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Met3 > Diabetes: Management > Flashcards

Diabetes: Management Flashcards

1
Q

How often does a diabetic review occur? [1]

State 6 factors reviewed in a diabetic review [6]

A

 Every person with diabetes should be seen at least twice a year

 The Diabetes Annual Review should include:
▪ Review of symptoms
▪ Review clinical issues
▪ Weight / BMI
▪ Glucose levels
▪ Blood pressure
▪ Cholesterol
▪ Creatinine (eGFR) + urine albumin creatinine ratio (ACR)

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2
Q

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]

A

BP persistantly over 140 / 90 mmHG

BP persistantly over 130 / 80 mmHG & kidney, eye or CV disease

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3
Q

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]

A

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

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4
Q

When should you provide statins for DMT1 patients? [2]

A
  • Anyone who has has DMT1 for over 10 years
  • Statins for anyone with complications (eyes / neuro etc
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5
Q

Describe the physiological effect for long term diabetic management of having tight glycaemic control [2]

A

Microvascular complications reduced

Macrovascular complications has no effect

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6
Q

Which conditions are HbA1c may be invalid for when assessing diabetic conditions? [2]

A

May be invalid in haemoglobinopathy or anaemia (reduced red blood cell survival)

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7
Q

What substance can be used if HbA1c is invalid to assess glycaemic control? [1]

A

Fructosamine (Another glycated protein, lasts around 2 weeks)

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8
Q

How can patients using insulin therapy assess their glycaemic control? [1]
What are pre-prandial and post-prandial glucose level aims? [2]

A

Self monitoring of blood glucose (SMBG):
Pre-prandial aim: 4-7 mmol/L
Post-prandial aim: 5-9 mmol/L

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9
Q

Name this [1]
Which Ptx populations can use it? [4]

A

Intermittently Scanned Continuous Glucose Monitoring (Freestyle Libre)
▪ Can be used in most people with T1D
▪ Consider in people with T2D if they are on
twice daily or more insulin therapy
▪ AND have recurrent hypos or severe hypos or hypo unawareness
▪ OrLearningdisability/Cognitiveimpairment

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10
Q

Which patient populations are the only group given Continuous Glucose Monitoring? [1]

A

Suffer from hypoglycaemic unawareness

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11
Q

DMT2 Management:
- MoA of Metformin? [3]

A
  • 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
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12
Q

DMT2 Management:
Advantages [4] and Disadvantages [2] of Metformin?

A

Advantages:
- Rapid & effective
- No effect on weight
- Insulin sparing
- Useful pregnant population
- Cheap

Disadvantages:
- Can cause lactic acidosis in renal / liver disease patients
- GI effects (nausea, anorexia, diarrhoea), intolerable in 20%.

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13
Q

Which diabetic drug class works by the MoA:

Works by stimulating insulin release from the beta cells (non- glucose dependent)

A

Sulfonylureas

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14
Q

Sulfonylurea works by which MoA? [1]

A

Works by stimulating insulin release from the beta cells (non- glucose dependent)

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15
Q

State 2 advantages of sulfonylureas
State 3 disadvantages of sulfonylureas

A

Advantage:
Oral
Cheap

Disadvantage
Hypoglycaemia

Weight gain
Testing glucose if driving

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16
Q

Describe the MoA of Acarbose [2]

A

 Blocks disaccharidase in the GI tract
 Reduces absorption of glucose }

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17
Q

State two disadvantages of acarbose

A
  • Bloating (due to fermentation of glucose
  • Not very effective
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18
Q

Works to improving insulin sensitivity by binding to PPAR- gamma refers to which diabetic drug class? [1]

A

Glitazones (thiazolidinediones)

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19
Q

Name 3 advantages of glitazones for diabetic control

A

Generally well tolerated
Oral / once daily
Cheap - ~ £2.00 per month

HbA1c reduction 10-15 mmol/mol

Little hypoglycaemia

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20
Q

Name 4 disadvantages of glitazones (thiazolidinediones) [4]

A

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

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21
Q

Describe the physiological effect of GLP-1 [4]

A

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)

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22
Q

Name a daily [1] & weekly [2] injectable GLP-1 drug

A

Liraglutide – daily injection
Dulaglutide – weekly injection
Semaglutide – weekly injection or oral tablet

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23
Q

Name 4 advantages of GLP-1 analogues [3]

A

Weight loss
Reduce CV risk
HbA1c reduction 10 / 30 mmol/mol
One weekly injection

24
Q

Name 4 disadvantages of GLP-1 analogues [4]

A

Injection
Cost ~ £73.00 per month

Needs some nursing
GI side effects
?? Pancreatitis risk

25
Q

Which drug class works by the following MoA:

Works to inhibiting DPP-4 which breaks down GLP-1, thereby increasing endogenous GLP-1

A

Gliptins

26
Q

What effect do gliptins have on weight? [1]

A

DPP-4 inhibitors:
Weight neutral

27
Q

Gliflozins inhibit which transporter? [1]

A

SGLT-2 inhibitors

28
Q

Name 5 advantages of using SGLT-2 inhibitors

A
  • Weight loss
  • CV protection
  • Renal protection
  • Oral
  • HbA1c reduction ~10-20 mmol/mol (but less with lower eGFR
29
Q

Name 4 disadvantages of using SGLT-2 inhibitors [4]

