Diabetes Mellitus Flashcards
T2DM - Mx - Updated NICE Guidelines
NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2015. Key points are listed below:
- HbA1c targets have changed. They are now dependent on what antidiabetic drugs a patient is receiving and other factors such as frailty
- There is more flexibility in the second stage of treating patients (i.e. after metformin has been started) - you now have a choice of 4 oral anti diabetic agents
NB: It’s worthwhile thinking of the average patient who is taking metformin for T2DM, you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%)
T2DM - Dietary Advice
Dietary advice:
- encourage high fibre, low glycaemic index sources of carbohydrates
- include low-fat dairy products and oily fish
- control the intake of foods containing saturated fats and trans fatty acids
- limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
- discourage use of foods marketed specifically at people with diabetes
- initial target weight loss in an overweight person is 5-10%
T2DM Mx: HbA1c Targets
This is area which has changed in 2015
- individual targets should be agreed with patients to encourage motivation
- HbA1c should be checked every 3-6 months until stable, then 6 monthly
- NICE encourage us to consider relaxing targets on ‘a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes’
- in 2015 the guidelines changed so HbA1c targets are now dependent on treatment:
LIFESTYLE OR DRUG TREATMENT
Lifestyle : HbA1c target 48 mmol/mol (6.5%)
Lifestyle + Metformin: HbA1c target 48 mmol/mol (6.5%)
Includes any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea): HbA1c target 53 mmol/mol (7.0%)
Already on one drug, but HbA1c has risen to 58 mmol/mol (7.5%): HbA1c target 53 mmol/mol (7.0%)
Practical examples:
A patient is newly diagnosed with HbA1c and wants to try lifestyle treatment first. You agree a target of 48 mmol/mol (6.5%)
You review a patient 6 months after starting metformin. His HbA1c is 51 mmol/mol (6.8%). You increase his metformin from 500mg bd to 500mg tds and reinforce lifestyle factors
T2DM - Drug Treatment
For pt who can tolerate Metformin:
Drug treatment
The 2015 NICE guidelines introduced some changes into the management of type 2 diabetes. There are essentially two pathways, one for patients who can tolerate metformin, and one for those who can’t.
Tolerates metformin:
metformin is still first-line and should be offered if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions
if the HbA1c has risen to 58 mmol/mol (7.5%) then a second drug should be added from the following list:
→ sulfonylurea
→ gliptin (DPP-4 Inhibitors)
→ pioglitazone
→ SGLT-2 inhibitor
if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then triple therapy with one of the following combinations should be offered:
→ metformin + gliptin + sulfonylurea
→ metformin + pioglitazone + sulfonylurea
→ metformin + sulfonylurea + SGLT-2 inhibitor
→ metformin + pioglitazone + SGLT-2 inhibitor
→ OR insulin therapy should be considered
Criteria for glucagon-like peptide1 (GLP1) mimetic (e.g. exenatide)
if triple therapy is not effective, not tolerated or contraindicated then NICE advise that we consider combination therapy with metformin, a sulfonylurea and a glucagonlike peptide1 (GLP1) mimetic if:
→ BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or
→ BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or
weight loss would benefit other significant obesityrelated comorbidities
only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
NB Insulin should not be combined with a GLP-1 mimetic.
Practical examples
you review an established type 2 diabetic on maximum dose metformin. Her HbA1c is 55 mmol/mol (7.2%). You do not add another drug as she has not reached the threshold of 58 mmol/mol (7.5%)
a type 2 diabetic is found to have a HbA1c of 62 mmol/mol (7.8%) at annual review. They are currently on maximum dose metformin. You elect to add a sulfonylurea
Example Names:
Sulfonylurea: Gliclazide, Tolbutamide, Glibenclamide, Glipizide, Glimerpiride
SGLT-2 Inhibitors: Dapagliflozin, Canaglifozin, Empagliflozin
Pioglitazone = Only thiazolidinedione licensed for DM
DPP-4 Inhibitors (Gliptins) = Sitagliptin, Linagliptin, Vildagliptin
GLP-1 Mimetic = Exenatide, Liraglutide, Lixisenatide, Dulaglutide
T2DM - Drug Treatment
For pt who cannot tolerate Metformin
The 2015 NICE guidelines introduced some changes into the management of type 2 diabetes. There are essentially two pathways, one for patients who can tolerate metformin, and one for those who can’t.
Cannot tolerate metformin or contraindicated (NB eGFR<30ml/minute/1.73m2 metformin is contraindicated)
If the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions, consider one of the following:
→ sulfonylurea
→ gliptin
→ pioglitazone
if the HbA1c has risen to 58 mmol/mol (7.5%) then a one of the following combinations should be used:
→ gliptin + pioglitazone
→ gliptin + sulfonylurea
→ pioglitazone + sulfonylurea
if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then consider insulin therapy
Starting insulin
metformin should be continued. In terms of other drugs NICE advice: ‘Review the continued need for other blood glucose lowering therapies’
NICE recommend starting with human NPH insulin (isophane, intermediate acting) taken at bed-time or twice daily according to need
*this is a bit confusing because isn’t the diagnostic criteria for T2DM HbA1c 48 mmol/mol (6.5%)? So shouldn’t all patients be offered metformin at diagnosis? Our interpretation of this is that some patients upon diagnosis will elect to try lifestyle measures, which may reduce their HbA1c below this level. If it then rises to the diagnostic threshold again metformin should be offered
T2DM - Risk Factor Modification
Risk factor modification
Blood pressure
target is < 140/80 mmHg (or < 130/80 mmHg if end-organ damage is present)
ACE inhibitors are first-line
Antiplatelets
should not be offered unless a patient has existing cardiovascular disease
Lipids
following the 2014 NICE lipid modification guidelines only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg on
Insulin Therapy
Insulin therapy
Insulin therapy revolutionised the management of diabetes mellitus when it was developed in the 1920’s. It is still the only available treatment for type 1 diabetes mellitus (T1DM) and is widely used in type 2 diabetes mellitus (T2DM) where oral hypoglycaemic agents fail to gain adequate control.
It can sometimes seem daunting to understand the various types of insulin but it is important you have a basic grasp to avoid potential harm to patients.
