Diabetes Flashcards
What degree of weight loss is recommended for people with T2DM who are overweight?
5-10%
What are the recommended levels of physical activity for adults with T2DM?
150 minutes of aerobic activity+ 2-3 sessions resistance training per week (to total of at least 60 mins) and with no more than 2 consecutive days without activity. Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits
What are the recommended levels of physical activity for children with T2DM?
At least 60 mins/day of moderate-to-vigorous physical activity, plus muscle and bone strengthening at least 3 days/week
What is the recommended alcohol intake for all adults with T2DM?
Less than or equal to 2 standard drinks (20g alcohol) per day for men and women
What BGL targets are recommended for people with T2DM who self-monitor?
4-7 fasting and 5-10 post prandial
Which T2DM patients should be taught to self-monitor BGLs?
Those on insulin, pregnant women with gestational diabetes, hyperglycaemia with intercurrent illness, and others on a case-by-case basis
What are the lipid targets in T2DM?
Treat according to risk. Total cholesterol <4.0 mmol/L; HDL-C ≥1.0 mmol/L; LDL-C <2.0 mmol/L (or <1.8 mmol/L if established CVD is present); Non–HDL-C <2.5 mmol/L; Triglycerides <2.0 mmol/L
What are the blood pressure targets in patients with T2DM? And for those with proteinuria?
140/90mmHg standard
130/80mmHg if proteinuria is present
What are the targets for urine albumin excretion in T2DM?
<3.5 for women
<2.5 for men
List at least 3 measurablebiochemical targets to chase in T2DM
BP
Lipids
HbA1c
UACR
How often should people who are low risk for T2DM be screened, and how?
Every 3 years from age 40 using the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK)
What particular food groups are associated with a lower risk of T2DM?
3 serves whole grains/day (cereals) and 1.5 serves/day of dairy foods
How often should Aboriginal and Torres Strait Islander people be screened for T2DM, and how?
Do not use AUSDRISK, as the background prevalence is much higher. Instead, test bloods every year from age 18 with fasting glucose, random glucose or HbA1c
List at least 4 groups who should be screened for T2DM with fasting glucose or HbA1c every 3 years
- AUSDRISK score greater than or equal to 12;
- On antipsychotics;
- Hx of cardiovascular event including MI and CVA;
- Hx of gestational diabetes;
- PCOS
How often should patients with an impaired fasting glucose or OGTT be screened for T2DM, and how?
Every 12 months with fasting glucose or HbA1c.
What are the 4 clinical classes of diabetes?
- T1DM
- T2DM
- Gestational diabetes mellitus
- Other specific types of diabetes (i.e., monogenic diabetes, diabetes secondary to other causes)
For which groups of T2DM patients should metabolic surgery be recommended?
BMI 40+
BMI 35-39.9 when hyperglycaemia is inadequately controlled by lifestyle and optimal medical therapy
What are the recommendations for SMBG in T2DM patients with inadequate glycaemic control?
Periodic pre- and post-prandial measurements and education in regards to modification of such readings via lifestyle measures and pharmacotherapy
A reasonable HbA1c goal for many non-pregnant T2DM adults is _____%
Less than 7%
In newly diagnosed T2DM patients, if glycaemic targets are not met within ___ of using healthy behaviour interventions, glucose-lowering therapy should be added to reduce the risk of _____ complications
3 months
Microvascular
Give 3 examples of ‘metabolic decompensation’ in reference to diabetes, and comment on what management should be instigated in these cases
Marked hyperglycaemia
Ketosis
Unintentional weight loss
Individuals with metabolic decompensation should receive insulin therapy to correct the relative insulin deficiency.
Adults with which conditions do not require absolute CVD risk assessment using the Framingham criteria because they are already known to be at clinically determined high risk? (Name at least 5 of the 6)
- Diabetes in patients > 60 years
- Diabetes with microalbuminuria (UACR >2.5 for men and >3.5 for women)
- Moderate to severe CKD (eGFR <45)
- Previous diagnosis of familial hypercholesterolaemia
- SBP >180 or DSP >110
- Serum total cholesterol >7.5
For which T2DM patients are SGLT2i indicated, and what benefit do they confer?
For those in the setting of CVD and insufficient glycaemic control despite metformin, to decrease the risk of cardiovascular events and decrease the risk of hospitalisation and heart failure
What is the difference between type 1 and type 2 diabetes?
In type 1 diabetes, there is autoimmune beta cell destruction which leads to insulin deficiency. Type 2 diabetes results from a progressive insulin secretory defect on the background of insulin resistance
Which specific group of T2DM patients may benefit from targeting BP <120mmHg?
Those in whom prevention of stroke is prioritised
Which adults with T2DM should receive maximum tolerated dose of a statin, irrespective of their lipid levels?
Those with known prior CVD (except hemorrhagic stroke)
In which group of T2DM should fibrates be used?
In those with known prior CVD, fibrates should be added to a statin (or commenced alone if intolerance to statin), when their fasting triglycerides are greater than or equal to 2.3 or HDL is low (and fenofibrate has fewer adverse effects than others) - it also reduces the progression of diabetic retinopathy.
For adults with T2DM and known prior CVD, who are already on max statin dose (or intolerant to the same), if fasting LDL remains greater than or equal to 1.8, consider commencing one of which 3 drugs?
Ezetimibe (first line), bile acid binding resin or nicotinic acid (rarely used)
Which T2DM patients should receive long term anti-platelet therapy (unless contraindicated)?
Those with known prior CVD
All adults with T2DM and history of ischaemic stroke or TIA should receive what therapy?
Low dose aspirin or clopidogrel, or combination low dose aspirin and extended release dipyidamole
All T2DM patients with recent ACS and/or coronary stenting should receive what therapy for 12 months after?
Dual anti-platelet therapy
All T2DM patients with a history of CAD but no acute event in the past 12 months should receive what therapy?
Long term low dose aspirin, or long term clopidogrel if intolerant to aspirin
T2DM patients should be screened for retinopathy at what point?
At the time of diagnosis, and then with frequency tailored to risk (1-2 years if minimal risk, annually if higher risk)
Give some examples of T2DM patients who are at higher risk of retinopathy
Longer duration of diabetes, suboptimal glycaemic management, suboptimal BP or lipid control, people from a non-English speaking background, ATSI
Which 2 variables should be optimised to delay onset and progression of diabetic retinopathy, as well as to prevent and delay the progression of CKD?
BP and glucose
What medication, in addition to statins, may slow the progression of established diabetic retinopathy
Fenofibrate
True or false? The presence of retinopathy in T2DM is a contraindication to aspirin therapy for cardioprotection
False. Aspirin does not increase the risk of retinal haemorrhage.
