Diabetes 4

Question 1

What type of blood glucose monitoring should be offered to patient to self manage their diabetes?

Answer 1

Continuous glucose monitoring (CGM)
- Intermittently scanned (flash) CGM (isCGM)
- Real-time CGM (rtCGM)

Question 2

What is an example of an intermittently scanned (flash) CGM?

Answer 2

Freestyle Libre

Question 3

What is a freestyle libre made up of?

Answer 3

A sensor and a reader

Question 4

Who is capillary glucose monitoring for and how often must they use it?

Answer 4

Patients unwilling to or unable to use CGM and they must use it at least four times a day, including before each meal and before bed

Question 5

Are blood glucose monitors available on the NHS?

Answer 5

No but test strips and lancets are, they are cheap to buy but proper instruction for use is needed

Question 6

What are the target levels for type 1 diabetics in terms of HbA1c and glucose levels?

Answer 6

• HbA1c of 48 mmol/mol (6.5%) or lower
• glucose levels:
  
  • fasting blood-glucose conc: 5-7mmol/l on waking
  • before meals blood-glucose conc: 4-7mmol/l
  • after meals blood-glucose conc: 5-9mmol/l at least 90 mins after

Question 7

What treatment and lifestyle advice is available for type 1 diabetics?

Answer 7

Insulin therapy, healthy diet, regular exercise, diabetes education, regular check-ups at diabetes clinics

Question 8

What were the results of the DCCT study?

Answer 8

• Intensive therapy reduced risk of complications
• Severe hypoglycaemia increased threefold (more tightly controlled sugar levels)

Question 9

What were the overall conclusions of the DCCT and EDIC studies?

Answer 9

STRICT control of blood glucose can reduce the risk of MICROVASCULAR complications of type 1 diabetes (retinopathy, nephropathy, neuropathy)

Question 10

What three insulin regimens are available for type 1 diabetes?

Answer 10

Basal-bonus, twice daily (biphasic insulin), Continuous subcutaneous infusion

Question 11

What is the basal-bonus regimen?

Answer 11

• Bolus of Rapid-acting/short-acting insulin before breakfast, lunch and evening meal
• Injection of prolonged/intermediate action insulin once or twice daily

Question 12

What are the advantages and the monitoring requirements of the basal bolus regimen?

Answer 12

Close to physiological insulin production and there’s great flexibility.
Regular and frequent blood glucose monitoring required

Question 13

What is the NICE guidance for a basal-bolus regimen?

Answer 13

Multiple daily injection basal-bolus regimens
- Basal - twice daily insulin detemir
- Bolus - aspart, lispro or glulisine

Question 14

What is the twice daily with biphasic insulin regimen?

Answer 14

Patient injects biphasic insulin twice a day (two thirds before breakfast, one third before evening meal)

Question 15

What are the disadvantages of the twice daily biphasic insulin regimen?

Answer 15

Does not match physiological insulin
- Risk of hypoglycaemia between meals (snacks required)
Less flexible than basal-Bolus

Question 16

What is the continuous sub-cutaneous infusion regimen?

Answer 16

Continuous sub-cutaneous infusion via an insulin pump, using short-acting or very rapid acting insulins

Question 17

What is an advantage and two disadvantages of continuous sub-cutaneous infusion?

Answer 17

Physiological insulin delivery
Intensive patient education required and 24hr access to diabetes team necessary

Question 18

According to NICE guidelines, only under what two instances can a patient be offered continuous sub cutaneous infusion?

Answer 18

• Patients who suffer disabling hypoglycaemia white trying to achieve target HbA1c
• Have high HbA1c levels after multiple daily injection therapy

Question 19

What are closed loop systems and what is their advantage?

Answer 19

Insulin released automatically by pump in response to blood glucose levels detected by a rtCGM sensor
Adv: better glucose control, reduces the risk of hypoglycaemia

Question 20

What instances might a patient might need to adjust their insulin dose?

Answer 20

• Pre-meal blood glucose reading
• Amount of carbohydrate required to be consumed
• Planned activity e.g. exercise