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Pre reg > Diabetes > Flashcards

Diabetes Flashcards

1
Q

For adults with T2DM who are overweight, what is the initial weight loss target?

A

5-10%

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2
Q

In adults with T2DM, measure HbA1c levels at:

A
  • 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
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3
Q

HbA1c target for adults with T2DM managed by either lifestyle and diet combined with a single drug not associated with hypoglycaemia

A

48mmol/mol (6.5%)

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4
Q

HbA1C target for T2DM adults on a drug assciated with hypoglycaemia

A

53mmol/mol (7%)

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5
Q

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)

A
  • Reinforce lifestyle and adherance
  • Support person to aim for 53%
  • Intensify drug Tx
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6
Q

Reasons for sudden low HbA1c

A
  • Deteriorating renal function

- Sudden weight loss

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7
Q

Do NOT offer self-monitoring of blood glucose levels for adults with T2DM unless:

A
  • 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
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8
Q

When would you consider short-term self-monitoring of blood glucose levels in adults with T2DM?

A
  • when starting tx with oral or IV corticosteroids

- to confirm suspected hypoglycaemia

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9
Q

Standard first line treatment for T2DM

A
  • Metformin
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10
Q

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?

A

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%)

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11
Q

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?

A

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%)

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12
Q

If metformin is CI or not tolerated what would be first line in T2DM?
And what would you aim for their HbA1C?

A
  • 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%)
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13
Q

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?

A

Dual therapy with:

  • DPP4i and pioglitazone
  • DPP4i and an SU
  • pioglitazone and an SU

Aim for 53%

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14
Q

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?

A

Insulin

<53mmol/L

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15
Q

What is MHRA safety advice for pioglitazone?

A
  • Increases risk of heart failure, bladder cancer and bone fracture
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16
Q

What is the MHRA safety advice for SGLT-2 inhibitors? (2)

What should you do if it happens?

A
  • 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
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17
Q

What is the MHRA safety advice for canagliflozin specifically?

A
  • Increased risk of lower-limb amputation (mainly toes), advise to stay well hydrated
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18
Q

When should you stop metformin in renal impairment?

A

<30ml/min eGFR

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19
Q

When would you not offer an adult with T2DM pioglitazone?

A
  • Heart failure or Hx of HF
  • Hepatic impairment
  • DKA
  • current or history of bladder cancer
  • uninvestigated macroscopic haematuria
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20
Q

If triple therapy with metformin and 2 other oral drugs not effective, CI, etc what would you consider?

A

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

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21
Q

You would only continue GLP-1 therapy in T2DM if

A

beneficial metabolic response,

at least 11mol/lmol reduction in HbA1c and weight loss of at least 3% of initial body weight in 6 months

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22
Q

Insulin regime for T2DM (there’s two regimes)

A

1) NPH (isophane insulin) OD/BD

2) NPH and short acting insulin - if HbA1C >75mmol/mol, administering either separately or pre-mixed (biphasic insulin)

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23
Q

When would you think of a diagnosis of gastroparesis in adults with T2DM

A
  • Erratic blood glucose control OR unexplained gastric bloating or vomitting, taking into account possible alternate diagnoses
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24
Q

Treatment of vomitting caused by gastroparesis in adults with T2DM

A
  • Consider erythromycin and metoclopramide

- Consider domperidone ONLY in exceptional circumstances

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25
Q

MHRA safety advice on domperidone and metoclopramide

A

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

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26
Q

Mechanism of action of Metformin, what class is it?

