Core Condition - Asthma & diabetes Flashcards
what is high probability of asthma
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
what is an intermedicate probability of asthma
1) some but not all presentation of asthma (those outlined in the high probability)
2) do not respond well with treatment
what is an low probability of asthma
no typical presentation of asthma at all
or
symptoms suggesting other diagnosis
what are some examples of SABA
salbutamol
terbutaline
exmaples of LABA
salmeterol
formoerol
pathology of asthma
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
what are some of the aetiology of asthma
childhood exposure to allergens
maternal smoking
intestinal bacterial and childhood infections
growing up in a relatively clean environment
Fhx of asthma/atopic conditions
what are the other atopic conditions?
eczema, hayfever
what are some examples of acute trigger for asthma
dust animal furs vapours/fumes virl infection cold air exercise emotion
drugs - beta blocker, aspirin, NSAIDs
what are some clinical features of asthma
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
what is the investigation strategy of asthma in patient under 5?
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
what are the order of diagnostic test for asthma
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.
do you conduct a direct bronchodilator with histamine or methacholine in patients aged between 5 and 16?
No
how +ve tests do patient between 5 and 16 years old require to diagnose asthma
2 and FeNO does not have superior accuracy in children
how +ve tests do patient between 17 years old or older require to diagnose asthma
3
how does FeNO test work?
Fractional Exhaled nitric oxide
o During airway inflammation, inc level of NO are released from epithelial cells of bronchial wall
in what situation is FeNO test not accurate
smoker - can dec FeNO acutely and cumulatively
what value would you consider spirometry to be obstructive
FEV1/FVC < 70%
what is considered to be +ve for bronchodilator reversibility test?
improvement in FEV1 > 12% + >200ml inc in FEV1 = +ve test
What medication is used to conduct a bronchodilator reversibility test?
SABA
what would you do if a patient between 5 and 16 can not perform any objective testings
treat based on observation and clinical judgement
+
try doing the tests again ever 6-12 months
what is considered to be +ve for peak flow monitoring test
> 20% in variability
what is considered complete control of asthma
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%)
when will you consider up titrating management in asthma
when required to use 3 doses or more of SABA a weak
what is the first line regular preventer for patient < 5 yrs old
Leukotriene Receptor Antagonist - Montelukast
what is the first line initial add-on therapy for patient between 5 and 16
V. low dose ICS + inhaled LABA or LTRA
what is the first line initial add-on therapy for patient < 5
v.low dose ICS + LTRA
what is the first line initial additional controller therapies for patient between 5 and 16
increasing dose ICS to low dose +
LTRA +
LABA
if no response to LABA, consider stopping LABA
What happen if asthma is still not controlled in pt who are already on additional controller therapies
refer to specialist care
what is the first line regular preventer for patients > 17 yrs old
low dose ICS
what is the first line initial add-on therapy for patient > 17 yrs old
LABA
what is the first line initial additional controller therapies for patients > 17 yrs old
increasing ICS to medium dose +
LABA +
LTRA
if no response to LABA, considering stopping LABA
how would you move down the asthmatic management ladder
ICS should be maintained at lowest possible dose, reduction in dosages should be slow generally every 3 months and dec approx. 25-50% each
what are some of the symptoms for T1DM
polyuria polydipsia unexplained weight loss lethargy hyperglycaemia despite diet and meds ketosis
what are some of the symptoms for T2DM
polyuria
polydipsia
recurrent infection eg thrush
lethargy
what are some symptoms of DKA
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
what are some symptoms of hypoglycaemia
BM <3.5 hunger anxiety/irritability palpitations sweating tingling lips weakness/lethargy impaired vision confusion irrational behaviour seizures LOC coma
what are other names for T1DM
insulin dependent diabetes
Juvenille onset diabetes
what is the diagnostic pathway for T1DM
• 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
treatment for T1DM
