Diabetes Flashcards
For adults with T2DM who are overweight, what is the initial weight loss target?
5-10%
In adults with T2DM, measure HbA1c levels at:
- 3-6 monthly intervals until the HbA1C is stable on unchanging therapy
- 6 monthly intervals once Hba1c level and blood glucose lowering therapy are stable
HbA1c target for adults with T2DM managed by either lifestyle and diet combined with a single drug not associated with hypoglycaemia
48mmol/mol (6.5%)
HbA1C target for T2DM adults on a drug assciated with hypoglycaemia
53mmol/mol (7%)
In adults with T2DM, if HbA1c levels are not adequately controlled by a single drug and rise to 58mmol/mol (>7.5%) or higher: (3)
- Reinforce lifestyle and adherance
- Support person to aim for 53%
- Intensify drug Tx
Reasons for sudden low HbA1c
- Deteriorating renal function
- Sudden weight loss
Do NOT offer self-monitoring of blood glucose levels for adults with T2DM unless:
- The person is on insulin
- There is evidence of hypoglycaemic episodes
- The person is on oral meds that may increase their risk of hypos whilst driving/operating heavy machinery
- The person is pregnant/planning on becoming pregnant
When would you consider short-term self-monitoring of blood glucose levels in adults with T2DM?
- when starting tx with oral or IV corticosteroids
- to confirm suspected hypoglycaemia
Standard first line treatment for T2DM
- Metformin
If HbA1c rises to 58mmol/L (7.5%) on lifestyle when on metformin? (for the first time) And what would you then aim for HbA1C level?
Consider dual therapy with:
- M and DPP-4i
- M and pioglitazone
- M and an SU
- M and an SGLT-2i
Aim for 53mmol/L (7.5%)
If HbA1c rises to 58mmol/L (7.5%) on lifestyle when on metformin? (for the second time) And what would you then aim for HbA1C level?
Consider triple therapy with:
- M, DPP4-i, and an SU
- M, pioglitazone and an SU
- M, pioglitazone or an SU and an SGLT-2
Aim for 53mmol/L (7.5%)
If metformin is CI or not tolerated what would be first line in T2DM?
And what would you aim for their HbA1C?
- DPP4-i, pioglitazone or SU
- SGLT-2 inhibitor instead of DPP4-i if SU or pioglitazone inappropriate
DPP4i, pioglitazone, SGLT-2 - 48mmol/L (6.5%)
SU - 53 (7%)
If metformin is CI or not tolerated what would the treatment be if HbA1c rose to >58mmol/L on drug Tx
And what would you aim for their HbA1C?
Dual therapy with:
- DPP4i and pioglitazone
- DPP4i and an SU
- pioglitazone and an SU
Aim for 53%
If metformin is CI or not tolerated what would the treatment be if HbA1c rose to >58mmol/L on drug Tx when on dual therapy
And what would you aim for their HbA1C?
Insulin
<53mmol/L
What is MHRA safety advice for pioglitazone?
- Increases risk of heart failure, bladder cancer and bone fracture
What is the MHRA safety advice for SGLT-2 inhibitors? (2)
What should you do if it happens?
- DKA (rapid weight loss, N or V, abdo pain, fast and deep breathing, sleepiness, a sweet/metallic smell to breath, different colour urine/sweat), test for ketones
- Discontiune
- Don’t restart if DKA occured whilst on, unless another reason
- Stop when hospitalised for surgery or acute serious illness
- Fournier’s Gangrene - severe pain, tenderness, erythema, swelling in genital or peineal area, accompanied by fever or malaise
What is the MHRA safety advice for canagliflozin specifically?
- Increased risk of lower-limb amputation (mainly toes), advise to stay well hydrated
When should you stop metformin in renal impairment?
<30ml/min eGFR
When would you not offer an adult with T2DM pioglitazone?