Classification of Insulin
Classification of insulin
By manufacturing process
porcine: extracted and purified from pig pancreas
human sequence insulin: either produced by enzyme modification of porcine insulin (emp) or biosynthetically by recombinant DNA using bacteria (crb, prb) or yeast (pyr)
analogues
By duration of action
Onset > Peak > Duration
Rapid-acting insulin analogues:
- 5 mins
- 1 hour
- 3-5 hours
Short-acting insulin
- 30 mins
- 3 hours
- 6-8 hours
Intermediate-acting insulin
- 2 hours
- 5-8 hours
- 12-18 hours
Long-acting insulin analogues
- 1-2 hours
- Flat profile
- Up to 24 hours
Premixed preparations - - -
Patients often require a mixture of preparations (e.g. both short and long acting) to ensure stable glycaemic control throughout the day.
Rapid-acting Insulin
Rapid-acting insulin analogues
the rapid-acting human insulin analogues act faster and have a shorter duration of action than soluble insulin (see below)
may be used as the bolus dose in ‘basal-bolus’ regimes (rapid/short-acting ‘bolus’ insulin before meals with intermediate/long-acting ‘basal’ insulin once or twice daily)
insulin aspart: NovoRapid
insulin lispro: Humalog
Short-acting Insulin
Short-acting insulins
soluble insulin examples: Actrapid (human, pyr), Humulin S (human, prb)
may be used as the bolus dose in ‘basal-bolus’ regimes
Intermediate-acting Insulin
Intermidate-acting insulins
isophane insulin
many patients use isophane insulin in a premixed formulation with
Long-acting Insulin
Long-acting insulins insulin determir (Levemir): given once or twice daily insulin glargine (Lantus): given once daily
Insulin - Pre-mixed Preparations
Premixed preparations
combine intermediate acting insulin with either a rapid-acting insulin analogue or soluble insulin
Novomix 30: 30% insulin aspart (rapid-acting), 70% insulin aspart protamine (intermediate-acting)
Humalog Mix25: 25% insulin lispro (rapid-acting), 75% insulin lispro protamine (intermediate-acting); Humalog Mix50: 50% insulin lispro, 50% insulin lispro protamine
Humulin M3: biphasic isophane insulin (human, prb) - 30% soluble (short-acting), 70% isophane (intermediate-acting)
Insuman Comb 15: biphasic isophane insulin 9human, prb) - 30% soluble (short-acting), 70% isophane (intermediate-acting)
Administration of Insulin
Administration of insulin
The vast majority of patients administer insulin subcutaneously. It is important to rotate injection sites to prevent lipodystrophy. Insulin pumps are available (‘continuous subcutaneous insulin infusions’) which delivers a continuous basal infusion and a patient-activated bolus dose at meal times.
Intravenous insulin is used for patients who are acutely unwell, for example with diabetic ketoacidosis. Inhaled insulin is available but not widely used and oral insulin analogues are in development but have considerable technical hurdles to clear.
Target Blood Sugars - Example Question
A 19-year-old man is reviewed prior to discharge. He presented with vomiting and abdominal pain and was found to have diabetic ketoacidosis. He was managed as an inpatient for five days before being well enough for discharge. He is also diagnosed with type 1 diabetes mellitus on this admission as a cause of the diabetic ketoacidosis. He has been educated by the diabetic nurse on how to manage his diabetes and insulin at home, but he is concerned about what his target plasma glucose should be after eating.
What is the recommended target after eating to be achieved by home monitoring?
3-6mmol/litre 5-10mmol/litre > 5-9mmol/litre 7-12mmol/litre 2-9 mmol/litre
The correct answer is 5-9mmol/litre. NICE recommends that people with type 1 diabetes should aim for 5-7mmol/litre on waking, 4-7mmol/litre before meals and 5-9mmol/litre 90 minutes after eating. Frequent testing is very important in patients starting with insulin therapy to avoid both high and low sugar levels.
Source:
‘Type 1 diabetes in adults: diagnosis and management’ Clinical guideline [NG17]. The National Institute for Health and Care Excellence, August 2015.
DM in Pregnancy
Pregnancy: diabetes mellitus
Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. It complicates around 1 in 40 pregnancies. NICE updated the guidance in 2015
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Gestational Diabetes - Screening and Diagnosis
Screening for gestational diabetes
women who’ve previously had gestational diabetes: oral glucose tolerance test (OGTT) should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Diagnostic thresholds for gestational diabetes
these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
Mx of Gestational Diabetes and Pre-existing Diabetes in Pregnancy
Management of gestational diabetes:
- Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
- Women should be taught about selfmonitoring of blood glucose
- Advice about diet (including eating foods with a low glycaemic index) and exercise should be given
- If the fasting plasma glucose level is < 7 mmol//l a trial of diet and exercise should be offered
- If glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
- If glucose targets are still not met insulin should be added to diet/exercise/metformin
- If at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
- If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
- Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Management of pre-existing diabetes
- Weight loss for women with BMI of > 27 kg/m^2
- Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
- Folic acid 5 mg/day from pre-conception to 12 weeks gestation
- Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
- Tight glycaemic control reduces complication rates
- Treat retinopathy as can worsen during pregnancy
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
Time Target
Fasting 5.3 mmol/l
1 hour after meals 7.8 mmol/l, or:
2 hour after meals 6.4 mmol/l
Mx of Gestational Diabetes - Example Question
You review a 28-year-old woman who is 26 weeks pregnant. She has just had a routine oral glucose tolerance test as her BMI is 34 kg/m². The following results were obtained:
Time (hours) Blood glucose (mmol/l)
0 7.4
2 11.2
There have been no other antenatal problems and her anomaly scan was normal. What is the most appropriate action?
Repeat oral glucose tolerance test in 4 weeks Start metformin + advice about diet / exercise + self-monitor glucose levels Advice about diet / exercise + self-monitor glucose levels > Start insulin + advice about diet / exercise + self-monitor glucose levels Reassure results within normal limits
NICE have recently changed their gestational diabetes guidelines. Insulin should be started in the fasting glucose is >= 7 mmol/l. Aspirin should also be considered given the increased risk of pre-eclampsia.
