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Endocrinology (Long) > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Diabetes History? (not PRICMCP!) ****

A

DIABETIC’s Follow-up (or DIABEdIC’s Follow-up)

Date of diagnosis

Insulin & other OHG - when did it start, current treatment, compliance

A1C (HbA1C)

BSL monitoring - how often, when, who, hypo episodes and awareness. What is your symptoms of hypos, do you feel lethargic in the morning, night sweats? (nocturnal hypo)

Education - level of understanding (do you know danger of not monitoring, not checking it before driving, complications long-term, danger of hypos?)

The Diet & exercise. Do they carbo-count (if not, suspect poor health-literacy)

Immediate/short-term complications: Infection, ICU admissions, hospitalisations with DKA/HHS.

  • Hypoglycaemia: how symptomatic? LOC (suspect hypo-unawareness)

Chronic complications: Macro (CVD, CVA, PVD) & Microvascular (retino - any laser treatment, nephro, neuro - erectile dysfunction, fainting, nocturnal diarrhoea, gastroparesis, PN)

Sick day management/Safety: driving, do you have action plan (for hypos)

Follow-up: Endocrinologist/GP, Podiatry 3 monthly, Ophthal 12 monthly.

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2
Q

Give carbo-count example.

A

1 unit of insulin for every 10g of Carbohydrate is an example.

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3
Q

How would you ask about microvascular complications of diabetes? (for neuro - 4)

A

Retinopathy: when was the last eye-exam, what was the results, any blurred vision?

Nephropathy: did doctors tell you that your kidney function is abnormal? or diabetes affected your kidneys?

Neuropathy:

  • Any numbness, tingling or weakness in legs? (PN)
  • Do you suffer from fainting, or dizzy when you stand up? (autonomic neuropathy)
  • Do you have diarrhoea at night? (nocturnal diarrhoea)
  • Erectile dysfunction
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4
Q

What 3 aspects of safety issues must be addressed?

A
  • Medication – cognition, who supervises them
  • Sick day (and perioperative Mx)
  • Driving (hypoglycaemia and vision)
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5
Q

What are the essential components of sick day management? (4)

A
  1. Knowing when to commence an action plan - unwell or BSL >15
  2. ↑ frequency of monitoring – 2-4 hourly
  3. ↑ food & water intake
  • try to maintain normal meal plan, water to prevent dehydration
  • If BSL >15: use sugar free fluids
  • If BSL <15: use oral rehydration solutions (may contain glucose)
  • If unable to tolerate oral fluids & BSL ↓ - seek medical attention
  1. Medication
  • Insulin
    • should generally be continued → see a doctor if BSL >15 on 2 consecutive readings.
    • ↑ long-acting insulin by 10-20% if hyper
    • ↓ short-acting insulin if not eating well
  • OHGs
    • If vomiting / dehydrated → metformin, GLP1 RA may need to be stopped (worsens NV)
    • SGLT-2 inhibitors should be ceased (worsens dehydration & euglycaemic DKA)
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6
Q

What are the features of autonomic neuropathy in diabetics? (4)

A

Erectile dysfunction

Postural hypotension

Gastroparesis

Nocturnal diarrhoea

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7
Q

Diabetes - examinations? (7 areas)

A

BMI

Retinopathy: proliferative or non-proliferative

Acanthosis nigricans & Skin tags (signs of insulin resistance)

Cardio: postural BP, heart failure, peripheral pulses

Abdomen: insulin injection sites / thighs (Lipodystrophy)

LL neuro - monofilament, vibration, reflexes

Foot: Charcot’s (?any collapse of foot arch)

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8
Q

How do you perform a monofilament test?

A

How: Hold the monofilament perpendicular to the foot and with a smooth, steady motion, touch the skin until the monofilament bends approximately 1 cm. Hold it against the skin for approximately 2 seconds.

Positive test if the patient can’t feel it.

Indicates peripheral neuropathy.

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9
Q

Signs of Charcot’s foot? (4)

A

Foot swelling

Redness

Warm

Deformed

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10
Q

What do you must check before you start a patient on Insulin therapy? (3)

A

Cognition - who will administer them?

Eye sight - visual acuity

Hand function - fine-motor to administer

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11
Q

Insulin – pros (2) and cons (3)?

A

Pros:

  • No ceiling effect
  • Minimal problems in renal or hepatic disease
  • Few non-physiologic adverse effects

Cons:

  • Hypoglycaemia and weight gain
  • Injection only – needs good hands and eyes
  • Can have variable absorption if injection site not rotated
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12
Q

Metformin – pros (3)& cons (3)?

