Diabetes I Flashcards
Which of the following is not considered a complication of HHS?
Deep vein thrombosis
Cerebrovascular event
Cerebral oedema
Foot ulceration
Transverse myelitis
Which of the following is not considered a complication of HHS?
Deep vein thrombosis
Cerebrovascular event
Cerebral oedema
Foot ulceration
Transverse myelitis
What diabetic drug class is the first line for MODY? [1]
A 35-year-old man, diagnosed as having type 2 diabetes mellitus 10 years ago, has had poor control despite taking metformin. Several family members also have diabetes mellitus and a recent genotyping revealed a mutation in the HNF -1 alpha.
What is the most appropriate treatment?
The patient has been diagnosed with maturity onset diabetes of the young (MODY) - type Hepatic Nuclear Factor 1 Alpha (HNF1A). HNF1A accounts for 70% of MODY cases. Sulfonylureas (e.g. gliclazide) are the optimal treatment in HNF1A-MODY.
Which of the following is the most common precipitant of hyperglycaemic hyperosmolar state (HHS)?
A Infection
B Non-compliance
C Inappropriate dose alteration
D New diagnosis of diabetes
E Myocardial infarction
Which of the following is the most common precipitant of hyperglycaemic hyperosmolar state (HHS)?
A Infection
B Non-compliance
C Inappropriate dose alteration
D New diagnosis of diabetes
E Myocardial infarction
Which of the following human leucocyte antigens is strongly associated with type 1 diabetes mellitus?
A HLA-DR4
B HLA-B27
C HLA-A3
D HLA-B5
E HLA-DQ2
Which of the following human leucocyte antigens is strongly associated with type 1 diabetes mellitus?
A HLA-DR4
B HLA-B27
C HLA-A3
D HLA-B5
E HLA-DQ2
Which is the predominant ketone body in Diabetic Ketoacidosis (DKA)?
A Acetone
B Acetoacetate
C Beta-hydroxybutyrate
D Vaccenic acid
E Palmitoleic acid
Which is the predominant ketone body in Diabetic Ketoacidosis (DKA)?
A Acetone
B Acetoacetate
C Beta-hydroxybutyrate
D Vaccenic acid
E Palmitoleic acid
He is started on a treatment protocol for hyperglycaemic hyperosmolar state and blood glucose is monitored hourly. After two hours his plasma glucose was still 33 mmol/L. A decision is made to start on a fixed rate intravenous insulin infusion (FRIII).
What is the most appropriate starting rate for the insulin infusion in this patient?
A 0.01 unit/kg/hr
B 0.05 unit/kg/hr
C 0.1 unit/kg/hr
D 0.5 unit/kg/hr
E 1.0 unit/kg/hr
He is started on a treatment protocol for hyperglycaemic hyperosmolar state and blood glucose is monitored hourly. After two hours his plasma glucose was still 33 mmol/L. A decision is made to start on a fixed rate intravenous insulin infusion (FRIII).
What is the most appropriate starting rate for the insulin infusion in this patient?
A 0.01 unit/kg/hr
B 0.05 unit/kg/hr
C 0.1 unit/kg/hr
D 0.5 unit/kg/hr
E 1.0 unit/kg/hr
Which of the following is not considered a complication of diabetic ketoacidosis?
A Cerebral oedema
B Hyponatraemia
C Hypokalaemia
D Hypoglycaemia
E Adult-respiratory distress syndrome
Which of the following is not considered a complication of diabetic ketoacidosis?
A Cerebral oedema
B Hyponatraemia
C Hypokalaemia
D Hypoglycaemia
E Adult-respiratory distress syndrome
Which of the following is not considered a electrolyte disturbance associated with HHS?
A Hypophosphataemia
B Hypokalaemia
C Hypermagnesaemia
D Hyperkalaemia
E Hyponatraemia
Which of the following is not considered a electrolyte disturbance associated with HHS?
A Hypophosphataemia
B Hypokalaemia
C Hypermagnesaemia
D Hyperkalaemia
E Hyponatraemia
Which of the following best describes the mechanism of action of the antidiabetic agent, gliclazide?
A Potentiates insulin release from pancreatic alpha-cells
B Inhibition of potassium efflux from pancreatic beta-cells
C Inhibition of calcium influx from pancreatic beta-cells
D Inhibition of hepatic gluconeogensis
E Enhanced peripheral uptake of blood glucose
Which of the following best describes the mechanism of action of the antidiabetic agent, gliclazide?