Insulin Therapy - Example Question
A 34 year-old woman is seen by her GP for the annual review of her type 1 diabetes. Her most recent HbA1c is 58 mmol/mol and the only problem she has noticed are severe hypoglycaemic episodes during the night around 2-4am, that she noticed she was getting while working night shifts for a local superstore. However, by breakfast time, her blood glucose levels often rise to around 15 mmol/mol. Her insulin regimen is currently a twice daily mixed insulin.
What is the most appropriate change to her current insulin treatment?
> Move to a basal bolus of insulin Take 1 dextrose tablet at 9pm Reduce nocturnal insulin dose Reduce morning insulin dose Add gliclazide
This patient is experiencing severe nocturnal hypoglycaemic episodes followed by rises in blood glucose by breakfast time. The most appropriate change to the insulin treatment regimen is changing to a basal bolus regime, with one daily injection of background long-acting insulin and three short acting injections of insulin.
Diabetes and the New Drugs
Diabetes mellitus: GLP-1 and the new drugs
A number of new drugs to treat diabetes mellitus have become available in recent years. Much research has focused around the role of glucagon-like peptide-1 (GLP-1), a hormone released by the small intestine in response to an oral glucose load
Whilst it is well known that insulin resistance and insufficient B-cell compensation occur other effects are also seen in type 2 diabetes mellitus (T2DM). In normal physiology an oral glucose load results in a greater release of insulin than if the same load is given intravenously - this known as the incretin effect. This effect is largely mediated by GLP-1 and is known to be decreased in T2DM.
Increasing GLP-1 levels, either by the administration of an analogue (glucagon-like peptide-1, GLP-1 mimetics, e.g. exenatide) or inhibiting its breakdown (dipeptidyl peptidase-4 ,DPP-4 inhibitors - the gliptins), is therefore the target of two recent classes of drug.
GLP-1 Mimetics eg Exenatide
Glucagon-like peptide-1 (GLP-1) mimetics (e.g. exenatide)
Exenatide is an example of a glucagon-like peptide-1 (GLP-1) mimetic. These drugs increase insulin secretion and inhibit glucagon secretion. One of the major advances of GLP-1 mimetics is that they typically result in weight loss, in contrast to many medications such as insulin, sulfonylureas and thiazolidinediones.
Exenatide must be given by subcutaneous injection within 60 minutes before the morning and evening meals. It should not be given after a meal.
Liraglutide is the other GLP-1 mimetic currently available. One the main advantages of liraglutide over exenatide is that it only needs to be given once a day.
Both exenatide and liraglutide may be combined with metformin and a sulfonylurea. Standard release exenatide is also licensed to be used with basal insulin alone or with metformin. Please see the BNF for a more complete list of licensed indications.
NICE state the following:
Consider adding exenatide to metformin and a sulfonylurea if:
BMI >= 35 kg/m² in people of European descent and there are problems associated with high weight, or
BMI < 35 kg/m² and insulin is unacceptable because of occupational implications or weight loss would benefit other comorbidities.
NICE like patients to have achieved a 11 mmol/mol (1%) reduction in HbA1c and 3% weight loss after 6 months to justify the ongoing prescription of GLP-1 mimetics.
The major adverse effect of GLP-1 mimetics is nausea and vomiting. The Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that is has been linked to severe pancreatitis in some patients.
DPP-4 Inhibitors eg Vildagliptin
Dipeptidyl peptidase-4 (DPP-4) inhibitors (e.g. Vildagliptin, sitagliptin)
Key points
oral preparation
trials to date show that the drugs are relatively well tolerated with no increased incidence of hypoglycaemia
do not cause weight gain
NICE guidelines on DPP-4 inhibitors
NICE suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated or the person has had a poor response to a thiazolidinedione
T2DM Mx - Example Question
A 60-year-old taxi driver presents to the diabetes clinic for review. He is obese with a body mass index of 36 kg/m², and has noticed a significant increase in his fasting blood glucose over the past 3 months from 6.5 mmol/l, to over 9 mmol/l. Apart from hypertension he has no other significant past medical history. Current medication includes metformin 1g BD, ramipril 10mg OD and atorvastatin 20mg OD. On examination his blood pressure is 155/82 mmHg, pulse is 70 beats per minute and regular. His chest is clear, abdomen is soft and non-tender with no masses, and he has no ankle swelling. Bloods reveal a normal creatinine and an HbA1c of 70 mmol/mol.
Which of the following is the most appropriate way to manage his blood glucose?
Gliclazide > Liraglutide Sitagliptin BD mixed insulin Acarbose
This patient is obese with a significantly elevated HbA1c and has a sedentary lifestyle. Given his occupation as a taxi driver, he requires blood glucose lowering which won’t increase risk of hypoglycaemia, is potent, and preferably promotes weight loss. As such liraglutide, GLP-1 agonist is the most appropriate option, bringing long-acting insulin like glucose control, coupled with weight reduction of approximately 3% over 6 months.
Both BD mixed insulin and gliclazide increase the risk of hypoglycaemia and potentially lead to weight gain, and could impact on his driving licence, as such they should be avoided in this situation. Sitagliptin offers only a modest reduction in HbA1c, and acarbose results in flatulence in a significant proportion of users. As such these are better avoided as therapeutic options.