A

Pros:

  • Relatively potent (HbA1c reduction of 1%)
  • hypoglycaemia unlikely
  • weight loss
  • improves cardiovascular outcomes in overweight patients

Cons

  • Renal disease (contraindicated < 30 eGFR)
  • GI side effects (nausea and diarrhea)
  • Lactic acidosis (rare)
  • B12 deficiency – needs regular checking
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13
Q

Diabetic on Metformin waiting for Contrast-CT scan: any thoughts?

A

It can interact with radiocontrast material

May worsen renal impairment

Stop Metformin on a day of procedure requiring contrast and 48 hours post

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14
Q

Sulfonylureas – e.g. gliclazides pros (2) & cons (3)

A

Pros:

  • Similar potency to metformin (HbA1c reduction of 1%)
  • Cheap

Cons

  • Hypoglycaemia
  • Weight gain
  • Not safe in renal impairment
  • Worse risk profile in elderly

** High threshold to start de novo, low threshold to cease **

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15
Q

DPP-IV inhibitors (Gliptins) – pros? (3)

A
  • Dipeptidyl-peptidase IV inhibitors
  • Good potency (0.5 - 1% HbA1c reductions)
  • Weight neutral
  • Unlikely to cause hypoglycaemia
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16
Q

DPP-IV inhibitors - what are the precautions related to comorbidities that patient may have? (3)

A
  1. Renal impairment - dose reduce
  2. Heart failure / IHD - increased risk with Saxagliptin
  3. Pancreatitis & Pancreatic Ca - if patient had history of this there is sig recurrence risk
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17
Q

GLP-1 agonists (exenatide, liraglutide, dulaglutide) - Pros (4)

A
  • High potency (>1% HbA1c reductions)
  • Weight loss
  • Unlikely to cause hypoglycemia
  • Evidence of CV and renal risk reduction
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18
Q

GLP-1 agonist cons (4)?

A
  • Injection only
  • Avoid in Pts with pancreatitis or pancreatic Ca (risk of recurrence)
  • Avoid in significant renal impairment
  • Expensive if not PBS funded (needs two+ oral agents)
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19
Q

SGLT-2 inhibitors pros (3) & cons (2)

A

Pros:

  • Weight loss
  • No hypoglycaemia
  • Excellent CVD (and now renal) risk reduction

Cons:

  • Needs sick day/periop management (risk of EKA)
  • Vulvovaginitis/balanitis
  • UTIs/urosepsis
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20
Q

Problem with Thia-zoledine-diones (TZDs)? 5+

A

Very potent but…

can cause:

  • weight gain
  • peripheral oedema
  • increased risk of heart failure
  • macular oedema (rare)
  • fracture in postmenopausal women (rare)
  • possible increased risk of bladder cancer (pioglitazone)
  • take 6 to 12 weeks to reach maximum effect
21
Q

So why would anyone use TZD (pio/rosiglitazones)?

A
  • Does not require dose adjustment for renal impairment
  • Still 3rd line agent – monitor LFTs
22
Q

So which OHG may also cause weight loss?

A

Weight loss: SGLT2, GLP-1

Weight neutral: Metfomin and DPPIV

23
Q

When would you stop following drugs according to CrCl?

Metformin

Sulfonylurea

TDZ

DPP-IV

GLP-1

SGLT2

A

Generally, 30 or less is a contraindication. There are exceptions however…

Metformin: 30

Sulfonylurea: 30

TDZ: none

DPP-IV: 45-60

GLP-1: 30

SGLT2: 45-60

24
Q

Which oral Hypoglycaemics do not need dose-adjustment for renal impairment? (3)

A

TDZs

Liraglutide (GLP-1, but not others)

Linagliptin (DPP-IV, but not others)

25
Q

Caution for using ACEi and DPP-IV together?

A

Increased risk of ACEi induced angioedema

26
Q

How would you go about starting insulin in outpatient for type I diabetic patient?

A

Goal: minimise ketosis while avoiding hypoglycaemia

  • Insulin requirement is usually between 0.4 – 1.0 unit/kg/day
  • So 70kg man’s requirement should be ~35-70 units/day
  • Start small – 0.25u/kg/day. For 80kg man – this would be 20 units per day.

Type 1 - consider

  • Basal – bolus regime: OD Lantus + TDS Novorapid with meals
  • Continuous SC infusion via insulin pump + extra-insulin at meal times after calculation of insulin: carb ratio and based on BSL
27
Q

How would you go about starting insulin in outpatient for TIIDM patient?

A

Goal: minimise ketosis while avoiding hypoglycaemia

  • Insulin requirement is usually between 0.4 – 1.0 unit/kg/day
  • So 70kg man’s requirement should be ~35-70 units/day
  • Start small – 0.25u/kg/day. For 80kg man – this would be 20 units per day.

TIIDM – reasonable starting point would be 10-12 units of lantus plus normal OHG

Increase 1-2 weekly

Aim BSL 4-7 throughout day and night

If not achieving the goal then consider changing to pre-mixed insulin BD

28
Q

Definition of insulin resistance in terms of insulin requirement?

