Diabetes

Question 1

Blood glucose should always be above what while driving?

Answer 1

5mmoll

Question 2

What action should be taken if BG falls below 4 while driving?

Answer 2

Stop the vehicle, eat/drink sugar and wait until 45 minutes after blood glucose has returned to normal before continuing therapy

Question 3

HBA1c test reflects the average plasma glucose levels over how long?

Answer 3

Over the previous 2 to 3 months

Question 4

Do patients need to fast for a HbA1c test?

Answer 4

No - unlike the oral glucose tolerance test, an HbA1c test can be performed at any time of the day and does not require any special preparation such as fasting.

Question 5

When should HBA1c NOT be used to diagnose diabetes?

Answer 5

suscepted Type ONE diabetes, in children, during pregnancy or in women who are up to two months post partum. Should also not be used if patient has had symptoms of diabetes for less than two months, inpatients taking medication that can cause hyperglycemia, end stage CKD and HIV infection.

Question 6

A target HbA1C of what is recommended in patients with type 1 diabetes?

Answer 6

48

Question 7

How often should BG concentrations be measured in T1DM?

Answer 7

At least four times a day, including before each meal and before bed.

Question 8

Patients with T1DM should aim for what BG concentration on waking?

Answer 8

5-7

Question 9

Patients with T1DM should aim for what BG concentration before meals?

Answer 9

4-7

Question 10

Patients with T1DM should aim for what BG concentration 90 minutes after eating?

Answer 10

5-9

Question 11

What is the first line recommended insulin regimen in T1DM?

Answer 11

Multiple daily injection basal-bolus regimen.

Insulin determir BD (or once daily insulin glargline) and a rapid acting insulin with meals.

Question 12

If a basal bolus regimen is not appropriate in T1DM what is the next regimen that should be offered?

Answer 12

A twice daily mixed insulin regimen.

Question 13

When can a continuous subcut insulin infusion be considered in diabetes?

Answer 13

Should only be offered to adults who suffer with disabling hypos, or who have a high HbA1c conc >69

Question 14

How would infection, stress or trauma impact on insulin requirements?

Answer 14

May increase the required insulin dose

Question 15

How might physical activity, intercurrent illness and reduce food intake impact on insulin requirements?

Answer 15

May decrease the insulin requirements

Question 16

Name the three rapid acting insulins

Answer 16

Gluisine, aspart and lispro (GAL)

Question 17

Why might a DPP-4 inhibitor be beneficial?

Answer 17

Do not appear to be associated with weight gain and have less incidence of hypoglycemia that with SU

Question 18

Why is the role of repaglinide in T2DM limited?

Answer 18

Only licensed in combination with metformin

Question 19

Why should ACEi be used with caution in patients with diabetes?

Answer 19

ACEi can potentiate the hypoglycemia effect of insulin and oral antidiabetic drugs

Question 20

How should insulin be managed before/during and after major surgery?

Answer 20

On the day before surgery - once daily long acting insulin should be given at 80% of the usual dose. Other insulin should be given as normal.

On the day of surgery - continue at 80% of the normal dose, all other insulin should be stopped until patient is eating and drinking again.

During surgery start an VRIII

Conversion back to s/c insulin should not beginuntil the patient can eat and drink without nausea or vomiting. The VRIII and IV fluids should be continued for 30-60 minutes after the first meal time short acting insulin dose.

Question 21

Can GLP-1 agonists be continued during surgery?

Answer 21

Yes can be taken as normal during the whole peri-op period

Question 22

How should SGLT2 inhibitors be managed before surgery?

Answer 22

Should be omitted on the day of surgery and not restarted until the patient is stable. Their use during periods of dehydration andacute illness is associated with an increased risk of ketoacidosis.

Question 23

How should SU be managed in patients undergoing surgery?

Answer 23

SU are associated with hypglycemia in the fasted state and therefore should always be omitted on the day of surgery and until the patient eating and drinking again.

Question 24

How should metformin be managed in patients undergoing surgery?

Answer 24

Metformin is renally excreted, renal impairment may lead to accumulation and lactic acidosis during surgery. If only one meal with be missed during surgery and the patients eGFR is greater than 60 and alow risk of AKI (and the procedure does not involve administration of contrast media), it may be possible to continue metformin - lunch time dose should be omitted.

If the patient will miss more than one meal or if there is a signif risk of the patient developing an AKI it should be stopped when fasting begins and a VRIII should be started if the dose is more than once daily.

Restart once eating and drinking again and renal function has been assured.

Question 25

Which oral antidiabetic drugs must be stopped during illness?

Answer 25

SGLT-2 inhibitors

Question 26

Signs of lactic acidosis include?

Answer 26

Dysponea, muscle cramps, abdominal pain, hypothermia, or asthenia.

Question 27

Metformin monitoring requirements

Answer 27

Renal function should be determined before treatment and at lest annually.

Question 28

DPP4 inhibitors can lead to what serious side effect?

Answer 28

Pancreatitis - discontinue if symptoms of acute pancreatitis occur (persistent, severe abdominal pain)

Question 29

Important side effects with exenatide (and other GLP-1 agonists)

Answer 29

Severe pancreatitis (sometimes fatal) including haemorrhagic or necrotising pancreatitis has been reported rarely. Discontinue permanently if diagnosed.

Question 30

Exenatide patient advice

Answer 30

Some oral medications hsould be taken at least 1 hour before or 4 hours after injection.
Inform patient on signs of pancreatitis.

Question 31

Exenatide missed dose advice

Answer 31

If a dose is missed continue with the next scheduled dose - do not administere after meal.

Question 32

How often is liraglutide (saxenda/victoza) administered?

Answer 32

Once a week

Question 33

How should liraglutaide be stored?

Answer 33

Store in a refrigerator, after first use can be stored below 30’C, discard 1 month after first use

Question 34

SGLT-2 important safety information

Answer 34

Risk of DKA

Question 35

Canagliflozin important safety information

Answer 35

Increased risk of lower limb amputation (does not apply to the other flozins). Consider stoping if a patient develops a significant lower limb complication e.g. ulcer, osteomyelitis.
and
DKA

Question 36

SGLT-2 monitoring requirements

Answer 36

Determine renal function before treatment and at least annually thereafter and before initiation of concomitant drugs that reduce renal function and periodically thereafter.

Question 37

SLGT-1 patient and carer advice

Answer 37

Patients should be advised to report symptoms of volume depletion, including postural hypotension and dizziness. Patients should be informed of the signs and symptoms of DKA.

Question 38

Pioglitazone important safety information

Answer 38

Increased risk of heart failure - incidence of HF is increased when pioglitazone is combined with insulin, especially in patients with predisposing factors e.g. MI. Should not be used in patients with HF.

Risk of bladder cancer. Patients should be advise to report anyhaematuria, dysuria or urinary urgency.

Question 39

Pioglitazone contraindications

Answer 39

History of HF, previous or active bladder cancer, uninvestigated blood in urine.

Also caution in those at increased risk of bone fractures, particularly women.

Question 40

Insulins important safety information (MHRA alert)

Answer 40

Risk of severe harm and death due to withdrawing insulin from pen devices.