immediate (same day) referral to specialist
immediate start of insulin to prevent ketoacidosis
- see separate card for treatment regimen
how often do you need to check HbA1c level of T1DM
every 3-6 months
what is the HbA1c target for T1DM
< 48
what is the blood glucose level for T1DM
fasting - 5-7
before meals 4-7
90mins after meal 5-9
what is the 1st line insulin regimen for T1DM
basal-bolus
what is the 2nd and 3rd line insulin regimen for T1DM
2nd line - twice daily long -acting insulin detemir (if not tolerating 1st line)
3rd line - once daily insulin glargine
when will you offer metformin for T1DM
if BMI > 25 and want better control of blood glucose
when will you refer a T1DM for islet or pancreas transplant
recurrent severe hypoglycaemia that has not responded to other treatment/suboptimal control
what medications will you prescribe for secondary prevention of CVD in T1DM
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)
what is the BP target for T1Dm if no albuminuria or metabolic syndrome
135/85
what is the BP target for T1Dm if there are signs of albuminuria or metabolic syndrome
130/80
what is the blood glucose level of pre-T2diabetes
fasting 5.6 - 6.9
HbA1c of 39-46
what is the blood glucose level of T2diabetes
fasting > 6.9
HbA1c > 48
what is diagnostic criteria for T2DM
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
what are some investigations required after diagnosis of T2DM
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
what are some of the differentiates for T2Dm
T1DM
Latent autoimmune diabetes in adults (LADA)
gestational diabetes
what is the treatment regimen for T2DM
- 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 & 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)
how does metformin work
dec gluconeogenesis
inc peripheral utilisation of glucose
what are good advantage for use of metformin
do not make you gain weight
cardioprotective
SE of metformin
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
what is the 1st line treatment if the patient is symptomatic hyperglycaemic
insulin or
SU
what other medication can one use if metformin is contra-indicated?
SGLT2 inhibitors eg empagliflozin
how does empagliflozin work
inc amount of sugar that is urinated
SE of empagliflozin
inc frequency, thrush and UTI
how does sulfonylurea work
works by encouraging pancreas to produce more insulin
what are good advantage for use of sulfonylurea
works quickly = useful for patients presenting with symptoms
takes before meals
SE for use of sulfonylurea
weight gain
what are some exampels of DPP-4 inhibitors
alogliptin, linagliptin
how does alogliptin, linagliptin work
in incretin hormone levels which stimulates pancreas to produce more insulin
what are good advantage for use of alogagliptin and linagliptin?
weight neutral, well tolerated, okay for poor renal function
but only work for short period of time
how does pioglitazone work
inc insulin sensitivity and screations
SE for use of pioglitazone
inc risk of osteoporosis, weight gain
what is the biggest advantage of using GLP-1
weight loss
when should you continue GLP-1
if a reduction of at least 11 mmol/mol if in HbA1c and weight loss of at least 3% is seen in 6 months
how doe GLP-1 work
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
how often do you conduct a HbA1c measure
every 3-6 months
what is the max allowance of HbA1c for an elderly and frail
70
what tests.screening do you need to conduct when carrying out an annual review for diabetes?
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)
what is the aim for BP for T1DM
135/80
what is the management for hypoglycaemia
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
what is the aim of BP for T2DM
130/80 if kidney or 2 or more features of metabolic syndrome
otherwise, target <135/85
what is metabolic syndrome
inc wrist circumference BMI >30 raised triglycerides reduced HDL raised BP raised blood glucose
inc risk of CVD and T2DM
what are the secondary prevention for CVD in T2DM
T1 = atorvastatin 20mg, if T!DM > 10 yrs - 40 mg
T2 = atorvastatn 20mg for those with QRISK2 of > 10%
what medication will you use to protect kidney function
when Albumin:Creatinine Ration > 3
start ACEi or ARB
maintain BP < 130/80
what are the different stages of diabetic retinopathy
1) minimal arteriolar narrowing - silver wiring with tortuosity
2) obvious narrowing - AV nipping
3) above + hemorrhages, exudates or cotton wool spots
4) above + papilloedema
what are some examples of neuropathy for DM
gastroparesis
erectile dysfunction
diabetes foot neuropathy
