Diabetes mellitus

Question 1

Screening

Answer 1

1. >40 yo/ 3 years with AUSDRISK 2. All ATSI >18yo 3. High risk FG/year

Question 2

High risk groups on screening

Answer 2

1. IFG/IGT 2. >40 w/ BMI >30 3. Women w/ history of GDM/PCOS 4. Pacific islanders >35 5. Previous CV event 6. Antipsychotic

Question 3

Risk of developing diabetes w/ AUSDRISK scores

Answer 3

1. For scores of 12–15, 1 in 14 will develop 2. 16–19, 1 in seven will develop diabetes. 3. 20 and above, 1 in three will develop diabetes.

Question 4

At what AUSDRISK is increased risk

Answer 4

When score is >12

Question 5

History

Answer 5

1. Symptoms: Glycosuria: polyuria, polydipsia, polyphagia, weight loss hyperglycaemia: malaise/fatigue, altered vision, delayed wound healing. Bacterial infections Loss of sensation 2. Risk assessment: Risk factors for complications: personal or family history of CVD, smoking, hypertension, dyslipidaemia, mental health problems 3. SNAP 4. Other aspects of history age, family history, cultural group, overweight, physical inactivity, hypertension obstetric history of large babies or GDM medication causing hyperglycaemia personal or family history of haemochromatosis personal or family history of other autoimmune diseases (e.g. hypothyroidism or hyperthyroidism). 5. Complications cardiovascular symptoms, neurological symptoms, bladder and sexual function, foot and toe problems and any recurrent infections

Question 6

Physical examination

Answer 6

General: adiposity, pigmentation, endocrinological features, acanthosis nigricans, skin tags, infections CV system, including postural BP Eyes->with fundoscopy, nerve palsies Abdomen->hepatomegaly Feet Urinalysis Evidence of impaired glucose tolerance: obesity, acanthosis nirgicans, hirsutism, skin tags, menstrual irregularities

Question 7

Investigations

Answer 7

Serum glucose: random and fasting HbA1C UEC LFTs Urine protein:creatinine, albumin Fasting lipids FBE Urine Consider opthalmology, podiatry

Question 8

Diagnostic criteria

Answer 8

Fasting blood glucose >7 Random blood glucose >11.1= diagnostic FBG 5.5-6.9/RBG5.5-11/ HbA1c >6.5–>consider

Question 9

DIagnostic criteria post OGTT

Answer 9

FBG >7 mmol/L, BG 2h ≥11 mmol/L= diagnostic FBG

Question 10

Management overview for T2DM

Answer 10

1. Lifestyle modification 2. Refer to allied health professionals 3. Medication 4. Problem areas in Diabetes tool 5. Vaccinations 6. General support, psychosocial 7. Management of co-morbidities 8. Driving 9. Annual diabetes screen, care plan 10. BP, Lipids->Statin and ACEi 11. BMI, kidney and liver function

Question 11

Lifestyle modification

Answer 11

1. Smoking cessation 2. Alcohol within guidelines (risk hypoglycemia) 3. Weight->5-10% loss= prevention, delay, control 4. Diet->balanced, wholefoods, mediterrenean 5. Physical activity

Question 12

Advice on physical activity

Answer 12

1. Minimum 210 minutes/week 2. No more than 2 consequetive days without activity 3. Strength training included 4. 6-12 hour hypoglycemic delay if on insulin or sulphonylureas 5. Monitor BG before, during and post activity 6. If on insulin or sulphonylureas be mindful of delayed hypoglycemia 6-12 hours post activity

Question 13

Vaccinations

Answer 13

1. Influenza annually 2. Tetanus booster after 50 3. Pneumococcal Non-ATSI single dose then another >65, or 10 years after first dose (whichever is first) Non ATSI >65, ATSI >50->single dose then repeat in 5 years

Question 14

Management algorithm

Answer 14

1. Lifestyle + metformin (or sulfonylurea if cannot tolerate) 2. Stop rule! 3-6 months r/v->if not achieved add Sulfonylural, thiazolinedione, DPP4 inhibitor, acarbose, Injectable insulin or GLP1 agonist 3. Stop rule! 3-6 months r/v->add/change If after 6 mo and appropriate titration not achieve Stop. Check health literacy, lifestyle changes, review non-adherence, occult infection? Ask about hypoglycemia and side effects 4. Add a. Insulin (continue MF if tolerated). If glycosuric symptoms or rising HbA1c (e.g >8.5%) –>Basal insulin or premixed insulin initially –>Add prandial insulin with time if required b. PBS: Thiazolidinedione (only pioglitazone is PBS listed), If no congestive heart failure-> acarbose, DPP4 inhibitor

Question 15

Glucose monitoring targets

Answer 15

Targets for SMBG levels are 6–8 mmol/L fasting and pre-prandial, and 6–10 mmol/L 2 h postprandial

