Diabetes Flashcards
1
Q
What are the 3 major types of Diabetes?
A
Type 1 Diabetes, Type 2 Diabetes and Gestational Diabetes.
2
Q
What is the classification of Type 1 Diabetes?
A
Characterised by autoimmune destruction of pancreatic β-cells leading to ABSOLUTE INSULIN DEFICIENCY
Typically presents in childhood or adolescence
3
Q
What is the classification of Type 2 Diabetes?
A
Results from a combination of insulin RESISTANCE and β-cell dysfunction.
Strongly associated with obesity and lifestyle factors.
More common in adults.
4
Q
What is the classification of Gestational Diabetes?
A
Hyperglycemia with onset or first recognition
during pregnancy
5
Q
What is the normal Fasting Glucose Level (mmol/l)
A
3.5 - 5.5 mmol/l
6
Q
What is the prediabetic Fasting Glucose Level (mmol/l)
A
5.6-6.9 (mmol/l)
7
Q
What is the diabetic Fasting Glucose Level (mmol/l)
A
≥ 7 mmol/L
Persistent Hypergylcaemia
8
Q
What is the diabetic Random Blood Glucose Level (mmol/l)
A
≥ 11.1 mmol/L
Persistent Hypergylcaemia
9
Q
What HbA1c is Diabetic? (mmol/mol)
A
48 mmol/mol (6.5%) or more
10
Q
How would you diagnose type 2 diabetes in a symptomatic patient?
A
SINGLE abnormal HbA1c OR fasting plasma glucose level can be used
11
Q
How would you diagnose type 2 diabetes in a asymptomatic patient?
A
REPEAT TESTING, preferably with the SAME TEST, to confirm the diagnosis.
If the repeat test result is normal, arrange to monitor the person for the development of diabetes
12
Q
What do you do if Hba1c is difficult to interpret?
A
Use fasting plasma glucose level of ≥ 7 mmol/L for diagnosis.
13
Q
In what patient groups should HbA1c NOT be used? (8)
A
1) < 18 years
2) Pregnant women or 2 months postpartum.
3) Symptoms of diabetes for < 2 months.
4) High diabetes risk and acutely ill.
5) Taking medication that may cause hyperglycaemia (e.g. long-term corticosteroid treatment).
6) Acute pancreatic damage, including pancreatic surgery.
7) People with end-stage renal disease (ESRD).
8) People with HIV infection.
14
Q
When is using Hba1c cautioned? (4)
A
1) Abnormal haemoglobin, such as haemoglobinopathy.
2) Severe anaemia (any cause). (Iron, B12, folate)
3) Altered red cell lifespan (e.g. post-splenectomy).
4) A recent blood transfusion.
15
Q
Are oral glucose tolerance tests recommended?
A
No
16
Q
What are the symptoms of Diabetes?
A
polydipsia
polyuria
blurred vision
unexplained weight loss (MORE COMMON IN T1D)
recurrent infections,
tiredness
17
Q
What is acanthosis nigricans?
A
A skin condition causing dark pigmentation of skin folds, typically the axillae, groin, and neck, which suggests insulin resistance.
18
Q
What is a typical feature of Type 1 Diabetes that is related to a patient’s weight?
A
In adults presenting with Type 1 Diabetes, a typical feature is a body mass index (BMI) below 25 kg/m²
19
Q
What may be the first presentation of Type 1 Diabetes following a viral illness?
A
Diabetic Ketoacidosis (DKA)
20
Q
What is Diabetic Ketoacidosis?
A
SERIOUS COMPLICATION!
Body starts breaking down fats at an excessive rate, producing ketones as a by-product.
Leads to a buildup of ketones in the blood, causing the blood to become acidic.
Finger-prick blood glucose level ≥ 11.1 mmol/L
21
Q
What are the key triggers for Diabetic Ketoacidosis?