T2DM - Drug Treatment
Drug treatment
The 2015 NICE guidelines introduced some changes into the management of type 2 diabetes. There are essentially two pathways, one for patients who can tolerate metformin, and one for those who can’t:
Tolerates metformin:
metformin is still first-line and should be offered if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions
if the HbA1c has risen to 58 mmol/mol (7.5%) then a second drug should be added from the following list:
→ sulfonylurea
→ gliptin
→ pioglitazone
→ SGLT-2 inhibitor
if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then triple therapy with one of the following combinations should be offered:
→ metformin + gliptin + sulfonylurea
→ metformin + pioglitazone + sulfonylurea
→ metformin + sulfonylurea + SGLT-2 inhibitor
→ metformin + pioglitazone + SGLT-2 inhibitor
→ OR insulin therapy should be considered
Criteria for glucagon-like peptide1 (GLP1) mimetic (e.g. exenatide)
if triple therapy is not effective, not tolerated or contraindicated then NICE advise that we consider combination therapy with metformin, a sulfonylurea and a glucagonlike peptide1 (GLP1) mimetic if:
→ BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or
→ BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or
weight loss would benefit other significant obesityrelated comorbidities
only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
Practical examples
you review an established type 2 diabetic on maximum dose metformin. Her HbA1c is 55 mmol/mol (7.2%). You do not add another drug as she has not reached the threshold of 58 mmol/mol (7.5%)
a type 2 diabetic is found to have a HbA1c of 62 mmol/mol (7.8%) at annual review. They are currently on maximum dose metformin. You elect to add a sulfonylurea
Cannot tolerate metformin or contraindicated
if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions, consider one of the following:
→ sulfonylurea
→ gliptin
→ pioglitazone
if the HbA1c has risen to 58 mmol/mol (7.5%) then a one of the following combinations should be used:
→ gliptin + pioglitazone
→ gliptin + sulfonylurea
→ pioglitazone + sulfonylurea
if despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then consider insulin therapy
Starting insulin
metformin should be continued. In terms of other drugs NICE advice: ‘Review the continued need for other blood glucose lowering therapies’
NICE recommend starting with human NPH insulin (isophane, intermediate acting) taken at bed-time or twice daily according to need
T2DM Mx - Example Question
A 45-year-old man was commenced on 500mg metformin BD for type 2 diabetes mellitus as he was unable to meet his target HBA1c of 6.5% 6 months ago. He is now presenting for his regular follow up and feels well. He states that he has been compliant with his metformin, maintaining a healthy diet and exercising more regularly. His latest HBA1c is 7.3% and the rest of his investigations are normal. What is the next best step to manage his diabetes?
> Increase his dose of metformin Add pioglitazone Make no change to his current treatment Add a sulfonylurea Advise to increase frequency of exercise
As per NICE guidelines on the management of type 2 diabetes in adults, at an HBA1c of 7.3% and a relatively low dose of metformin, the first step would be to increase his dose of metformin. His aim should still be an HBA1c of 6.5% on metformin.
Additional medications are only required if his HBA1c is 7.5% or higher, therefore the addition of pioglitazone or a sulfonylurea is incorrect. Whilst regular exercise is important, it is unlikely to be sufficient at this stage.
Click on the link below for more information and the algorithm for blood glucose lowering therapy in adults with type 2 diabetes:
https://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#drug-treatment-2
Testing for Gestational Diabetes - Example Question
A lady who is 10 weeks pregnant presents to her antenatal appointment asking for advice regarding gestational diabetes. She is a 31 year old English lady with a BMI (body mass index) of 28.7. In terms of family history she has a cousin who has type 1 diabetes mellitus and an aunt who is being treated for breast cancer. She has had two previous pregnancies, the first one she unfortunately miscarried at 8 weeks, and the second was a normal pregnancy that she took to term with a birth weight of 4.6kg. Neither of these pregnancies was complicated with gestational diabetes, and the baby is now 2 years old and has not had to be taken to see a doctor other than routine appointments.
What is the most appropriate testing regime for ruling out gestational diabetes in this woman?
> Oral glucose tolerance test at 24-28 weeks pregnant None - as she has no risk factors for gestational diabetes Oral glucose tolerance test at 12-14 weeks pregnant Self-monitoring of sugars and repeat appointment in 2 weeks HBa1c
This question requires knowledge on the risk factors for developing gestational diabetes and appropriate testing based on risk:
Risk factors for gestational diabetes include:
BMI >30kg/m²
Previous delivery of a baby over 4.5kg - which qualifies this patient
Previous gestational diabetes
Family history of diabetes (1st degree relative)
Minority ethnic family origin with a high prevalence of diabetes
If any one of these risk factors is present then one should offer testing for gestational diabetes. The gold standard testing for patients with risk factors is 2-hour 75g oral glucose tolerance test (OGTT) at 24-28 weeks gestation. If the patient has had gestational diabetes in a previous pregnancy then early-self monitoring of blood glucose or OGTT as soon as possible after booking could also be used for diagnosis.
A diagnosis of gestational diabetes is made if the patient has either:
Fasting glucose of 5.6 mmol/L or above OR
A 2-h plasma glucose of 7.8 mmol/L or above
Osteomyelitis
Osteomyelitis
Osteomyelitis describes an infection of the bone.
Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate.
Predisposing conditions diabetes mellitus sickle cell anaemia intravenous drug user immunosuppression due to either medication or HIV alcohol excess
Investigations
MRI is the imaging modality of choice, with a sensitivity of 90-100%
Management
flucloxacillin for 6 weeks
clindamycin if penicillin-allergic
Diabetic Cx: Osteomyelitis - Example Question
A 58-year-old man who has no fixed abode comes to the Emergency department because he is unable to walk. He has a history of alcoholism and type 2 diabetes. His main complaint is that his shoes have worn out and because of loss of sensation he didn’t notice that he had stepped on a nail. In total the lesion on his right foot has been present for approximately 3 weeks.
Which of the following is the next step in evaluating his foot injury?
Inflammatory markers MRI foot > Plain x-ray foot USS foot Wound swab
The key next step here is to gather useful information about the extent of any foot infection. By 3 weeks post injury, changes consistent with osteomyelitis should be visible on plain x-ray. These may include soft tissue swelling, bone demineralisation, cortical irregularity, and an elevated periosteum.
Many patients progress from a plain x-ray on to MRI imaging of the foot for further evaluation of the extent of infection and to guide potential operative approaches for debridement. Inflammatory markers are a very non-specific marker of infection and ultrasound of the foot is only useful to visualise soft tissue swelling or collection of pus / fluid. A wound swab is likely to show a range of bacteria, this is what drives selection of a broader spectrum antibiotic such as co-amoxiclav in the diabetic population.
T2DM - Mx: Example Question
A 57-year-old man with a history of type 2 diabetes mellitus and chronic heart failure is reviewed in the diabetes clinic. His current medication list is as follows:
metformin 1g bd gliclazide 160mg bd ramipril 10mg od bisoprolol 5mg od furosemide 40mg od simvastatin 20mg on
His annual bloods show the following:
Na+ 140 mmol/l K+ 3.9 mmol/l Urea 5.2 mmol/l Creatinine 78 µmol/l HbA1c 7.7% (61 mmol/mol) Total cholesterol 4.2 mmol/l HDL cholesterol 1.1 mmol/l
Blood pressure today is 124/78 mmHg and body mass index is 29 kg/m².
