Diabetes

Question 1

What is a HbA1c measurement?

Answer 1

It reflects average plasma glucose over the previous 2-3 months; measures glycated haemoglobin which forms when red blood cells are exposed to glucose.

Question 2

HbA1c tests can be used to diagnose Type 2 diabetes, but not type 1 diabetes. Which other patient categories should it not be used to diagnose diabetes in?

Answer 2

Children
Women that are up to 2 months post-partum
HIV infected patients
End-stage CKD
Acutely ill patients
Had diabetes symptoms less than 2 months

Question 3

For type 1 and type 2 diabetics, how often should HbA1c be measured?

Answer 3

Type 1: Every 3-6 months, or more if needed
Type 2: Every 3-6 months, when stable can be reduced to every 6 months

Question 4

What are the units used for blood-glucose concentration in the UK?

Answer 4

mmol/litre

Question 5

What are the risks associated with diabetic women becoming pregnant?

Answer 5

-Pre-eclampsia
-Rapidly worsening retinopathy
-Miscarriage
-Stillbirth
-Congenital malformations

Question 6

What should diabetic women who are planning to get pregnant aim to keep their HbA1c below?

Answer 6

48 mmol/mol (6.5%)

Question 7

Folic acid should be offered to all diabetic women that are planning to get pregnant. True or False?

Answer 7

True

Question 8

Which oral antidiabetic drugs should be discontinued before pregnancy, and swapped to insulin?

Answer 8

All except metformin

Question 9

Metformin is unsafe during breast-feeding. True or False?

Answer 9

False- it is the only safe oral antidiabetic drug

Question 10

Which insulin is the first-choice for long-acting insulin during pregnancy?

Answer 10

Isophane insulin (can keep women on their current long-acting insulin analogues such as insulin detemir and insulin glargine if their control is good)

Question 11

At what point during pregnancy is the risk of hypoglycaemia highest?

Answer 11

First trimester- advise to always carry a fast-acting form of glucose

Question 12

During pregnancy, which antihypertensive medication should be stopped?

Answer 12

ACE inhibitors and ARBs- swap to more suitable alternative

Question 13

Gestational Diabetes

-Women with gestational diabetes who have a fasting plasma glucose below 7 mmol/litre at diagnosis, should first attempt a change in diet and exercise alone in order to reduce blood-glucose. If blood-glucose targets are not met within 1 to 2 weeks, metformin hydrochloride may be prescribed. Insulin may be prescribed if metformin is contraindicated or not acceptable, and may also be added to treatment if metformin is not effective alone.

-Women who have a fasting plasma glucose above 7 mmol/litre at diagnosis should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise.

-Women who have a fasting plasma glucose between 6 and 6.9 mmol/litre alongside complications such as macrosomia or hydramnios should be considered for immediate insulin treatment, with or without metformin hydrochloride.

-Women with gestational diabetes should discontinue hypoglycaemic treatment immediately after giving birth.

Answer 13

.

Question 14

What are some potential complications of diabetes?

Answer 14

Diabetic nephropathy
Neuropathy
Retinopathy
Stroke
Cardiovascular disease

Question 15

How can the CVD risk in diabetics be reduced, besides being well-controlled?

Answer 15

ACE inhibitors, or ARBs. Also statins

Question 16

For all diabetic patients with confirmed nephropathy and an ACR of 3mg/mmol, how should they be treated?

Answer 16

An ACE inhibitor or ARB, even if BP is normal

Question 17

What drugs can be used to treat painful diabetic peripheral neuropathy?

Answer 17

Amitriptyline
Pregabalin
Gabapentin

Opioid analgesic can be used alongside gabapentin if pain is not adequately controlled with monotherapy

Question 18

How can autonomic neuropathy be managed?

Answer 18

Tetracycline
Codeine

Question 19

What is a diabetic foot infection?

Answer 19

Diabetic foot infection is defined as any type of skin, soft tissue or bone infection below the ankle in patients with diabetes. It includes cellulitis, paronychia, abscesses, myositis, tendonitis, necrotising fasciitis, osteomyelitis, and septic arthritis. It is defined clinically by the presence of at least 2 of the following: local swelling or induration, erythema, local tenderness or pain, local warmth, or purulent discharge.

Question 20

What is the oral first-line antibiotic for a mild diabetic foot infection?

Answer 20

Flucloxacillin (then clarithromycin, doxycyline or erythromycin-pregnancy if unsuitable)

Question 21

For moderate or severe diabetic foot infections, what is the first-line antibiotic treatment?

Answer 21

`Flucloxacillin with OR without IV gentamicin and/or metronidazole

OR

co-amoxiclav with OR without IV gentamicin OR IV ceftiaxone with metronidazole

If pt has a penicillin allergy then co-trimoxazole with or without IV gentamicin and/or metronidazole would be used.

