DIABETES

Question 1

What is the target fasting blood glucose level

Answer 1

4-7mmol/L

Question 2

What are the 3 rules for making insulin dose adjustments

Answer 2

Make 1 adjustment at a time
make small adjustments
review blood glucose levels 2-3 days after adjustment

Question 3

What does it mean if the blood glucose level is rising over night several nights a week?

Answer 3

Basal dose is too low and needs to be increased

Question 4

What does it mean if the blood glucose level falls over night

Answer 4

basal dose is too high

Question 5

How should you adjust the insulin dose if the patient is on 10 units or less

Answer 5

increase/decrease by 0.5 units

Question 6

How should you adjust the insulin dose if the patient is on 10-20 units

Answer 6

increase/decrease by 1-1.5 units

Question 7

How should you adjust the insulin dose if the patient is on 20-30 units

Answer 7

increase/decrease by 2-2.5 units

Question 8

How should you adjust the insulin dose if the patient is on more than 30 units

Answer 8

increase/decrease by 3-4

Question 9

What issues should be checked before adjusting the insulin dose?

Answer 9

is the carb counting accurate?
Are injection sites lumpy?
are injections given 10-20 minutes before meals?
was any exercise done?
any injections missed?

Question 10

What should the blood glucose level be after eating?

Answer 10

3-10mmol

Question 11

What is the Once daily insulin regimen and who is it suitable for?

Answer 11

Suitable for type 2 and for people that require assistance in taking injections. Involves either long acting peakless insulin or an intermediate

Question 12

What is the twice daily insulin regimen and who is it suitable for?

Answer 12

Type 1/type 2. Must stick to consistent daily routine with 3 meals on this regimen. Biphasic due to 2 phases of activity: mix of short and intermediate.

Question 13

What is the basal/bolus insulin regimen and who is it suitable for?

Answer 13

4/more injections daily. Basal = once or twice. Bolus at each main meal. Involves long acting or intermediate acting dose with short or rapid insulin at each meal. Common in type 1: offers flexibility over when meals are taken and allows dose variation in response to different carb quantities in meals

Question 14

What is the continuous s/c insulin infusion/pump regime and who is it suitable for?

Answer 14

Insulin pump connected to body constantly. At mealtimes increase bolus of insulin delivered to control blood glucose levels

Question 15

What is the fixed dose insulin regimen and who is it suitable for?

Answer 15

Fixed dose at each meal, can be on this and another regimen, no flexibility with carbs

Question 16

Discuss rapid acting insulins (when taken, onset, peak and duration of action, examples)

Answer 16

Novorapid, humalog
taken just before, with or after food
onset of action = 10-20 mins
peak of action= 1-3 hours
duration of action 2-5 hours

Question 17

Discuss short acting insulins (when taken, onset, peak and duration of action)

Answer 17

Actrapid, humulin s, insuman rapid
taken 15-30 minutes before food
onset of action: 30-60 mins
peak of action: 1-5 hours
duration of action: 5-9 hours

Question 18

Discuss intermediate acting insulins (when taken, onset, peak and duration of action)

Answer 18

Insulatard, humulin 1, insuman basal
taken about 30 mins before food or bed time
onset of action= 60-90 mins
peak of action 2-12 hours
duration of action = 12-24 hours

Question 18

Discuss intermediate acting insulins (when taken, onset, peak and duration of action)

Answer 18

Insulatard, humulin 1, insuman basal
taken about 30 mins before food or bed time
onset of action= 60-90 mins
peak of action 2-12 hours
duration of action = 12-24 hours

Question 19

Discuss long acting insulins (when taken, onset, peak and duration of action)

Answer 19

levemir, lantus, tresiba
Taken once or twice a day
onset of action 2-4 hours, 6-14 hour or no peak, action between 16 and 42 hours

Question 20

Discuss mixed acting insulins (when taken, onset, peak and duration of action)

Answer 20

Novomix, humalog, humulin, insuman.

Taken before or just after food, fast acting, with peaks after 1-4 hours but up to 24 hour coverage

Question 21

When must meals be eaten around ultra rapid acting insulin?

Answer 21

Meals must be spaced out to prevent stacking of insulin

Question 22

In hospital, what must be remembered with rapid acting insulins?

Answer 22

Wait 4 hours before redosing

Question 23

What is the honeymoon phase?

Answer 23

A period where no insulin or reduced insulin is required, can last up to a year and requires careful counselling

Question 24

How do you calculate total daily dose of insulin?

Answer 24

0.3-0.5 units per kg, split as 50% basal and 50% bolus, bolus split across 3 meals

Question 25

how do you calculate how much one unit of insulin will drop blood sugar?

Answer 25

1800(TDDx18)

Question 26

How should insulin be adjusted if a patient is experiencing morning hypos

Answer 26

Give more in morning and less at night - 2/3 basal in morning and 1/3 at night

Question 27

How should insulin dose be adjusted if the patient is experiencing erratic levels and hypos

Answer 27

Give a flatter profile insulin, with a 10-18% increase/ decrease in strength

Question 28

How can diabetes be managed?

Answer 28

Healthy diet, lose weight, stop smoking, attend diabetes checks, regular foot care, regular blood tests every 3 months then every 6 months when stable

Question 29

What hba1c is classed as pre diabetic

Answer 29

42mmol/L

Question 30

What are the symptoms of hypoglycaemia?

Answer 30

Sweating, palpitations, tremor, hunger, confusion, drowsiness

Question 31

What are risk factors for hypos

Answer 31

history of hypos, decreased awareness, impaired renal funtion, dementia, alcohol misuse, starvation and high exercise, food malabsorption, glucose level less than 3mmol/L

Question 32

What counselling should be given around injection technique?