A
1) Uncontrolled diabetes
2) Missed insulin doses
3) Infection
4) Significant stress
22
Q
What are the key symptoms for Diabetic Ketoacidosis?
A
Frequent urination
Extreme thirst
Nausea and vomiting
Abdominal pain
Weakness
Confusion
Distinctive fruity odour on the breath.
23
Q
Is the routine measurement of C-peptide and diabetes-specific autoantibody titres recommended for confirming a Type 1 diabetes diagnosis?
A
No
24
Q
How would you diagnose Type 1 Diabetes?
A
The diagnosis of Type 1 Diabetes is primarily based on clinical symptoms and a random blood-glucose concentration ≥ 11.1 mmol/litre.
25
What are the acute complications of diabetes? (3)
1) Diabetic ketoacidosis (DKA) in T1D
2) Hyperosmolar hyperglycemic state (HHS) in T2D
3) Hypoglycemia
26
What are the chronic complications of diabetes? (2)
1) MICROvascular (retinopathy, nephropathy, neuropathy)
2) MACROvascular (coronary artery disease, cerebrovascular disease, peripheral arterial disease)
27
How would you diagnose and treat Nephropathy?
Check for protein (especially albumin) in the urine, a sign of kidney damage.
Management includes controlling
blood pressure with an ACE inhibitor/ARB.
SGLT2 recommended if significant albuminuria.
28
How would you treat Neuropathy?
Tricyclics (amitriptyline hydrochloride, imipramine hydrochloride)
Duloxetine
Venlafaxine
29
How would you treat autonomic neuropathy? (diabetic diarrhoea)
Tetracycline or codeine phosphate
30
How would you treat diabetic gastroparesis?
IV Erythromycin
31
How would you treat neuropathic postural hypotension?
Increasing salt intake + fludrocortisone acetate
32
How often should diabetic patients have foot checks and why is this necessary?
Annually - regular inspection for sensation, cuts, blisters, and other injuries
Diabetic Foot Infection caused by neuropathy and peripheral vascular disease leading to the development of foot ulcers and possible amputation.
33
What is the first line choice for the pharmaceutical management of Type 1 Diabetes?
Insulin Therapy
Patients with type 1 diabetes should be offered multiple daily injection basal-bolus insulin
regimen as the FIRST LINE CHOICE.
34
Describe a basal-bolus regimen?
Mimics the body's natural pattern of insulin secretion
Long-acting or intermediate-acting insulin as the 'basal' component to provide a steady level of insulin
throughout the day and night
Rapid-acting or short-acting insulin are administered at mealtimes to manage the rises in blood glucose levels following food intake
35
What is the first line insulin for the basal component of a basal-bolus regimen?
Twice-daily insulin detemir (Levemir)
36
What are the alternatives to basal insulin therapy?
Once-daily insulin glargine (100 units/ml) if detemir is not tolerated or a twice-daily regimen is not suitable.
Insulin degludec for concerns about nocturnal hypoglycemia.
Ultra-long acting insulins (e.g. insulin degludec or insulin glargine (300 units/ml)) for patients requiring assistance from a carer.
37
What is the first line insulin for the bolus component of a basal-bolus regimen?
Rapid Acting Insulin - LAG
Lispro (Humalog)
Aspart (NovoRapid)
Glulisine (Apidra)
38
What is the Onset, Peak and Duration of Rapid Acting Insulins? (Lispro, Aspart, Glulisine)
Rapid - Onset 15-30 minutes, Peak 1-3 hours, Duration 4-6 hours.
Use just BEFORE a meal
Has the highest hypoglycaemic risk however some studies now show this may not be clinically significant.
39
What is the Onset, Peak and Duration of Short Acting Insulins? (Regular, Humulin-R, Novolin-R)
Short - Onset 30-60 minutes, Peak 2-4 hours, Duration 5-8 hours.
