Diabetes

Question 1

What is the screening for Diabetes?

Answer 1

• Use AUSDRISK every 3 years from 40yo to screen people for diabetes
  
  • requires waist measurement, heritage, FHx, gender, , levels of physical activity, diet, smoking, BP, and gestational diabetes Hx
  • use FBG or HbA1c for a score of 12 or more
• individuals at high risk should be screened every 12 months
  
  • IGT (impaired glucose tolerance)
  • Hx of CVD
  • >35 from china, subcontinent, or pacific islands
  • BMI >30
  • PCOS or gestational diabetes
  • antipsychotic medications

Question 2

Complications of Diabetes?

Answer 2

1. Painful Neuropathy:
   * Paracetamol
   * TCA
   * Carbamazepine / pregabalin
2. Erectile Dysfx

• May be ~50% (macrovascular disease, autonomic neuropathy)
• Can use PDE inhibitor
• But must assess CV risk first

1. Postural Hypotension

• r/v exacerbating medications
• Δ behaviour - eg. Sitting quietly after sitting b/f standing
• Graded compression stockings
• Fludrocortisone - if severe

1. Gastroparesis

• Domperidone - D2 antagonist
• Cisapride - ↑gut motility (5HT4 receptor agonist - PNS-mimetic)
• Erythromycin

1. Driving

• Can impair driving due to
• Hypoglycemia
• ↓VA
• Must report to VicRoads
• If diet controlled → safe to drive

Review

• 5y = Ø insulin
• 2y = insulin-dependent
• Consider if retinopathy

Question 3

Go through some Oral Agents for Diabetes treatment, talk through some side effects.

Answer 3

Consider it when 3-6 months of poor BSL control with diet treatments.

1. Metformin

• 2g/day (3g/day if obese)
• 60-90 eGFR 2g/day max
• 30-60 eGFR 1g/day
• <30 - can’t use
• side effects lactic acidosis, GI disturbance

Other OHG:

• Sulphonylureas (e.g. gliclazide)
  
  • safe in renal impairment
  • weight gain and hypoglyemia common
• DPP-4 Inhibitors (gliptins)
  
  • pancreatitis
  • do not use with GLP-1
• GLP-1 analogues (e.g. exenetide)
  
  • only injectible
  • weight loss - good efficacy
  • SE = GIT
• SGLT-2 inhibitors (e.g. dapagliflozin)
  
  • SE = dehydration, euglycemic ketoacidosis, UTIs

Question 4

What is the Annual Cycle of Care for Diabetes?

Answer 4

• 3-6mo
  
  • HbA1c
    
    • 3mo - after Δ rx / unstable
    • 6mo - stable DM
  • ACR
  • Podiatry review (up to 5x / year)
  • ± urine dipstick (infx)
• 12mo
  
  • Full exam
  • ± ECG
  • Eye review
• Eyes
  
  • Every 2y
  • Every 1y if nephropathy, poor control, ASTI, social disadvantage
  • 3-6mo if established retinopathy
• Feet
  
  • Low risk = annual assessment
  • Medium/high risk = every 3-6mo podiatry r/v

Question 5

How do you diagnose Diabetes?

Answer 5

• should be confirmed in 3-6 months with an OGTT
• if symptomatic only need one suggestive result for a diagnosis

Question 6

What is the treatment for Diabetes?

Answer 6

1. Lifestyle + rx co-morbidities​​
   * Register w. National Diabetes Service Scheme + GPMP
   * Advise on obligations to VicRoads
   * Diabetes education
   * Dietary advice
   * Hypo education + action plan
   * Sick day mx
   * Tell someone so they can check on you
   * BSL every 2-4h
   * Keep eating + drinking
   * Eat normally if possible
   * If Ø eating normally
   * Easy to manage carbohydrates
   * If Ø food at all → check BSLs
   * >15 → unsweetened fluids
   * <15 → sweetened fluids
   * May need to Ø insulin temporarily
   * Call doctor if:
   
   • BSL ≥15mmol for ≥12h
   • Vomiting / diarrhoea for ≥12h
   • ↑unwell / become drowsy
     * Alcohol intake
     * Vaccination
   • Flu
   • Pneumococcus
   • Tetanus when 50yo
2. Monotherapy
3. Combination therapy
4. Combination + insulin

Question 7

What is the management for a lady who has IGT?

Answer 7

ST:

• weight,
• cholesterol,
• BP
• Dietician.
• Education about risk

More evidence program (LIFE! Program) - 5 sessions and a session before 40% power.

MT/LT

• HbA1c in a year
• BP, weight, PAP smear

Question 8

How would you manage someone with newly diagnosed diabetes?

Answer 8

ST:

• NDSS,
• diabetes education nurse,
• vicroads
• medication ,
• PAID tool

MT:

• chronic care plan

LT:

• annual cycle of care

Question 9

Counsel someone who has just been prescribed insulin, what are some barriers to insulin initiation?

Answer 9

Barriers to Initiation:

• Hypoglycemia
• Titration flow charts
• Education and revisit on regular basis (diabetes australia)
• Weight gain (2kg over 12month) - proportional to HbA1c
• 1x a day injection starting on that.
• Patient Factors: Stigma, fear, cognitive impairment, dexterity, fear of hypoglycemia
• Doctor Factors: easier just to take a tablet (time), compliance, confidence (refer)

Counselling initiation:

• Rotating injection site = should be ≥3cm from previous injection site
• hypoglycemia (RFs for hypoglycemia flashcard)
• glycemic goals - generally start on basal insulin and may maintain site

*

Question 10

Triggers for hypoglycemia?

Answer 10

Triggers:

EX: exogenous insulin

P: pituitary failure

L: liver failure

A: adrenal failure (addison’s)

I: insulinoma

N: non-pancreatic neoplasms

S: skipped meals