Diabetes Flashcards
1
Q
What are the four types of diabetes?
A
- type 1 diabetes
- type 2 diabetes
- gestational diabetes (GDM)
- secondary diabetes (results as a consequence of another condition)
2
Q
Who needs to be made aware when a person is on insulin?
A
DVLA
3
Q
Is HbA1c used for monitoring glycaemic control in type 1 and 2 diabetes?
A
- yes (both)
- should not be used for diagnosis of type 1
4
Q
How often should Hba1c be measured in diabetes?
A
- Every 3-6 months
- If type 2 and stable, can be every 6 months
5
Q
What is the recommended HbA1c target in type 1 diabetes?
A
48mmol/L or lower
6
Q
How often should blood glucose be measured in type 1 diabetes?
A
at least 4 times a day
7
Q
What are the blood glucose aims for:
a) waking
b) before meals
c) 90 mins after eating
d) driving
A
a) 5-7mmol/L on waking
b) 4-7mmol/L before meals
c) 5-9mmol/L at least 90 mins after eating
d) at least 5mmol/L when driving
8
Q
What is a basal bolus insulin regimen?
A
One or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue as the basal insulin; alongside multiple bolus injections of short-acting insulin before meals
9
Q
What is a mixed (biphasic) insulin regimen?
A
One, two, or three insulin injections per day of short-acting insulin mixed with intermediate-acting insulin
10
Q
What insulin regimen is first choice for Type 1 diabetics?
A
- Basal bolus
- Insulin detemir BD should be offered as the long insulin therapy
11
Q
n a basal bolus regimen for Type 1 diabetes, what basal insulin would be first choice?
What would be the second choice?
A
- Insulin determir BD - can also be offered as once daily
- Once daily insulin glargine
12
Q
Are non-basal bolus regimens recommended in newly diagnosed Type 1 diabetics?
A
- NO
- Should only be considered after trying basal bolus regimen
13
Q
In basal bolus regimen in Type 1 diabetes, what type of insulin is recommended for the bolus aspect?
A
- Rapid acting insulin
- (Rather than soluble human or animal insulin)
14
Q
Continuous subcut insulin infusion therapy should only be offered to what group of people?
A
- Suffer from disabling hypoglycaemia
- High HbA1c of 69 or above with multiple daily injection therapy
15
Q
What situations can cause an INCREASE in required insulin dose?
A
- infection
- stress
- Accidental/surgical trauma
16
Q
What situations can cause an DECREASE in required insulin dose?
A
- Physical activity
- Intercurrent illness
- Reduced food intake
- Impaired renal function
- Certain endocrine disorders
17
Q
Patients’ awareness of hypoglycaemia should be assessed annually using what score tools?
A
Gold or Clarke score
18
Q
What cardiac class of drug can blunt hypoglycaemia awareness?
A
- beta blockers reduce warning signs such as tremor
19
Q
What is an impaired awareness of hypoglcyaemia?
A
Can occur when the ability to recognise usual symptoms of hypoglycaemia is lost, or when the symptoms are blunted or no longer present
20
Q
What are the 3 types of insulin sources?
A
Human insulin
Human insulin analogues
Animal insulin
21
Q
Which area of the body has the fastest absorption rate for insulin?
A
Abdomen
22
Q
What can occur if you repeatedly inject insulin into the same area without rotating?
A
Lipohypertrophy
Can cause erratic absorption of insulin
23
Q
How much time before meals do you administer short acting soluble insulin?
A
15-30 minutes before
24
Q
What is the most appropriate form of insulin to use in diabetic emergencies e.g. DKA
A
Soluble insulin IV
25
What are the 3 types of rapid acting insulin?
Insulin aspart
Insulin glulisine
Insulin lispro
26
How much time before meals do you administer rapid acting insulin?
Immediately before
27
What are the advantages of rapid acting insulin over short acting insulin?
- Can be given immediately before meals
- Improved glucose control, reduction of HbA1c, and reduction in the incidence of severe hypoglycaemia, including nocturnal hypoglycaemia.
28
Is injecting short acting insulins post meals recommended?
NO
29
What type of insulin is isophane?
Intermediate - designed to mimic the effect of endogenous basal insulin
30
What are biphasic insulins?
Pre-mixed insulin preparations containing various combinations of short-acting insulin (soluble insulin or rapid-acting analogue insulin) and an intermediate-acting insulin.
31
What are the long acting insulins?
Insulin detemir
Insulin glargine
Insulin degludec
Rarely prescribed:
Protamine zinc insulin
Insulin zinc suspension
32
Does metformin cause hypoglycaemia?
NO
33
If standard release metformin is not tolerated e.g. GI side effects, what should be given?