What factors can be used to risk stratify patients with T2DM in regards to foot health/microvascular complications?
Previous foot ulceration and amputation, structural abnormalities and ulceration on examination, presence of neuropathy
What is the recommended management for T2DM patients who are at intermediate-high risk of foot microvascular complications?
Foot protection program - includes foot care education, podiatry review and appropriate foot care
What are the general principles of wound/ulcer care in T2DM patients?
Provision of physiologically moist wound environment and off-loading the ulcer
In T2DM patients stratified as having low-risk feet (where no risk factors or previous foot complications have been identified), how often should foot examination occur?
Annually
How often should ACR and eGFR be tested in T2DM patients?
At least once a year
What is the recommended treatment for T2DM patients and CKD with either HTN or albuminuria, to delay the progression of the CKD?
ACE or ARB
At what points should creatinine and potassium be monitored in T2DM patients who take an ACE or ARB?
At baseline, within 1-2 weeks of initiation or titration, and during times of acute illness
List some groups of T2DM patients for which a HbA1c target of < 8% might be appropriate (as opposed to the general recommendation of <7%)
History of severe hypoglycaemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions or long-standing diabetes in which the goal is difficult to achieve despite optimal management including insulin
How is gestational diabetes defined?
Glucose intolerance with onset or first recognition during pregnancy
What are the 2 major metabolic dysfunctions in T2DM?
- Insulin resistance
- Followed by pancreatic islet cell destruction, causing a relative insulin deficiency.
The relative deficiency leads to chronic hyperglycaemia and disturbances in carbohydrate, protein and fat metabolism.
List at least 3 causes of secondary diabetes
Diseases of the exocrine pancreas (pancreatic cancer, CF, haemochromatosis)
Metabolic
Drug-induced
List at least 5 groups of people who are considered high risk of T2DM, regardless of the AUSDRISK score
- People 40+ years who are overweight or obese;
- People of any age with IGT or IFG;
- People with first degree relatives with diabetes;
- All patients with hx of cardiovascular event;
- Women with GDM;
- Women with PCOS;
- Those on antipsychotics;
- Indigenous Australians;
- High risk backgrounds such as pacific islanders
What is the only test available that detects impaired fasting glucose?
OGTT
HbA1c is a better predictor of which outcomes cf FBG and OGTT?
Better predictor of macrovascular disease
At what HbA1c threshold does microvascular disease escalate?
6.5%
List some of the scenarios in which HbA1c may lack accuracy
- Acute onset glycaemic states such as pancreatitis, rapid onset of glycaemia with sepsis and steroid use;
- Within 4 months post-partum;
- In people with haemoglobinopathy or haemolysis or advanced CKD;
- People with iron deficiency (artificially elevated);
- People who have recently had a blood or iron transfusion
List the thresholds for FBG where diabetes is unlikely, possible or likely, and the subsequent recommendations
<5.5 unlikely (retest in 3 years);
5.5-6.9 possible (OGTT);
>7 fasting or random >11.1 likely (confirm with repeat FBG)
List the thresholds for OGTT and what they indicate, and the subsequent recommendations
Fasting glucose <6.1 and 2 hour < 7.8 unlikely (retest 3 years);
Fasting 6.1-6.9 and 2 hour <7.8 IFG (retest 1 year);
Fasting glucose <7 and 2 hour 7.8-11.1 IGT (retest 1 year); Fasting >7 and 2 hour >11.1 diabetes
List the thresholds for HbA1c where diabetes is unlikely, possible or likely, and the subsequent recommendations
<6% unlikely (retest 3 years);
6-6.4% high risk/possible (retest 1 year);
>6.5% likely (confirm with repeat HbA1c)
What is the difference between diagnosis of diabetes in a symptomatic vs asymptomatic patient?
Any person with symptoms suggestive of hyperglycaemia need only 1 confirmatory test (or if in hyperglycaemic crisis) - single elevated FBG >7, single HbA1c >6.5% or random BGL >11.1
What are the clinical symptoms suggestive of diabetes? (Name 7)
Lethargy, polyuria, polydipsia, frequent infections, blurred vision, loss of sensation (touch, vibration, cold), poor wound healing, weight loss
List at least 3 signs of insulin resistance
- Acanthosis nigricans
- Skin tags
- Central obesity
- Hirsutism
Describe acanthosis nigricans
Hyperpigmentation accompanied by velvety change in texture of skin. Common in neck and axillae.
How is central obesity defined?
By a high hip-to-waist ratio, waist-to-thigh ratio, and waist circumference
What are the diagnostic criteria fo T2DM in asymptomatic patients (in each of the 3 biochemical tests)
HbA1c greater than or equal to 6.5% on 2 separate occasions;
FBG greater than or equal to 7, or random BGL greater than or equal to 11.1 confirmed by a second abnormal FBG on a separate day;
OGTT where FBG greater than or equal to 7 immediately or greater than or equal to 11.1 after 2 hours.
List 2 special tests that can be used in the diagnosis of T1DM, which are positive in 90% of cases
GAD (glutamic acid decarboxylase)
IA-2 antibodies (insulinoma antigen 2)
What is latent autoimmune diabetes of adults (LADA)? What is significant about this particular subtype of diabetes?
Diabetes with beta islet cell antibodies that occurs more commonly in adulthood. Presents similarly to T2DM but there is more rapid destruction of the islet cells and poorer metabolic response to non-insulin therapy
What is monogenic diabetes? How is this subtype of diabetes unique?
A collection of single-gene mutation disorders that account for 1-2% of diabetes cases. Usually develop before age 25 and often do not require insulin.
At what points should HbA1c be measured in a known diabetic patient?
3 monthly in newly diagnosed patients.
When undergoing therapeutic changes.
Where the HbA1c is outside of the individualised target. Less often in stable patients who have reached the agreed targets (but at least yearly for the cycle of care).
According to the MBS diabetes cycle of care, what investigations/examinations should be performed every 6 months?
Height, Weight, BMI, foot exam and BP
According to the MBS diabetes cycle of care, what item of care should be provided every 2 years?
Comprehensive eye examination
What formal tests should be ordered every 12 months according to the MBS diabetes cycle of care?
HbA1c, lipids, microalbuminuria (ACR)
What management should be instigated for patients with IGT or IFG?
Lifestyle intervention programs to achieve and maintain 7% weight reduction, and increase moderate-intensity activity to at least 150 minutes/week
How is metabolic syndrome related to development of T2DM?
It confers a 3-5 fold risk of developing T2DM.
