Diabetes

Question 1

Who is screened for diabetes and how?

Answer 1

AUSDRISK for 40+ or ATSI 18+ (3y or 1y), FBG or HbA1c for score 12+, 40 + overweight, FDR w diabetes, GDM, PCOS, antipsychotics, CVD, ethnicities, IFG.

Question 2

What children require diabetes screening?

Answer 2

ATSI,Maori/pacific island age 10 if BMI >85th centile, maternal GDM, FDR w T2DM, acanthosis nigracans, psychotropic drugs, HTN/PCOS/dyslpidaemia.

Question 3

Metformin - SE, monitoring, risks, peri-op plan.

Answer 3

Nausea, abdo pain, diarrhoea. 1g if eGFR < 60, cease < 30. Monitor b12. Stop if N/V/D, bowel prep and morning of surgery/dehydration.

Question 4

SGLT2 inhibitors - risks, benefits, C/I, SE, peri-op plan.

Answer 4

Genitourinary infections, euglycaemia ketoacidosis, small risk hypos. Help w CVD, CCF, CKD, slight weight. C/I eGFR < 45. WH 2d before bowel prep, 2d before surgery, 1 day for procedure. WH if N/V/D/dehydrated.

Question 5

What are GLP1-RA/analogues? Benefits, risks, C/I, pre-op plan

Answer 5

Glutides, weight loss, CVD/CKD benefit. SE: N/V, injection site reaction, gallstone, pancreatitis, worsen retinopathy. C/I eGFR < 30 (dula < 15). WH if N/V/D and day of surgery.

Question 6

Gliptins and sulphonylureas - effects, C/I

Answer 6

G: small hypo risk, small pancreatitis risk, no C/I. S: risk hypo, may increase weight, C/I GFR < 15.

Question 7

What should be discussed when commencing insulin?

Answer 7

Impacts of diet, fasting, exercise, sick day management plan, hypos. Notify vicroads. SMBG when starting. Store at room temp for 1mo. Rotate injection sites. Single use short 4mm needles, sharp disposal.

Question 8

How is insulin first dosed and titrated?

Answer 8

Usually long acting glargine 0.2U/Kg at night. Use fasting glucose to titrate - aiming BSL over 2-3 days 6-6.9. Adjust by 2-4 units as needed.

Question 9

What is involved in a diabetic sick day action plan?

Answer 9

Indications - unwell, BSL >15. SMBG - 2-4hourly monitoring. Meds plan (metformin, SLGT2, GLP1-RA may need WH). Maintain hydration and aim to have normal meals. Seek assisstance if unwell.

Question 10

Hyperosmolar hyperglycaemia - features, triggers, management, risks.

Answer 10

Thirst, altered consciousness over days. T: infection, CV event, AKI. High serum osmolality and BSL (>20). Endo review, slow IV fluid (50% loss in 12hr). Risk thrombosis, ketosis, death.

Question 11

Diabetic retinopathy - appearance, screening.

Answer 11

Non-proliferative or proliferative. Exudates (white spot), haemorrhages, cotton wool spots and neovascularisation. Screen 2 yearly unless HbA1c >8, diabetes for 15y, ATSI, NESB, systemic disease - yearly.

Question 12

How is diabetic retinopathy managed?

Answer 12

If diagnosed, start fenofibrate. Control HTN. Opthal if oedema, proliferative, moderate non-proliferative, near optic disc. Can do phototherapy + AntiVEGF. Improving BSL can worsen retinopathy.

Question 13

How is diabetic peripheral neuropathy assessed?

Answer 13

Symmetric. Pinprick sensation, vibration w 128Hz fork, 10g monofilament pressure sensation at distal plantar toes and MTP. Ankle reflexes. Proprioception at big toes.

Question 14

Diabetic peripheral neuropathy - differentials, management.

Answer 14

B12, Hypothyroid, CKD. Vascular (chillblains, PVD w small vessel). Idiopathic. Myeloma. Pain: amitriptyline 25mg 1st line, 2nd: duloxetine, pregab, gabapentin. Consider capsaicin cream.

Question 15

What are the risk factors for GDM? How is it tested for?

Answer 15

Prev GDM, age, PCOS, high BMI or weight gain, Fhx DM, prev preg loss, ATSI/maori, migrants. HbA1c or FBG in 1st trimester, OGTT in 2nd trimester. FBG >5.5 or 2h >8.0.

Question 16

How is GDM managed? What are the risks and followup?

Answer 16

Diet, BSL monitoring. Add metformin, insulin. CV malformation, macrosomia, hypoglycaemia, low iron, prematurity. Post partum OGTT 6-12wk post, bloods 3yearly. 30-50% T2DM within 20y.

Question 17

How is pre-existing diabetes managed in pregnancy?

Answer 17

Aim HbA1c < 6.5%, cease ACEI statins, likely swap to insulin - DW endo for metformin - check B12. Folate 5mg, check GFR and retinopathy prior to pregnancy.

Question 18

What are the requirements for driving with diabetes? Private vs commercial.

Answer 18

If no meds, no restriction. Private, no insulin - notify authority, 5y review unconditional. Private with insulin - conditional with annual review. Commercial always needs specialist. Conditions: minimal risk hypoglycaemia, awareness of hypoglycaemia. Aim BSL >5 before drive, have monitor and snacks.

Question 19

How is type 1 diabetes diagnosed?

Answer 19

Sx: weight loss, polyuria/polydipsia, autoimmune history. Glutamic acid decarboxylase + insulinoma antigen 2 (GAD, IA2) antibodies in 90%. C-peptide < 0.2 supportive.

Question 20

What are the non-pharm management aspects for diabetes?

Answer 20

Diet: low GI, limit saturated fats. Cease smoking. Alcohol < 2std/day. Exercise 150min + 2-3 resistance sessions (No hypos 48hr prior, aim BSL >5, have snacks). Weight loss if BMI >25 (meds if >27, surgery if >40 - bypass/sleeve)

Question 21

What should be checked in the setting of poor diabetes control?

Answer 21

Understanding of meds, adherence meds + lifestyle. Exclude infection, steroids, antipsychotics. Anaemia/transfusion will lower HbA1c. Check for hypos limiting use.

Question 22

Acute hypoglycaemia - risk factors, management.

Answer 22

RF: meds, insulin, age, exercise, fasting, GI disease, alcohol (BSL + awareness). If awake, swallow - 15g oral glucose (6 jellybeans), recheck 15min then give long acting. Monitor 4hr. If decreased GCS, ambulance IV 200mL 10% over 15min OR IM/sc 1mg (0.5 in kids) glucagon, (20ml of 50% glucose - necrosis risk). Needs review.