A Potentiates insulin release from pancreatic alpha-cells
B Inhibition of potassium efflux from pancreatic beta-cells
C Inhibition of calcium influx from pancreatic beta-cells
D Inhibition of hepatic gluconeogensis
E Enhanced peripheral uptake of blood glucose
Which of the following is considered a rapid-acting exogenous insulin?
A Glargine
B Humulin N
C Humulin 70/30
D Determir
E Aspart
Which of the following is considered a rapid-acting exogenous insulin?
A Glargine
B Humulin N
C Humulin 70/30
D Determir
E Aspart
Which of the following albumin:creatinine ratio (ACR) is indicative of moderately increased albuminuria?
A < 3 mg/mmol
B 3 - 20mg/mmol
C 3 - 30 mg/mmol
D 30 - 50 mg/mmol
E 50 - 70 mg/mmol
Which of the following albumin:creatinine ratio (ACR) is indicative of moderately increased albuminuria?
A < 3 mg/mmol
B 3 - 20mg/mmol
C 3 - 30 mg/mmol
D 30 - 50 mg/mmol
E 50 - 70 mg/mmol
A1: < 3 mg/mmol
A2: 3 - 30 mg/mmol
A3: > 30 mg/mmol
What would be the most appropriate investigation to assess for early signs of diabetic nephropathy in this patient?
A Glomerular filtration rate (GFR)
B Urinalysis
C Serum creatinine
D Serum urea
E Albumin:creatinine ratio (ACR)
What would be the most appropriate investigation to assess for early signs of diabetic nephropathy in this patient?
A Glomerular filtration rate (GFR)
B Urinalysis
C Serum creatinine
D Serum urea
E Albumin:creatinine ratio (ACR)
- An ACR > 3 mg/mmol and < 30 mg/mmol is suggestive of microalbuminuria
Which of the following auto-antibodies is associated with type 1 diabetes mellitus?
A Anti-centromere
B Anti-glutamic acid decarboxylase
C Anti-21-hydroxylase
D Thyroid peroxidase antibody
E Anti-mitochondrial antibody
Which of the following auto-antibodies is associated with type 1 diabetes mellitus?
A Anti-centromere
B Anti-glutamic acid decarboxylase
C Anti-21-hydroxylase
D Thyroid peroxidase antibody
E Anti-mitochondrial antibody
In DKA, which of the following parameters would warrant referral to high-dependency care (HDU)?
A GCS < 14
B Bicarbonate level > 18 mmol/L
C Diastolic BP < 90 mmHg
D Blood ketones > 6 mmol/L
E pH < 7.35
In DKA, which of the following parameters would warrant referral to high-dependency care (HDU)?
A GCS < 14
B Bicarbonate level > 18 mmol/L
C Diastolic BP < 90 mmHg
D Blood ketones > 6 mmol/L
E pH < 7.35
One or more of which parameters would warrant referral to a high-dependency unit (level 2 care)? [7]
- Blood ketone > 6 mmol/L
- Bicarbonate level < 5 mmol/L
- pH < 7.0
- GCS ≤ 12
- Systolic BP < 90 mmHg
- Hypokalaemia on admission < 3.5 mmol/L
What is the minimum recommended time to check potassium during treatment of DKA?
30 minutes
1 hourly
2 hourly
4 hourly
12 hourly
What is the minimum recommended time to check potassium during treatment of DKA?
30 minutes
1 hourly
2 hourly
4 hourly
12 hourly
A patient is diagnosed with DMT1 after an admission for DKA.