The metabolic syndrome is diagnosed based on which factors? (Name 4)
- Increased waist circumference
- High triglycerides
- Low HDL
- High BP
- High fasting glucose
What is the difference in C-peptide measured in T1 and T2DM?
In T1DM, C-peptide will be below the normal range < 0.2;
In T2DM, C-peptide will be normal or above >0.2
List at least 3 types of antibodies which might be positive in T1DM
IAA; ICA; GAD; IA-2; IA-2beta; AnT8
Early onset T2DM is defined as occurring under the age of ___
40
List at least 5 risk factors for early onset T2DM
Obesity, sedentary behaviour, ethnicity, low SES, strong family history, in utero exposure to T2DM, low birth weight
List 5 complications in early-onset T2DM compared to older onset disease
- Reduced life expectancy (more than a decade)
- Earlier onset of micro and macrovascular complications
- Higher lipids despite treatment
- Diastolic hypertension
- Increased risk of earlier cognitive decline
List the 5 realms of lifestyle modification that are paramount to management of T2DM
- Physical activity
- Diet
- Weight
- Smoking cessation
- ETOH consumption
The physical activity goal for patients with T2DM, IFG or IGT is to accumulate a minimum of _____ minutes/week of moderate exercise, with no more than __ consecutive days without training
210; 2
How many hours after exercise can post-exercise hypoglycaemia occur in patients with T2DM on insulin or sulphonylureas?
12-15 but up to as long as 48
Explain how an insulin-dependent diabetic should be instructed to manage their BGLs whilst exercising
Check BGL before (ideal = 5-13.9) and during exercise, every 30-45 minutes and adjust medication and carbohydrates as needed (carry sugar load at all times)
List at least 3 classes of medications which are associated with weight gain in diabetes
Insulin, sulphonylureas, thiazolidinediones, second generation antipsychotics (olanzapine and clozapine), beta blockers, TCAs, lithium, pizotifen, valproate and steroids
Adults at high absolute risk of CVD should be simultaneously treated with which 2 pharmacological therapies?
Lipid and BP lowering medications
Commencing a SGLT2i in patients with T2DM in the setting of CVD and poor glycaemic control is known to reduce which risks?
Risk of CVD and hospitalisation for heart failure
For high CVD risk T2DM patients, what are the recommendations for lipid lowering therapy?
Should be on maximum tolerated dose of a statin, irrespective of lipid levels. A fibrate should be started in addition to the statin when fasting triglycerides are greater than or equal to 2.3, or HDL is low. And ezetimibe should be added on if LDL remains high.
Which fibrate medication presents a lower risk of adverse events when used in combination with statins?
Fenofibrate
What is the leading cause of death in people with diabetes?
CVD
When should patients with T2DM be assessed for CVD risk?
At the time of diagnosis, then again at frequencies depending on risk.
Low risk every 2 years;
Moderate risk every 6-12 months,
High risk as clinically indicated
What did the Look AHEAD study find, in relation to lifestyle interventions in diabetes management?
Lifestyle intervention focussed on weight loss improved HbA1c and QOL, but did not significantly reduce the risk of cardiovascular morbidity or mortality
What are the benefits of ACE-I and ARBs in T2DM?
Decreases rate of progression to albuminuria, promotes regression to normoalbuminuria and may reduce the risk of decline in renal function
Conditions that alter kidney function may increase the risk of ______ _____ in patients on metformin
Lactic acidosis
What is the basic mechanism of action of sulfonylureas?
Insulin secretagogues
Which patients who take sulfonylureas are at particular risk of hypoglycaemia?
Those with kidney impairment and the elderly, particularly because of the long duration of action
What are incretins?
Neuroendocrine hormones produced by the GIT in response to food - they stimulate insulin secretion and suppress glucagon secretion i.e., GLP
What are the major incretin hormones, and how are these metabolised?
Glucagon-like peptide (GLP) and glucose-dependent insulinopropic polypeptide (GIP) - metabolised by dipeptidyl peptidase (DPP4)
Name the 2 types of incretin mimetic drugs that are effective in the management of T2DM
Oral DPP4 inhibitors and injectable GLP-1 analogues (receptor agonists)
What is the family name for the DPP4 inhibitors?
Gliptins
What are the perioperative recommendations for SGLT2 inhibitors?
Cease 3 days pre and postoperatively to reduce the risk of ketoacidosis, dehydration, renal impairment and UTI. Cease for surgery or procedures that require 1+ days in hospital and/or bowel preparation. For day procedures, they may be ceased just on the day of the procedure. Can be restarted when eating normally.
Which oral T2DM medication class is the only one which must be stopped when adding insulin?
Sulfonylurea
Why are sulfonylureas still recommended as the second line treatment option for T2DM?
They achieve similar reductions in HbA1c to other second-line oral agents, they have long-term safety data and beneficial microvascular outcome date; they are cost effective for the healthcare system
Why are short acting sulfonylureas preferred to long-acting ones?
Less likely to cause hypoglycaemia; gliclazide can avoid escalation to insulin treatment for longer than long-acting sulfonylureas, long-acting sulfonylureas have metabolites that are excreted renally and therefore not so good in renal impairment (both short acting are metabolised by the liver)
When should patients with T2DM be referred to an optometrist for evaluation of retinopathy?
At the time of diagnosis
The minimal interval for retinopathy screening for patients with no or minimal retinopathy is how long?
1-2 years (or more frequently if higher risk) - annually for ATSI
When should T2DM patients be screened for retinopathy during pregnancy?
Before (or in first trimester), then monitored every trimester and for 1 year post partum
List 2 conditions that are associated with charcot osteoarthropathy
Diabetes and chronic alcoholism (due to the association with peripheral neuropathy)
Any peripheral neuropathy is also associated with Charcot’s - i.e., syphilis, leprosy, spinal cord injury
Describe the appearance of Charcot Osteoarthropathy of the foot and what imaging findings may be supportive
Foot will be hot, tender and swollen. Plan XR will be normal but MRI will show bone marrow oedema
Which oral T2DM medication has evidence of reduction in cardiovascular death in patients with T2DM and cardiovascular disease?
Empagliflozin (SGLT2i) - reduces risk of hospitalisation for heart failure and overall mortality, and slows progression of kidney disease
What parameters for waist circumference predict increased risk of obesity-related consequences?
Greater than 94cm in men and 80cm in women.
High risk is above 88 in women and 102 in men.
What medication class is not recommended in T2DM patients on VLEDs, and why?
SGLT2 inhibitors(risk of euglycemicketoacidosis)
Which weight loss drugs can be considered in T2DM as adjuncts to lifestyle measures in those with BMI greater or equal to 27?