- Heart failure or Hx of HF
- Hepatic impairment
- DKA
- current or history of bladder cancer
- uninvestigated macroscopic haematuria
If triple therapy with metformin and 2 other oral drugs not effective, CI, etc what would you consider?
sulfonylurea, metformin and GLP1 if BMI > 35 and specific psycholigcal or medical problems associated with obesity
OR BMI <35 AND for whom insulin would have significant occupational implications, weight loss would benefit other significant obestiy-related co-morbidites
You would only continue GLP-1 therapy in T2DM if
beneficial metabolic response,
at least 11mol/lmol reduction in HbA1c and weight loss of at least 3% of initial body weight in 6 months
Insulin regime for T2DM (there’s two regimes)
1) NPH (isophane insulin) OD/BD
2) NPH and short acting insulin - if HbA1C >75mmol/mol, administering either separately or pre-mixed (biphasic insulin)
When would you think of a diagnosis of gastroparesis in adults with T2DM
- Erratic blood glucose control OR unexplained gastric bloating or vomitting, taking into account possible alternate diagnoses
Treatment of vomitting caused by gastroparesis in adults with T2DM
- Consider erythromycin and metoclopramide
- Consider domperidone ONLY in exceptional circumstances
MHRA safety advice on domperidone and metoclopramide
Domperidone - Cardiac side effects, not licenced <12 or <35kg, max duration should not exceed 1 week
Metoclopramide - Neurological adverse effects (EPSE and tardive dsykinesia), short term 5 days
Mechanism of action of Metformin, what class is it?
Biguanide
- Enhances effect of insulin
- Reduction in insulin resistance via modification of glucose metabolic pathways (decreases gluconeogenesis)
Clinical characterisitics of metformin:
- Hypos
- Weight/gain loss
- Surgery
No hypo
Weight loss
Stopped prior to surgery
Important side effects of metformin
- Associated lactic acidosis (elderly and renal impairment and CHF), measure serum lactate, stop meformin and treat
- Vitamin B12 deficiency
- Metallic taste in mouth (dysgeusia)
Contra-indications of metformin
- 30ml/min eGFR
- IV iodinated contrast medium
- Sever liver failure
Mechanism of action of pioglitazone
Reduces peripheral insulin resistance, leading to a reduction in blood glucose concentration
Important side effects of pioglitazone
- increased risk of HF, bone fractures, fluid retention and oedema, weight gain
Which anti-diabetics can cause weight gain
- Sulfonyueras, pioglitazone
Which anti-diabetics can cause weight loss
- Metformin, SGLT-2i, DPP4-i
Which anti-diabetics have no effect on weight?
- Gliptins
Long vs short acting sulfonurea and elderly, which is prferred
- Short acting preferred in elderly
List some short and long acting sulfonureas
Short - tolbutamide, gliclazide
Long - Glibenclamide, glimepiride
Mechanism of action of sulfonureas
Stimulates pancreatic insulin production
Mechanism of action of GLP-1
Slows gastric emptying, suppress glucagon secretion and increase insulin secretion
Mechanism of action of ‘gliptins’, DPP4-i
Inhibits DPP4 enyzme. Stimulate insulin secretion and suppress glucagon secretion
Mechanism of action of SGLT-2 inhibitors
Reduce glucose reabsorption and increase urinary glucose excretion by inhibiting SGLT2 in the renal proximal convulated tubule
Which anti-diabetics have high and low risk of hypos
- High risk, sulfonylureas
- Low risk, metformin, pioglitazone and gliptins
Name some examples of GLP-1 receptor agonists
Exenatide, liraglutide, dulaglutide
Side effects of GLP-1 receptor agonists
Pancreatitis
MHRA alert for GLP-1 receptor agonists
Reports risks of DKA when concomitant insulin rapidly reduced or discontinued
Counselling advice for GLP-1 receptor agonists
- Acute pancreatitis
- Dehydration - in relation to GI SEs
What to do if a missed dose of GLP-1 receptor agonist
- Dulaglutide/albglutide
- Exenatide
- Lixeisenatide
D/A
If a dose missed, soon as poss.
if there are at least 3 days until next scheduled dose
if there are less than 3 days remain before the next scheduled dose, don’t take
Exenatide
- Continue with next weekly dos
Lixeisenatide
- If a dose is missed, inject within 1 before next weel, NOT AFTER meal
DON’T INJECT AFTER MEAL
Exenatide pregnancy
- MR should use effective contraception during and for 12 weeks after discontinuation
Important side effects of SGLT-2 inhibitors
- UTI, genital infections
- Dehydration -> orthostatic hypotension
- Severe DKA
Patients usually treated with insulin who have good glycaemic control (HbA1c < 69) and are undergoing MINOR procedures can be managed..