Modified release metformin
34
Give examples of sulfonylureas
Glibenclamide
Gliclazide
Tolbutamide
35
Give examples of DPP-4 inhibitors
```
Alogliptin
Linagliptin
Sitagliptin
Saxagliptin
Vildagliptin
```
36
What is an advantage of DPP-4 inhibitors over sulphonylureas in terms of side effects?
Not associated with weight gain and have less incidence of hypoglycaemia
37
Give examples of SGLT2 inhibitors
Canaglifozin
Dapaglifozin
Empaglifozin
38
Give examples of GLP-1 receptor agonists
Dulaglutide
Exenatide
Liraglutide
Lixisenatide
39
What should be the target HbA1c in a Type 2 diabetic that is managed by lifestyle/ a single antidiabetic agent that is NOT associated with hypoglycaemia?
48 mmol/mol
40
What should be the target HbA1c in a Type 2 diabetic that is managed with one or more antidiabetic drugs that cause hypoglycaemia?
53 mmol/mol
41
In terms of HbA1c, when should treatment in a Type 2 diabetic on ONE antidiabetic drug be intensified?
58 mmol/mol or higher
42
What should be the target HbA1c in a Type 2 diabetic that is managed with 2 or more antidiabetic drugs?
53 mmol/mol
43
What is first line drug treatment in Type 2 diabetes and why?
Metformin
- Positive effect on weight loss
- Reduced risk of hypoglycaemia
- Long term cardiovascular benefits
44
If a sulphonylurea is indicated in one of the following:
- Elderly patients
- Renal impairment
- Particular risk of hypoglycaemia
What sulphonylurea should you opt for?
Short acting one e.g. gliclazide or tolbutamide
45
If a Type 2 diabetic is not been adequately controlled on metformin and requires intensification of treatment, what are the add in options?
- Sulphonylurea
- Pioglitazone
- DPP-4 inhibitor
- SGLT-2 inhibitor - only when sulphonylureas are contraindicated or if patient is at significant risk of hypoglycaemia
46
Type 2 diabetes:
| Dapagliflozin is not recommended in a triple therapy regimen with what drug?
Pioglitazone
47
Type 2 diabetes:
| If dual therapy is unsuccessful, what are the triple therapy combination options?
- Metformin + DPP-4 + sulphonylurea
- Metformin + pioglitazone + sulphonylurea
- Metformin + sulphonylurea + SGLT-2 inhibitor
- Metformin + sulphonylurea + SGLT-2 inhibitor (not dapaglifozin)
May be appropriate to start insulin at this stage
48
When is GLP-1 receptor agonists indicated in Type 2 diabetes?
- If triple therapy with metformin and 2 other oral drugs are tried
- BMI of 35 kg/m2 or above (adjusted for ethnicity) and who also have specific psychological or medical problems associated with obesity; or for those who have a BMI lower than 35 kg/m2 but for whom insulin therapy would have significant occupational implications or if the weight loss associated with glucagon-like peptide-1 receptor agonists would benefit other significant obesity-related comorbidities
49
If started on a GLP-1 receptor agonist for Type 2 diabetes, when should this be reviewed and how do you know it is okay to continue?
After 6 months, the drug should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight).
50
If metformin is contraindicated or not tolerated, what should be used for initial treatment?
Sulphonylurea or DPP-4 inhibitor monotherapy
SGLT2 inhibitor monotherapy can be used only if the above are not appropriate
Repaglinide can be used as monotherapy however cannot be used in combination with anything else other than metformin
51
What is the problem with using repaglinide monotherapy in Type 2 diabetes?
If intensification of treatment is required, can only be given with metformin
It is NOT licensed in combination with any other antidiabetic drugs
52
In patients where metformin is contraindicated/not tolerated:
If a patient is on a non-metformin single therapy however requires intensification of treatment, what dual combinations can be prescribed?
- DPP-4 inhibitor and pioglitazone
- DPP-4 inhibitor and sulfonylurea
- Pioglitazone and sulfonylurea
If dual therapy does not provide control, consider insulin
53
If a patient is on dual therapy for Type 2 diabetes, and metformin is contraindicated/not tolerated, what should be considered?
Insulin
54
In Type 2 diabetes, if insulin therapy is required, what should happen to their other antidiabetic drugs?
- Continue metformin if not contraindicated or tolerated
| - Review all others and stop if necessary
55
In Type 2 diabetics, what insulin regimens can you use?
- Isophane (NPH) OD/BD
- Isophane + short acting (either separate or pre-mixed) - particularly appropriate if HbA1c is 75 or higher
- Insulin detemir or glargine can be an alternative to isophane
56
In Type 2 diabetics, at what HbA1c would the following insulin regimen be particularly appropriate:
Isophane + short acting insulin (separate or pre-mixed)
75mmol/mol or higher
57
In type 2 diabetics requiring insulin therapy, when would long acting insulin (glargine or detemir) be preferable?
