Diabetes

Question 1

Treatment algorithm for T2DM

Answer 1

Duodenal jejunal bypass if BMI >41

Otherwise:

1) Metformin If HbA1c >58:
2) + DPP4 inhibitor/ pioglitazone/ sulfonylurea
3) Metformin + DPP4 + SU
4) Metformin + pioglitzaone + SU
5) GLP-1 agonist (liraglutide) or SGLT2 inhibitors (-flozins)
6) + insulin

Question 2

What should the Hba1c target be?

Answer 2

<48mmol

Question 3

What should the target be if there is a hypo risk + how is this achieved?

Answer 3

Monotherapy to keep Hba1c at 53mmol

Question 4

When to add a 2nd + 3rd drug?

Answer 4

Hba1c >53, 58mmol

Question 5

When to diagnose T1DM?

Answer 5

Fasting glucose >7

Glucose tolerance >11.1

Urine dip ++ glucose

Question 6

What is the mechanism behind DKA?

Answer 6

Metabolic acidosis, hyperglycaemia, ketonamia

Lack of insulin = reduced production of pyruvate

Acetyl coA increases so ketones increase

Question 7

Genetic link with diabetes

Answer 7

T1DM - HLA D4/3 lniked

T2DM - stronger family link but no HLA association

Question 8

T2DM RF

Answer 8

CVD risk factors - HTN, high cholesterol

Age >45

Obesity Fam Hx

Ethnicity - Asian + Hispanic

Gestational DM or baby >4.5kg

PCOS - leads to insulin resistance

Question 9

Diagnosis of T2DM

Answer 9

Symptomatic + 1 positive test result

Asymptomatic + 2 positive test results

Positive tests: fasting >7, random >11.1, OGTT >11.1

HbA1c >48 = diagnostic

Question 10

Microvascular complications of DM

Answer 10

Retinopathy Nephropathy Neuropathy

Question 11

Macrovascular complications of DM

Answer 11

IHD Stroke PVD

Question 12

General complications of DM

Answer 12

Immunocompromised - due to bacteria thriving in hyperglycaemic environment

Poor healing

Question 13

Annual monitoring for DM

Answer 13

ABCDEFG

Advice

BP

Cholesterol

Diabetic control - HbA1c, albumin:creatinine ratio

Eyes - fundoscopy

Feet - diabetic foot exam

Glycaemic control (drugs)

Question 14

What is ACR?

Answer 14

Albumin: creatinine ratio/ PCR first wee in the morning

Should be low <30 - high result indicates nephropathy

Question 15

What are the stages of diabetic retinopathy?

Answer 15

Background = dot+blot haemorrhages, microaneurysms, hard exudates

Maculopathy = decreasing visual acuity, haemorrhages around macular

Pre-proliferative = cotton wool spots

Proliferative = new vessel formation

Question 16

Difference between microaneurysms + haemorrhages

Answer 16

Microaneurysms = along the line of blood vessels Haemorrhages = random bleeds (flame + splinter)

Question 17

What are cotton wool spots + hard exudates?

Answer 17

Soft exudate = ischaemia of retina

Hard exudates = lipid deposition

Question 18

Types of insulin

Answer 18

Short, medium + long acting

Question 19

Types of insulin regime

Answer 19

BD biphasic: premixed insulins BD

QDS regimen (basal bolus): before meals short acting insulin + long acting at bedtime

ON regime: OD long acting before bed

DAFNE regime: calculate carbs + adjust insulin

Question 20

What is the sick day rule?

Answer 20

Don’t stop, maintain calorie intake, check BM QDS

Question 21

Mechanism of metformin + CI

Answer 21

Biguanide

Increases sensitivity to insulin

Doesn’t increase amount of insulin therefore no hypos

Helps with weight loss

CI with high creatinine

Question 22

SE of metformin

Answer 22

Nausea + diarrhoea - less so with modified release

Doesn’t cause hypos

Question 23

Mechanism + SE of SU, name of SU

Answer 23

eg Gliclazide, Glimeparide

Increases insulin secretion

Causes weight gain

Can get hypos

Need to monitor BM + inform DVLA

Question 24

Mechanism, names of + SE of DPP4 inhibitors

Answer 24

eg Sitagliptin

Blocks action of DPP4 - augments insulin + lowers blood glucose

Question 25

Mechanism, names of + SE of Glitazone

Answer 25

eg Pioglitazone Increases insulin sensitivity CI in HF - due to fluid retention Can get hypos SE: deranged LFTs, fluid retention

Question 26

Mechanism, names of + SE of SLGT-1

Answer 26

eg Gliflozins Blocks reabsorption of glucose in kidneys

Question 27

What are the diabetic emergencies?

Answer 27

DKA HHS Hypo

Question 28

S+S of DKA

Answer 28

Drowsiness, vomiting, dehydration Abdo pain Polyuria/ dipsia Kussmaul hyperventilation = trying to blow off CO2 (trying to get a respiratory alkalosis to compensate)

Question 29

ABG results for DKA

Answer 29

high O2, low CO2 (due to hyperventilation - normal if not) pH = acidotic, base excess will be low, bicarb low \<18

Question 30

Causes of DKA

Answer 30

Infection, surgery, MI, pancreatitis, non-compliance (diabolemia)

Question 31

Management of DKA

Answer 31

ABCDE approach If hypotensive = fluid challenge (1L over an hour, then 1L over 2 hours, then 1L over 4 hrs) Fixed rate insulin infusion 0.1 units/ kg/ hour (70kg = 7 units per hour) Check VBG at 1h, 2h + 2hrly afterwards When glucose \<14, start 10% glucose fluids

Question 32

Caution of hypokalaemia in DKA

Answer 32

Insulin pushes K+ into cells causing hypokalaemia Check VBGs regularly, and give K+ if hypokalaemic

Question 33

When do you stop insulin infusion in DKA?

Answer 33

When ketones \<0.3, venous pH \<7.3, HCO3 \>18

Question 34

What is a hypo?

Answer 34

BM \<4 GCS \<15

Question 35

What is bronze diabetes?

Answer 35

Caused by haemochromatosis likely to get liver cancer

Question 36

How often are diabetics checked up?

Answer 36

Diet controlled - once a year Tablet controlled - twice a year Unstable/ symptomatic - 4 times a year (HbA1c takes 3 months to change)

Question 37

What is HHS caused by?

Answer 37

Hyperglycaemia \>40 High serum osmolality \>320 Absence of significant acidosis

Question 38

S+S of HHS

Answer 38

Confusion Dehydration Neuro dysfunction Weakness Seizures Coma

Question 39

Management of HHS

Answer 39

IV 0.9% NaCl Aim for fall in glucose no more than 5mmol/ hr Start IV insulin when blood glucose no longer falling with fluids Treat underlying cause

Question 40

Complications of HHS

Answer 40

Vascular complications eg MI, stroke, PAD can cause: Seizures, cerebral oedema + central pontine myelinosis