Usual insulin regimen.
On the day before the surgeru, the patient’s usual insulin should be given as normal other than OD long-acting insulins and dose reduced by 20%
Patients usually treated with insulin who have poor glycaemic control (HbA1c < 69) OR undergoing MAJOR surgery managed by..
Variable rate rate iv insulin infusion (achieve 6-10mmol/L glucose conc)
- day before - 20% reduction of long acting
- day of and throughout operative period - long acting continued at 80% of ususal dose and all others stopped until patient eating and drinking again after surgery
- day of surgery start IV substrate infusion of potassium chloride with glucose and sodium chloride and infuse at rate appropriate to patient’s fluid requirements, don’t stop while insulin infusion still running - hypo
- VRII should be given based on hourly blood glucose measurements
- IV glucose 20% glucose given if blood glucose drops below 6
When can conversion back to SC insulin be done
When patient starts eating and drinking without n and v
When can previous sc basal-bolus regimens restart
restarted when first postop meal time insulin due
iv infusion insulin should be continued until 30-60 mins AFTER the first meal-time short acting insulin
80% long acting continued until pt leave hospital
When insulin is required and given during surgery whic anti-diabetics should be stopped and not restarted until pt eating and drinking
Acarbose, meglitinides, slufonylureas, pioglitazone, DPP4i and SGLT2
GLP can be done still
What anti-diabetics can be continued during short-term surgery and which ones cannot
pioglitazone, DPP4 and GLPi
SLGT2 and sulf (omitted on day of surgery -> DKA and hypo)
Metformin if eGFR >60 and low risk of AKI, just lunch time dose admitted if TDS (insulin iv infusion if more than TDs metformin
If eGFR <60 and contrast medium used how long should metformin be omitted for
omitted on day and following 48 hours
Definition of hypoglycaemia
<4 mmol/L
Which anti-diabetic medications cause hypos the most?
Insulin and sulfonlyureas
What is treatment for hypoglycaemia if conscious
Conscious and able to swallow:
15-20 g of fast-acting carbohydrate. Repeat after 10-15 mins up to a max of 3 times if necessary. Once blood-glucose concentration is above 4 mmol/litre and the patient has recovered, a snack providing a long-acting carbohydrate should be given to prevent blood glucose from falling again. Hypoglycaemia which does not respond should be treated with intramuscular glucagon or glucose 10% intravenous infusion.
Which anti-diabetics are unlikely to cause hypos
Metformin, pioglitazone, DPP4i, SGLT2 and GLP1 agonists
Examples of fast acting carbohydrates for hypos
- Lift glucose liquid
- glucose tablets (4-7)
- glucose 40% gel
- Pure fruit juice (150-200ml)
- Sugar (sucrose) dissolved in appropriate amount of water (3-4 heaped teaspoons)
What should be avoided as fast acting carbohydrate for hypo
- OJ avoided in patients following low K diet due to CKD
- sugar dissolved in water not effective for patients taking acarbose which prevents breakdown of sucrose to glucose
- avoid chocs and biscuits as they have lower sugar content and their high fat content may delay stomach emptying
Examples of long acting carbohydrates after hypo
- two biscuits
- one slice of bread
- 200-300ml of milk not alternative
- or a normal carbo meal if due
What if hypo does not respond after 3 treatment cycles?
IM glucagon or IV glucose 10% infusion
What is given with admin of IV glucose in alcoholic patients and why
thiamine supplementation to minimise the risk of Wernicke’s encephalopathy.
what is treatment for hypo if decreased level of consciousness
IM glucagon. if not effective after 10 mins glucose 10% IV infusion
Treatment for unconscious hypo
IV insulin stopped and initially treated with glucagon, no response after 10 mins, glucose 10/20% IV infusion.