A

Biguanide

  • Enhances effect of insulin
  • Reduction in insulin resistance via modification of glucose metabolic pathways (decreases gluconeogenesis)
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27
Q

Clinical characterisitics of metformin:

  • Hypos
  • Weight/gain loss
  • Surgery
A

No hypo
Weight loss
Stopped prior to surgery

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28
Q

Important side effects of metformin

A
  • Associated lactic acidosis (elderly and renal impairment and CHF), measure serum lactate, stop meformin and treat
  • Vitamin B12 deficiency
  • Metallic taste in mouth (dysgeusia)
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29
Q

Contra-indications of metformin

A
  • 30ml/min eGFR
  • IV iodinated contrast medium
  • Sever liver failure
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30
Q

Mechanism of action of pioglitazone

A

Reduces peripheral insulin resistance, leading to a reduction in blood glucose concentration

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31
Q

Important side effects of pioglitazone

A
  • increased risk of HF, bone fractures, fluid retention and oedema, weight gain
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32
Q

Which anti-diabetics can cause weight gain

A
  • Sulfonyueras, pioglitazone
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33
Q

Which anti-diabetics can cause weight loss

A
  • Metformin, SGLT-2i, DPP4-i
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34
Q

Which anti-diabetics have no effect on weight?

A
  • Gliptins
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35
Q

Long vs short acting sulfonurea and elderly, which is prferred

A
  • Short acting preferred in elderly
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36
Q

List some short and long acting sulfonureas

A

Short - tolbutamide, gliclazide

Long - Glibenclamide, glimepiride

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37
Q

Mechanism of action of sulfonureas

A

Stimulates pancreatic insulin production

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38
Q

Mechanism of action of GLP-1

A

Slows gastric emptying, suppress glucagon secretion and increase insulin secretion

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39
Q

Mechanism of action of ‘gliptins’, DPP4-i

A

Inhibits DPP4 enyzme. Stimulate insulin secretion and suppress glucagon secretion

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40
Q

Mechanism of action of SGLT-2 inhibitors

A

Reduce glucose reabsorption and increase urinary glucose excretion by inhibiting SGLT2 in the renal proximal convulated tubule

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41
Q

Which anti-diabetics have high and low risk of hypos

A
  • High risk, sulfonylureas

- Low risk, metformin, pioglitazone and gliptins

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42
Q

Name some examples of GLP-1 receptor agonists

A

Exenatide, liraglutide, dulaglutide

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43
Q

Side effects of GLP-1 receptor agonists

A

Pancreatitis

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44
Q

MHRA alert for GLP-1 receptor agonists

A

Reports risks of DKA when concomitant insulin rapidly reduced or discontinued

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45
Q

Counselling advice for GLP-1 receptor agonists

A
  • Acute pancreatitis

- Dehydration - in relation to GI SEs

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46
Q

What to do if a missed dose of GLP-1 receptor agonist

  • Dulaglutide/albglutide
  • Exenatide
  • Lixeisenatide
A

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

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47
Q

Exenatide pregnancy

A
  • MR should use effective contraception during and for 12 weeks after discontinuation
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48
Q

Important side effects of SGLT-2 inhibitors

A
  • UTI, genital infections
  • Dehydration -> orthostatic hypotension
  • Severe DKA
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49
Q

Patients usually treated with insulin who have good glycaemic control (HbA1c < 69) and are undergoing MINOR procedures can be managed..

A

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%

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50
Q

Patients usually treated with insulin who have poor glycaemic control (HbA1c < 69) OR undergoing MAJOR surgery managed by..

A

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
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51
Q

When can conversion back to SC insulin be done

A

When patient starts eating and drinking without n and v

52
Q

When can previous sc basal-bolus regimens restart

A

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

53
Q

When insulin is required and given during surgery whic anti-diabetics should be stopped and not restarted until pt eating and drinking

A

Acarbose, meglitinides, slufonylureas, pioglitazone, DPP4i and SGLT2
GLP can be done still

54
Q

What anti-diabetics can be continued during short-term surgery and which ones cannot

A

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

55
Q

If eGFR <60 and contrast medium used how long should metformin be omitted for

A

omitted on day and following 48 hours

56
Q

Definition of hypoglycaemia

A

<4 mmol/L

57
Q

Which anti-diabetic medications cause hypos the most?

A

Insulin and sulfonlyureas

58
Q

What is treatment for hypoglycaemia if conscious

A

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.