A

•Insulin requirement >200 units per day

29
Q

What are the causes of treatment-resistant diabetes (with insulin) how would you approach this? (3)

A

Exclude lipodystrophy & compliance issues

Investigate for circulating antagonist hormones – GH, Cortisol, Thyroxine, and Glucagon (i.e. anything that promotes growth)

Insulin antibodies (uncommon – but an indication for more purified insulin)

30
Q

What is Somogyi (somoji) & dawn effect and how would you address these?

A

Somogyi effect = nocturnal hypo → rebound hyper in the morning

  • Due to release of counter-regulatory hormones
  • Treatment = reduce the evening insulin dose

Dawn effect = normal nocturnal BSL → hyper mane

  • Treatment = increase the evening insulin dose
31
Q

What are the causes of hypoglycaemia in previously stable diabetics on insulin? (6)

A

↓ oral intake

↑ exercise

Injection errors – suspect cognitive problems

Diabetic nephropathy

Under secretion of counter-regulatory hormones: i.e. ↓cortisol, T4, pan-hypopituitarism

Insulinoma (rare)

32
Q

You saw him in a few months time and BSL target has not been yet – not even close. What is your approach? (4)

A
  1. Check compliance
  2. Educate – make sure patient understand the point of treatment & complications thereof if poorly controlled
  3. Exclude infection or review if any new medications (e.g. steroids) was started
  4. Consider diet, weight, exercise program
33
Q

What is your approach to the management of this patient’s diabetes?

A

Goals: 1) improve glucose control, 2) avoid hypoglycaemia, 3) prevent micro/macrovascular complications.

Confirm Dx: OGTT (2h postprandial ≥11), fasting glucose (≥7), HbA1C (6.5%)

A: screen & treat secondary causes

  • Endocrinopathies (Acromegaly, Cushing’s, Obesity)
  • Pancreatic insufficiency (CF, Haemochromatosis, Pancreatitis)
  • Drug-induced (antipsychotics, antiretrovirals, NODAT if transplant)

Screen for Complications

  • Micro: review previous Opthalmology records, UACR/UPCR, NCS guided by symptoms
  • Macro: ECG (LVH), Stress Test, TTE (RWMA), ABPI/dopplers (PVD), CTB/Carotids
  • Autonomic: postural BP, gastric emptying if hx suggestive of gastroparesis

T: non-pharm

  • CV risk factor mx: weight loss, exercise (exercise program enrolment), Mediterranean diet, smoking/ETOH cessation. These increases insulin sensitivity and improves BSL and lipids profile
  • Losing weight is hard & previous attempts have failed, I would start by getting patient to join a walking group or hydrotherapy
  • Education: involve diabetic educator, teach the importance of close monitoring in preventing life-thretening short & long term complications
  • Safety!: Sick day plan: have it documented & provide, Glucagon kit (family must know how to use it)
  • infection prophylaxis: hygiene, vaccinations, avoiding contacts, foot care

T: pharm

  • Specific to each case with regards to pharmacological regime
  • Consider Bariatric surgery if obesity is the cause
  • Complications: BP/Lipid Mx, symptom Mx for neuropathy (e.g. lyrica), consider transplant for ESRF.

Involve: dietician, diabetic educator, diabetes group/society for continuing support & motivation

C: monitor EUC, UACR/UPCR, vision, PN, ECG, bruits. If nephropathy - check Hb, Calcium/Vit D, PTH…etc.

Ensure F/U and appropriate F/U are organised - 3 monthly podiatry, 12m ophthal (check safety to drive!). If Charcot’s consider referral to high-risk foot clinic (very MDT - ID, endo, vascular teams), PT/Rehab

34
Q

What is your advice on this diabetic patient’s diet? (5)

A

The principle is to minimise saturated fats, cholesterol, whilst increasing fibre, healthier carbohydrates and protein in the diet.

Aim: 50% Carb, 20% Protein, 10% Poly-unsat fat, <10% sat fat, <300mg Chol, >30g fibre.

  1. Healthier Carbohydrate: whole grains, brown rice, avoid processed cereals
  2. Healthier fats: avocado, oily fish, olive oil, unsalted nuts instead of butter, ghee
  3. Salt restriction
  4. Eat less red/processed meats, swap for poultry, unsalted nuts, fish.
  5. Increase fruit & veg (sugar is natural, not added sugar. Not juice with added sugar)
35
Q

What is insulin pump? (3)

A

Continuous infusion of very short acting insulin + mealtime boluses

Only used in T1DM, studies have shown mild improvement (0.2%) improvement in HbA1c

Need to carb count

36
Q

On a follow-up you note that urine ACR is 30. What do you do? (short, 1 word answer) do you know what are the cut off values for micro, macro, nephrotic range proteinuria? (UACR)

A

UACR

  • <3 normal
  • 3-30 microalbuminuria
  • 30-300 macroalbuminuria
  • >300 Nephrotic range proteinuria

Treat microalbuminuria with ACEi or ARB.