What is the most appropriate action with regards to his anti-diabetic medication?
No changes to medication Exenatide Repaglinide Pioglitazone > Sitagliptin
Pioglitazone should be avoided in this man due to his history of heart failure. He would also not fit the NICE criteria for exenatide.
A HbA1c of 7.7% (61 mmol/mol) should be improved if possible. Sitagliptin may be added to metformin and gliclazide.
T2DM - Insulin Therapy - Example Question
A 56-year-old man with a history of type 2 diabetes managed with Humalog mix 30 and metformin 1g BD comes to the clinic for review. HbA1c is currently 57. He has troublesome hypoglycaemia episodes in the late afternoon and early mornings and wants to know what to do about it. On examination his blood pressure is 132/82 mmHg, his pulse is 72 beats per minute and regular. His body mass index is 32 kg/m².
Investigations
Na+ 139 mmol/l K+ 4.9 mmol/l Urea 5.1 mmol/l Creatinine 94 µmol/l HbA1c 57 mmol/mol
Which of the following is the most appropriate next step in his management?
Continue current regimen, eat a snack mid afternoon and before bed time Reduce the dose of metformin Reduce the dose of mixed insulin > Switch to a basal bolus regimen Switch to Humalog mix 20
This person’s HbA1c is above target at 57 mmol/mol or 7.4%. In spite of this, he is still suffering from hypoglycaemia episodes as a result of delivering his insulin as a twice a day regimen. Moving him to basal bolus will allow splitting up of the short acting component of his insulin requirements, and therefore reduce the risk of hypoglycaemia at the end of each dosing period.
Reducing the dose of his mixed insulin may drive a further rise in his HbA1c, as would reducing the dose of metformin. Switching to Humalog mix 20 will increase the proportion of long-acting insulin and worsen the risk of hypoglycaemia. Eating a snack will drive weight gain and worsen his HbA1c.
Insulin SE
Insulin therapy: side-effects
Hypoglycaemia
patients should be taught the signs of hypoglycaemia: sweating, anxiety, blurred vision, confusion, aggression
conscious patients should take 10-20g of a short-acting carbohydrate (e.g. a glass of Lucozade or non-diet drink, three or more glucose tablets, glucose gel)
every person treated with insulin should have a glucagon kit for emergencies where the patient is not able to orally ingest a short-acting carbohydrate
patients who have frequent hypoglycaemic episodes may develop reduced awareness. If this develops then allowing glycaemic control to slip for a period of time may restore their awareness
beta-blockers reduce hypoglycaemic awareness
Lipodystrophy
typically presents as atrophy of the subcutaneous fat
can be prevented by rotating the injection site
T2DM - Example Question
A 64-year-old man is reviewed in clinic. He has a history of ischaemic heart disease and was diagnosed with type 2 diabetes mellitus around 12 months ago. At this time of diagnosis his HbA1c was 7.6% (60 mmol/mol) and he was started on metformin which was titrated up to a dose of 1g bd. The most recent bloods show a HbA1c of 6.8% (51 mmol/mol). He has just retired from working in the IT industry and his body mass index (BMI) today is 28 kg/m². His other medication is as follows:
Atorvastatin 80mg on
Aspirin 75mg od
Bisoprolol 2.5 mg od
Ramipril 5mg od
What is the most appropriate next step?
Add sitagliptin > Make no changes to his medication Add glimepiride Add pioglitazone Add exenatide
Since the publication of the 2015 guidelines, NICE recommend we only add another drug if the HbA1c has risen to >= 58 mmol/mol (7.5%) at this stage.
T2DM and SGLT-2 Inhibitors - Example Question
You are seeing a 50-year-old lady with type 2 diabetes mellitus in the outpatient clinic. She has a past medical history of gastritis, moderate left ventricular dysfunction and chronic obstructive pulmonary disease. She is currently on metformin and gliclazide. Since last review she has gained 5kg in weight and her HbA1c has deteriorated to 70 mmol/mol from 62 mmol/mol. Body mass index today in clinic is 33 kg/m².
Recent blood tests are as follows:
Na+ 141 mmol/l
K+ 3.9 mmol/l
Urea 6 mmol/l
Creatinine 140 µmol/l
She was unable to previously tolerate liraglutide due to nausea and vomiting. What would be the best alteration to her therapy?
> Empagliflozin (SGLT-2 inhibitor) Add insulin Add pioglitazone Increase dose of metformin Increase dose of gliclazide
SGLT inhibitors have the advantage of improving glycaemic control/HbA1c and having beneficial effects on weight. This is because their mode of action is independent of insulin release. They act upon the SGLT-2 receptors in the kidney and lead to increased loss of glucose in the urine.
T2DM - Mx: Example Question
You are reviewing a 57 year-old gentleman in the diabetes outpatient clinic. He has type 2 diabetes mellitus and is currently taking metformin 850mg three times a day and gliclazide 80mg once daily.
On further questioning he admits having frequent hypoglycaemic episodes at night that distress him as he lives alone. His BMI is calculated at 30.3 kg/m², HbA1c 7.8% (62 mmol/mol) and his co-morbidities include congestive cardiac failure.
How would you change his diabetic treatment?
Stop gliclazide, start insulin Add exenatide Add sitagliptin to current regimen Stop gliclazide, start pioglitazone > Stop gliclazide, start sitagliptin
The NICE guidance on the management of type 2 diabetes mellitus:
•This gentleman has been started on metformin and a sulphonyurea as first line therapy.
•He is having frequent hypoglycaemic episodes secondary to his sulphonylurea and yet control remains poor, HbA1c 7.8% (62 mmol/mol)
•Pioglitazone is contraindicated due to his congestive cardiac failure.
•A DPP-4 inhibitor such as sitagliptin would be a sensible option, the sulphonylurea should be stopped to prevent hypoglycaemia
Hypoglycaemia - Example Question
A 24-year-old nurse presents after collapsing on a night shift. His blood glucose is measured at being 1.4 mmol/l. His blood pressure at the time was noted to be 115/82 mmHg. He has no palpitations and had not bitten his tongue or become incontinent during the episodes. He was shaken afterwards, although did not have memory loss and stated he had not tripped over anything. He also said he has had five of these episodes over the last two weeks.
