Diabetes

Question 1

Describe the management of type 1 diabetes

Answer 1

Insulin therapy – subcutaneous insulin (short, medium, long acting)
Plan the regime to suit the lifestyle
Insulin pumps (continuous subcutaneous insulin) – consider when attempts to reach HbA1C with multiple daily injections have resulted in disabling hypoglycaemia/person hasn’t been able to control HbA1c despite careful management

Question 2

Describe principles of safe insulin prescribing

Answer 2

Vital to write units in full when prescribing insulin to avoid misinterpretation
Advise patients to avoid stopping insulin during acute illness
Self-adjust doses in light of exercise, finger-prick glucose, calorie intake & carbohydrate counting

Question 3

Describe the management of type 2 diabetes

Answer 3

Lifestyle modification
Monotherapy – 1st line = standard release metformin
If HbA1C rises to 58, consider dual therapy of metformin with either:
1) DPP4 inhibitor
2) Pioglitazone
3) Sulphonylurea
4) SGLT2-inhibitor
If HbA1C rises to 58 after this consider triple therapy
Insulin

Question 4

Describe the management of diabetic ketoacidosis

Answer 4

Replace volume and then correct metabolic defects
Insulin
Check capillary blood glucose and ketones hourly
Consider catheter if not passed urine by 1 hour, consider NG tube if vomiting/drowsy
Start all patients on LMWH

Question 5

Describe hyperglycaemic hyperosmolar state

Answer 5

Life-threatening emergency characterised by marked hyperglycaemia, hyperosmolality and mild/no ketosis
Metabolic emergency characteristic of uncontrolled type 2 diabetes mellitus

Question 6

Describe the management of hyperglycaemic hyperosmolar state

Answer 6

Give LMWH prophylaxis
Rehydrate slowly with saline IVI over 48hr
Replace K+ when urine starts to flow
Only use insulin if blood glucose not falling with rehydration & if ketonaemia

Question 7

Describe the management of a diabetic foot ulcer

Answer 7

Regular podiatry
Bed rest +/- therapeutic shoes
For Charcot joints – bed rest/crutches/total contact cast until oedema & local warmth reduce and bony repair is complete
Cellulitis – IV antibiotics

Question 8

Describe the management of retinopathy

Answer 8

Annual retinal screening
Refer to an ophthalmologist if pre-proliferative changes/if any uncertainty at or near the macula

Question 9

Describe the management of nephropathy

Answer 9

ACEi/ARBs if UA:CR > 3
Spironolactone

Question 10

Describe the management of neuropathy

Answer 10

Symmetric sensory polyneuropathy – ‘glove & stocking’ numbness, tingling & pain -> give paracetamol, tricyclics, duloxetine, gabapentin, pregabalin, opiates
Avoid weight bearing helps
Postural hypotension may respond to fludrocortisone/midodrine (alpha-agonist)