Question 22

What is diabetic ketoacidosis (DKA) and Hyperosmolar hyperglycaemic state (HHS)?

Answer 22

Diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycamic state ((HHS), previously referred to as hyperosmolar non-ketotic (HONK) coma) are medical emergencies with significant morbidity and mortality. HHS has a higher mortality than DKA.

Question 23

What are the main precipitating factors for both DKA and HHS?

Answer 23

• Infection (main one)
  -Discontinuation or inadequate insulin therapy
  -Acute illness such as MI
  -New onset of diabetes
  -Stress

Question 24

DKA mainly affects type 1 diabetics, where HHS is more likely to occur in T2 diabetics. True or false?

Answer 24

True

Question 25

DKA

-Develops rapidly within hours
-Mainly occurs in T1 diabetics
-Characterised by hyperglycaemia, ketonaemia (elevated ketone levels) and acidosis (low venous pH).

-Common signs include dehydration, weight loss, fatigue, nausea, vomiting, abdominal pain, acetone breath and reduced consciousness.

Treatment involves IV fluid replacement and IV insulin, as well as potential electrolyte replacement. The aim is to restore cirulatory volume and to correct electrolyte imbalance and high BG, clear ketones.

Answer 25

.

Question 26

HHS

-Can take days to develop
-Features tend to be hypovolaemia, marked hyperglycaemia (above 30mmol/L) and hyperosmolality.

Commons signs include dehydration, weakness, weight loss, tachycardia, hypotension, acute cognitive impairment.

Main aim of treatment is to correct fluid and electrolyte losses, hyperosmolality and hyperglycaemia and to prevent complications. IV fluid replacement and IV insulin is the main treatment.

Answer 26

.

Question 27

What is lipohypertrophy?

Answer 27

Can occur due to repeatedly injecting insulin into the same area- can cause erratic insulin absorption

Question 28

What are short-acting insulins used for?

Answer 28

To replicate the insulin usually produced around meals, so they are used at meal times.

Question 29

What are the two types of short-acting insulins?

Answer 29

Soluble insulins (very rarely used0
Rapid-acting insulin

Question 30

Rapid-Acting Insulin

-Insulin aspart, insulin glulisine and insulin lispro
-Onset within 15 minutes, should be injected immediately before meals

Answer 30

.

Question 31

Intermediate-Acting Insulin

-Isophane insulin- can be given as a one or more daily injection alongside separate meal-time short-acting uslin injections

-Biphasic insulins: pre-mixed insulin preparations that contain short-acting and intermediate-acting insulin.

Answer 31

.

Question 32

Long-Acting Insulin

• Mimic endogenous basal insulin secretion, can last up to 36 hours.
  -Insulin glargine and insulin degludec are given once a day, insulin detemir is once or twice daily.

Answer 32

.

Question 33

What is the first choice antihypertensive treatment for a diabetic?

Answer 33

Ramipril

Question 34

How many grams of carbohydrate should be used to treat a hypo?

Answer 34

15-20g

Question 35

Management of Ketoacidosis

-IV fluid replacement
-IV insulin- patients who take long acting insulin should continue taking this insulin throughout treatment.
Same management for HHS

Question 36

Management of Diabetic Nephropathy

-If no contraindications, patients with an ACR of 3mg/mmol or more should be started on an ACEi (ARB if CI), even if BP is normal.
-For T2 patients with CKD that are already on an ACEi or ARB, an SGLT2 inhibitor should be offered if the ACR is over 30mg/mmol (consider if between 3-30mg/mmol).

Answer 36

.

Question 37

How should diabetic nephropathy initially be managed?

Answer 37

Starting an ACEi or ARB

Question 38

What is the requirement if if someone has a hypo whilst driving?

Answer 38

Stop, eat, wait 45 minutes after BG normalised before continuing to drive

Question 39

What is the HbA1c target for a type 2 diabetic controlled by lifestyle alone, or lifestyle+metformin?

Answer 39

48 mmol/mol (6.5%)

Question 40

What is the HbA1c target for a type 2 diabetic controlled by lifestyle + an antidiabetic drug that can cause hypoglycaemia?

Answer 40

53 mmol/mol (7.0%)

Question 41

What are some potential microvascular complications of diabetes?

Answer 41

Retinopathy
Neuropathy
Nephropathy
Foot problems
Metabolic- dyslipidaemia, Ketoacidosis, Hyperosmolar, HHS

Question 42

What are some potential macrovascular complications of diabetes?

Answer 42

Coronary heart disease
Cardiomyopathy
Arrhythmias
Cerebrovascular disease
Peripheral artery disease