Phentermine (sympathomimetic amine, i.e., Duromine), orlistat (inhibitor of gastrointestinal lipase); glutide(glucagon-like peptide receptor agonist); combined naltrexone and bupropion
List the 3 main bariatric surgery options available in Australia for T2DM patients.
Sleeve Gastrectomy (SG);
Roux-en-Y gastric bypass (RYGB);
Biliopancreatic diversion;
Laparoscopic adjustable gastric banding (LAGB)
What is a sleeve gastrectomy?
Removes proportion of the fundus and body of stomach, reducing the volume from 2.5L to 200mL. Provides fixed restriction and does not require adjustments (such as in gastric banding)
What is a Roux-en-Y bypass?
A combination procedure in which a small stomach pouch is created to restrict food intake and the lower stomach, duodenum and first part of the jejunum are bypassed to produce modest malabsorption of nutrients and thereby caloric intake
What is biliopancreatic diversion surgery?
A combination procedure that involves removing the lower part of the stomach and bypassing the duodenum and jejunum to produce significant malabsorption.
List some of the advantages of metabolic surgery in obese T2DM patients
Reduces micro and macroascular complications, reduces mortality (can prevent or delay the onset of T2DM in patients who are obese and at risk).
According to the RACGP, which groups of T2DM patients should be considered for bariatric surgery?
BMI >30 in those with suboptimal BGLs, increased CVD risk and not achieving medical targets with medical therapy.
How does alcohol consumption affect BGLs in T2DM?
Interferes with the action of insulin, insulin secretagogues and glucagon, and thereby increases the risk of hypoglycaemia in patients taking these medications. It can also impede hypoglycaemia awareness.
Explain why it is important to screen for haemoglobinopathies with SPEP in some populations before doing a HbA1c?
Because diseases which alter hemoglobinsurvival/age will affect the result.
List 5 conditions that result in abnormally low HbA1c
Anaemias (haemolytic, haemoglobinopathies); Recovery from acute blood loss Blood and iron transfusions Chronic blood loss Chronic renal failure
List at least 2 conditions that result in abnormally high HbA1c
IDA, splenectomy, alcoholism
List some of the situations in which a more stringent HbAc target (i.e., 6.5%) may be appropriate.
Early disease onset; early in disease course; few comorbidities; where the risk of hypoglycaemia is low; long life expectancy
When should glucose-lowering therapy be initiated for patients with newly diagnosed T2DM?
Depends on patient factors, but ideally after 3 months if behaviour modification has not been effective (unless symptomatic in which case treatment should start immediately)
What is the first line pharmacotherapy recommended for T2DM, and why?
Metformin, due to lower risk of hypoglycaemia and weight gain
What is the recommendation for treatment in patients with newly diagnosed T2DM who are showing evidence of metabolic decompensation (i.e., marked hyperglycaemia, ketosis, unintentional weight loss)?
Insulin with or without metformin to correct the relative insulin deficiency
In patients with newly diagnosedT2DM, what is the timeframe suggested to optimise HbA1c?
3-6 months
Name the only oral hypoglycaemic agent that can be used in severe renal impairment without dose adjustment.
Linagliptin (DPP4 inhibitor)
Which diabetes medication is associated with higher risk of hospitalisation in patients with heart failure?
Saxagliptin (DPP4 inhibitor)
It is contraindicated to use a DPP4 inhibitor with which other class of diabetes medication?
GLP-1 Receptor Agonist
Which diabetes medications are known to have higher intolerances in patients at risk of gastrointestinal disease (i.e., IBS, IBD)
Metformin and GLP1-RAs
Which diabetes medications are associated with weight loss?
SGLT-2 inhibitors and GLP1 RAs
What specific side effect is associated with Thiazolidinedione (TZD) diabetic medications?
Increased risk of atypical fractures
Which specific diabetes medication is contraindicated in bladder cancer or people undergoing investigation for haematuria?
Pioglitazone
When should you consider stopping second-line medications for type 2 diabetes?
If those medications have not reduced the HbA1c by greater than or equal to 0.5% in 3 months
Which 3 interventions remain the foundation for all T2DM treatment?
Healthy eating, physical activity and education
What are the signs of acute metabolic decompensation in diabetes?
Weight loss, severe fatigue, polydipsia, polyuria, ketosis
What is the ‘review rule’ in treatment of T2DM?
Emphasis the optimisation of existing treatments and lifestyle modifications and the review of these elements before advancing through additional pharmacological strategies. The review should take place at 3 months.
What are the two important uncommon side effects of SGLT2 inhibitors?
Euglycemic ketoacidosis and mycotic infection
Guidelines suggest adding ______ to a diabetic medications before insulin due to the possible weight gain and hypoglycaemiathat can result from insulin therapy
GLP1 RA
What is the result of incorrent injection of insulin into muscle rather than subcutaneously?
Can increase absorption rate by up to 50%
List at least 7 factors which increase the risk of hypoglycaemia in a patient on insulin
- Incorrect dose
- Incorrect type
- Alcohol consumption
- Decreased oral intake without dose adjustment
- Incorrect timing
- Accidental injection into muscle
- Unplanned physical activity
- Renal failure (decreased clearance)
- Changes to other medications
Why are single use pen needles and syringes recommended in insulin therapy?
Lipohypertrophy has been associated with reuse
Why is it important to rotate insulin injection sites?
Lipohypertrophy and lipodystrophy can result from repeated injections into the same site, and this can affect insulin absorption.
Insulin therapy should be offered in all patients with a HbA1c over _____
11%
Insulin can be stored at room temperature for how long?
1 month
Premix insulin must be ____ prior to every use
Resuspended
When starting insulin therapy, name the two schedule options available
- Basal insulin (i.e., glargine 100 or 300 units) once daily, irrespective of meals.
- Co-formulated insulin or premixed insulin once daily before the largest carbohydrate meal of the day
List 3 reasons why glucose-lowering medications should be continued even when adding insulin?
Because cessation before blood glucose targets are achieved may result in significant hyperglycaemia;
Ongoing use can mitigate weight gain
Ongoing use may be insulin-sparing and can reduce the risk of hypoglycaemia
What is an appropriate starting dose for premixed, co-formulated or basal insulins?
10 units or 0.1 - 0.2 units/kg is usually safe, but will need titration as unlikely to be sufficient to achieve glycaemic targets.
What options are available to manage diabetic retinopathy?