Blood tests are sent off and unremarkable except for a low-normal C-peptide level and markedly raised insulin level.
Which of the following is the most likely diagnosis of his multiple episodes of collapse?
Sulphonylurea misuse > Insulin misuse Alcohol misuse Retroperitoneal sarcoma Insulinoma
Hyperinsulinaemia in the absence of raised C-peptide points towards the diagnosis of insulin abuse. Elevation of C-peptide, when combined with hyperinsulinaemia suggests sulphonylurea abuse. To rule this out it may be appropriate to assay levels of commonly used sulphonylureas in urine. Insulinomas are a more rare cause of repeated hypoglycaemic episodes.
Hypoglycaemia Causes
Hypoglycaemia
Causes
•insulinoma - increased ratio of proinsulin to insulin
•self-administration of insulin/sulphonylureas
•liver failure
•Addison’s disease
•alcohol
Other possible causes in children
•nesidioblastosis - beta cell hyperplasia
T2DM and Indications for Exenatide - Example Question
A 52-year-old lorry driver was referred to the secondary care diabetes mellitus by his GP with poorly controlled diabetes. He was diagnosed with type 2 diabetes mellitus six years ago. Unfortunately, he has not engaged with lifestyle interventions and his diabetes has been poorly controlled since diagnosis. He has since developed diabetic nephropathy and proliferative retinopathy. Other than diabetes he has a past medical history comprising of ischaemic heart disease, hypertension, hypercholesterolaemia, osteoarthritis and gout. At the point of referral he was prescribed aspirin 75mg OD, ramipril 10mg OD, simvastatin 40mg ON, naproxen 250mg BD, co-codamol 8/500 2tabs QDS, lansoprazole 30mg OD, metformin 500mg TDS, gliclazide 80mg BD and pioglitazone 30mg OD. He smoked 20 cigarettes per day and consumed 15 units of alcohol per week.
Examination revealed an obese gentleman with a BMI of 38 kg/m. His blood pressure was 148/88 mmHg. Cardiovascular examination revealed the presence of normal heart sounds and a JVP of 3cm. Examination of the respiratory, abdominal and neurological systems was unremarkable. Investigations reveal the following results:
Na+ 136 mmol/l K+ 5.1 mmol/l Urea 14.1 mmol/l Creatinine 148 µmol/l Total cholesterol 5.1 mmol/l HDL cholesterol 1.3 mmol/l HbA1c 68 mmol/mol (8.4%)
What is the next best step management step?
> Commence exenatide Commence sitagliptin Commence insulin glargine Increase dose of pioglitazone Commence orlistat
This gentleman fulfills the NICE guidelines criteria for exenatide therapy. He is obese with poorly controlled diabetes despite multiple oral hypoglycaemic agents and is suffering from other morbidities relating to his weight. Exenatide may help facilitate weight loss and does not cause hypoglycaemia. Insulin is the other option here, but it may lead to weight gain. Furthermore, owing to his occupation as a lorry driver he would require a period of close observation of his blood sugar levels prior to being allowed to resume HGV driving. Exenatide is therefore the best option.
DKA - Features
Diabetic ketoacidosis
Precipitating Factors:
Infection
MI
Missed Insulin doses
Diabetic ketoacidosis may be a complication existing type 1 diabetes mellitus or be the first presentation, accounting for around 6% of cases. Whilst DKA remains a serious condition mortality rates have decreased from 8% to under 1% in the past 20 years.
The most common precipitating factors of DKA are infection, missed insulin doses and myocardial infarction
Features
•abdominal pain
•polyuria, polydipsia, dehydration
•Kussmaul respiration (deep hyperventilation)
•Acetone-smelling breath (‘pear drops’ smell)
DKA - Diagnostic Criteria
Diagnostic criteria
American Diabetes Association (2009) Key points •glucose > 13.8 mmol/l •pH < 7.30 •serum bicarbonate <18 mmol/l •anion gap > 10 •ketonaemia
Joint British Diabetes Societies (2013)
Key points
•glucose > 11 mmol/l or known diabetes mellitus
•pH < 7.3
•bicarbonate < 15 mmol/l
•ketones > 3 mmol/l or urine ketones ++ on
DKA - Mx
Management
•fluid replacement: most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially. Please see an example fluid regime below.
•insulin: an intravenous infusion should be started at 0.1 unit/kg/hour. Once blood glucose is < 15 mmol/l an infusion of 5% dextrose should be started
•correction of hypokalaemia
JBDS Example of Fluid Regime for DKA
JBDS example of fluid replacement regime for patient with a Systolic BP on admission 90mmHg and over
Fluid > Volume
- 9% sodium chloride 1L 1000ml over 1st hour
- 9% sodium chloride 1L with potassium chloride 1000ml over next 2 hours
- 9% sodium chloride 1L with potassium chloride 1000ml over next 2 hours
- 9% sodium chloride 1L with potassium chloride 1000ml over next 4 hours
- 9% sodium chloride 1L with potassium chloride 1000ml over next 4 hours
- 9% sodium chloride 1L with potassium chloride 1000ml over next 6 hours
Please note that slower infusion may be indicated in young adults (aged 18-25 years) as they are at greater risk of cerebral oedema.
JBDS potassium guidelines
Potassium level in first 24 hours (mmol/L )> Potassium replacement in mmol/L of infusion solution
Over 5.5 = Nil
3.5-5.5 = 40
Below 3.5 = Senior review as additional potassium needs to be given
Complications of DKA and its treatment
Complications of DKA and its treatment
•gastric stasis
•thromboembolism
•arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
•iatrogenic due to incorrect fluid therapy: cerebral oedema, hypokalaemia, hypoglycaemia
•acute respiratory distress syndrome
•acute kidney injury
DKA - Example Question
A 30-year-old male with background of type one diabetes mellitus presents with abdominal pain and shortness of breath. Investigations confirm he has diabetic ketoacidosis. Which one of the following investigations would suggest a discussion for possible intensive care admission?
