Diabetes I Flashcards by patrick ellis

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

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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.

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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

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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

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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

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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

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Which HLA is associated with DMT1? [2]

HLA DR3 & DR4

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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

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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]

**S**GLT2 inhibitors: (risk of **DKA**) **A**CE inhibitors: (risk of **AKI**) **D**iuretics (risk of **AKI**) **M**etformin (risk of **lactic** **acidosis**) **A**RBs (risk of **AKI**) **N**SAIDs (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