Pharmacotherapy (anti-vascular endothelial growth factor VEGF agents), laster therapy and vitrectomy
List the 3 distinct forms of diabetic retinopathy
- Macular oedema
- DR caused by microvascular changes (proliferative and non-proliferative)
- Retinal capillary non perfusion
What does macular oedema (in the context of diabetic retinopathy) involve?
Diffuse focal vascular leakage within the macula
Describe the difference between non-proliferative and proliferative diabetic retinopathy caused by microvascular changes
Non-proliferative includes micro-aneurysms, intra-retinal haemorrhage, malformation and tortuous vessels.
Proliferative involves abnormal vessel growth on the optic disc or retina
List the 3 types of sight-threatening diabetic retinopathy
- Severe non-proliferative DR
- Proliferative DR
- Foeval-threatening diabetic macular oedema
Which types of diabetic retinopathy are associated with elevated cardiovascular risk?
Proliferative DR and macular oedema
List at least 5 risk factors for the onset or progression of diabetic retinopathy
- Existing diabetic retinopathy
- Poor glycaemic control
- Raised BP
- Diabetes > 10 years
- Microalbuminuria
- Dyslipidaemia
- Anaemia
- Pregnancy
Patients who have T2DM and no retinopathy should be routinely re-screened every 2 years - except in which cases? (name at least 3)
- People with diabetes for longer than 15 years
- People with suboptimal glycaemic control
- Those with systemic disease or foot ulcers
- ATSI populations and ESL patients
What is the standard recommendation for screening of peripheral neuropathy in patients with T2DM?
At time of diagnosis and at least annually thereafter (based on risk)
Screening for peripheral neuropathy in T2DM should be conducted by assessing loss of sensitivity to which instruments?
10g monofilament, or loss of vibration sense at the dorsum of the great toe.
List at least 2 classes of agents that can be used alone or in combination to relieve painful peripheral neuropathy in T2DM patients, and give at least 1 example of each
Anticonvulsants (pregabalin, gabapentin, valproate), antidepressants (amitriptyline, duloxetine, venlafaxine), topical nitrite spray, opioids
What is the most common manifestation of diabetes-related peripheral neuropathy?
Polyneuropathy
List at least 3 manifestations of diabetes-related peripheral neuropathy
Polyneuropathy (most common), mononeuropathy, polyradiculoneuropathy, thoracic radiculopathy, cranial neuropathy
Which medications have been shown to reduce the risk of CKD progression +/- cardiovascular events in patients with T2DM and CKD?
SGLT2i and GLP-1 RA
List at least 5 of the presentations of autonomic neuropathy in T2DM patients
Orthostatic hypotension, erratic BGLs due to impaired and unpredictable gastric emptying (gastroparesis), bowel changes, reduced anal sphincter control, erectile dysfunction, reduced vaginal lubrication and arousal, silent ischaemia, sudden cardiac arrest, hypoglycaemia unawareness, unexplained ankle oedema
What treatment may be initiated for a diabetic patient with gastroparesis and consequent erratic BGLs?
Pro-kinetic agents such as metoclopramide, domperidone or erythromycin
Provided that all modifiable factors (off-loading, infection, deformity) have been addressed, what adjunctive wound-healing therapies might be considered for non-healing non-ischaemic wounds?
Topical growth factors and granylocyte colony-stimulating factor (G-CSF) or dermal substitutes
In T2DM patients who are stratified as having intermediate or high-risk feet, how often should foot examination take place?
At least every 3-6 months
Patient education around foot care in T2DM patients should include which 3 points?
- Emphasising appropriate footware and foot care
- Establishing self-monitoring regime
- Developing an action plan to respond to early problems such as skin breakdown
Stratification of foot-risk in T2DM patients depends on which 4 risk factors?
- Peripheral arterial disease
- Peripheral neuropathy
- Deformity
- Previous amputation or ulceration
What are the indications for immediate referral to a MDT foot clinic for patients with T2DM?
Active foot disease, including foot ulcers (with or without infection), and suspected Charcot neuroarthropathy
What are the general principles of dressing choice in ischaemic vs non-ischaemic diabetic ulcers?
In non-ischaemic ulcers, create a moist wound environment. In ischaemic ulcers, maintain a dry environment using a dry and non-adherent dressing until PAD has been reviewed
What is the single leading cause of end-stage renal disease?
Diabetic nephropathy
What measurement appears to be the best indicator for the risk of CKD in T2DM?
Systolic BP
How is CKD diagnosed?
By the persistent presence of elevated urine albumin excretion, low eGFR, or other manifestation of kidney damage
Screening for CKD can be performed by either of which 2 laboratory tests?
Random spot urine-albumin-to-creatinine ratio (UACR, preferred method) or serum creatinine converted to eGFR
List at least 3 possible contributors to transient albuminuria
UTI, decompensated heart failure, acute severe elevation in BP or BGL, recent major exercise, febrile illness
What are the recommended dose adjustments of Metformin in CKD?
Dose reduce for eGFR 30-60, cease if below 30
What are the recommended dose adjustments of DPP-4i in CKD?
Nil for linagliptin (hepatic), dose reduce others if eGFR less than 60
What are the recommended dose adjustments of SGLT-2i in CKD?
Need renal function for glycaemic effect, so need at least 30-45 eGFR
What are the recommended dose adjustments of GLP-1 RAs in CKD?
Avoid if CrCl < 30
Why should dose reduction of insulin and sulfonylureas be considered in T2DM patients with CKD?
Because CKD increases the risk of hypoglycaemia with both
How is hypogycaemia defined?
BGL less than or equal to 3.9 and/or to a level that causes neurogenic and neuroglycopaenic symptoms and signs
What is pseudo-hypoglycaemia and when might this occur?
Symptoms of hypoglycaemia with normal BGL, can occur in persistent, prolonged hyperglycaemia and the elevated glucose levels have become normalised
Symptoms of hypoglycaemia fall into which 2 main categories?
- Adrenaline activation symptoms
2. Neuroglycopenic symptoms
Name at least 3 adreneline activation symptoms of hypoglycaemia
Pale skin, sweating, shaking, palpitations, feeling of anxiety or dizziness
Name at least 3 neuroglycopaenic symptoms of hypoglycaemia
Hunger, change in intellectual processing, confusion and changes in behaviour (irritability), paraesthesia, coma and seizures
What is the definition of severe hypoglycaemia?
Signs of hypoglycaemia whereby the person requires the assistance of another person to actively administer corrective action
What are the hyperglycaemic emergencies?
HHS (formally HONC) and DKA
List at least 5 signs of hyperglycaemic state
Severe dehydration with polyuria and polydipsia, abdominal pain, nausea, vomiting, altered consciousness, shock, ketotic breath in DKA
Which 2 major life-threatening underlying causes should be considered in a patient presenting with hyperglycaemic crisis?