Take 30 - 60 minutes before a meal
Useful in the management of Diabetic Ketoacidosis
40
What is the Onset, Peak and Duration of Intermediate Acting Insulins? (NPH, Humulin-N, Novolin-N)
Intermediate - Onset 2-4 hours, Peak 8-12 hours, Duration 10 - 18 hours.
Act as a basal insulin
Covers insulin need for half a day
41
What is the Onset, Peak and Duration of Long Acting Insulins? (Glargine - Lantus)(Detemir - Levemir)
Long - Onset 1-2 hours, Peak 0, Duration 24+ hours
Acts as a basal insulin
Covers insulin need for a full day
42
What is the Onset, Peak and Duration of Ultra Long Acting Insulins? (Degludec - Tresiba)
Ultra Long - Onset 1 hour, Peak 0, Duration 42+ hours
Useful for extra long glucose coverage and nocturnal hypoglycaemia concerns
43
What would you do if a multiple daily injection basal-bolus regimen is not possible?
Consider a twice-daily mixed (biphasic) insulin regimen
e.g. NovoMix® 30 combines two distinct types of insulin, featuring both rapid-acting and long-acting components. This formulation allows for flexible administration, enabling dosing once, twice, or thrice daily.
44
What would you do if a patient using twice-daily human mixed insulin regimen experiences life-impacting
hypoglycemia?
Consider a trial of a twice-daily analogue mixed insulin regimen
e.g. Humalog Mix 25 contains 25% rapid-acting insulin and 75% long-acting insulin. The rapidacting part helps manage blood sugar spikes after meals, while the long-acting portion maintains a more consistent insulin level.
45
When should a continuous subcutaneous insulin infusion (insulin pump) be considered?
1) Disabling Hypoglycaemia
2) HbA1c ≥69 mmol/mol or 8.5% despite following an intensive multiple daily injection therapy regimen
46
Is continuous home blood glucose monitoring recommended in type 2 diabetes?
No
47
What are ideal targets for blood glucose monitors / capillary blood glucose tests, including when driving?
5–7 mmol/litre upon waking (fasting).
4–7 mmol/litre before meals at other times.
5–9 mmol/litre at least 90 minutes post-meal.
A minimum of 5 mmol/litre for driving, as per DVLA guidelines.
48
What is hypoglycaemia?
Hypoglycemia occurs when your blood sugar (glucose) levels drop below normal, usually 4 mmol/l or below
49
What are the causes of hypoglycaemia?
Excessive insulin,
Delayed or missed meals,
Strenuous exercise,
Excessive alcohol consumption
50
What are the symptoms of hypoglycaemia?
Rapid heartbeat
Sweating
Confusion
Weakness
Blurred vision
51
What is the treatment of hypoglycaemia?
Consume 15 to 20g of fast-acting carbohydrates.
3-4 heaped teaspoons in water (cant give with acarbose)
Five glucose tablets
Four jelly babies
150-200ml non-diet drink
200ml pure fruit juice - (no orange juice for low potassium diet due to CKD)
2 tubes of glucogel
52
How many times can you offer oral glucose to treat hypoglycaemia?
If necessary, repeat treatment after 15 minutes, up to a maximum of 3 treatments in total.
53
How would you treat unresponsive hypoglycaemia?
In an emergency, if the patient has a decreased level of consciousness caused by hypoglycaemia, the patient should be put in the recovery position and intramuscular glucagon can be given by a family member or friend who has been shown how to use it.
If glucagon is not effective after 10 minutes, CALL AN AMBBULANCE
Glucose 10% intravenous infusion will then be given.
54
How would you treat unresponsive hypoglycaemia in an alcoholic patient?
Intramuscular glucagon or glucose 10% intravenous infusion.
Thiamine supplementation should be given with, or following, the administration of intravenous glucose to minimise the risk of Wernicke's encephalopathy.
55
What do you do once the patient has recovered from hypoglycaemia who has not received glucagon?
