Diabetes: Management Flashcards
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)
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
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)
What substance can be used if HbA1c is invalid to assess glycaemic control? [1]
Fructosamine (Another glycated protein, lasts around 2 weeks)
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
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
Which patient populations are the only group given Continuous Glucose Monitoring? [1]
Suffer from hypoglycaemic unawareness
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
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%.
Which diabetic drug class works by the MoA:
Works by stimulating insulin release from the beta cells (non- glucose dependent)
Sulfonylureas
Sulfonylurea works by which MoA? [1]
Works by stimulating insulin release from the beta cells (non- glucose dependent)
State 2 advantages of sulfonylureas
State 3 disadvantages of sulfonylureas
Advantage:
Oral
Cheap
Disadvantage
Hypoglycaemia
Weight gain
Testing glucose if driving
Describe the MoA of Acarbose [2]
Blocks disaccharidase in the GI tract
Reduces absorption of glucose }
State two disadvantages of acarbose
- Bloating (due to fermentation of glucose
- Not very effective
Works to improving insulin sensitivity by binding to PPAR- gamma refers to which diabetic drug class? [1]
Glitazones (thiazolidinediones)
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
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 a daily [1] & weekly [2] injectable GLP-1 drug
Liraglutide – daily injection
Dulaglutide – weekly injection
Semaglutide – weekly injection or oral tablet
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
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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 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
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]
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)
DPP4 inhibitors have a risk of causing which pathology? [1]
Pancreatitis