59
Q

Which anti-diabetics are unlikely to cause hypos

A

Metformin, pioglitazone, DPP4i, SGLT2 and GLP1 agonists

60
Q

Examples of fast acting carbohydrates for hypos

A
  • 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)
61
Q

What should be avoided as fast acting carbohydrate for hypo

A
  • 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
62
Q

Examples of long acting carbohydrates after hypo

A
  • two biscuits
  • one slice of bread
  • 200-300ml of milk not alternative
  • or a normal carbo meal if due
63
Q

What if hypo does not respond after 3 treatment cycles?

A

IM glucagon or IV glucose 10% infusion

64
Q

What is given with admin of IV glucose in alcoholic patients and why

A

thiamine supplementation to minimise the risk of Wernicke’s encephalopathy.

65
Q

what is treatment for hypo if decreased level of consciousness

A

IM glucagon. if not effective after 10 mins glucose 10% IV infusion

66
Q

Treatment for unconscious hypo

A

IV insulin stopped and initially treated with glucagon, no response after 10 mins, glucose 10/20% IV infusion.

67
Q

Why is glucose 50% not recommended

A

hypertonic - increases risk of extravasation injury

Also viscous making admin difficult

68
Q

Symptoms of hypoglycaemia

A
  • Shakiness, feeling cold/clammy, mood changes, lack of energy, hunger, restless sleep, blurred vision, fast heartbeat, pale skin, feeling anxious
69
Q

Signs of DKA

A

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

70
Q

What do you give first to treat DKA

A
  • Fluids and electrolytes replacement
71
Q

What do you give To restore circulating volume if systolic blood pressure is below 90 mmHg? (DKA)

A

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

72
Q

What do you give When blood pressure is over 90 mmH?

A

sodium chloride 0.9% should be given by intravenous infusion (at a rate that replaces deficit and provides maintenance)

73
Q

What should you include in the fluids?

A

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)

74
Q

What else should you start in diabetic ketoacidosis? (other than electrolytes and fluid)

A

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

75
Q

What insulins should be continued in DKA

A

Established subcutaneous therapy with long-acting insulin analogues (insulin detemir or insulin glargine)

76
Q

What should you monitor during DKA

A

Blood ketone and blood glucose conc hourly, should fall 0.5mmol/L and 0/4mmol/L every hour respectively

77
Q

What should be given Once blood-glucose concentration falls below 14 mmol/litre? (DKA)

A

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.

78
Q

How long should you continue insulin infusion for?

A

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

79
Q

Diabetes in pregnancy is associated with an increased risk of

A

Pre-eclampsia and rapidly worsening retinopathy

80
Q

Women with pre-existing diabetes before pregnancy:

  • Target HbA1c
  • Dose of folic acid
A
  • below 48

- 5mg (high chance of neural tube defect)

81
Q

What anti-diabetics can be given during pregnancy

A
  • Metformin

- All others substituted with insulin

82
Q

What anti-diabetics can be given during BF

A
  • just metformin
83
Q

What is first line for long-acting insulin during pregnancy

A
  • Isophane,
    however, if they had good blood glucose control before preg with determir or glargine, may be appropriate to continue during pregnancy
84
Q

Women with pre-existing diabetes treated with insulin during pregnancy are at an increased risk of ______ in the postnatal period and should _____ insulin ?

A

hypoglycaemia and reduce

85
Q

Gestational diabetes diagnosis and treatment

A

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

86
Q

Gestational diabetes, when to discontinue treatment

A

Immediately after birth

87
Q

Symptoms of diabetes

A

Polyphagia, polydipsia, polyuria, weight loss, fatigue, blurred vision, poor wound healing

88
Q

How often should patients with T1DM measure blood glucose and what should they aim for?

A

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

89
Q

What should blood glucose concentration be to drive?

A

5 to drive

90
Q

What is T1DM

A

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.

91
Q

Three types of insulin regimens

A

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

92
Q

Recommended insulin regimen for T1DM

A
  • 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
93
Q

What factors can lead to poor glucose control?