Lactate 3 mmol/L Bicarbonate level 19 mmol/L pH 7.27 White cell count 30 x 10^9/L > Potassium 3.4 mmol/L
Parameters indicate severe diabetic ketoacidosis: •pH < 7 •Blood ketone > 6 mmol/L •Bicarbonate < 5 mmol/L •Anion gap >16 mmol/l •Potassium < 3.5 mmol/L on admission •Tachycardia or bradycardia •Systolic blood pressure <90 mmHg •Oxygen saturation <92% on air •GCS < 12
DKA - Mx: Example Question
A 31-year-old female presents with a 2-day history of abdominal pain, a 5-day history of diarrhoea and vomiting and reduced appetite. She is a known type one diabetic with background diabetic retinopathy and stage 3 chronic kidney disease. She usually takes 32 units lantus at night and variable doses of Novomix with meals however due to her poor appetite she has not taken these for 2 days. On examination, she looks unwell. The airway is patent and chest is clear. Respiratory rate is 26/min with normal oxygen saturations on air. Pulse is 120/min and thready with a capillary refill of 3 seconds centrally. Blood pressure is 103/45 mmHg with a temperature of 36.7oC. Abdomen is generally tender without guarding. Capillary blood glucose is 26 and ketones are 4.9. Arterial blood gas is as follows:
pH 7.32 pO2 11.6 kPa pCO2 3.32 kPa Bicarbonate 14 mmol/l Base Excess -6.5 mmol/l Lactate 2.1 mmol/l
The patient is currently being fluid resuscitated appropriately. What form of insulin therapy would you advise?
Dose of novomix now and increase usual lantus by 8 units
Variable rate i.v insulin, continue all s/c insulins
Recommence normal s/c insulin regimen
> Fixed rate i.v insulin, continue lantus
Fixed rate i.v insulin, stop all s/c insulin
This patient has a compensated metabolic acidosis and despite her reasonably preserved pH, a bicarbonate of 14 suggests significant metabolic acidosis. In the presence of high blood ketones and hyperglycaemia, the diagnosis is diabetic ketoacidosis (DKA). Fluid therapy and potassium supplementation is a key part of DKA management but will not be dealt with in this question. Current recommendations advise fixed rate insulin with the addition of 10 % dextrose when capillary blood glucose drops below 14. The aim is to correct the underlying ketoacidosis brought about by a hypoinsulinaemic state. Patients should be continued on their long acting insulin but short/medium term insulins should be held. This ensures a smooth transfer from fixed rate to usual insulin regimen when the patient has clinically and biochemically improved.
Guidelines for the management of DKA can be found here:
https://www.bsped.org.uk/clinical/docs/DKAManagementOfDKAinAdultsMarch20101.pdf
Diabetic Complications: Diabetic Nephropathy
Diabetic nephropathy
Basics
commonest cause of end-stage renal disease (ESRD) in the western world
33% of patients with type 1 diabetes mellitus have diabetic nephropathy by the age of 40 years
approximately 5-10% of patients with type 1 diabetes mellitus develop (ESRD)
The pathophysiology is poorly understood, however:
changes to the haemodynamics of the glomerulus is thought to be key, which leads to an increased glomerular capillary pressure
histological changes include: basement membrane thickening, capillary obliteration, mesangial widening. Nodulular hyaline areas develop in the glomuli - Kimmelstiel-Wilson nodules
Risk Factors for Developing Diabetic Nephropathy
Risk factors for developing diabetic nephropathy
Modifiable Hypertension Hyperlipidaemia Smoking Poor glycaemic control Raised dietary protein
Non-modifiable
Male sex
Duration of diabetes
Genetic predisposition (e.g. ACE gene polymorphisms)
T1DM and Gastroparesis Mx: Example Question
A 39 year-old man presents to his GP for an annual review of his type 1 diabetes. His main complaints over the last year are having several episodes of vomiting after meals and chronic constipation, as well as having loss of sensation on both of his legs up to his knees and some sensory loss in his fingertips. On further questioning, you establish there has been no weight loss or haematamesis. On examination, his HbA1c is 72 mmol/mol, blood pressure is 138/88 mmHg and his pulse is regular and 84 beats per minute. Neurological examination demonstrates a lack of proprioception up to the ankle joint and loss of sensation as described above.
What is the most appropriate symptomatic treatment for the gastrointestinal symptoms described above?
Lansoprazole Omeprazole > Metoclopramide Mirtazapine Cyclizine
The most likely diagnosis in this scenario is gastroparesis, caused by the type 1 diabetes. Metoclopramide is the most appropriate treatment as it is a pro-kinetic antiemetic, although erythromycin and domperidone can also be used as alternatives.
Diabetes and HTN - Example Question
A 54-year-old gentleman is reviewed prior to discharge. He was admitted three days ago with an infective exacerbation of COPD requiring nebulisers and IV antibiotics but he did not need non-invasive ventilation or ITU admission. He has responded well to treatment and his wheeze is completely gone. His cough is also much improved. He has a background of type 2 diabetes mellitus, gout, diabetic retinopathy and hypertension. He raises concerns about his blood pressure as the nurses have told him it is persistently around 150mmHg systolic. He monitors blood pressure at home and normally his readings are much better. You reassure him that it is likely because his ramipril was held on admission. What should his blood pressure be less than during his next GP review?
> 130/80mmHg 135/85mmHg 140/80mmHg 140/90mmHg 130/90mmHg
The correct answer is 130/80mmHg. This is a patient with hypertension, type 2 diabetes and diabetic retinopathy. For a patient with hypertension without any other comorbodities, a target of less than 140/90mmHg is recommended. If the patient also has diabetes then a target of less than 140/80mmHg is recommended, whilst if there is diabetes and organ damage (kidney, eye or cerebrovascular) then a target of less than 130/80mmHg is recommended.
Source:
‘Type 2 diabetes in adults: management.’ NICE Guideline [NG28]. National Institute of Care and Health Excellence, July 2016.
T2DM Mx: Example Question
A 55-year-old man presents to the endocrine clinic. He was diagnosed five years ago with type 2 diabetes and is struggling to control his sugars. He is currently taking:
Metformin 1g BD
Glicazide 160mg BD
Sitagliptin 100mg OD
He is a bus driver and struggles to control his weight with his hectic shifts. Current BMI is 34 kg/m².
