Diabetes ***

Question 1

Med for wt loss

Answer 1

Semaglutide 2.4mg SC q1weekly,

Question 2

RF for T1

Answer 2

fam hx

Question 3

Sx

Answer 3

Polyuria, polydipsia, wt loss

Question 4

Complications

Answer 4

Macrovascular (CVD, CVA, PAD), microvascular (retinopathy, nephropathy, neuropathy), infection, ED

Question 5

Hypoglycemia Sx

Answer 5

palpitations, sweating, trembling, anxiety, hunger, N/V, drowsiness, vision change, HA

Question 6

Hypoglycemia RF

Answer 6

prior episode, low a1c, hypoglycemia unawareness, CKD, preschool/ adolescent/ pregnancy/ elderly

Question 7

Hypoglycemia Rx

Answer 7

15g carbs (¾ cup juice, 1 tbsp honey) - restest in 15 mins and repeat if BG <4
Severe: 1mg glucagon SC/ IM

Question 8

Hyperglycemia Sx

Answer 8

Polyphagia, polydipsia, polyuria, blurred vision, fatigue, paresthesia, arrhythmia

Question 9

DKA sx

Answer 9

Kussmaul’s breathing, confusion, dehydration, impaired cognition, abdo pain, N/V

Question 10

DKA precipitating factors

Answer 10

Infection, illness, missed insulin, infarction, intoxication

Question 11

Dx of T1

Answer 11

If asymptomatic, repeat test on another day
8hr FPG >7
Random BG >11.1
Hba1c >6.5

Question 12

Factors that increase a1c

Answer 12

iron deficiency, low B12, alcoholism, chronic opioid use

Question 13

Factors that decrease a1c

Answer 13

use of iron/ B12/ ASA/ vit C, hemaglobinopathy, chronic liver disease, RA

Question 14

Targets for pre + postprandial glucose (+ if frail)

Answer 14

Preprandial 4-7
Postprandial 5-10
If frail/ dementia = preprandial 6-9 and postprandial <14

Question 15

Ix for new dx DM

Answer 15

ECG if >40 y/o, DM >15 yrs, end ogan damage, CVD RF (HTN, smoking, CKD, obesity, ED)
Stress test if cardiac sx

Question 16

Monitoring (q6mo + annual)

Answer 16

q6mo
BP <130/80
A1C <7% adults, <7.5% children

Annual
Fasting lipids
Optometry (5 yrs after dx)
Albumin/Cr ratio + Cr (5 yrs after dx)
Monofilament + foot exam (5 yrs after dx)
Screen for ED, depression, eating disorder, NAFLD

Question 17

Driving safety

Answer 17

Measure BG before driving
Keep supply of carbs in car
Do not drive if BG <4
Report to licensing if on insulin and 1) any severe hypo while driving in past 12 months or 2) >1 severe hypo while awake but not driving in past 6 months

Question 18

Nutrition advice

Answer 18

Low glycemic index carbs
Fibre 30g day
Maintain consistent carb intake
Alcohol 2hrs after dinner can cause low glucose next AM

Question 19

Exercise advice

Answer 19

Aerobic exercise 150 mins over >3d/week
Resistance training >2x/w
Consider extra carbs for exercise

Question 20

Basal bolus regime

Answer 20

Basal
Long acting insulin e.g. glargine
Long acting degludec (reduced nocturnal hypoglycemia)
Bolus
Dose based on carb content, exercise, time since last dose and BG
Rapid acting (aspart) 0-15 mins before meal

Question 21

Management of complications:
HTN, nephropathy, neuropathy, retinopathy, ED, macrovascular

Answer 21

HTN: target 130/80, use ACEi/ ARBs, CCB, thiazide

Nephropathy: CKD + HTN: ACEi/ ARB. Consider kidney + pancreas transplant in ESRD

Neuropathy: pregabalin 1st, 2nd line: gabapentin, valproate, amitriptyline, duloxetine

Retinopathy: laser therapy + vitrectomy

ED: PDE5 inhibitor, consider hypogonadism if ineffective

Statin +/- ezetimibe: if macrovascular disease, age >40, DM >15 yrs + microvascular disease
ACEi/ARB: if CVD, age >55 w/ CV RF, microvascular disease
ASA: if CVD

Question 22

Metabolic syndrome measurements

Answer 22

Sex, Waist Circumference, Triglycerides, HDL, Blood Pressure, Fasting Glucose

Question 23

Screening for T2

Answer 23

Adolescents: screen q2yr if 2-3 of following: obesity, high risk ethnic group, FDR, S+S insulin resistance, PCOS, AP use
Adults:
>40 y/o q3yr
<40 y/o + CANRISK score ‘high risk’ q3yr
Screen earlier if additional RF (e.g. prediabetes)

