diabetes in practice Flashcards
1
Q
When is treatment started?
A
HbA1c levels rise to 48 mmol/mol on lifestyle interventions
2
Q
metformin dose
A
500mg od with meals
titrated up after 7 days
max 2g daily
3
Q
s/e of metformin
A
GI side effects - transient
4
Q
When should metformin be avoided?
A
eGFR < 30 ml/min/1.73 m cubed
5
Q
What can happen if metformin is given when eGFR is < 30?
A
lactic acidosis
6
Q
When is the 1st intensification done?
A
if HbAc1 rises to 58 mmol/mol
7
Q
What drugs can be given with metformin for the 1st intensification?
A
DPP 4i
pioglitazone
sulfonylurea
SGLT 2i
8
Q
example of sulfonlyurea
A
gliclazide
9
Q
another name for DPP4i
A
giliptin
10
Q
example of a giliptin
A
sitagliptin
11
Q
another name for SGLT 2 inhibitor
A
gilflozins
12
Q
example of SGLT 2 inhibitor
A
dapagliflozin
13
Q
aim for 1st intensification of treatment
A
HbA1c 53 mmol/mol
14
Q
When is a 2nd intensification of treatment given?
A
HbA1c levels rise to 58 mmol/mol
15
Q
drug combinations for 2nd intensification (metformin)
A
- metformin and: SU + DPP 4i SU + pioglitazone SU + SGLT2i pioglitazone + SGLT 2i
- insulin based treatment
16
Q
What can be given if triple therapy is not effective/tolerated/contraindicated?
A
combination therapy with metformin, SU and a GLP 1
17
Q
example of a GLP 1
A
exenatide
18
Q
When is exenatide considered?
A
- BMI > 35 in patients of European decent and there are problems associated with high weight/obesity
- BMI < 35 and insulin is unacceptable because of occupational implications or weight loss would benefit other comorbidities
19
Q
aim for triple therapy
A
53 mmol/mol
20
Q
treatment if metformin is c/i or not tolerated
A
monotherapy:
- DPP 4i
- SU
- pioglitazone
- SGLT 2i
21
Q
aim for monotherapy where metformin is c/i
A
48 mmol/mol for DPP 4i, pioglitazone and SGLT 2i
53 mmol/mol for sulphonylurea
22
Q
1st intensification for non-metformin treatment
A
DPP 4i + pioglitazone
DPP 4i + SU
piolgitazone + SU
23
Q
aim for 1st intensification?
A
53 mmol/mol
24
Q
2nd intensification for non-metformin treatment
A
insulin based treatment
25
aim for insulin based treatment (2nd intensification)?
53 mmol/mol
26
What random plasma glucose levels indicates hyperglycaemia?
> 11 mmol/L
27
characteristic features of hyperglycaemia in children/young people
polyuria
polydipsia
weight loss
excessive tiredness
28
characteristic features of hyperglycaemia in adults
```
(polyuria, polydipsia, weight loss, excessive tiredness)
ketosis
< 50 yrs
BMI < 25 kg/m squared
Hx/FHx of autoimmune disease
```
29
plasma glucose optimal targets
- 5-7 mmol/L on waking (fasting)
- 4-7 mmol/L before meals and during the day
- 5-9 mmol/L 90 mins after meals
30
How often are HbA1c tests carried out?
every 3-6 months
31
What is the natural profile of insulin?
1. basal - steady, low level of background insulin
| 2. bolus - meal time, increased secretion in response to glucose absorbed from food/drink
32
4 types of insulin
1. animal insulin
2. human insulin (recombinant DNA technology)
3. insulin analogues (modified human insulin to have an extended duration of action/faster absorption)
4. biosimilars
33
3 insulin regimens
1. 1/2/3 injections per day
2. MDI (multiple daily injections)
3. CSII (continuous subcutaneous insulin infusion)
34
What type of insulin is used when giving 2/3 insulin injections per day?
- rapid or short acting insulin
- mixed with intermediate acting insulin
- can be premixed/self mixed
35
MDI regimen?
- rapid or short acting insulin before meals
AND
- one or more separate daily injections of intermediate/long acting insulin analogue
36
CSII (continuous subcutaneous insulin infusion)
portable electromechanical pump that can give basal infusion and individual bolus doses when required
37
What is the first line insulin regimen?
basal-bolus insulin regimen
38
What types of insulin are in the basal-bolus regimen?
long acting twice daily
and
rapid acting insulin before meals
39
Glucose levels for hypoglycaemia?
< 3.5 mmol/L
40
less serious signs of hypoglycaemia
```
hunger
anxiety/irritability
palpitations
sweating
tingling lips
```
41
medium signs of hypoglycaemia
```
weakness
leathargy
visual disturbances
confusion
behavioural changes
```
42
serious signs of hypoglycaemia
convulsions
loss of consciousness
coma
43
management of hypoglycaemia
10-20g fast acting carbohydrate
| - recheck blood glucose levels after 10-15 mins (no response, repeat carbs)
44
hypoglycaemia treatment if person is unconscious and can't swallow
IM glucagon
| 1mg adults
45
What is fasting plasma glucose levels that indicates DM?