Investigations:
Serum creatinine 120 µmol/L (60-110)
Haemoglobin A1c 66 mmol/mol (8.2%)
What would be the most appropriate next step?
Canagliflozin Glibenclamide Increase metformin Stop sitagliptin and add insulin > Stop sitagliptin and add exenatide
Given the NICE guidance the most appropriate step would be to start this patient on exenatide. This patient is already of metformin, glicazide and sitagliptin and the blood sugar levels are not under control. His BMI is under 35 but insulin would make ‘it much more difficult for you to do your job’.
Monitoring of Gestational DM postpartum: Example Question
A 28-year-old lady is diagnosed with gestational diabetes in her first pregnancy. Her fasting blood glucose is 5.9mmol/l and blood glucose after oral glucose tolerance test (OGTT) is 8.2mmol/l. Blood glucose control during pregnancy is achieved with diet, exercise and metformin. She gives birth to a healthy child at 39 weeks. A fasting blood glucose at day 1 post-partum is 5.2mmol/l.
Which of the following statements is correct with respect to follow-up monitoring for diabetes?
OGTT 6-13 weeks postpartum > Fasting blood glucose test 6-13 weeks postpartum No routine follow up unless further pregnancy HbA1c 6-13 weeks postpartum Annual fasting blood glucose checks only
Women with gestational diabetes whose glucose returns to normal after birth need a postnatal glucose check 6-13 weeks postpartum to stratify their risk of developing diabetes in the future. NICE recommends that this is a fasting blood glucose. Further follow up will depend on the result of this postnatal check. Even if postnatal glucose is less than 6mmol/l, annual fasting glucose checks are still recommended thereafter.
T2DM Mx: Example Question
A 62-year-old man comes to the Emergency department with nausea and vomiting which has steadily worsened over the past 2-3 weeks. He had Type 2 diabetes for the past 7 years and is currently treated with metformin, sitagliptin and empagliflozin. He tells you he has lost some 5kg in weight over the past month. On examination his blood pressure is 110/65 mmHg, his pulse is 85 beats per minute and regular. Emergency blood testing reveal elevated ketones and a glucose of 12.2 mmol/l.
Which of the following is the most appropriate way to manage his glucose control?
Add liraglutide Add long-acting insulin Change the empagliflozin for liraglutide > Change the empagliflozin for long-acting insulin Stop the metformin
Given the duration of Type 2 diabetes and the fact that patient has lost weight in the past month, the possibility that he is insulinopenic is raised. In this situation, calorie loss and metabolic disturbance can be exacerbated by the use of SGLT-2 inhibitors and patients may present as here, with euglycaemic ketoacidosis. The SGLT-2 inhibitor should be withdrawn, and given he is insulinopaenic, long-acting insulin added.
In this situation the empagliflozin must be withdrawn, therefore options including adding liraglutide and long-acting insulin are incorrect. GLP-1 agonists such as liraglutide work less well in patients who are relatively insulinopenic, so liraglutide is incorrect. Stopping the metformin won’t remove the cause of ketosis, the empagliflozin.
http://care.diabetesjournals.org/content/38/9/1638
Normoglycemic Ketoacidosis: Cx of SGLT-2 Inhibitors
Normoglycaemic ketoacidosis
Normoglycaemic ketoacidosis is increasingly recognised as a consequence of SGLT-2 inhibitor therapy in type 2 diabetes, and now more and more in patients with type 1 diabetes who are prescribed the drug off-license. The reason is thought to be that spilling of glucose into the urine leads to a reduction in plasma glucose and patients back off on insulin dose. They are then underdosed with respect to insulin, and SGLT-2 inhibitors also promote a rise in glucagon, which drives lipid oxidation and can further worsen the risk of ketoacidosis.
The problem can be avoided potentially by reducing the dose of the SGLT-2 inhibitor as patients reach blood glucose target.
Normoglycaemic Ketoacidosis - Example Question
A 30-year-old woman with a history of type 1 diabetes presents to the Emergency department with nausea and vomiting coupled with increased urinary frequency over the past 3 days. She has been progressively losing weight and reducing her insulin dose after starting empagliflozin prescribed to help her lose weight and reduce glucose fluctuations. She also admits to taking a Chinese herbal remedy for weight control. Blood pressure is 100/70 mmHg, pulse is 88 beats per minute. pH is 7.25, glucose is 8.1 mmol/l, urine testing reveals ketones +++
Which of the following is the most likely diagnosis?
Empagliflozin related nephrotoxicity Hyperosmolar non-ketotic state > Normoglycaemic ketoacidosis Starvation ketoacidosis Urinary sepsis
Hyperosmolar non-ketotic state is associated with marked hyperglycaemia and no ketosis. Starvation ketosis results in the formation of urinary ketones, but pH remains normal.
http://www.fda.gov/Drugs/DrugSafety/ucm446845.htm
Diabetes and HTN - Example Question
A 48-year-old man who was diagnosed with type 2 diabetes mellitus presents for review. During his annual review he was noted to have the following results:
Total cholesterol 5.3 mmol/l HDL cholesterol 1.0 mmol/l LDL cholesterol 3.1 mmol/l Triglyceride 1.7 mmol/l HbA1c 6.4%
A QRISK2 score is calculated showing that he has a 12% 10-year risk of developing cardiovascular disease. His current medication is metformin 500mg tds. According to recent NICE guidelines, what is the most appropriate action?
Simvastatin 40mg on Lifestyle advice, repeat lipid profile in 3 months Atorvastatin 40mg on > Atorvastatin 20mg on Increase his metformin slowly to 1g tds
NICE recommend the following when considering the use of statins in patients with type 2 diabetes mellitus:
Offer atorvastatin 20 mg for the primary prevention of CVD to people with type 2 diabetes who have a 10% or greater 10-year risk of developing CVD.
Hyperosmolar Hyperglycaemic State (HHS)
Hyperosmolar hyperglycaemic state
Hyperosmolar hyperglycaemic state (HHS) is confirmed by:
Dehydration
Osmolality >320mosmol/kg
Hyperglycaemia >30 mmol/L with pH >7.3, bicarbonate >15mmolL and no significant ketonenaemia <3mmol/L