Sepsis, MI
Give at least 3 examples of when to refer T2DM patients for mental health assessment
Diabetes distress and impaired self-care, positive screen for depression using a validated tool, symptoms of disordered eating behaviour, deliberate omission of insulin, positive screen for cognitive impairment
Multi-morbidities may or may not be diabetes related, and can be either concordant or discordant with diabetes care. Explain what this means.
Concordant conditions have similar risk profile to T2DM and share the same management goals. Discordant conditions are not related in pathogenesis to T2DM and do not share similar management goals
List at least 5 common conditions that are comorbid with T2DM
Macrovascular disease, obesity, painful conditions like arthritis, fractures, cancer, OSA, renal impairment, cognitive impairment, mental health issues, dental problems
Before attempting to become pregnant, women with T2DM should aim to achieve a HbA1c of what?
Less than or equal to 6.5%
Why should women with T2DM be counselled to strive to attain a pre-conception HbA1c as close to normal as possible?
To decrease the risk of congential abnormalities, pre-eclampsia, macrosomia, spontaneous abortion, retinopathy and stillbirth
Before attempting to become pregnant, women with diabetes should discontinue medications that are potentially embryopathic. Give at least 1 example
ACE-I or ARB (prior to conception in woman with HTN alone, or upon detection of pregnancy in women with CKD), and statins
What is the consensus recommendation for hypoglycaemic medications in pregnancy?
Metformin and sulfonylureas can continue until pregnancy is achieved. All other oral medications should be ceased and switched to insulin (there is no safety data for the use of other glucose-lowering medication agents in pregnancy)
How can women with T2DM protect against neural tube defects when attempting to conceive?
Take 5mg (max) daily folate for one month prior to conception and for the first trimester
Sub-optimal glycaemic management at conception and in early pregnancy is associated with increased risk of which complications?
Congenital malformations and first trimester miscarriages
Women with pre-existing diabetes are prone to increased rates of what pregnancy complications?
Higher rates of preeclampsia, prematurity, C section, pregnancy may accelerate maternal complications of diabetes such as retinopathy. Both maternal and fetal complications are increased
What is the recommendation for treatment of hypothyroidism in T2DM who become pregnant?
Requirement for thyroid replacement will be higher due to the effects of bHCG. Increase dose by 30% (after assessment)
What factors are indicators for a pre-pregnancy nephrology assessment in a T2DM patient planning to conceive?
Elevated creatinine or eGFR <45, or ACR >30
How does US monitoring in pregnant patients with T2DM differ from non-diabetic patients?
Additional 4 weekly US for foetal growth and amniotic fluid volume from 28-36 weeks
In regards to diabetes management, intensive glycaemic management reduces __vascular but not ____macrovascular complications
Microvascular, macrovascular
What is the generally agreed-upon acceptable BGL target for diabetes patients in palliative care? Why?
6 - 15mmol/L - to optimise wellbeing and cognitive function, but still needs to be treated as hyperglycaemia can worsen pain, confusion, thirst, cognition, confusion and incontinence
List the 5 vaccinations that are recommended for people with T2DM
- Influenza
- DTP
- Hep B
- Herpes zoster
- Pneumonoccus
(now covid)
What are ‘sick days’ in relation to T2DM?
Periods of minor illness 1-4 days in duration that require changes to a person’s usual diabetes self-management
What is the elective surgery peri-operative advice for T2DM patients on oral medications (EXCEPT SGLT2, which has it’s own set of recommendations)
Continue the day prior, but omit on the day regardless of whether they are on a morning or afternoon list
What is the elective surgery perioperative advice for T2DM patients on insulin?
Never withhold basal insulin, continue as normal including the morning dose. Short acting/rapid insulin should be omitted if not eating (withhold the morning dose if on a morning list, or take half the normal morning dose if on the afternoon list). For premixed insulin - take one third to one half of the usual morning dose.
What is the minimum time before returning to driving in a patient who has had a severe hypoglycaemic event?
6 weeks
What is diabetes mellitus in pregnancy (DMiP)
Defined as a pregnant woman whose blood glucose levels in pregnancy meet the criteria used for diagnosing diabetes outside of pregnancy
When should women who are at risk of hyperglycaemia (including GDM) be tested in pregnancy?
During the first trimester and (if normal) again between 24-28 weeks
List at least 7 risk factors for GDM
- Obstetric history of GDM
- Increased maternal age
- Increased maternal BMI
- Excessive weight gain in early pregnancy
- PCOS
- Obstetric history of high weight baby
- Obstetric history of pregnancy loss
- FHx diabetes
- Ethnic groups with high prevalence
At what time of day should BGLs be carried out in pregnant women with GDM?
Post-prandial
What follow up is required after pregnancy for women who have had GDM?
OGTT 6-12 weeks post partum
True or false? Women with GDM can reduce their risk of developing T2DM by breastfeeding?
True
True or false? Physical activity and healthy eating during pregnancy help reduce excessive weight gain and reduce the risk of developing GDM
False - these measures have been shown to reduce excess weight gain but do not appear to directly reduce the risk of developing GDM
Which Australians are eligible to attend a T2DM risk evaluation by their GP and for subsequent referrals to subsidised lifestyle modification programs?
Adults 40-49 who return a ‘high’ risk score on the Aus T2Diabetes risk assessment tool (AUSDRISK)
DKA is defined using which biochemical criteria?
Serum glucose > 11;
Venous pH <7.3 or bicarbonate <15;
Presence of ketoanaemia or ketonuria
Individuals who are not at high risk of T2DM should be screened how often, and how?
Every 3 years from 40 years of age using the Australian Type 2 diabetes risk assessment tool (AUSDRISK)
How often should ATSI patients be screened for T2DM, and how?
Annually with blood testing (fasting glucose, random glucose or HbA1c) from 18 years of age
Explain why the AUSDRISK tool is of limited use in the ATSI population?
Because of the high background risk in this population. They should proceed directly to blood testing from 18 years of age
What is the leading cause of death in Australia?
Cardiovascular disease
What MBS item numbers are available to patients aged 40-49 (or ATSI 15-54) if they score ‘high’ on AUSDRISK?
701, 703, 705, 707 - These are numbers for a type 2 diabetes risk evaluation and eligble patients can be referred to a subsidised lifestyle modification program
What HbA1c corresponds to impaired fasting glucose (impaired glucose tolerance)?
6 - 6.4%
Why is a diagnosis of pre-diabetes (IFG/IGT) important?
