diabetes

Question 1

most significant glucose transporters and site

Answer 1

glut 1 (CNS,BBB)
2( renal tubular cells, liver)
3( neurons and placenta)
4 (muscle and adipose)- insulin sensitive

Question 2

what is the significance of GLUT 4

Answer 2

its important for uptake of excess glucose from the bloodstream

Question 3

what is the purpose of basal insulin secretion

Answer 3

suppresses hepatic glucose production between meals overnight

Question 4

prospandial insulin

Answer 4

occurs in response to food intake and controls hyperglycemia after meals

Question 5

glucagon function

Answer 5

stimulates glycogenolysis- break down of glycogen to glucose in the liver
stimulates gluconeogenesis by the liver and kidney
turns off glycolysis causing the intermediates to be shunted for gluconeogenesis

Question 6

describe diabetes type 1

Answer 6

occurs in younger people
the patients are lean 
autoimmune 
insulin deficiency
always need insulin
develop ketoacidosis 
c peptide disappears

Question 7

describe diabetes type 2

Answer 7

older patients 
overweight 
partil insulin deficiency 
develop HONK 
many come to need insulin when beta cells fail overtime 
c peptide persists

Question 8

how to diagnose diabetes

Answer 8

impaired fasting glucose- fasting plasma glucose (6.1-6.9)
impaired glucose tolerance
FPG greater than 7
2 hour OGTT 7.8-11.0

diabetes 
FPG greater than 7
2 hr OGTT- greater than 11 
HbA1c  greater than 6.5 percent 
random plasma glucose greater than 11

Question 9

complications of diabetes

Answer 9

Macrovascular complications
Ischaemic Stroke
Miocardial infarction
Peripheral arterial disease
Microvascular complications 
Cataracts, Retinopathy
Nephropathy
Neuropathy (autonomic neuropathy, painful polyneuropathy)

Question 10

metabolic syndrome

Answer 10

atleast 3 out of 5 symptoms 
central obesity
hypertension
hyperglycemia 
raised serum triglycerides 
low serum HDL

Question 11

treatment of type 1 diabetes

Answer 11

insulin therapy

Question 12

types of insulin therapy

Answer 12

short acting
intermediate acting
biphasic

Question 13

shorting acting

Answer 13

3 times daily 
30 mins before meals 
peak action - 2-5 hours 
duration of action 5-8
eg actrapid

Question 14

intermediate acting

Answer 14

once or twice daily 
usually at night before 10
onset of action 1-3 hpurs 
peak action 6-12
duration of action 16-24 hours 
e.g protophane

Question 15

biphasic

Answer 15

mixture of short and intermediate
onset of action 30
peak action 2-12 hours
duration of action 16-24

Question 16

basal bolus regimen

Answer 16

Preferred management with “basal bolus regimen”
Combined pre-meal short-acting insulin (bolus) and bedtime (not later than 22:00) intermediate-acting insulin
The initial total daily insulin dose: 0.6 units/kg body weight
The total dose is divided into: 40–50% basal insulin and rest as bolus insulin, split equally before each meal.

Question 17

dangers of not changing injection site

Answer 17

lipoatrophy (immunologic reaction to insulin)

Question 18

education related to insulin therapy

Answer 18

Insulin storage (stock in fridge; room temp if in use)
Recognition and treatment of acute complications, e.g. hypoglycemia

Question 19

type 1 diabetes monitoring

Answer 19

HbA1c annually

one month before next appointment

Question 20

Metformin function

Answer 20

reduces gluconeogenesis and glycogen metabolism
decreases carbohydrate absorption from GIT
lowers ldl and cholesterol
phosphorylates GLUT4 increasing its sensitivity to insulin

Question 21

metformin dosing

Answer 21

contraindicated if GFR less than 30
Initially 500mg once or twice daily; or 850mg once or twice daily, with meals
After 5-7 days, up-titration, maximum 2000 mg/day (based on GIT side effects)