Above 4 mmol/l
Give a long acting carbohydrate (two biscuits, one slice of bread, 200–300 mL of milk)
56
What do you do once the patient has recovered from hypoglycaemia who has received glucagon?
Above 4 mmol/l
Give a double portion of long acting carbohydrate (four biscuits, two slices of bread, 400–600 mL of milk)
57
How long can hypoglycaemia caused by a sulfonylurea or long acting insulin last?
Up to 24–36 hours following the last dose, especially if there is concurrent renal impairment.
58
How long should blood glucose monitoring be continued post hypoglycaemia?
At least 24–48 hours.
59
Should you omit insulin injections after hypoglycaemia?
No - however, a review of the usual insulin regimen may be required
60
What is the type 2 diabetes target for lifestyle modification or a single diabetic drug e.g., diet and metformin?
< 48 mmol/mol (6.5%)
61
What is the type 2 diabetes target for a single drug with risk of hypoglycaemia?
< 53 mmol/mol (7.0%)
62
What is the type 2 diabetes target for two or more antidiabetic drugs ?
< 53 mmol/mol (7.0%)
63
What are the monitoring requirements for T2D?
HbA1c every 3-6 months
Regular blood pressure and lipid profile checks
Annual eye examinations
Annual foot examinations.
64
Give an example of a biguanide?
Metformin
65
What is the mechanism of action of metformin?
Decreases hepatic glucose production and increasing peripheral utilisation of glucose
66
Give examples of DPP4 inhibitors?
Sitagliptin, Saxagliptin, Linagliptin, Alogliptin, Vildagliptin
67
What is the mechanism of action of DPP4 inhibitors?
Inhibits DPP-4 enzyme to increase incretin levels, enhancing insulin secretion and decreasing glucagon
levels.
68
Give examples of Sulfonylureas?
Glimepiride, Glibenclamide, Glipizide, Gliclazide, Tolbutamide
69
What is the mechanism of Sulfonylureas?
Stimulates insulin secretion from
pancreatic beta cells.
70
Which sulfonylureas are safer in elderly patients?
Gliclazide and Tolbutamide
71
Give an example of a thiazolidinedione?
Pioglitazone
72
What is the mechanism of thiazolidinediones?
Peroxisome proliferator-activated receptor gamma agonist, reducing insulin resistance.
73
Give examples of SGLT-2 inhibitors?
Empagliflozin, Canagliflozin, Dapagliflozin, Ertugliflozin, Sotagliflozin
74
What is the mechanism of SGLT-2 inhibitors?
Inhibits glucose reabsorption in the kidney, increasing glucose excretion and lowering blood glucose levels.
75
What is the first line treatment for T2D (≥48mmol/l) in a patient with a low CVD risk?
Lifestyle advice + Immediate Release Metformin
76
What lifestyle advice is recommended in T1D and T2D?
Type 1 = Carb counting
Type 2 = Healthy diet, Regular physical activity and weight loss.
77
When is metformin contraindicated?
Acute metabolic acidosis (including lactic acidosis and diabetic ketoacidosis)
if eGFR is less than 30 mL/minute/1.73 m2.
78
What are risk factors of lactic acidosis and what must you do in these situations?
Chronic stable heart failure - Monitor cardiac function
Concomitant use of drugs that can acutely impair renal function (monitor renal function)
Interrupt treatment if dehydration occurs, and avoid in conditions that can acutely worsen renal function, or cause tissue hypoxia.
79
Does metformin cause any vitamin deficiencies?
YES - B12 Deficiency (MHRA WARNING)
A European review, with input from the MHRA, has found vitamin B12 deficiency to be a common side-effect in patients treated with metformin, especially in those receiving a higher dose or longer treatment duration and in those with risk factors for vitamin B12 deficiency.
Healthcare professionals are advised to check serum-vitamin B12 levels if deficiency is suspected and consider periodic monitoring in patients with risk factors for deficiency. Vitamin B12 deficiency should be treated according to current guidelines and treatment with metformin continued for as long as it is tolerated. Patients and their carers should be counselled on the signs and symptoms of vitamin B12 deficiency and advised to seek medical advice if these occur. Patients should continue taking metformin unless they are advised to stop.