A

- UTIs / Thrush
- Euglycaemic DKA (rare) - get DKA but at normal glucose levels
- Care in acute illness
- £ 36

30
Q

Describe an overview of the drug pathway for glycaemic management of DMT2

A
  • 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
31
Q

Which subset of diabetic ptx population is GLP-1 prescribed to? [1]

A

After triple therapy offered; BMI over 35 (NICE)

32
Q

What is rescue therapy prescribed for symptomatic hyperglycaemia? [2]

A
  • Consider insulin or sulfonylurea
  • Review when glucose control achieved
33
Q

How do you chose between GLP-1 analogue versus insulin for DMT2 after triple oral therapy has not controlled HbA1c? [1]

A

GLP-1:
- BMI > 35

Insulin:
- BMI < 35

34
Q

A patient has DMT2 and when measured, their ACR level is found to be above 30. What drug class do you prescribe? [1]

A

Gliflozin

35
Q

A patient has DMT2 and when reviewing their notes you find their Qrisk score has increased by over 10% . What drug class do you prescribe? [1]

A

Gliflozin

36
Q

Describe when insulin is released in a normal person [2]

A

Biphasic:
- Short-lived, rapidly generated meal-related insulin peaks
- Low, steady, basal insulin profile

37
Q

Name indications for insulin therapy for DMT2 patients [5]

A

▪ inadequate glycaemic control on tablets
▪ contraindications to tablets
▪ symptomatic hyperglycaemia
▪ pregnancy
▪ infection / foot ulcers
}

38
Q

Where should you inject insulin?

A

 Insulin should be injected into subcutaneous fat
 Several injection sites can be used:
▪ Abdomen: Fastest absorption
▪ Thighs
▪ Buttocks: Slowest absorption

39
Q

State the three different types of insulin regimens

A

 Once-daily / twice-daily intermediate- or long-acting (basal) insulin
 Once-/ twice-/ three-times daily premixed insulin
 Basal–bolus therapy

40
Q

Describe the dosing regimen of twice daily insulin [2]

A

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

41
Q

Describe basal bolus therapy regime for insulin

A

3 injections of rapid acting, 1 injection of long acting: mimics normal physiology

42
Q

A man sees his GP for a review of his type 2 diabetes. He is on metformin at the maximum tolerated dose. His latest HbA1c is 64 mmol/mol.

His GP starts him on gliclazide and plans to repeat the HbA1c in 3 months’ time.

What is the patient’s new target HbA1c? [1]

A

The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol

43
Q
A
44
Q

How often should HbA1c be checked in a DMT1 patient? [1]

A

Every 3-6 months

45
Q

Blood glucose targets for DMT1 patients are’
[] mmol/l on waking and
[] mmol/l before meals at other times of the day

A

Blood glucose targets
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day

46
Q

Pioglitazone is contraindicated in which type of cancer? [1]

A

Bladder cancer

47
Q

If a diabetic patient is suffering from gastroparesis induced by diabetic neuropathy, what symptoms might they be suffering from? [3]

Which drugs may you prescribe? [3]

A

symptoms include erratic blood glucose control, bloating and vomiting

management options include metoclopramide, domperidone or erythromycin (prokinetic agents)

48
Q

Which diabetic drug has an increased risk of leg ulcers and amputation? [1]

A

canagliflozin and the increased risk of leg ulcers and amputation, with a potential class effect across the SGLT-2 inhibitors.

49
Q

A 72-year-old man is reviewed in the diabetes clinic. He has a history of heart failure and type 2 diabetes mellitus. His current medications include furosemide 40mg od, ramipril 10mg od and bisoprolol 5mg od. Clinical examination is unremarkable with no evidence of peripheral oedema, a clear chest and blood pressure of 130/76 mmHg. Recent renal and liver function tests are normal. Which one of the following medications is contraindicated?

Sitagliptin
Pioglitazone
Gliclazide
Exenatide
Metformin

A

A 72-year-old man is reviewed in the diabetes clinic. He has a history of heart failure and type 2 diabetes mellitus. His current medications include furosemide 40mg od, ramipril 10mg od and bisoprolol 5mg od. Clinical examination is unremarkable with no evidence of peripheral oedema, a clear chest and blood pressure of 130/76 mmHg. Recent renal and liver function tests are normal. Which one of the following medications is contraindicated?

Sitagliptin
Pioglitazone: contra-indicated in HF because they cause oedema
Gliclazide
Exenatide
Metformin

50
Q

A helpful mnemonic someone posted to help remember the side effects of Pioglitazones? [5]

A

A helpful mnemonic someone posted to help remember the side effects of Pioglitazones:

Fat Bastards Won’t Feel Lighter

Fat- Fractures
B- Bladder Cancer risk
W- Weight gain
F- Fluid retention (contra in HF)
L- LFT derangement

51
Q

Label the treatment choices for the DM patients with multi-morbidities for patients already on metformin management and HbA1c remains above 53

A

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

52
Q

Which drugs are contraindicated for patients with DMT2 who might also be suffering from:

Heart Failure [2]
CKD [1]
Frail / elderly [3]
Obesity [2]

A

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)

53
Q

When are the following useful / recommended as an additional step to DM patient medication? [3]

Sulfonylurea [1]
Pioglitazone [1]
Repaglinide [1]

A

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

54
Q

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]

A

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)

55
Q

DPP4 inhibitors have a risk of causing which pathology? [1]

A

Pancreatitis

Met3 (52 decks)

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