- If once daily injection is beneficial e.g. assistance is needed to inject, trouble with the device
- If recurrent symptomatic hypoglycaemic episodes are a problem
- If BD isophane would still require oral antidiabetics
58
When starting insulin therapy in Type 2 diabetes, when should the first basal insulin be given and how do you adjust the dose?
Bedtime basal insulin should be initiated and the dose titrated against fasting glucose in the morning
59
Providing there are no contraindications, what should you give for diabetic nephropathy that is causing proteinuria or established microalbuminuria?
Blood pressure should be reduced to the lowest achievable level to reduce the glomerular filtration rate
ARB or ACEi to be started even if the blood pressure is normal
60
What is the potential problem with ACEis in diabetics if the patient is on insulin or oral antidiabetic drugs?
Can potentiate the hypoglycaemic effect
More likely in the first few weeks of combined treatment and in patients with renal impairment
61
The management of DKA involves what?
What should happen to their basal insulin?
What should be monitored and how often?
Replacement of fluid and electrolytes
Include potassium chloride in the fluids unless anuria is suspected
Administration of soluble insulin in sodium chloride 0.1 units/kg/hr
Long acting insulin (basal) should be continued in the background
If blood glucose falls below 14, give glucose 10%
Monitor ketones and glucose hourly
Monitor BP
Blood pH
62
During DKA treatment when the patient is on an insulin infusion, when should you recommence the short acting subcut insulin and stop the infusion and how is this done?
Continue insulin infusion until blood-ketone concentration is below 0.3 mmol/litre, blood pH is above 7.3 and the patient is able to eat and drink; ideally give subcutaneous fast-acting insulin and a meal, and stop the insulin infusion 1 hour later.
63
Diabetic women who are planning on becoming pregnant should aim to keep their HbA1c to what?
Below 48mmol/mol if possible without causing any problematic hypoglycaemia
64
What is the folic acid supplementation recommendation in diabetic patients planning on becoming pregnant?
High dose - 5mg daily as classed in the high risk group of neural tube defects
65
What is the treatment recommendation for diabetic patients when they become pregnant?
What about during breastfeeding?
All antidiabetic drugs APART from metformin should be stopped and substituted with insulin therapy
For breastfeeding, the options are:
- Insulin continued
- Metformin continued
- Glibenclamide is fine to restart if originally on it
However, all other antidiabetic agents should be avoided during breastfeeding
66
What is the first choice for long acting insulin therapy during pregnancy?
Isophane insulin
However in women who have good blood-glucose control before pregnancy with the long-acting insulin analogues (insulin detemir or insulin glargine), it may be appropriate to continue using them throughout pregnancy.
67
What is the patient advice regarding insulin therapy during pregnancy?
Should be aware of the risk of hypoglycaemia and should always carry a fast-acting form of glucose
68
It is recommended that pregnant women with Type 1 diabetes should be prescribed what just in case of hypoglycaemia?
Glucagon
69
Women with pre-existing diabetes treated with insulin during pregnancy are at an increased risk of what?
Hypoglycaemia during the postnatal period
Should reduce their insulin immediately after birth and blood glucose levels monitored
70
If a diabetic patient is on an ACEi or ARB for diabetic complications, however wishes to become pregnant, what would be the most appropriate action?
ACEi or ARB should be discontinued and an alternative antihypertensive suitable in pregnancy should be used
(Preferably before conception if pregnancy is planned)
71
If a diabetic patient becomes pregnant but is on a statin, what would be the most appropriate action?
Discontinue the statin during pregnancy (Preferably before conception if pregnancy is planned)
72
True or false:
| A patient with gestational diabetes should continue their hypoglycaemic treatment after birth
False - should discontinue hypoglycaemic treatment immediately after giving birth
73
How would you manage an insulin dependent diabetic patient with good glycaemic control due for an elective minor procedure?
(Day before surgery and during the operative period)
On the day before surgery, give the usual insulin dose
However, once daily long acting insulins should be given at 80% of normal dose
Then their usual insulin regimen can be adjusted accordingly during the operative period
74
On the day before a minor op in an insulin dependent diabetic with good glycaemic control, you can give their usual insulin dose as normal. With what insulin would you not give the full dose?
Long acting insulin
| You give 80% of normal dose
75
SGLT2 inhibitors are associated with an increased risk of DKA, particularly the case in what situations?
```
Dehydration
Stress
Surgery
Trauma
Acute medical illness or any other catabolic state
```
76
What is the maximum licensed daily dose of standard release metformin compared to MR metformin?
Standard release - 3g/day
MR - 2g/day
77
What are the side effects of metformin?