> 7 mmol/mol
46
HbA1c recommendations for patient on a drug not associated with hypoglycaemia and on a drug assocoated with hypoglycaemia?
48 mmol/mol
| 53 mmol/mo, (drug associated with hypoglycaemia
47
sulphonylurea (glicazide) dose
```
initially 40 - 80mg od
increased if necessary to 160mg od
dose taken with breakfast
> 160mg given in divided doses
max dose 320mg
```
48
s/e and risks associated with sulphonylurea
can cause weight gain
risk of hypoglycaemia - increased risk in renal/hepatic impairment
49
pioglitazone dose
15 - 30mg OD
| max 45mg OD
50
risks with pioglitazone
increased incidence of HF (don't Rx in HF)
increased incidence of bladder cancer
increased fracture risk
51
Gliptins (DPP4i - sitagliptin)
- reduced dose in renal impairment
- can help with weight loss
- reduced appetite
- increased incidence of pancreatitis
52
Warning/risks with SGLT 2 inhibitors (gliflozins)?
- increased risk of DKA
- restrictions with renal impairment
- increased UTI risk (increased glucose excretion in the urine)
53
diabetic complications
cardiovascular risk (BP, lipids, anti-thrombotic therapy)
kidney damage
eye damage
nerve damage
54
BP targets for T2DM already on hypertensive meds U80?
below 140/90 mmHg
55
BP targets for T2DM already on hypertensive meds
| OVER 80?
below 150/90 mmHg
56
BP treatment
1. lifestyle advice
2. ACEI/ARB
3. CCB/diuretic (thiazide)
4. diuretic/CCB
5. alpha blocker/BB/K sparing diuretic
57
lipids treatment
statin - atorvastatin 20mg
58
antithrombotic therapy
aspirin 75mg daily
| NOT unless there's established risk of CVD
59
How to identify kidney damage?
- first-pass morning urine specimen to estimate albumin:creatinine ratio (ACR)
- measure serum creatinine
- calculate eGFR
60
How is kidney damage confirmed?
2 or more raised ACR results:
>2.5 mg/mmol (men)
> 3.5 mg/mmol (women)
61
treatment for kidney damage
ACEI/ARB titrated to full dose
62
What is periodontis?
chronic inflammatory disease caused by bacterial infection of the supporting tissues surrounding the teeth
63
What OTC treatments should diabetics avoid?
systemic decongestants
| - pseudoephedrine (Benadryl), phenylephedrine (Sudafed)
64
Why should systemic decongestants be avoided?
unwanted sympathomimetic effects (CV risk, inc BP)
65
What could diarrhoea be a sign of in diabetics?
- side effect of meds (metformin titrated too quickly)
| - autonomic nervous system damage
66
Can topical decongestants be used in diabetics?
yes
| short term use only
67
example of topical decongestant that should be used with caution/short time in diabetics
xylometazoline (Otrivine)
68
If a diabetic patient has an infection what should be questioned?
their blood glucose control
69
If a patient NOT diagnosed with diabetes has a topical infection (throat) what should be questioned?
questioned about symptoms of hyperglycaemia (polyuria, thirst, weight loss)
70
Diabetic patient with cystitis/thrush
cannot be treated OTC
can be a sign of worsening diabetes
infections can cause diabetics to become hyperglycaemic
71
3 signs of DKA
ketosis
hyperglycaemia
acidaemia
72
What is increased in DKA?
counter regulatory hormones
- glucagon
- cotrisol
- growth hormone
- catecholamines
73
What is enhanced in DKA?
gluconeogenesis
| glycogenolysis
74
What does DKA cause?
severe hyperglycaemia
75
What causes ketogenesis (production of ketones) in DKA?
increased lipolysis and metabolism of free fatty acids
76
diagnosis of DKA
ketonaemia > 3mmol/L or ketonuria
blood glucose > 11 mmol/L (or knowm DM)
bicarbonate < 15 mmol/L
venous pH < 7.3
77
diagnosis of DKA
ketonaemia > 3mmol/L or ketonuria
blood glucose > 11 mmol/L (or knowm DM)
bicarbonate < 15 mmol/L
venous pH < 7.3
78
symptoms of DKA
```
polyuria
polydipsia
weight loss
vomiting/diarrhoea
abdominal pain
lethargy/confusion
fruity smell of acetone on breath
acidotic breathing (deep sighing)
dehydration
shock - tachycardia, hypotension, decreased consciousness, reduced urine output
```
79
management of DKA
- fluid replacement (correct hypotension, osmotic diuresis, electrolyte disturbance)
- insulin (0.1 units/kg)
- IV glucose (avoid hypoglycaemia, usually when glucose < 14 mmol/L, continue until normal eating/drinking)
79
management of DKA
- fluid replacement (correct hypotension, osmotic diuresis, electrolyte disturbance)
- insulin (0.1 units/kg)
- IV glucose (avoid hypoglycaemia, usually when glucose < 14 mmol/L, continue until normal eating/drinking)
80
When to start a statin after QRISK3 assessment?
if the risk is > 10%