A

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

94
Q

What factors can lead to increased requirement of insulin dose?

A

Infection, stress, accidental or surgical trauma

95
Q

What factors can lead to decreased insulin requirements

A

Physical activity, intercurrent illness, reduced food intake, impaired renal function and in certain endocrine disorders

96
Q

Recommended insulin regimen for T2DM

A

Isophane OD/BD +/- short acting

97
Q

What non-diabetic medication should you stop during sick day

A
  • ACEi/ARB, diuretics, NSAIDS
98
Q

What anti-diabetic medication needs to stop during SICK day

A
  • metformin, sulfonylureas, GLP-1 analogues and SGLT-2 inhibitors
99
Q

What should drivvers on insulin always bring with them

A

fast acting carbohydrate

glucose meter and blood glucose strips

100
Q

If blood glucose falls below 4 whilst driving what to do

A

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

101
Q

How often to check blood glucose whilst driving and before

A

2 hours before and every 2 hours whilst driving

102
Q

Microvascular complications of diabetes

A

Retinopathy, nephropathy, neuropathy

103
Q

WHO HbA1C diabetes diagnosis

A

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.

104
Q

HbA1C recommended target in T1DM

A

<48mmol/mol

105
Q

In basal bolus regimen in T2DM, what type of insulin is recommended for bolus aspect

A 
Rapid acting insulin
- Lispro - HUMALOG
- Aspart - NOVORAPID
- Glulisine - APIDRA 
Rather than soluble human or animal insulin
106
Q

Patient’s awareness of hypoglycaemia should be assessed annually using what score tools

A

Gold or Clarke score

107
Q

What cardiac class of drug can blunt hypoglycaemia awareness

A

Beta blockers

108
Q

What can occur if you repeatedly inject insulin in same area without rotating

A

Lipohypertrophy - erratic absorption of insulin

109
Q

How much time before meals do you administer short acting soluble insulin

A

15-30 mins before

110
Q

How much time before meals do you administer rapid acting insulin

A

Immediately before

111
Q

What type of insulin is isophane

A

Intermediate - designed to mimic endogenous basal insulin

112
Q

What are biphasic insulins

A

Pre-mixed insulin preparations containing various combos of short-acting (soluble or rapid acting) and an intermediate acting insulin

113
Q

What are the names of some long acting insulins

A

Insulin determir
Insulin glargine
Insulin degludec

114
Q

In terms of HbA1C, when should treatment in a T2DM on ONE antidiabetic drug be intensifed

A

> 58

115
Q

Which drug should not be given with triple therapy with dapaglifozin

A

Pioglitazone

116
Q

What is the problem using repaglinide monotherapy in T2DM

A

If intensification of treatment required, can only be given with metformin. Not licensed in combo with any other antidiabetic drugs

117
Q

In T2DM, at what HbA1c would the following insulin regimen be appropriate: Isophane + short acting insulin (separate or pre mixed)

A

> 75 mmol/mol

118
Q

What two antidiabetic drug classes can cause pancreatitis

A

Gliptins and GLP-1 agonists

119
Q

With what antidiabetic drug would it not be suitable in those with hernias or GI obstruction

A

Acarbose

120
Q

When would you offer a prophylactic statin in T1DM and T2DM

A

T2DM - QRISK > 10%

T1DM - Over 40 years, Had diabetes for >10 years, Have established nephropathY, Have other CVD risk factors

121
Q

What class of antidiabetic durgs can cause volume depletion

A

SGLT2 inhibitors

122
Q

How to take acarbose

A

Manufacturer advises tablets should be chewed with first mouthful of food or swallowed whole with a little liquid immediately before food.

123
Q

Which drug (not class) causes sever pancreatitis

A

Exenatide

124
Q

What diaetes does OGTT normally diagnose

A

Gestational diabetes

125
Q

How is OFTT conudcted

A

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.

Pre reg (45 decks)

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