Because, aside from increasing the risk of developing frank diabetes, it is an independent risk factor for cardiovascular disease
When dietary saturated fats are decreased and replaced by which other fat, there is a significant reduction in risk of developing diabetes?
Polyunsaturated fatty acids
2-4 serves of dairy foods per day is associated with a reduced risk of what condition? Whereas 1.5 serves/day has been shown to reduce the risk of which other condition?
Metabolic syndrome; T2DM
What type of diet has the best overall evidence of long-term effects on CVD risk reduction?
Mediterranean diet
What is the definition of the Mediterranean diet?
Must comprise at least 2 of the following:
- high monounsaturated fat:saturated fat ratio;
- low to moderate red wine consumption;
- high consumption of legumes;
- high consumption of grains and cereals;
- high consumption of fruits and vegetables;
- low consumption of meat and increased consumption of fish;
- moderate consumption of milk and dairy
What is the definition of a low carb ketogenic diet (LCKD)?
<50g of carbs (10% of the total kJ allowance) daily
What is the definition of a low carb diet (LCD)?
50-130g carbs (10-26% of the total kJ allowance) daily
What is the definition of a moderate carb diet (MCD)?
130-225g carbs daily (26-45% of the total kJ allowance)
If a T2DM patient has a BGL of <4 and they are symptomatic but awake and can swallow - what is the treatment?
Manage according to rule of 15:
Provide 15g fast acting carb (half can soft drink, half glass fruit juice, 3 teaspoons sugar or honey, 6-7 jelly beans).
Wait 15 minutes and repeat BGL.
If not rising, add another 15g.
If the patients next meal is more than 15 minutes away, provide a longer acting carb like a sandwich, glass of milk, or a piece of fruit)
Test glucose again in 2-4 hours
What strategies have the best evidence for long-term prevention of diabetic nephropathy?
Management of HTN through the use of pharmacotherapy and sodium restricted diet, in addition to tight glycaemic and lipid control
Give some examples of foods with a low glycaemic index that help to optimise glycaemic control
Wholegrain bread and pasta, fruits, dairy
Why should sweeteners containing fructose be avoided?
Because fructose promotes triglyceride synthesis in the liver, exacerbates insulin resistance and interferes with satiety mechanisms
When does the eTG recommend commencing metformin for patients with T2DM?
Immediately (and also with a second drug) if HbA1c 8.5% or more. Or, if HbA1c less than 8.5%, either start metformin immediately as monotherapy, or trial 2-3 months of lifestyle modification prior.
As per the eTG, what are the usual second line medications for T2DM, where glycaemic target has not been met after 3 months?
Sulfonylurea, DPP4 inhibitor or SGLT2 inhibitor
As per the eTG, what are the usual third line medications for T2DM, where glycaemic target has not been met after 3 months?
Sulfonylurea, DPP4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist or insulin.
As per the eTG, what is the management for patients who fail to achieve glycaemic target despite being on triple therapy for T2DM?
If using triple therapy, change one or more of the oral drugs to a GLP-1 receptor agonist or insulin. If using a regime that already includes a GLP1 RA, change this to a basal or mixed insulin, or ADD a basal or mixed insulin
Which 2 oral hypoglycaemic medications have the greatest reduction in HbA1c?
Metformin, sulfonylureas.
Give at least 1 example of a short acting vs long acting sulfonylurea
Gliclazide vs glibenclamide (also useful to note that the short acting are metabolised by the liver, whereas long acting are renally excreted)
Which oral hypoglycaemic is not safe in pregnancy?
Sulfonylurea
For which patients with T2DM should thiazolidinediones and acarbose be reserved?
For those with contraindications to all other oral drugs, and those who will not tolerate injectable drugs
Give the 2 reasons why sulfonylureas may not be chosen as the second line medication for patients with T2DM?
Weight gain and hypoglycaemia risk
When should escalation of therapy be pursued in T2DM?
When the glycaemic target (HbA1c) has not been met, or has not improved by at least 0.5% after 3 months
What are the recommendations for glucose monitoring when adding a second line agent for T2DM?
Aim is to ensure there is no hypoglycaemia - measure at least once daily and at varied times across the day
A dose reduction is required for metformin if creatinine clearance is less than ____
60
Explain why sulfonylureas are associated with a higher risk of hypoglycaemia
They act as insulin secretagogues, thereby increasing the risk of hypoglycaemia
Gliptins (DPP4 inhibitors) are effective in reducing ____prandial glucose
postprandial
Gliptins should not be prescribed to patients with a past history of ____
pancreatitis
GLP-1 analogues predominantly target ____prandial glucose
postprandial
GLP-1 analogues carry an increased risk of which pancreatic diseases?
Pancreatitis and pancreatic malignancy
What are the current PBS restrictions around GLP-1 analogues?
Restricted as third line drugs, prescribed in combination with both metformin + sulfonylurea, or with either metformin or sulfonylurea if there is a contraindication to a combination of both oral drugs
Which is the only oral T2DM medication that should be stopped when commencing insulin?
Sulfonylurea
Name some of the adverse effects caused by the thiazolidinedione family
Cardiac ischaemia, bladder cancer, risk of fracture in OP, worsening diabetic macular oedema, worsening heart failure
State the 3 components of the 24 hour blood glucose in T2DM
- Flat baseline set by the fasting blood glucose.
- Daytime baseline change (usually an increase) in preprandial blood glucose which occurs between breakfast and the evening meal.
- Prandial blood glucose that increases above baseline and generally reaches maximum within 1-2 hours and returns to baseline 3-4 hours after the meal (insulin therapy aims to control the blood glucose components that are above target)
Describe the KISS principle when treating a T2DM patient with insulin
- First: fix the fasting baseline with basal insulin at night, which will lower BGLs and the 24 hour basal glucose.
- If the pre-prandial blood glucose in the evening remains above target despite fasting glucose being on target, add a second morning dose of basal insulin to control any daytime increase in basal glucose.
- Then look for the hidden hypers if the HbA1c remains above target.
Explain why insulin therapy should commence with basal insulin to control the fasting BGL baseline
Because normalising basal glycaemia almost eliminates overall excess glycaemia and lowers HbA1c the most (i.e., from 11.5-7.3!). Then treating the daytime glucose increase will further lower HbA1c - usually to within target. Correcting excess prandial glucose would further lower the HbA1c but risks hypoglycaemia and weight gain
For each 1% change in the HbA1c percentage, it changes by ___mmol/mol
11
What are the HbA1c targets for patients with short duration T2DM and no CVD?
