

62
Q

how does empagliflozin work

A

inc amount of sugar that is urinated

63
Q

SE of empagliflozin

A

inc frequency, thrush and UTI

64
Q

how does sulfonylurea work

A

works by encouraging pancreas to produce more insulin

65
Q

what are good advantage for use of sulfonylurea

A

works quickly = useful for patients presenting with symptoms

takes before meals

66
Q

SE for use of sulfonylurea

A

weight gain

67
Q

what are some exampels of DPP-4 inhibitors

A

alogliptin, linagliptin

68
Q

how does alogliptin, linagliptin work

A

in incretin hormone levels which stimulates pancreas to produce more insulin

69
Q

what are good advantage for use of alogagliptin and linagliptin?

A

weight neutral, well tolerated, okay for poor renal function

but only work for short period of time

70
Q

how does pioglitazone work

A

inc insulin sensitivity and screations

71
Q

SE for use of pioglitazone

A

inc risk of osteoporosis, weight gain

72
Q

what is the biggest advantage of using GLP-1

A

weight loss

73
Q

when should you continue GLP-1

A

if a reduction of at least 11 mmol/mol if in HbA1c and weight loss of at least 3% is seen in 6 months

74
Q

how doe GLP-1 work

A

natural hormone that body produces in the intestine in response to food and then causes the pancreas to produce insulin + slows the stomach emptying time

75
Q

how often do you conduct a HbA1c measure

A

every 3-6 months

76
Q

what is the max allowance of HbA1c for an elderly and frail

A

70

77
Q

what tests.screening do you need to conduct when carrying out an annual review for diabetes?

A

HbA1c
TSH
eGFR
early morning urine - sent off to check albumin:creatinine ration
BMI
assess for depression/anxiety/eating disorder
monitoring for neuropathy complications
check injection site
examine feet
Assess for CV risk (DO not give aspirin to T1DM in primary care setting, DO NOt use QRISK2 for T1DM)

78
Q

what is the aim for BP for T1DM

A

135/80

79
Q

what is the management for hypoglycaemia

A

fast acting form fo oral glucose + high conc carbohydrate meal

if unable to swallow then IM glucagon (family and friends need to be shown), assess for 10 mins then oral carbohydrate

80
Q

what is the aim of BP for T2DM

A

130/80 if kidney or 2 or more features of metabolic syndrome

otherwise, target <135/85

81
Q

what is metabolic syndrome

A 
inc wrist circumference 
BMI >30 
raised triglycerides 
reduced HDL 
raised BP 
raised blood glucose

inc risk of CVD and T2DM

82
Q

what are the secondary prevention for CVD in T2DM

A

T1 = atorvastatin 20mg, if T!DM > 10 yrs - 40 mg

T2 = atorvastatn 20mg for those with QRISK2 of > 10%

83
Q

what medication will you use to protect kidney function

A

when Albumin:Creatinine Ration > 3

start ACEi or ARB

maintain BP < 130/80

84
Q

what are the different stages of diabetic retinopathy

A

1) minimal arteriolar narrowing - silver wiring with tortuosity
2) obvious narrowing - AV nipping
3) above + hemorrhages, exudates or cotton wool spots
4) above + papilloedema

85
Q

what are some examples of neuropathy for DM

A

gastroparesis

erectile dysfunction

diabetes foot neuropathy

Year 4 CCC conditions (7 decks)

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