Answer 32

Wash hands, roll bottle, draw up correct dose, clean and pinch injection site, safely discard.
Rotate the injection site to prevent lipohypertrophy which can lead to insulin dumping

Question 33

How do you calculate the amount of insulin an individual will need to follow sick day rules?

Answer 33

Calculate total daily dose (total of all meal time and background insulin) and calculate 10-20% of this

Question 34

Which medications should be stopped according to sick day rules?

Answer 34

Metformin - can make you dehydrated 
sulfonylureas
gliclazide, glibenclamide, gliplizide
exenatide, liraglutide, semaglutide,
flozins
ace inhibitors
ARBs

Question 35

How should blood sugars and ketones be managed on sick days?

Answer 35

Check blood sugars and ketones

Question 36

How should a patient act if they have tested their blood glucose and their ketones are less than 1.5mmol/L?

Answer 36

Sip sugar free fluids
Test blood glucose and ketones every 2-4 hours
Usual insulin:carb at meal time
use corrective quick acting insulin if blood glucose is raised
when unwell, may need larger bolus to reduce
if glucose levels above target, consider a 10-20% increase in basal dose

Question 37

How should a patient act if their blood ketones are more than 1.5mmol/L or blood glucose is above 13mmolL

Answer 37

Sip sugar free fluids
test blood glucose or ketones every 2 hours
calculate total daily dose from previous day

Question 38

What should a patient do if their blood ketones are 1.5-3mmol/L on blood test

Answer 38

Give 10% of TDD as quick acting insulin every 2 hours plus usual insulin:carb if eating. basal dose may need a 10-20% increase in basal dose.
If ketones still present, go back and result

Question 39

What should patients do if their ketones are over 3mmol/L on a blood test

Answer 39

Give 20% total daily dose as quick acting insulin, plus usual insulin:carb. May need to increase basal by 10-20%. If ketones still present, go back and restart process

Question 40

What should a patient do if ketones are still present after 4-6 hours or if they vomit

Answer 40

go to hospital as it is an emergency

Question 41

What are the driving rules?

Answer 41

Check blood glucose less than 2 hours before the start of a journey and every 2 hours after driving has started. If 5.0mmol or less, eat a snack. If 4.0mmol or less don’t drive. Don’t drive until 45 mins after reading is 5mmol/l. tell DVLA if more than 1 sever hypo when driving in last 12 months.

Question 42

What is diabetic ketoacidosis?

Answer 42

severe lack of insulin so body uses fat for energy instead of sugar, releases ketones
Ketone build up leads to blood becoming acidic

Question 43

What are the symptoms DKA?

Answer 43

Toilet, thirsty, tired, thinner, confusion, blurred vision, stomach pain, feeling pain, sweet/fruity smelling breath.

Question 44

How should you avoid DKA?

Answer 44

Monitor sugar levels and alter insulin in response to what you eat

Question 45

What is the treatment pathway for type 2 diabetes?

Answer 45

Manage lifestyle issues
Offer a structured education programme DESMOND.
Target HBA1c 53mmol/L measure 3-6 monthly
1st line metformin dose gradually increased to minimise GI AEs
Monitor renal function <45mL/min.1.73m2 review dose, stop if <30mL/min.1.73m2

Question 46

What should be given to type 2 diabetic patients if Metformin is contraindicated?

Answer 46

If metformin is not tolerated or C/I 
– Gliptin - sitagliptin
– Pioglitazone
– Sulphonylurea - gliclizide
– SGLT-2i - canagliflozin

Question 47

What can be done if patients have GI disturbances due to metformin?

Answer 47

Give m/r metformin

Question 48

What should be given second line for type 2 diabetes if metformin is ineffective?

Answer 48

For people for whom metfomin is ineffective combine metformin with:
–Gliptin
–Pioglitazone
–Sulphonylurea
–SGLT-2i
For those who don’t tolerate metformin combine:
–Gliptin plus pioglitazone
–Gliptin plus sulphonylurea
–Pioglitazone plus sulfonylurea
–Substitute a SGLT-2i instead of a gliptin

Question 49

What should be given if second line diabetes treatment fails?

Answer 49

If second line fails:
For people who can take metformin:
– Triple therapy with metformin, a gliptin, and a sulfonylurea, or
– Triple therapy with metformin, pioglitazone, and a sulfonylurea, or
– Triple therapy with metformin, pioglitazone or a sulfonylurea and an SGLT-2i. (The SGLT-2i dapagliflozin in a triple therapy regimen is recommended as an option for treating type 2 diabetes in adults, only in combination with metformin and a sulfonylurea NOT pioglitazone), or
– Starting insulin-based treatment.
For people in whom metformin is contraindicated or not tolerated:
– Consider starting insulin-based treatment.

Question 50

What should be given in type 2 diabetes if third line treatment fails?

Answer 50

For people on triple therapy with metformin and two other oral antidiabetic drugs, consider combination treatment with metformin, a sulfonylurea, and a glucagon-like peptide-1(GLP-1) mimetic (exenatide) for:
– Adults who have a body mass index (BMI) of 35 kg/m2 or higher (adjust accordingly for people from Black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity, or
– Adults who have a BMI lower than 35 kg/m2 and insulin therapy would have significant occupational implications, or weight loss would benefit other significant obesity-related comorbidities.
For people on insulin-based treatment:
– Seek specialist advice (or refer the person to their diabetes team) for consideration of treatment with a GLP-1 mimetic plus insulin.