80
What are the signs and symptoms of B12 deficiency?
CAUSES NEUROPATHY
Cognitive changes
Dyspnoea
Headache
Indigestion
Loss of appetite
Palpitations
Tachypnoea
Visual disturbance
Weakness, lethargy
81
What is the first line treatment for T2D if metformin is contraindicated in a patient with a low CVD risk?
Monotherapy with one of these drugs:
1) Sulfonylurea
2) Pioglitazone
3) DPP4-inhibitor
4) SGLT-2 inhibitor (if sulfonylurea and pioglitazone are contraindicated, unsuitable or cardiovascular disease)
82
What is the first line treatment for T2D if metformin is contraindicated in a patient with a high CVD risk?
SGLT-2 inhibitor alone
83
What is the first line treatment for T2D if metformin is contraindicated in a patient with established CVD?
SGLT-2 inhibitor alone
84
What would you do if a patient has GI side-effects on immediate release metformin?
Switch to MR Metformin
85
What is a high risk of cardiovascular disease classified as in type 2 diabetes?
Adults with type 2 diabetes who have:
* QRISK2 more than 10% in adults aged 40 and over OR
* an elevated lifetime risk of cardiovascular disease (defined as the presence of 1 or more cardiovascular
risk factors in someone under 40).
86
What are the cardiovascular disease risk factors?
Cardiovascular disease risk factors: hypertension, dyslipidaemia, smoking, obesity, and family history (in
a first-degree relative) of premature cardiovascular disease.
87
What is the first line treatment for T2D in a patient with chronic heart failure, established atherosclerotic cardiovascular disease or at a high risk of cardiovascular disease?
Lifestyle advice + Metformin + SGLT-2 inhibitor (Dapagliflozin, Empagliflozin, Canagliflozin) for cardiovascular benefits in patients with established CVD.
SGLT-2 inhibitors are CONSIDERED in patients with a high CVD risk
88
What is the next step if T2D is still uncontrolled after optimal first line therapy i.e. does not hit agreed target?
Add another of these drugs:
1) Sulfonylurea
2) Pioglitazone
3) DPP-4 inhibitor
4) SGLT-2 inhibitor (if sulfonylurea contraindicated, unsuitable or cardiovascular disease)
89
When should insulin be considered in T2D?
When dual therapy has not continued to control HbA1c to below the person's individually agreed threshold
90
What should occur with other prescribed drugs when insulin treatment is started in T2D?
Metformin hydrochloride should be continued unless it is contra-indicated or not tolerated.
Other antidiabetic drugs should be reviewed and stopped if necessary.
91
Which insulin regimens are preferred in T2D?
Human isophane insulin injected once or twice daily, according to requirements;
A human isophane insulin in combination with a short-acting insulin, administered either separately or as a pre-mixed (biphasic) human insulin preparation (this may be particularly appropriate if HbA1c is 75 mmol/mol (9.0%) or higher);
Insulin detemir or insulin glargine as an alternative to human isophane insulin. This can be preferable if a once daily injection would be beneficial (for example if assistance is required to inject insulin), or if recurrent symptomatic hypoglycaemic episodes are problematic, or if the patient would otherwise need twice-daily human isophane insulin injections in combination with oral glucose-lowering drugs.
Also consider switching to insulin detemir or insulin glargine from human isophane insulin if significant hypoglycaemia is problematic, or in patients who cannot use the device needed to inject human isophane insulin;
Biphasic preparations (pre-mixed) that include a short-acting human analogue insulin (rather than short-acting human soluble insulin) can be preferable for patients who prefer injecting insulin immediately before a meal, or if hypoglycaemia is a problem, or if blood-glucose concentrations rise markedly after meals.
