Diabetes

Question 1

Example of sulfonylurEA

Answer 1

Gliclazide - avoid in acute porphyrias
Glimepiride
Glipizide
Tolbutamide- avoid in acute porphyrias

Question 2

Sulfonylurea side effects

Answer 2

Hypos
Weight gain

Rare:
Hyponatraemia secondary to SIADH
Bone marrow suppression
Hepatotoxicity (typically cholestatic)
Peripheral neuropathy

Question 3

Sulfonylurea contraindications

Answer 3

Pregnancy and breastfeeding

Question 4

Thiazolidinediones example

Answer 4

Pioglitazone

Question 5

pioglitazone mechanism

Answer 5

agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance.

Question 6

Pioglitazone side effects

Answer 6

Think alien LOL
- Weight gain
- Liver impairment: monitor LFTs
- Fluid retention - Risk of this is increased if the patient also takes insulin. C/I in CCF
-Increased risk of fractures
- Increased risk of bladder ca

Question 7

Pioglitazone contraindications

Answer 7

Heart failure
Bladder ca

Question 8

Sulfonylurea mechanism of action

Answer 8

Increase pancreatic insulin secretion so only work if B-cells are working

Question 9

DPP4 inhibitor examples

Answer 9

Think DPD man delivering your hairclip HAHAH
GLIP(i)Tin(s)
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Vildagliptin

Question 10

SGLT2 inhibitor
1. Examples?
2. Mechanism

Answer 10

Mechamism: inhibit sodium-glucose co-transporter 2 - so pee out more glucose.

Examples: Think of that sugar FLO in out
Canagliflozin
Dapagliflozin
Empagliflozin
Ertugliflozin

Question 11

SGLT2 inhibitor side effects

Answer 11

-UTIs
-Fournier’s gangrene
-Normoglycaemic ketoacidosis
-Increased risk of lower-limb amputation: feet should be closely monitored

**can’t give in mod- severe renal impairment or to people with foot disease

Question 12

What do you need for diagnosis of T2DM?

Answer 12

Symptomatic:
- Random ≥ 11.1 or fasting ≥ 7
- Hba1c of 48 (6.5%) or above

Asymptomatic need above on 2 sep occasions

**HbA1c value of less than 48 does not exclude diabetes, so if you think they have it do fasting/random.

Question 13

Pre-diabetes diagnostic criteria

Answer 13

Hba1c 42-47
or
Fasting 6.1-6.9

Question 14

What is impaired fasting glucose?
What do you do if they have this?

Answer 14

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

If they have IFG then do OGTT.
if ≥ 7.8 but < 11.1 then they don’t have diabetes but do have impaired glucose tolerance

Question 15

What is impaired glucose tolerance and when do you do this?

Answer 15

First do fasting glucose. If fasting 6.1-6.9 then do OGTT.

Impaired glucose tolerance (IGT) is defined as:
Fasting plasma glucose less than 7.0
AND
OGTT 2-hour value ≥ 7.8 but < 11.1

Question 16

Type 2 diabetes hba1c targets and when to step up treatment?

Answer 16

Lifestyle = 48

Lifestyle and metformin = 48

Any drug that might cause hypos = 53

Intensify treatment if hba1c over 58

Question 17

When to use SGLT2 inhibitors

Answer 17

Need to assess cardio risk. If any of:
1. Heart failure
2. Q risk> 10%
3. Atherosclerotic disease e.g. ACS, prev MI, angina, prev. ischaemic stroke or TIA, PVD
then add SGLT2 inhibitor (flozins)

Question 18

T2DM 1st line management

Answer 18

Metformin - titrate dose upwards, if GI side effects arise then offer MR

If any CVS risk then add SGLT2 inhibitors once established on metformin.

Question 19

T2DM 2nd line management

Answer 19

Add any of
Sulphonylurea (gliclazide)
DPP4 inhibitor (gliptins)
Pioglitazone

Question 20

What to do first line if metformin C/I or not tolerated

Answer 20

If CCF/Q-risk >10%/ atherosclerotic disease - SGLT2 monotherapy

If not any of sulfonylurea/ DPP4/ Pioglitazone

Question 21

3rd line therapy for T2DM

Answer 21

Add another drug from 2nd line options OR start insulin

Question 22

When to use GLP-1 mimetic?

Answer 22

If triple therapy not effective or tolerated consider swapping one out for this.

Must have:
-BMI ≥ 35 AND and specific psychological or other medical problems associated with obesity
OR
- BMI < 35 kg/m² and insulin would have occupational implications, or - weight loss would benefit other significant obesity-related comorbidities

Don’t add them to insulin - must be specialist led

Question 23

GLP-1 mimetic examples

Answer 23

Think of people walking along the beach in America… -TIDES

Cause wt loss

Adverse effects:
Nausea and vomiting.
Exenatide, has been linked to severe pancreatitis in some patients.

Question 24

How would you start insulin?

Answer 24

NICE recommend starting with human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need

Question 25

Gestational diabetes blood glucose targets

Answer 25

CBG should be below following

fasting: 5.3mmol/L

AND

1 hour postprandial: 7.8 mmol/L or
2 hours postprandial: 6.4 mmol/L

Question 26

Gestational Diabetes diagnostic criteria

Answer 26

Fasting glucose over 5.6
2h glucose over 7.8

Question 27

How to manage gestational DM

Answer 27

If fasting glucose below 7:
Trial diet and exercise
R/v in 2 week. If no better then add metformin.
If still no better add insulin.

If fasting glucose above 7:
Start insulin

If 6.1-6.9 but complications eg macrosomia, insulin

Question 28

Which diabetes drug can you use if metformin no good or pt refuses insulin

Answer 28

glibenclamide

Question 29

Is C-peptide high or low in T2DM

Answer 29

High in T2, Low in T1

Question 30

T1DM hba1c target

Answer 30

48

Question 31

When would you give T1 metformin?

Answer 31

considering adding metformin if the BMI >= 25 kg/m²