Question 24

Prediabetes FPG + A1C

Answer 24

FPG 6.1-6.9
A1C 6-6.4

Question 25

Prevention in prediabetes

Answer 25

Wt loss > 5% Mediterranean or DASH diet Exercise >150 mins week over 5d Consider metformin, especially in pts <60 y/o, BMI >35, hx of GDM

Question 26

Self monitoring when on insulin >1/d, 1/d or no insulin

Answer 26

On insulin >1/d = monitor >3x day w/ pre + postprandial On insulin 1/d = FPG 1/d at varied times no insulin = no CBG daily except if not on target or at risk of hypos

Question 27

Management T2

Answer 27

Lifestyle measures - if not in target in 3mo, start metformin Metformin Add insulin if metabolic decompensation + symptomatic hyperglycemia Start basal insulin + titrate to achieve target If >1.5% above target, metformin plus another agent

Question 28

Management of T2 + ASCVD, CKD, HF + CV RF

Answer 28

ASCVD: add dulaglutide (GLP1-RA) or empagliflozin (SGLT2i) CKD: add empagliflozin (SGLT2i) HF: add empagliflozin (SGLT2i) CV RF: add dulaglutide (GLP1-RA)

Question 29

Management on sick days

Answer 29

Vomiting or diarrhea >6 hrs, feeling sick or fevers x few days Check sugars Q4H Check urine for ketones Maintain adequate food and fluids, if not able to then eat concentrated carbs Hold metformin, sulfonylureas and SGLT2 inhibitors Hold ACEi, ARBs, diuretics, NSAIDs Call doc if glucose >13.3 or >11 if pregnant call doc w/ signs of DKA or dehydration Avoid exercise

Question 30

HHS vs DKA pathology

Answer 30

HHS = Hyperglycemia -> intracellular water depletion -> osmotic diuresis DKA = Absence of insulin -> reduced glucose utilisation -> increased TG breakdown -> ketone production

Question 31

What do you need to watch out for with SGLT2i in DKA?

Answer 31

SGTL2i can cause euglycemic DKA

Question 32

RF for DKA

Answer 32

Poor adherence ($, wt control, depression, understanding) Not monitoring glucose

Question 33

Precipitating factors for DKA

Answer 33

Infection Alcohol Stress Pregnancy CV events (stroke, MI) Trauma Meds (steroids, cocaine, APs, thiazide) Cushings, thyrotoxicosis GI disease (pancreatitis, obstruction) No cause

Question 34

Sx DKA

Answer 34

Polyuria, polydipsia, fatigue, weakness, AMS, HA N/V, abdo pain Tachycardia Kussmaul breathing Dehydration

Question 35

Ix for DKA + Ix for secondary causes of DKA

Answer 35

Glucose Cr, urea, lytes, bicarb Blood gas Serum + urine ketones Secondary causes: Amylase/ lipase (?pancreatitis) CBC Urine + BC CXR ECG

Question 36

Rx for DKA in peds

Answer 36

Q1H glucose, lytes, ex lytes, urea, CBC, VBG, ECG NS 10ml/kg over 1 hr then replace fluid deficit with 5ml/kg/hr NS + 40mmol KCl over next 24-48 hrs When glucose <17 or dropping >5 mmol/hr, change to 0.45% NS and add dextrose (D51/2NS) and transition to SC insulin, then stop IV insulin Start insulin 1-2 hrs after fluids at rate of 0.1 units/kg/hr

Question 37

Rx for adult DKA

Answer 37

Q2H glucose, lytes, urea, bicarb, AG, osmolality, fluid status, mental status NS 1-2L/hr Once euvolemic, check corrected sodium If corrected sodium low = continue NS If normal or high = switch to ½ NS When glucose <14, D5W or D10W to maintain glucose 12-14 When K+ <5.5 AND pt urinating = add KCl

Question 38

Insulin infusion for DKA - when to start, when to reduce, dose

Answer 38

Start when K >3.3 0.1 units/kg/hr When glucose <11.1, reduce to 0.02-0.05 units/kg/hr

Question 39

Potassium in DKA - when to start, when to reduce, dose

Answer 39

<3.3 = no insulin, give 40mmol/ hr 3.3-5.5 = give 10-40 mmol/ hr >5.5 = check K Q2H, don’t give more

Question 40

Resolution of DKA criteria

Answer 40

Glucose <11.1 Bicarb >15 pH >7.3 AG <12

Question 41

Complications of DKA/ HHS

Answer 41

Mortality Cerebral edema Hypogylcemia AKI PE, stroke, DVT ARDS, shock

Question 42

Meds that cause DM

Answer 42

glucocorticoids, atypical APs, statins, anti-rejection drugs

Question 43

RF for hypoglycemia

Answer 43

increasing age, long duration of dz, prev episodes of hypoglycemia