Diabetes: Management Flashcards by patrick ellis

How often does a diabetic review occur? [1]

State 6 factors reviewed in a diabetic review [6]

 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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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

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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

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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

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

Microvascular complications reduced

Macrovascular complications has no effect

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

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

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

Fructosamine (Another glycated protein, lasts around 2 weeks)

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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

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

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

Suffer from hypoglycaemic unawareness

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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

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

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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Which diabetic drug class works by the MoA:

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

Sulfonylureas

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Sulfonylurea works by which MoA? [1]

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

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State 2 advantages of sulfonylureas
State 3 disadvantages of sulfonylureas

Advantage:
Oral
Cheap

Disadvantage
Hypoglycaemia

Weight gain
Testing glucose if driving

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Describe the MoA of Acarbose [2]

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

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State two disadvantages of acarbose

Bloating (due to fermentation of glucose
Not very effective

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

Glitazones (thiazolidinediones)

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Name 3 advantages of glitazones for diabetic control

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

HbA1c reduction 10-15 mmol/mol

Little hypoglycaemia

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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

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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)

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

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

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Name 4 advantages of GLP-1 analogues [3]

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

Name 4 disadvantages of GLP-1 analogues [4]

Injection
Cost ~ £73.00 per month

Needs some nursing
GI side effects
?? Pancreatitis risk

Which drug class works by the following MoA: *Works to inhibiting DPP-4 which breaks down GLP-1, thereby increasing endogenous GLP-1*

**Gliptins**

What effect do gliptins have on weight? [1]

DPP-4 inhibitors: **Weight neutral**

Gliflozins inhibit which transporter? [1]

**SGLT-2 inhibitors**

Name 5 advantages of using SGLT-2 inhibitors

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

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

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

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**

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

After triple therapy offered; **BMI over 35** (NICE)

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

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

**Gliflozin**

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]

Gliflozin

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 }

Where should you inject insulin?

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

State the three different types of insulin regimens

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

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

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]

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

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

Every 3-6 months

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

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

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

Bladder cancer

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]

symptoms include **erratic blood glucose control, bloating and vomiting** management options include **metoclopramide, domperidone or erythromycin** (prokinetic agents)

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

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

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

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

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