Diabetes

Question 1

What is a sign of type 2 diabetes

Answer 1

acanthosis nigricans (dry, dark skin in armpit, neck or groin)
Polyuria and polydipsia

Question 2

Investigations for diabetes

Answer 2

Random glucose > 11.1
Fasting glucose > 7.0
2hr post prandial glucose > 11.1
HbA1c > 48
Diagnosis can be made if symptomatic + 1 of above tests, or asymptomatic + 2 of above tests on different days

Question 3

Management of type 1 diabetes

Answer 3

Basal-bolus regimen - long acting (subcutaneous insulin glargine) and short acting

Monitored with capillary glucose and HbA1c tests

Question 4

Management of type 2 diabetes

Answer 4

1 - lifestyle changes
2 - Metformin if HbA1c above 48
3 - SGLT2 Inhibitor if CVD risk
4 - if HbA1c above 58 then triple therapy with DPP-4 inhibitor, pioglitazone or sulfonylurea
5 - if not effective then replace one with GLP-1 miemetic

Question 5

Wat happens if gastro system doesn’t accept the metformin

Answer 5

take modified release ne instead

Question 6

BP medication

Answer 6

ACE inhibitor
ARB (angiotensin receptor blocker) are better for afro Caribbean people

Question 7

What is diabetic ketoacidosis

Answer 7

Absolute lack of insulin → lack of glucose uptake into cells → breakdown of fats for energy use → ketone production

caused by infection, non-adherence to medication

Question 8

triad of diabetic ketoacidosis

Answer 8

• Hyperglycaemia
• Ketonaemia
• Metabolic acidosis

Question 9

History of ketoacidosis

Answer 9

• Nausea and vomiting
• Dehydration
• Polyuria and polydipsia
• Hyperventilation (Kussmaul breathing)
• Abdominal pain
• Ketotic breath
• Collapse/confusion

Question 10

Investigations for ketoacidosis (ketones, pH, plasma glucose)

Answer 10

• Ketones > 3mmol/L
• pH < 7.3 (high anion gap metabolic acidosis)
• Plasma glucose > 11

Question 11

DKA resolution (ketones, pH, bicarbonate)

Answer 11

• pH >7.3
• blood ketones < 0.6 mmol/L and
• bicarbonate > 15.0mmol/L

Question 12

DKA management

Answer 12

• Saline + potassium chloride (if K+ < 5.5)
• IV insulin (0.1 unit/kg/hour) after fluids, only when K+ is not < 3.5
• Include 10% dextrose in fluids once glucose falls < 14 mmol/L
• Continue long-acting insulin, stop short-acting insulin
• Treat underlying cause, e.g Abx

Question 13

History of diabetic nephropathy

Answer 13

• Oedema
• Polyuria
• Lethargy
• Hypertension

Question 14

How to test for diabetic nephropathy

Answer 14

urinalysis to look for microalbuminuria so should be scanned annually
albumin to creatinine ratio (ACR) more than 2.5

Question 15

What would be found in the renal biopsy of a patient with diabetic nephropathy

Answer 15

Kimmelstiel-Wilson nodules

Question 16

What happens if ACR is 3 or more

Answer 16

ACE inhibitor or ARB (Angiotensin receptor blocker)

Question 17

What is diabetic neuropathy

Answer 17

Dysfunction of the vasa nervorum vessels which supply peripheral nerves

Question 18

peripheral neuropathy - what is it?

Answer 18

loss of sensation - important to check feet
Neuropathic ulcers typically develop over callouses or pressure points
loss of ankle jerk reflex

Question 19

distribution of peripheral neuropathy

Answer 19

glove and stockings

Question 20

How is diabetic mononeuropathy characterised

Answer 20

sudden motor loss - wrist drop, foot drop, 3rd nerve palsy

Question 21

What is Autonomic neuropathy

Answer 21

• GI tract - difficulty swallowing, delayed gastric emptying, bladder dysfunction
• Postural hypotension
  -Loss of bladder control
  -Sweating

Question 22

management of diabetic neuropathy

Answer 22

get glycaemic control back to alleviate symptoms long term
Neuropathic pain agent

Question 23

Neuropathic pain agent

Answer 23

Duloxetine, amitriptyline, pregabalin, gabapentin

Question 24

localised neuropathic pain treatment

Answer 24

capsaican

Question 25

rescue therapy for exacerbations of neuropathy

Answer 25

tramadol

Question 26

When is pioglitazone not suitable

Answer 26

Previous history of bladder cancer instead focus more on gliptins such as sitagliptan (DPP-4 inhibitor)

Question 27

target clinic blood pressure

Answer 27

140/90

Question 28

when should metformin be avoided

Answer 28

in times of moderate or severe renal failure (anything below 30 eGFR)

Question 29

Types of SGLT-2 inhibitor

Answer 29

empagliflozin

Question 30

HbA1c for a patient that is on glucose decreasing medication

Answer 30

if on medication such as sulfonylureas then aim is 53

Question 31

What is Ramipril

Answer 31

ACE i for high blood pressure

Question 32

when is amlodipine used over ramipril

Answer 32

When patient is over 55 and does not have type 2 diabetes (T2DM first line is always ramipril)

Question 33

first line insulin regime when it comes to new T2DM patients

Answer 33

Twice-daily basal insulin detemir, insulin aspart bolus with meals

Question 34

How does hypoglycaemia present

Answer 34

As appearing to be drunk

Question 35

At what QRISK should SGLT-2 inhibitor be given?

Answer 35

anything above 10 SLGT_2 inhibitors are ones ending in flozin like dapagliflozin

Question 36

what is gliclazide

Answer 36

sulfonylurea

Question 37

How do DPP-4 inhibitors work

Answer 37

reduce peripheral breakdown of incretins such as GLP-1

Question 38

What should not be given as a first line with someone who has diabetes but an eGFR below 30

Answer 38

Metformin because it can lead to lactic acidosis