What is the insulin regime you should start them on post-admission? [1]
Twice-daily basal insulin detemir (long acting), insulin aspart (short acting) bolus with meals
Which HLA is associated with DMT1? [2]
HLA DR3 & DR4
Describe what pancreatic diabetes is [1]
Name 4 causes of pancreatic diabetes [4]
Pancreatic diabetes:
* Severe disease of pancreas causes damage to B cells
Causes:
Acute / Chronic Pancreatitis
Trauma / Pancreatectomy
Neoplasia
Cystic fibrosis
Haemochromatosis / Thalassaemia – due to iron overload
Name 6 endocrine diseases known to cause diabetes [6]
Acromegaly (excess growth hormone)
Cushing’s syndrome (excess cortisol)
Glucagonoma (excess glucagon)
Phaechromocytoma (excess adrenaline)
Hyperthyroidism (excess thyroid hormone)
Conn’s syndrome (excess aldosterone hormone
State 5 causes of drug induced diabetes [5]
Glucocorticoids
b-blockers
Thiazide diuretics
Tacrolimus (used in transplantation – may cause “New Onset Diabetes after Transplantation” [NODAT])
Atypical anti-psychotics – eg. olanzapine, risperidone, clozapine
Insulin resistance AND B-cell failure are exacerbated by hyperglycaemia:
What is this concept called? [1]
Explain the pathophysiology [2]
Glucose toxicity:
High levels of glucose lead to poorer b-cell function leading to reduced insulin secretion
therefore lowering glucose may actually help b-cell function
Describe how alpha and beta cell mass changes in diabetic patients [2]
b-cell mass is relatively preserved (50% at autopsies) - but function declines
a-cell population increased
Which factors contribute to metabolic syndrome? [6]
BMI > 30 kg/m2 , or:
Abdominal Waist Circumference – ethnic specific
Low HDL Concentration
Blood pressure
Fasting glucose
Triglyceride
Label the treatment choices for the DM patients with multi-morbidities for patients already on metformin management and HbA1c remains above 53
CVD:
A: SGLT-inhibitor
B: GLP-1
Heart Failure:
C: SGLT-inhibitor
D: GLP-1
CKD
E: SGLT-inhibitor
F: GLP-1
High CV Risk:
G: SGLT-inhibitor
H: GLP-1
Frail / elderly:
I DPP-inhibitor (low hypoglycaemia risk)
Obesity
A: SGLT-inhibitor
B: GLP-1
Which drugs are contraindicated for patients with DMT2 who might also be suffering from:
Heart Failure [2]
CKD [1]
Frail / elderly [3]
Obesity [2]
Heart Failure:
- Pioglitazone: causes oedema as an AE
- Saxagliptin: increase risk of HF
CKD [2]
- Caution with SUs
Frail / elderly [3]
- SGLT2i (hypoglycaemia risk)
- GLPs (hypoglycaemia risk)
- Caution with SUs (hypoglycaemia risk)
Obesity
- SUs (weight gain)
- Pioglitzaone (weight gain)
When are the following useful / recommended as an additional step to DM patient medication? [3]
Sulfonylurea [1]
Pioglitazone [1]
Repaglinide [1]
Sulfonylurea: (gliclazide, glimepiride): if rapid glucose lowering needed and hypos are not a concern
Pioglitazone: can improve lipids, useful for insulin resistance if no C/Is
Repaglinide: can be useful in shift workers/ irregular meal patterns
Sick day rules:
During an acute dehydrating illness, patients with diabetes should be advised to stop the SADMAN drugs, and restart once they have been eating and drinking normally for 24-48 hours.
What do the SADMAN drugs refer to? [6]
State why need to stop each of the SADMAN drugs [6]
SGLT2 inhibitors: (risk of DKA)
ACE inhibitors: (risk of AKI)
Diuretics (risk of AKI)
Metformin (risk of lactic acidosis)
ARBs (risk of AKI)
NSAIDs (risk of AKI)
DPP4 inhibitors have a risk of causing which pathology? [1]
Pancreatitis
What BP in DM patients would indicate BP treatment? [1]
What BP for a diabetic patient would indicate BP treatment if they have kidney, eye or CV disease ? [1]
BP persistantly over 140 / 90 mmHG
BP persistantly over 130 / 80 mmHG & kidney, eye or CV disease
What drug, dose and administration would you give to DMT2 patients with no CVD, but Qrisk score of greater than 10% to modify their lipid levels? [1]
What drug, dose and administration would you give to DMT2 patients with known CVD modify their lipid levels? [1]
If not achieving target, which drugs should be prescribed modify their lipid levels? [2]
Diabetic patients with no CVD, but Qrisk score of greater than 10%:
- Arvostatin, 20mg daily
Diabetic patients with known CVD:
- Arvostatin, 80mg daily
No response:
- Ezetimibe
- PCSK9 inhibitors
When should you provide statins for DMT1 patients? [2]