Why is glucose 50% not recommended
hypertonic - increases risk of extravasation injury
Also viscous making admin difficult
Symptoms of hypoglycaemia
- Shakiness, feeling cold/clammy, mood changes, lack of energy, hunger, restless sleep, blurred vision, fast heartbeat, pale skin, feeling anxious
Signs of DKA
High blood sugar levels and ketones in urine
Excessive thirst
Urinating much more often and in larger amounts
Sudden loss of weight
Complaints of stomach pains or nausea
Vomitting
Signs of dehydration, dry mouth, tongue, sore throat, dark circles under eyes
Deep, heavy breathing
Fruit-smelling breath
Drowsiness leading in time to unconsciousness
What do you give first to treat DKA
- Fluids and electrolytes replacement
What do you give To restore circulating volume if systolic blood pressure is below 90 mmHg? (DKA)
500 mL sodium chloride 0.9% by intravenous infusion over 10-15 minutes; repeat if blood pressure remains below 90 mmHg and seek senior medical advice
What do you give When blood pressure is over 90 mmH?
sodium chloride 0.9% should be given by intravenous infusion (at a rate that replaces deficit and provides maintenance)
What should you include in the fluids?
potassium chloride in the fluids unless anuria is suspected; adjust according to plasma-potassium concentration (measure at 60 minutes, 2 hours, and 2 hourly thereafter; measure hourly if outside the normal range)
What else should you start in diabetic ketoacidosis? (other than electrolytes and fluid)
an intravenous insulin infusion: soluble insulin should be diluted (and mixed thoroughly) with sodium chloride 0.9% intravenous infusion to a concentration of 1 unit/mL; infuse at a fixed rate of 0.1 units/kg/hour
What insulins should be continued in DKA
Established subcutaneous therapy with long-acting insulin analogues (insulin detemir or insulin glargine)
What should you monitor during DKA
Blood ketone and blood glucose conc hourly, should fall 0.5mmol/L and 0/4mmol/L every hour respectively
What should be given Once blood-glucose concentration falls below 14 mmol/litre? (DKA)
glucose 10% should be given by intravenous infusion (into a large vein through a large-gauge needle) at a rate of 125 mL/hour, in addition to the sodium chloride 0.9% infusion.
How long should you continue insulin infusion for?
Until blood ketone below 0.3mmol/L , blood pH above 7.3 and patient able to eat and drink, give sc fast acting insulin amd meal and stop insulin infusion 1 hour later
Diabetes in pregnancy is associated with an increased risk of
Pre-eclampsia and rapidly worsening retinopathy
Women with pre-existing diabetes before pregnancy:
- Target HbA1c
- Dose of folic acid
- below 48
- 5mg (high chance of neural tube defect)
What anti-diabetics can be given during pregnancy
- Metformin
- All others substituted with insulin
What anti-diabetics can be given during BF
- just metformin
What is first line for long-acting insulin during pregnancy
- Isophane,
however, if they had good blood glucose control before preg with determir or glargine, may be appropriate to continue during pregnancy
Women with pre-existing diabetes treated with insulin during pregnancy are at an increased risk of ______ in the postnatal period and should _____ insulin ?
hypoglycaemia and reduce
Gestational diabetes diagnosis and treatment
If fasting plasma glucose below 7mmol/L, should first attempt diet and exercise alone
If blood glucose targets not met within 1-2 weeks, metformin prescribed
If fasting plasma glucose >7mmol/l, immediately start insulin immediately with or without metformin in addition to diet and exercise
Women who have fasting plasma glucose between 6-6.9mmol/l alongisde complication such as macrosomia and hydramnios should be considered for immediate insulin w/w metformin
Gestational diabetes, when to discontinue treatment
Immediately after birth
Symptoms of diabetes
Polyphagia, polydipsia, polyuria, weight loss, fatigue, blurred vision, poor wound healing
How often should patients with T1DM measure blood glucose and what should they aim for?
At least QDS (BEFORE EACH MEAL AND BED)
fasting blood glucose 5-7mmol/L on waking
4-7 before meals
5-9 at least 90 mins after eating
What should blood glucose concentration be to drive?
5 to drive
What is T1DM
Absolute insulin deficiency in which there is little or no endogenous insulin secretion due to destruction of inuslin producing beta cells on the islets of Langerhans.
Three types of insulin regimens
Basal bolus regimen - One of more separate daily injections of intermediate/long as the basal, alongisde multiple bolus injections of short-acting insulin before meals (allows pt to tailor regimen in accordance to meal)
Mixed (biphasic) - one, two, three insulin injections per day mixed of short and intermediate
Continuous sc insulin infusion (pump) - rapid or soluble mized and delivered by a pump
Recommended insulin regimen for T1DM
- First line - BASAL BOLUS. BD determir, OD glargine if that not tolerated or if BD not acceptable to pt (determir can also be offered as OD). Rapid-acting recommended as bolus
What factors can lead to poor glucose control?