If low risk of hypoglycaemia, 6% or less. If risk of hypoglycaemia, 6.5-7% as per the usual
For patients with longer duration of T2DM who have a high risk of hypoglycaemia, what is the HbA1c target?
8% or less
List at least 6 contraindications to VLEDs
Pregnancy, breastfeeding, infants/children/adolescents, history of psychological disturbances, alcohol or drug misuse, porphyria, recent MI or unstable angina
State the BMI definitions of overweight, obese class I, II, and III
Overweight 25-29.9
Class I 30-34.9
Class II 35-39.9
Class III 40+
What class of medication is phentermine?
Dopaminergic agonist
How does Orlistat work?
Inhibits pancreatic and gastric lipase (decreases amount of dietary fat that is absorbed in the gut)
Name the 3 lifestyle areas related to overweight and obesity management
- Nutrition
- Physical activity
- Psychological approaches to behavioural change
What is the recommendation for physical activity in patients who are overweight or obese?
300 minutes of moderate intensity, or 150 minutes of vigorous activity (or a combo of each) per week, combined with reduced dietary intake
What is the most serious and life-threatening complication of DKA?
Cerebral oedema
Assume a patient with diabetes presents unwell. A finger prick BGL and ketones are taken. At what ketone level should further testing be undertaken to assess for DKA? What is the next step in investigation?
Blood ketones 0.6 and above (0.6-1.5 confers risk of DKA, while ketones >1.5 is high risk). A VBG for pH (<7.3), HCO3 (<15) and anion gap is the next step.
What will be seen on the VBG of a patient with DKA?
pH <7.35 and HCO3<15, increased anion gap and ketones >1 (glucose can be normal)
List 4 clinical signs and symptoms of DKA in an adult
Hyperventilation, dehydration, abdominal pain +/- vomiting, impaired consciousness
To prevent phlebitis, what is the maximum concentration of potassium that can be given peripherally?
40mmol (unless prepared as a mini bag)
What is the maximum rate that potassium can be given peripherally with an infusion pump?
20mmol/hr
What are the common presenting features of cerebral oedema in DKA patients?
More likely if younger age, presents as headaches +/- reduced consciousness, agitation/aggression
Presume you are treating a patient with DKA. You have commenced the treatment protocol and the patient has improved, is eating, has ketones <0.6 and a normal anion gap - however, they remain mildly acidotic on VBG. What is the likely explanation for this?
Hyperchloraemic acidosis from the large volumes of sodium chloride used in the resuscitation
Explain why intravenous glucose 10% should be commenced in the DKA pathway once blood glucose falls to 14mmol/L
Because as ketoacidosis resolves, the glucose can fall very rapidly as a result of rebound ketosis driven by counter-regulatory hormones. The addition of IV glucose is commenced to prevent hypoglycaemia whilst continuing insulin infusion to correct the acidosis
Long acting/basal insulin should be commenced at least ____ hours prior to ceasing IV insulin the treatment of DKA
2 (if patient was already on basal insulin, this could be continued even whilst treating DKA and therefore the infusion can be stopped as soon as the other criteria are met)
List at least 3 common precipitating causes of DKA
Omission of insulin, infection, newly diagnosed diabetes, MI
What are the HbA1c, total cholesterol and BP targets for a newly diagnosed T2DM patient with no comorbidities? How would this differ if a urine ACR showed protein or albumin?
HbA1c 7% or less
Total cholesterol < 4
BP less than 140/90 (if there was albuminuria/proteinuria, the BP target would be <130/80)
In which 3 situations should a diabetic patient follow their sick-day plan?
- If they feel unwell
- If blood ketones are positive (over 0.6) and if BGL higher than 15 for 6+ hours (or more than 2 times in a row) even if feeling ok
- If BGL <4
How often should BGLs and ketones be tested during sick day management of diabetes?
BGL every 2 hours until back in target range, ketones every 2-4 hours until less than 0.6
In a sick day management plan for diabetes, if a patient has BGL > 15 and is taking basal insulin, what change in management is recommended?
Temporarily increase basal insulin by 10% (i.e., if normal 40 units, increase to 44 units). If BGL goes back to normal, return to regular dose.
If still above 15 after 4 hours, may need to take extra rapid acting insulin (2-4 units as a single dose).
If still high after another 4 hours, repeat the dose and call the doctor.
What is the recommendation for diet and fluids in a diabetic patient’s sick day management plan?
Drink 250mL fluid every hour.
If BGL >15, drink water or drinks that don’t contain carbs. If BGL < 15, drink any fluid including any that contain sugar.
Keep eating some carbs - if there is N+V try soup
A 48 year old woman presents with symptoms and signs of hyperthyroidism. She has a radioactive isotope scan which shows poor uptake. What is the most likely diagnosis?
Subacute thyroiditis (due to inflammation and destruction of the gland)
Name 3 thyroid disorders which would show increased uptake on a thyroid radioisotope scan
Graves, toxic multinodular goiture & toxic adenoma
What feature is suspicious for a thyroid carcinoma on a radioisotope scan?
Cold node with no uptake (carcinomas very rarely result in hyperthyroidism)
Which biochemical thyroid test is not recommended in the workup of a patient with a thyroid nodule?
Serum thyroglobulin, as not sensitive nor specific for thyroid cancer
Assume a patient presents with a thyroid nodule, and she is symptomatic of hyperthyroidism. Her TSH is suppressed. What is the next most appropriate step in her management?
Referral to an Endocrinologist - suppressed TSH best investigated outside of the GP setting
Assume a 38 year old woman presents with a thyroid nodule. Her TFTs are normal and FNA shows benign histopathology. What follow up is recommended?
Depends on the clinical features and risk of the nodule on US. However, clinical monitoring with a repeat thyroid US in 12-24 months to assess for interval change would be appropriate for a benign thyroid nodule with low or intermediate suspicion
What test should be ordered for a patient with a thyroid lump when the TSH is low?
Radionuclide scan
You are seeing a patient with a new diagnosis of T2DM for the first time. As per the SNAP guidelines, what lifestyle management goals would you provide to this patient today?
- Smoke 0 ciagrettes/day
- Normal healthy eating
- No more than 2 standard drinks/day (for men and women)
- 150 minutes aerobic activity plus 2-3 sessions of resistance exercise (total at least 60 minutes) per week
What is the current recommendation regarding elevations in serum creatinine after commencing an SGLT2 inhibitor?
An initial decline is expected and is reversible. It is thought to be related to a beneficial reduction in renal hyper-filtration. Up to 20% decline can be tolerated in the first month, provided there is no evidence of hypovolaemia or alternate pathology that could contribute to AKI.
