Diabetes in Practice

Question 1

Define diabetes

Answer 1

Group of metabolic disorders in which persistent hyperglycaemia (random plasma glucose more than 11.1mmol/L) is caused by deficient insulin secretion, resistance to the action of insulin/both

Question 2

What is the difference between Type 1 and Type 2 diabetes?

Answer 2

• Type 1: absolute deficiency of insulin
• Type 2: insulin resistance with relative deficiency of insulin

Question 3

What lifestyle advice can be given for diabetes?

Answer 3

• Lifestyle advice > diet, exercise, weight management (aim for healthy BMI)
• Structured education programmes (Type 1 - DAFNE, Type 2 - DESMOND)
• Annual foot checks
• Alcohol
• Smoking

Question 4

How does Type 1 diabetes develop?

Answer 4

Due to destruction of pancreatic beta cells, mostly by immune-mediated mechanisms

Question 5

Diagnosis of Type 1 diabetes

Answer 5

Children - polyuria, polydipsia, weight loss, excessive tiredness

Adults - ketosis, rapid weight loss, <50 years, BMI below 25kg/m2, family history of autoimmune disease

Question 6

What glucose monitoring is required?

Answer 6

Self monitoring - plasma/capillary glucose, ketone test strips

Clinical monitoring - HbA1c every 3-6 months
Urine glucose

Question 7

What are the target blood sugars for the day?

Answer 7

• Waking 5-9mmol/L
• Before meals + other times of day 4-7mmol/L
• After meals (90mins after eating) 5-9mmol/L

Question 8

What is a flash monitor and how long does it last?

Answer 8

Freestyle libre (14 days)

Question 9

What is HbA1c?

Answer 9

Measure of glycosylated haemoglobin

Question 10

What is the aim for HbA1c in type 1 diabetes without disabling hypoglycaemia?

Answer 10

<48mmol/mol

Question 11

What are the limitations to HbA1c?

Answer 11

<18
Type 1 diabetes suspected
Medication that can cause hyper (corticosteroids)
Acute pancreatic damage, end stage renal, HIV

Question 12

What is the difference between basal and bolus?

Answer 12

Basal - steady, low level of background insulin

Meal time bolus - increased secretion in response to carbohydrate absorbed from food & drink

Question 13

What is human insulin?

Answer 13

Recombinant DNA technology

Question 14

What are insulin analogues?

Answer 14

Modified human insulins to extend duration or action/faster absorption

Question 15

What are the 3 insulin regimens?

Answer 15

1. Multiple daily injection (MDI) > rapid/short-acting & intermediate/long-acting
2. 1,2 or 3 insulin injections per day
3. CSII

Question 16

What is the first line insulin?

Answer 16

• Basal (twice daily insulin detemir) and bolus (rapid-acting before meal)

Question 17

What is hypoglycaemia?

Answer 17

When blood sugars drop below 3.5mmol/L

Question 18

How to manage hypoglycaemia?

Answer 18

• 10-20g of fast-acting carb (liquid form) > 3-6 glucose tabs, 90-180ml fizzy drink, 4 large jelly babies, seven large jelly beans, 1-2 tubes of Dextrogel
• Recheck blood glucose after 10-15 mins
• If person unconscious/unable to swallow (1mg of IM glucagon administered STAT)

Question 19

What are the sick day rules?

Answer 19

• Do not stop insulin therapy (dosing may need to be adjusted)
• Increase monitoring every 1-2 hours
• Ketone monitoring
• Maintain meal pattern where possible
• 3L of fluid
• Monitor until blood glucose returns to normal

Question 20

What is Type 2 diabetes associated with?

Answer 20

Obesity, physical inactivity, hypertension, disturbed blood lipid levels, increased CVD risk

Question 21

What are clinical features of Type 2 diabetes?

Answer 21

Polydipsia, polyuria, blurred vision, tiredness, recurrent infections

Question 22

How do we diagnose Type 2 diabetes?

Answer 22

• HbA1c of 48mmol/mol (6.5% or more)
• Fasting plasma glucose level of 7.0mmol/L or more
• Random plasma glucose of 11.1mmol/L or more
• No additional features of type 1 (rapid onset, childhood, insulin dependence, ketoacidosis)

Question 23

What are the HbA1c targets?

Answer 23

• If medication not associated with hypoglycaemia 48mmol/mol
• If medication is associated with hypoglycaemia 53mmol/mol

Question 24

List the types of glucose lowering agents in Type 2 diabetes

Answer 24

• Biguanide: metformin
• Sulfonylurea: glicalzide, glimepiride, tolbutamide
• SGLT2 inhibitors: glifozins
• DPP4 inhibitors: gliptins
  -GLP-1 mimetics: tides
  -Insulin: NPH/isophane first line in Type 2
• Thiazolidinefione: pioglitazone

Question 25

What are the risks of metformin?

Answer 25

• Caution in renal impairment
• Lactic acidosis
• B12 deficiency with long term treatment

Question 26

What drugs do we withold in AKI?

Answer 26

D - diuretics
A - ACEIs/ARBs
M- Metformin
N - NSAIDs.