92
At what time is insulin started and what must be monitored in T2D?
When starting insulin therapy, bedtime basal insulin should be initiated and the dose titrated against morning (fasting) glucose. Patients who are prescribed a basal insulin regimen (human isophane insulin, insulin detemir or insulin glargine) should be monitored for the need for short-acting insulin before meals (or a biphasic insulin preparation).
Patients who are prescribed a biphasic insulin should be monitored for the need for a further injection of short-acting insulin before meals or for a change to a basal-bolus regimen with human isophane insulin or insulin detemir or insulin glargine if blood-glucose control remains inadequate.
93
Which triple oral drug therapies are licensed in T2D?
Metformin + Sulfonylurea + SGLT-2 inhibitor
Metformin + Pioglitazone + SGLT-2 inhibitor
Metformin + Sulfonylurea + DPP-4 inhibitor
94
When should triple therapy with a glucagon-like
peptide-1 receptor agonists (GLP-1) be
used in diabetes treatment?
If triple therapy involving metformin hydrochloride and two other oral
antidiabetic drugs proves ineffective, intolerable, or contra-indicated.
95
Which GLP-1 mimetic is preferred in patients with CVD?
Liraglutide (has cardiovascular benefits)
96
Is BMI a considered factor when offering a GLP-1 mimetic?
Yes
The patient must have a body mass index (BMI) of 35 kg/m2 or higher AND specific psychological or other medical problems
associated with obesity
OR
have a BMI lower than 35 kg/m2 AND for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity related comorbidities
97
For how long is a GLP-1 mimetic trialled for?
6 months
The drug should be stopped if there has not been a beneficial response
98
What is a beneficial response when using a GLP-1 mimetic?
A reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight
99
What is the mechanism of action of a GLP-1 mimetic?
Binds to, and activates, the GLP-1 (glucagon-like peptide-1) receptor to increase insulin secretion, suppresses glucagon secretion, and slows gastric emptying.
100
Which drugs for T2D cause weight gain?
Insulin
Pioglitazone
Sulfonylureas
101
Which drugs for T2D cause weight loss?
SGLT-2 Inhibitors
GLP-1 Agonists
102
Which drugs for T2D have a high hypoglycaemia risk?
Insulin
Sulfonylureas in older people
103
Which drugs for T2D have a low hypoglycaemia risk?
DPP4 Inhibitors
GLP-1 Agonists
Pioglitazone
SGLT-2 Inhibitors
104
What are the contraindications and special warnings for DPP4 inhibitors?
Ketoacidosis
Discontinue if symptoms of acute pancreatitis occur such as persistent, severe abdominal pain.
105
What are the contraindications and special warnings for Metformin?
Acute metabolic acidosis
106
What are the contraindications and special warnings for Piaglitazone?
Ketoacidosis
History of heart failure
Previous or active bladder cancer
Uninvestigated macroscopic haematuria
107
What are the contraindications and special warnings for SGLT-2 Inhibitors?
*Ketoacidosis* - Important for SGLT2
UTIs
108
What are the contraindications and special warnings for Sulfonylureas?
All sulfonylureas: ketoacidosis
Gliclazide and tolbutamide: avoid where possible in acute porphyrias (short acting)
109
What are the contraindications and special warnings for GLP-1 agonists?
Ketoacidosis when concomitant insulin rapidly reduced
Diabetic gastroparesis
inflammatory bowel disease
Beware of falsified products of saxenda
110
Renal and T2D drugs?
Insulin - Insulin requirements may need to be DECREASED
DPP4 - dose reduction or caution (Linagliptin safe)
Metformin - dose reduction or avoid if EGFR <30
SGLT2 - Dose reduction or caution or avoid (Dapagliflozin preferred if EGFR <45 and can be used if EGFR > 15)
GLP1 - Caution or avoid (not for dulaglutide, exenatide and lixisenatide)
Sulfonylurea - Sulfonylureas should be used with care in those with mild to moderate renal impairment, because of the hazard of hypoglycaemia. Care is required to use the lowest dose that adequately controls blood glucose.
