Diabetes Mellitus

Question 1

What is the classical presentation of Type 1 Diabetes?

Answer 1

Polydipsia
Polyphagia
Polyuria
Glycosuria 
Weight loss

Question 2

What is the presentation of DKA?

Answer 2

Abdominal pain
Vomiting
Reduced GCS 
Dehydration
Kussmaul breathing

Question 3

What is the diagnostic criteria for Diabetes Mellitus?

Answer 3

If the patient is symptomatic…
Fasting glucose = equal to 7.0mmol/l
Random glucose = greater than or equal to 11.1mmol/l (or after 75g oral glucose tolerance test)

If the patient is asymptomatic…
Evidence of the above is needed on two occasions

Also, a HbA1c of greater than or equal to 6.5% (48mmol) is diagnostic of DM.

Question 4

What values would you have to have to be diagnosed as ‘pre-diabetic’?

Answer 4

HbA1c 42-47 (6.0-6.4%)

Fasting glucose: 6.1-6.9mmol/l

Question 5

What electrolyte abnormality can insulin produce?

Answer 5

Hypokalaemia

Question 6

What is the diagnostic criteria for DKA?

Answer 6

Plasma glucose >13.9mmol/L
pH <7.3
Presence of ketonaemia/ketonuria

Question 7

If metformin is tolerated, what is the treatment algorithm for Type 2 Diabetes?

Answer 7

1) Metformin
If HbA1c still >58 (7.5%)
1) metformin + DPP4 inhibitor 
2) metformin + pioglitazone
3) metformin + sulfonylurea 
4) metformin +SGLT2

If HbA1c still >58 (7.5%)
Either start insulin or triple therapy
Triple therapy:
metformin + gliptin + sulfonylurea
metformin + pioglitazone + sulfonylurea
metformin + sulfonylurea + SGLT2 inhibitor
metformin + pioglitazone + SGLT2 inhibitor

Question 8

If metformin is contra-indicated, what is the treatment algorithm for Type 2 Diabetes?

Answer 8

1) gliptin or sulfonylurea or pioglitazone

If HbA1c is still >58 (7.5%)

Start double therapy
gliptin + pioglitazone
gliptin + sulfonylurea
pioglitazone + sulfonylurea

If still HbA1c >58 (7.5%)

Start insulin

Question 9

What are the guidelines on fasting during Ramadan for patients with diabetes?

Answer 9

Try and eat a meal containing long acting carbohydrates prior to sunrise

For patients taking metformin, split the dose one third before sunrise and two thirds after sunset

For patients taking once daily sulfonylureas, take this after sunset

For patients taking gliclazide, take the majority of the dose after sunset

Question 10

In which conditions may HbA1c not be used for a diagnosis of diabetes?

Answer 10

Anaemia
CKD
Children
HIV
Haemoglobinopathies 
Splenectomy

Question 11

In a patient with Type 1 Diabetes, how often should HbA1c be checked and blood glucose levels?

Answer 11

Check HbA1c every 3-6 months.

Self monitoring: monitor 4 times each day. More frequent monitoring is recommended if the patient is ill, playing sports, during pregnancy and while breastfeeding

Question 12

What are the daily blood glucose targets for Type 1 Diabetics?

Answer 12

5-7 on waking

4-7 before meals at any other time

Question 13

What type of insulin is recommended for Type 1 Diabetics?

Answer 13

Multiple daily injection basal-bolus insulin regimens
Twice daily insulin determir
Rapid acting insulin analogues before meals

Question 14

When should you give a Type 1 Diabetic metformin?

Answer 14

If there BMI is >25

Question 15

What is the management of diabetes if a patient is ill?

Answer 15

Increase frequency of BG monitoring to four hourly
Drink 3L in 24h
If unable to eat any food, may need sugary drinks
Continue taking oral hypoglycaemic medications and insulin despite a poor food intake

Question 16

What are the indications for an unwell diabetic patient being admitted to hospital?

Answer 16

Inability to keep fluids down
Persistent diarrhoea
BG persistently >20
Lack of support at home

Question 17

For a diabetic patient to hold a HGV license, what criteria need to be met?

Answer 17

No severe hypoglycaemic events in the last 12 months
Driver has full hypoglycaemic awareness
Adequate control of BG = measure at least twice a day
Understand the risk of hypoglycaemic attacks

Question 18

What are the DVLA requirements for driving with diabetes?

Answer 18

Patients on insulin must inform the DVLA and must have full hypoglycaemic awareness and must not have had >1 hypo in the past 12 months

If on tablets or exenatide no need to inform DVLA. If on tablets that induce hypoglycaemic episodes then no more than >1 in the preceding 12m

Question 19

What are the blood pressure targets for diabetics?

What are the first line antihypertensives for diabetic patients?

Answer 19

If end organ damage; 130/80mmHg
If no end organ damage in Type 1; 135/85mmHg
If no end organ damage in Type 2; 140/80

First line; ACEi as they have a renoprotective effect in diabetes. Afro-Caribbean patients should be offered an ACEi and thiazide diuretic/CCB.

Question 20

What education about insulin should you give patients?

Answer 20

Self adjust in light of exercise 
How to finger prick
Carbohydrate counting education 
Phone support available 24/7
Avoid binge drinking 

Partner can abort hypoglycaemia; GlucoGel, sugary drinks

Question 21

When would you give fast acting insulins (Humalog, NovoRapid)?

Answer 21

Inject at start of meal

Question 22

When are long acting human insulin analogues given?

Answer 22

Insulin glargine (S/C) is an example
At bedtime
Good if nocturnal hypoglycaemia is an issue

Question 23

What is the pathophysiology of HHNS?

Answer 23

Occurs in Type 2 Diabetics
Relative insulin deficiency so the ketogenesis pathway is inhibited
Hyperglycaemia leads to hyperosmolarity and osmotic diuresis, thus thirst and frequent urination, signs of dehydration, and altered mental status

Question 24

How would you treat HHNS?

Answer 24

Admit to ICU
Administer IV insulin
IV rehydration with fluids (replaces fluid loss that occurs with osmotic diuresis)

Question 25

What is the ideal treatment for MODY?

Answer 25

Sulfonylureas (gliclazide)

Question 26

What is a severe complication of Fluid resuscitation following DKA particularly in young patients?

Answer 26

Cerebral oedema