- GI upset (slow increase in dose may improve tolerability)
- taste altered
- metallic
- lactic acidosis
- vitamin b12 absorption decreased
78
At what eGFR should you avoid metformin?
<30mg/min
79
What are the risk factors for lactic acidosis?
- chronic heart failure
| - concomitant use of drugs that acutely impair renal function
80
What is the patient advice with metformin?
- should be informed of the risk of lactic acidosis and told to seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia (weakness/lack of energy) occur
- Take with meals
81
MR gliclazide is equivalent to what standard release gliclazide dose?
30mg MR = 80mg standard release
82
What are the main side effects of gliclazide to warn your patient about?
weight gain
| hypoglycaemia
83
What is the safety information regarding pioglitazone?
- CV safety - heart failure especially combined with insulin in patients with risk factors. Should NOT be used in history of heart failure
- risk of bladder cancer (increases with age)
- not appropriate for those who have investigated macroscopic haematuria
- liver toxicity
84
What is the MHRA advice surrounding SGLT2 inhibitors?
- risk of DKA (inform to be aware of symptoms e.g. rapid weight loss, sweet smell breath, urine odour
- reports of fournier's gangrene (necrotising fasciitis if the genitalia of perineum)
85
What is the MHRA advice surrounding the use of canagliflozin?
risk of lower-limb amputation
86
Which antidiabetic class can cause pancreatitis?
DPP-4 inhibitors (gliptins)
87
Which antidiabetic drug class commonly causes UTIs?
SGLT2 inhibitors
88
Can you use nateglinide as monotherapy in diabetes?
NO - only metformin
89
With what antidiabetic drug would it not be suitable in those with hernias or GI obstructions?
Acarbose
90
What is the dose frequency of the 4 different GLP-1 receptor agonists?
- weekly for albiglutide and dulaglutide
- twice daily with exenatide (MR can be once weekly)
- liraglutide is once weekly
91
What is the name of the ultrarapid acting insulin?
Fiasp (aspart)
92
What are the types of soluble insulin (short acting)?
```
Humulin S
Actrapid
Insuman rapid
Hypurin neutral
(povine/porcine)
```
93
Is Actrapid classed as a rapid acting insulin?
NO - it is short acting insulin
94
What insulins are classed as rapid acting?
Novorapid (aspart)
Humalog (lispro)
Apidra (glulisine)
95
What insulins are classed as intermediate acting?
Insulatard
Humulin 1 (isophane)
Insuman basal
Hypurin isophane
96
What insulins are classed as long acting?
Levemir (detemir)
Lantus/Absalgar (glargine)
Tresiba (degludec)
Toujeo (glargine)
97
What insulins are classed as biphasic (pre-mixed)?
Novomix 30
Humalog mix 25 or 50
Humulin M3 Insuman
Combp 15 or 25 or 30
98
What does the 30 mean in Novomix 30?
The suspension contains rapid acting and intermediate acting insulin aspart in the ratio 30/70
99
What is recommended for the treatment of acute hypoglycaemia and the patient is conscious?
- initially glucose 10-20g is given by mouth (liquid/sugar etc)
- repeated if necessary after 10-15 mins
- snack provided after initial treatment e.g. carbohydrate like sandwich or fruit to prevent blood glucose conc falling again
100
What is recommended for the treatment of acute hypoglycaemia and the patient is UNconscious?
- gucagon given subcut or IM injection
| - if this does not work within 10 mins, IV glucose 20% needs to be given
101
Can glucagon be used for chronic hypoglycaemia?
NO
102
What is given for chronic hypoglycaemia?
Diazoxide
103
Which antidiabetic drug can cause lactic acidosis and B12 deficiency ?
Metformin
104
If a pregnant patient diagnosed with gestational diabetes presents with a fasting glucose of <7mmol/L what should be done?
If this does not work after 1-2 weeks what should be done then?
first attempt a change in diet and exercise alone in order to reduce blood-glucose
If blood glucose targets are not met within 1-2 weeks, metformin may be rxed (unlicensed).
Insulin may be rxed if metformin is contraindicated/not tolerated/ can also be added to metformin if not effective alone
105
If a pregnant patient diagnosed with gestational diabetes presents with a fasting glucose of >7mmol/L what should be done?
Should be treated with insulin immediately, with or without metformin in addition to diet and exercise
106
If a pregnant lady presents with complications of gestational diabetes how should this be managed?
- considered for immediate insulin treatment
| , with or without metformin
107
Do gliptins or sulphonylureas have a higher incidence of hypoglycaemia?
sulphonylureas
108
A HbA1c alone at what level would indicate diabetes?
48mmol/mol
109
What class of antidiabetic drugs can cause volume depletion?
SGLT2 inhibitors