Avoid where possible in severe renal impairment.
111
Hepatic and T2D drugs?
Insulin requirements may need to be DECREASED
DPP4 - dose reduction or caution or avoid (Linagliptin and Sitagliptin safe)
Metformin - Withdraw if tissue hypoxia is likely
Pioglitazone - Avoid
SGLT2 - Caution or avoid
Sulfonylurea - Caution or avoid (metabolised mainly by the liver)
GLP1 - Dose reduction or caution or avoid
112
Pregnancy and T2D drugs?
Insulin requirements may need to be INCREASED in the second and third trimester
Only Metformin and Insulin are safe in pregnancy
113
Breastfeeding and T2D drugs?
During breast-feeding, insulin requirements may alter and doses should be assessed frequently by an experienced diabetes physician.
Only metformin and Insulin are safe in breastfeeding
114
How does alcohol affect diabetes and what is the specialist recommendation for alcohol consumption for diabetic patients?
Alcohol can make the signs of hypoglycaemia less clear, and can cause delayed hypoglycaemia.
It is recommended that patients with diabetes should drink alcohol only in moderation, and when accompanied by food.
115
Which drug is recommended as an
option for treating stage 3 and 4
chronic kidney disease (with
albuminuria) associated with type
2 diabetes in adults?
Finerenone
Finerenone is a non-steroidal mineralocorticoid receptor antagonist that inhibits receptor-mediated sodium reabsorption and decreases receptor overactivation, thereby reducing the inflammation and fibrosis that lead to kidney damage.
Therefore contraindicated in Addison's disease and hyperkalaemia
116
How would you treat gestational diabetes in a patient with a fasting plasma glucose < 7 mmol/L?
1) Encourage lifestyle modifications like dietary
changes and increased physical activity.
2) If there's no improvement in blood-glucose levels
within 1 to 2 weeks, consider metformin
117
How would you treat gestational diabetes in a patient with a fasting plasma glucose < 7 mmol/L if metformin is unsuitable or ineffective?
Insulin therapy
118
How would you treat gestational diabetes in a patient with a fasting plasma glucose > 7 mmol/L?
Immediate insulin therapy +/- metformin
119
Which type of insulin is preferred in gestational diabetes?
Isophane insulin is the first-choice for long-acting insulin during pregnancy
Women who have good blood-glucose control before pregnancy with the long-acting insulin analogues (insulin detemir or insulin glargine), it may be appropriate to continue using them throughout pregnancy.
120
What do you need to make the patient aware of when using insulin in gestational diabetes?
Be aware of the risks of hypoglycaemia, particularly in the first trimester, and should be advised to always carry a fast-acting form of glucose, such as dextrose tablets or a glucose-containing drink.
Pregnant women with Type 1 diabetes should also be prescribed glucagon for use if needed.
Women with PRE-EXISTING diabetes treated with insulin during pregnancy are at increased risk of hypoglycaemia in the postnatal period and should REDUCE THEIR INSULIN IMMEDIATELY AFTER BIRTH
121
When should patients with ONLY gestational diabetes stop treatment?
Immediately after birth
122
What is the DVLA requirement for diabetic patients?
All drivers who are treated with insulin must inform the DVLA.
Drivers treated with insulin should always carry a capillary blood-glucose meter and test strips when driving, even if they use a continuous glucose monitoring (CGM) system
Blood-glucose concentration should be checked no more than 2 hours before driving and every 2 hours while driving
Blood-glucose concentration should be at least 5 mmol/litre while driving. If blood-glucose is 5 mmol/litre or below, a snack should be taken. Drivers treated with insulin should ensure that a supply of fast-acting carbohydrate is always available in the vehicle.
Drivers should wait until 45 minutes after their blood-glucose has returned to normal (at least 5 mmol/litre), before continuing their journey.