Adherance, injection technique, injection site problems, blood-glucose monitoring skills, lifestyle issues (diet, eercise and alcohol), pyschological issues, and organic causes such as renal disease, thyroid disorders, coeliac disease, Addison’s disease or gastroparesis
What factors can lead to increased requirement of insulin dose?
Infection, stress, accidental or surgical trauma
What factors can lead to decreased insulin requirements
Physical activity, intercurrent illness, reduced food intake, impaired renal function and in certain endocrine disorders
Recommended insulin regimen for T2DM
Isophane OD/BD +/- short acting
What non-diabetic medication should you stop during sick day
- ACEi/ARB, diuretics, NSAIDS
What anti-diabetic medication needs to stop during SICK day
- metformin, sulfonylureas, GLP-1 analogues and SGLT-2 inhibitors
What should drivvers on insulin always bring with them
fast acting carbohydrate
glucose meter and blood glucose strips
If blood glucose falls below 4 whilst driving what to do
stop vehicle in safe place
switch off engine, remove keys and move from driver’s seat
- eat or drink a suitable source of sufar
wait until 45 mins after glucose returned to normal before continuing
How often to check blood glucose whilst driving and before
2 hours before and every 2 hours whilst driving
Microvascular complications of diabetes
Retinopathy, nephropathy, neuropathy
WHO HbA1C diabetes diagnosis
HbA1c below 42 mmol/mol (6.0%): Non-diabetic.
HbA1c between 42 and 47 mmol/mol (6.0–6.4%): Impaired glucose regulation (IGR) or Prediabetes.
HbA1c of 48 mmol/mol (6.5%) or over: Type 2 diabetes.
HbA1C recommended target in T1DM
<48mmol/mol
In basal bolus regimen in T2DM, what type of insulin is recommended for bolus aspect
Rapid acting insulin - Lispro - HUMALOG - Aspart - NOVORAPID - Glulisine - APIDRA Rather than soluble human or animal insulin
Patient’s awareness of hypoglycaemia should be assessed annually using what score tools
Gold or Clarke score
What cardiac class of drug can blunt hypoglycaemia awareness
Beta blockers
What can occur if you repeatedly inject insulin in same area without rotating
Lipohypertrophy - erratic absorption of insulin
How much time before meals do you administer short acting soluble insulin
15-30 mins before
How much time before meals do you administer rapid acting insulin
Immediately before
What type of insulin is isophane
Intermediate - designed to mimic endogenous basal insulin
What are biphasic insulins
Pre-mixed insulin preparations containing various combos of short-acting (soluble or rapid acting) and an intermediate acting insulin
What are the names of some long acting insulins
Insulin determir
Insulin glargine
Insulin degludec
In terms of HbA1C, when should treatment in a T2DM on ONE antidiabetic drug be intensifed
> 58
Which drug should not be given with triple therapy with dapaglifozin
Pioglitazone
What is the problem using repaglinide monotherapy in T2DM
If intensification of treatment required, can only be given with metformin. Not licensed in combo with any other antidiabetic drugs
In T2DM, at what HbA1c would the following insulin regimen be appropriate: Isophane + short acting insulin (separate or pre mixed)
> 75 mmol/mol
What two antidiabetic drug classes can cause pancreatitis
Gliptins and GLP-1 agonists
With what antidiabetic drug would it not be suitable in those with hernias or GI obstruction
Acarbose
When would you offer a prophylactic statin in T1DM and T2DM
T2DM - QRISK > 10%
T1DM - Over 40 years, Had diabetes for >10 years, Have established nephropathY, Have other CVD risk factors
What class of antidiabetic durgs can cause volume depletion
SGLT2 inhibitors
How to take acarbose
Manufacturer advises tablets should be chewed with first mouthful of food or swallowed whole with a little liquid immediately before food.
Which drug (not class) causes sever pancreatitis
Exenatide
What diaetes does OGTT normally diagnose
Gestational diabetes
How is OFTT conudcted
It involves having a blood test in the morning, when you have not had any food or drink for 8 to 10 hours. You’re then given a glucose drink.
After resting for 2 hours, another blood sample is taken to see how your body is dealing with the glucose.