37
Q

What is the progression rate to ESRF in patients with proteinuria?

A

•They will progress to ESRF in 5-10 years – this is inevitable.

So need to think/plan-ahead about dialysis

38
Q

How would you manage Charcot’s joints?

A

Exclude other pathology – OM, septic joint, gout/pseudogout (XR, CT)

Non-pharm:

Acute attack – NWB for 8 weeks until resolution or oedema and erythema

Chronic – regular podiatry appointment to prevent ulcers. Consider surgery.

39
Q

How often would you monitor for retinopathy?

A

Opthalmoscopy +/- retinal photography 1-2 yearly

If anything more than minimal disease = 6-12 monthly

Refer to ophthalmology if

Moderate non-proliferative

Proliferative

Macular involvement

40
Q

What are the HbA1C, BP, Lipids targets in diabetics?

A

HbA1C

  • <7 for most patients
  • <6.0 if no CVD and only on metformin/ lifestyle
  • <6.5% if no CVD and on OHGs but NO insulin
  • <7.0 if on insulin
  • <8 if previous hypoglycemic events or in older patients with limited life expectancy

BP

  • < 130/80 if no proteinuria
  • <125/75 if proteinuria

Lipids

-LDL <2.0 (<1.8 if known IHD)

-HDL >1.0

-TG <1.5

-Total chol <4.0

Exercise

At least 30min of brisk walking, five or more days per week

41
Q

Diabetic patient with dynamic bone disease from nephropathy with fracture – would you give anti-resorptive therapy? How would you approach this?

A

Difficult issue because it is hard to distinguish whether this is adynamic bone disease (renal osteodystrophy – where turn over is very low which decreases osteoblast & osteoclast) or high-turn over ⇒ ALP (and P1NP) can be useful

If ALP or P1NP is elevated, argument for starting anti-resorptive therapy

In renal impairment, these should really be elevated

In normal, high normal range would be enough to start

42
Q

What is your approach to managing this patient’s erectile dysfunction? (3)→

A

Exclude alternative diagnosis: check pituitary / primary hypogonadal pathologies / depression à address these

Non-pharm: Sexual therapists & Sexual health specialist

Pharm: Cautious use of sildenafil ⇒ hypotension and type II injury. So if history of IHD, consider intra-cavernosus injection

43
Q

Foot care – what would you advise the patient from practical view point?

A

To regularly check his feet

Continues to have good footwear

Orthodics review to ensure his footwear is appropriate

Custom shoes to offload pressure site

Podiatrist 6 weekly

44
Q

Which investigations are useful to distinguish between type I vs II diabetes? (5)

A

C-peptide (will be low in TIDM due to endogenous insulin deficiency)

Antibodies: ZnT8 (Zink-transporter), GAD (glutamic acid decarboxylase), Islet cell, Anti-Insulin

45
Q

When would you consider advising against driving? (3)

A

Significant retinopathy or neuropathy

Recurrent hypoglycaemia

46
Q

What is the problem with Haemodialysis in patients with diabetic retinopathy + ESRF?

A

Retinopathy can get worse by HD. PD is better.

47
Q

Pregnancy and Diabetin on insulin. What are important considerations you need to think of?

A

Due to effects of HPL (human placental lactogen), the insulin requirement goes up in the 2nd + 3rd trimester (as much as by 50%)

After delivery, there is dramatic reduction of insulin requirement - watch for hypo and reduce the dose.

Aim to normalise HbA1C prior to pregnancy - to minimise complications such as congenital malformations, IU death, imaturity…etc.

Especially in poorly controlled diabetics, involve NICU and paediatrics early.

48
Q

The implication of poor vision in diabetics?

A

Driving - often a big implication for jobs/employment and risk factor for social isolation.

Bring it up!

49
Q

Sick day rules for diabetics?*** Gold for long case

A

SICK

Sugar: explain that BSL will increase during illness - increase freq of monitoring

Insulin: NEVER stop insulin. WH Metformin & SGLT2 but others should continue.

Carbohydrate: maintain adequate oral hydration and carbo intake. If vomiting → replace meals to sugary fluids.

  • If BSL >13, sugar free fluids + increase insulin by X (provide chart attached)
  • If <13, sugary fluids + insulin as normal.

Ketones - if TIDM, monitor ketones 2-4 hours + extra Novorapid if ketone present.

If vomiting and unable to keep fluids down, persistently high BSLs or ketones → come to ED.

Endocrinology (Long) (9 decks)

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