Drivers must not drive if hypoglycaemia awareness has been lost and the DVLA must be notified; driving may resume if a medical report confirms that awareness has been regained.
Drivers must inform the DVLA if renal function deterioration, visual acuity or severe hypoglycaemia occurs.
123
When is a diabetic patient on insulin allowed to drive?
No more than 1 episode of severe hypoglycaemia WHILE AWAKE in the preceding 12 months and the most recent episode occurred more than 3 months ago
124
When would you need to inform the DVLA about oral antidiabetic drugs with a high hypoglycaemia risk?
If more than 1 episode of severe hypoglycaemia WHILE AWAKE in the preceding 12 months and the most recent episode occurred less than 3 months ago
125
What are the important facts about metformin?
Check renal function before starting treatment and annually
Avoid starting Metformin if eGFR is less than 30 mL/min/1.73 m².
Increased risk of lactic acidosis with alcohol; alcohol may also enhance the hypoglycemic effect.
Potential for vitamin B12 deficiency with longterm use.
Modified-release preparations can be considered if patients develop adverse GI effects.
Skin reactions such as erythema, pruritus, and urticaria are rare.
126
What are the important facts about DPP-4 inhibitors?
Check liver and kidney function before starting saxagliptin, vildagliptin, or alogliptin.
Monitor liver function every three months during the first year with vildagliptin, and periodically thereafter.
Avoid DPP-4 inhibitors in patients with ketoacidosis, severe hepatic impairment, and severe heart failure.
Common gastrointestinal effects include constipation, vomiting, nausea, diarrhea, and dyspepsia.
Uncommon but serious effects include acute pancreatitis and hepatic reactions (with vildagliptin and alogliptin).
Potential interactions with beta-blockers, ACE inhibitors, digoxin, ketoconazole, and rifampicin.
127
What are important facts about pioglitazone?
Check liver function before starting treatment.
Assess risks for heart failure, bone fracture, and bladder cancer prior to initiation.
Do not prescribe to patients with heart failure, macroscopic haematuria, active or past bladder cancer, or hepatic impairment.
Common side effects include numbness, visual impairment, weight gain, and insomnia.
Increased risks of bone fractures, infections, and bladder cancer.
Beta-blockers may mask hypoglycemic signs; gemfibrozil can increase pioglitazone plasma concentration.
Advise patients to seek urgent medical assessment if symptoms or signs of bladder cancer develop such as
haematuria, dysuria, or urinary urgency.
128
What are important facts about sulfonylureas?
Common effects include gastrointestinal issues, hepatic impairment, skin reactions.
Risk of hypoglycemia
Special attention is needed in the elderly due to increased risk of prolonged hypoglycemia with
glibenclamide or glimepiride.
Increase weight gain, which should be monitored in obese patients.
129
What are important facts about SGLT-2 inhibitors?
Assess the risk of diabetic ketoacidosis (DKA) before starting treatment.
Regular monitoring of renal function is crucial, especially in the presence of moderate renal impairment. This includes at least biannual checks.
Be aware of potential adverse effects like vulvovaginitis, urinary tract infections, Fournier’s gangrene (especially in men), and lower limb amputation risks (particularly
with canagliflozin)
SGLT2 Inhibitors can have additive effects with diuretics, potentially leading to dehydration and hypotension.
Advise patients on the importance of diet and medication management to minimise the risk of DKA. Instruct them to avoid starting a very low carbohydrate or ketogenic diet without medical consultation.
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What are important facts about GLP-1 agonists?
Should not be prescribed in ketoacidocis, pancreatitis, severe hepatic or gastrointestinal disease.
Adverse effects include GI upset, decreased appetite, altered taste, headaches, dizziness and fatigue.
Injection sites should be rotated each dose to prevent tissue damage and irritation.
Lixisenatide reduces absorption of paracetamol when given 1-4 hours before paracetamol.