Question 22

Metformin side effects

Answer 22

loss of apetite
nausea
diarrhoea
lactic acidosis- due to inhibited conversion of lactate to glucose
reduced vitamin B12 absorption

Question 23

sulphonylureas types

Answer 23

glipenclamide
glimepiride
glipizide
gliclazide- lowest risk of hypoglycemia

Question 24

mech of action of sulphonylureas

Answer 24

stimulates insulin secretion from pancreatic beta cells
enhances beta cell sensitivity to glucose
reduces glucagon release

Question 25

contraindications of sulphonylureas

Answer 25

severe hepatic impairment (hepatic metabolism py450 isoenzymes) pregnancy renal impairment GFR less than 60

Question 26

sulphonylureas dosing

Answer 26

Glimepiride Initially 1mg daily, adjusted according to response in 1mg increments at 1-2 week intervals (maximum dose of 4 mg daily) Preferred in the elderly Glibenclamide 2.5mg daily and titrate slowly to maximum of 15mg daily When ≥7.5mg per day is needed – 2/3 of the total dose in the morning and 1/3 at night Avoid in the elderly

Question 27

side effects of sulphonylureas

Answer 27

hypoglycemia | weight gain

Question 28

what happens in hypoglycemia

Answer 28

``` plasma glucose of less than 4mmol/l whipple's triad low plasma glucose symptoms of hypoglycemia relief of those symptoms after the plasma glucose level is raised ```

Question 29

clinical features of mild hypoglycemia

Answer 29

``` Pallor Sweating Tachycardia Palpitations Hunger Paraesthesiae Tremor ```

Question 30

mild hypoglycemia treatment

Answer 30

Fast acting oral carbohydrates (at least 15g) Sources include Three glucose tablets (5g each) 2 ½ cups of fruit juice ½ to ¾ cup regular soda 1 cup of milk If patient is unable to take orally give IV dextrose

Question 31

clinical features of moderate hypoglycemia

Answer 31

``` Inability to concentrate Confusion Slurred speech Irrational behaviour Slower reaction time Blurred vision Somnolence Extreme fatigue Weakness ```

Question 32

clinical features severe hypoglycemia

Answer 32

``` Associated with severe impairment of neurologic function Completely disoriented behavior Loss of consciousness Coma Seizures Can be fatal ```

Question 33

treatment for moderate to severe hypoglycemia

Answer 33

Dextrose - 50mL of 50% dextrose IV bolus after blood drawn, followed by 10% dextrose Glucagon – 1mg IM or SC can be given (family or friend) – effective in treating hypoglycemia only if sufficient liver glycogen present These measures raise blood glucose only transiently Patient is urged to eat as soon as possible, once fully awake

Question 34

how to prevent hypoglycemia

Answer 34

Patient education Knowing signs and symptoms of hypoglycemia Take meals on a regular schedule Carry a source of carbohydrate Self monitoring of blood glucose Take regular insulin at least 30 min before eating

Question 35

other diabetes non insulin therapy

Answer 35

``` Thiazolidinediones (Glitazones) SGLT-2 inhibitors (Dapagliflozin) α-Glucosidase inhibitors Incretin (GLP-1) based drugs DPP-4 inhibitors GLP-1 receptor agonists ```

Question 36

what monitoring do we do for type 2 diabetic patients

Answer 36

finger prick weight creatinine, K+, foot and eye examination, ab circumference

Question 37

outline the stepwise approach to diabetes type 2

Answer 37

``` step 1 presents with typical diabetes symptoms and test results treatment: lifestyle modification metformin aim- reduce glucose and HbA1c ```

Question 38

step 2 of managing diabetes 2

Answer 38

failed step 1 (2-3 months) life style modification metformin add sulphonylureas

Question 39

step 3 of managing diabetes type 2

Answer 39

insulin lifestyle modification stop sulphonylureas but continue metformin