- Anyone who has has DMT1 for over 10 years
- Statins for anyone with complications (eyes / neuro etc
Describe the physiological effect for long term diabetic management of having tight glycaemic control [2]
Microvascular complications reduced
Macrovascular complications has no effect
How can patients using insulin therapy assess their glycaemic control? [1]
What are pre-prandial and post-prandial glucose level aims? [2]
Self monitoring of blood glucose (SMBG):
Pre-prandial aim: 4-7 mmol/L
Post-prandial aim: 5-9 mmol/L
DMT2 Management:
- MoA of Metformin? [3]
- Acts by activation of the AMP-activated protein kinase (AMPK)
- Increases insulin sensitivity / improving insulin resistance
- Decreases hepatic gluconeogenesis
- inhibits glucose absorption in the gut
Describe the MoA of Acarbose [2]
Blocks disaccharidase in the GI tract
Reduces absorption of glucose }
Name 4 disadvantages of glitazones (thiazolidinediones) [4]
Oedema (avoid in HF)
Weight gain 3-5 kg
Fractures in post menopausal women
Query around cause of bladder cancer
ELBOW
Edema
Liver failure
Bladder cancer
Osteoporosis
Weight gain
Describe the physiological effect of GLP-1 [4]
Glucose-dependently stimulates insulin secretion and decreases glucagon secretion:
Delays gastric emptying
Decreases food intake and induces satiety
Stimulates B-cell function and preserves or increases B-cell mass in animal models (stimulating insulin release)
Name 4 disadvantages of GLP-1 analogues [4]
Injection
Cost ~ £73.00 per month
Needs some nursing
GI side effects
?? Pancreatitis risk
Describe an overview of the drug pathway for glycaemic management of DMT2
- HbA1c above 48 at diet and lifestyle alone: condiser Ptx CV risk or CV disease
- If Ptx has low CV risk: metformin first line
- If Ptx has high CV risk or CV disease: metformin AND gliflozin
- If HbA1c continued not to be controlled: dual oral therapy
- If HbA1c continued not to be controlled: triple oral therapy
What is rescue therapy prescribed for symptomatic hyperglycaemia? [2]
- Consider insulin or sulfonylurea
- Review when glucose control achieved
How do you chose between GLP-1 analogue versus insulin for DMT2 after triple oral therapy has not controlled HbA1c? [1]
GLP-1:
- BMI > 35
Insulin:
- BMI < 35
Describe when insulin is released in a normal person [2]
Biphasic:
- Short-lived, rapidly generated meal-related insulin peaks
- Low, steady, basal insulin profile
Name indications for insulin therapy for DMT2 patients [5]
▪ inadequate glycaemic control on tablets
▪ contraindications to tablets
▪ symptomatic hyperglycaemia
▪ pregnancy
▪ infection / foot ulcers
}
Describe the dosing regimen of twice daily insulin [2]
Two injections:
First injection (contains both):
- Short acting acts on breakfast
- Long acting works on lunch
Second injection:
- Short acting acts on dinner
- Long acting works in background
Describe basal bolus therapy regime for insulin
3 injections of rapid acting, 1 injection of long acting: mimics normal physiology
Name three anti-VEGF medications used to treat diabetic retinopathy [3]
ranibizumab, bevacizumab & Aflibercept
Name two corticosteroids used to treat diabetic retinopathy [2]
Which
Triamcinolone
Dexamethasone implant can also be used, particularly in refractory DME
Describe how you would treat mild-moderate hypokalaemia (2.5-3.4) and severe hypokalaemia (< 2.5) [2]
Mild to moderate hypokalaemia 2.5 - 3.4 mmol/l:
- oral potassium provided the patient is not symptomatic and there are no ECG changes.
Severe hypokalaemia (< 2.5mmol/l) or symptomatic hypokalaemia:
- should be managed with IV replacement.
- If there are no contraindications to fluid therapy (e.g. volume overload, heart failure) potassium should be diluted to low concentrations as higher concentrations can be phlebitic.
- The infusion rate should not exceed 20mmol/hr
A second drug should be added in type 2 diabetes mellitus if the HbA1c is > [] mmol/mol
A second drug should be added in type 2 diabetes mellitus if the HbA1c is > 58 mmol/mol
What is the rule about hypoglycaemic episodes and informing the DLVA? [1]
If patients with medication-controlled diabetes have had more than one severe hypoglycaemic episode within the last twelve months they are required to inform the DVLA and will need to surrender their licence while the DVLA review their situation