Question 16

Reasons for abnormally high HbA1C

Answer 16

IDA Splenectomy Alcoholism Steroid/stress/surgery

Question 17

Reasons for abnormally low HbA1C

Answer 17

Hemolysis Blood loss Chronic renal failure

Question 18

Components of the 3-6 monthly review

Answer 18

Hx: SNAP, home testing, feet, symptoms Physical: wt, ht, BP, feet, waist Ix: HbA1C, lipids Reviews goals of management

Question 19

Components of annual review

Answer 19

History and PE as 3 monthly Referrals as new issues develop Evaluate care plan, suitability, goals 1. Ask: symptoms, goal setting, issues, glycemic control 2. Asses risk factors: wt, ht, CVD, foot, psychological, eyes, dental, cognition 3. Advise: SNAP, driving, immunisation, sick day, medication, self monitoring 4. Assist: Eye examination/2 years, podiatrist/shoes, register with NDSS, care plan, psychological 5. Arrange: register and recall, referrals, review, liscence, investigations->Lipids, HbA1C, LFTs, kidney function, albumin:creatine, urinalysis

Question 20

Targets for lipids

Answer 20

Lipids: TC <4.0 mmol/L;
HDL-C ≥1.0 mmol/L;
LDL-C <2.0 mmol/L;
Non-HDL-C <2.5 mmol/L;
TG <2.0 mmol/L.

Question 21

Targets for BP

Answer 21

≤ 130/80 mm Hg for everyone with diabetes, regardless of macro- or micro-albuminuria

Question 22

Explanation of metformin

Answer 22

Increases the body’s sensitivity to insulin->makes better use of the insulin available Immediate release 500mg orally BD, or extended release 1g with evening meal Take with or immediately after meal, same time each day. Taken lifelong if it works Will required UEC prior to starting, then annually. SE may include nausea, vomiting diarrhea, weight loss. Complication is lactic acidosis Caution: renal impaired, ketoacidosis, low BMI Must be stopped prior to GA or contrast due to ++risk of lactic acidosis If missed dose, take as soon as remember, unless close to next dose.

Question 23

Initiating insulin

Answer 23

Before starting: ensure adequate use of other oral hypoglycemic agents, adherence and health literacy 1. Premixed biphasic: when both fasting and post prandial elevated 2. Basal insulin->less risk of nocturnal hypoglycemia

Question 24

Titration of insulin

Answer 24

1. Check HbA1C in 3 months 2. If not at target: look for hidden hyperglycemias before/post meals ->Post prandial: consider changing meal size, composition, +activity after meals, adding acarbose, adding a prandial insulin dose or switching to premixed

Question 25

Intensification of insulin

Answer 25

If goals still not reached, add a second insulin Regimes 1. Basal-bolus 2. Basal-plus 3. Premixed

Question 26

Basal bolus

Answer 26

Basal + bolus before meals, most number of injections Suitable for those with variable meal times, need post prandial

Question 27

Bolus ++dose of short acting

Answer 27

Least injections Variable meal times Need post prandial management

Question 28

Premixed

Answer 28

Suitable when fewest injections wanted, poor congnition/dexterity

Question 29

Hospital management of hyperglycemia->medication issues, why insulin is best in hospital setting

Answer 29

1. Metformin not to be used when possibility of needing contrast 2. Sulfonylureas and metaglinides can cause unpredictable hypoglycemia in patients who are not eating reliably. 3. Thiazolidinediones can cause fluid retention, especially in combination with insulin. 4. Parenteral glucagon-like peptide-1 and amylin agonists can cause nausea and should be withheld in acutely ill patients. 5. For these reasons, inpatient hyperglycemia is best managed with insulin only->Insulin sliding scale 6. Physical activity—depending on the intensity of the activity, decrease insulin dosage 1 to 2 units per 20 to 30 minutes of activity. 7. During illness, administer all of the routine insulin. Many episodes of DKA occur during episodes of illness. 8. Stress and changes in diet require dosing adjustments. 9. Patients undergoing surgery should get one-third to one-half of the usual daily insulin requirement that day, with frequent monitoring and adjustments as necessary

Question 30

Dosing of basal and bolus

Answer 30

Total insulin = 1unit/kg Basal is 2/3 total insulin Bolus= 1/3->divide by number of meals per day

Question 31

Insulin sliding scale

Answer 31

Example Order for Typical Insulin Sliding Scale (Regular Insulin) Blood glucose Insulin dose 150—200 (8.3 +)→ 2 units 201—250 (11.1 +)→ 4 units 251—300 (13.9+)→ 6 units 301–350 (16.7+) → 8 units 351–400 (19.4+)→ 10 units >400 (22+) → Call house officer (who will usually give 10 to 14 units and adjust the SSI)