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Diabetes mellitus Flashcards

1
Q

difference between type 1 and type 2 diabetes?

A

type 1: insulin deficiency

type 2: insulin resistance

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2
Q

what are the symptoms of diabetes ?

A 
polyphagia ( hunger)
polydipsia ( thirst)
polyuria ( myzimas)
weight loss
fatigue
blurred vision
poor wound healing
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3
Q

are statins given in diabetes ?

A

yes high intensity statin atorva 20 mg in type 1 diabetes and type 2 diabetes with CV risk of 10% or more as primary prevention

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4
Q

what are microvascular complications of diabetes ?

A

retinopathy ( important to treat hypertension) and nephropathy

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5
Q

In which pregnancy trimester does insulin requirements increase ?

A

second and third

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6
Q

women who are pregnant and have diabetes which supplement they should take and why ?

A

folic acid 5 mg because there is a high risk of neural tube defects

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7
Q

Women who have diabetes and are pregnant what is the target of hba1C and why ?

A

target must be below 48mmol/mol (6.5%)

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8
Q

which type of insulin is a first choice in pregnancy ?

A

longer acting : isophane insulin
(may be appropriate to continue using long-acting analogues : glargine or detemir if good glycaemic control before pregnancy

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9
Q

what should be done to insulin regime after giving birth and why ?

A

reduce insulin immediately after birth, because increased risk of hypoglycaemia postnatal period. monitor bg to establish dose

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10
Q

what counselling should you provide to all pregnant women treated with insulin ?

A

hypoglycaemic risk in all pregnant women, especially in first trimester.
carry fact acting glucose: dextrose/ glucose drink
for type 1 prescribe glucagon

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11
Q

for women who are type 2 diabetic and are pregnant what changes should be made to their oral anti diabetic drugs ?

A

stop all of them apart from metformin can add insulin or just metformin alone

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12
Q

which sulfonylurea can be given in pregnancy from 11 weeks ?

A

glibenclamide

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13
Q

pregnant women fasting BG is less than 7 mmol/L, what would be the first and second line treatment ?

A

1st line: dietary and exercise measures

Second line: metformin if BG target not met in 1-2 weeks , alternative is insulin, also can be added to metformin

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14
Q

pregnant women fasting BG is more than 7 mmol/L, what would be the first line treatment ?

A

insulin with or without metformin

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15
Q

if pregnant women presents with fasting blood glucose of 6-6.9 mmol/l with hydramnios or macrosomia, what treatment should be given ?

A

insulin with or without metformin

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16
Q

what are precipitating factors for diabetic ketoacidosis?

A

Infection (for example pneumonia or a urinary tract infection).
Physiological stress (such as trauma or surgery).
Non-adherence to insulin treatment regimen or intentional insulin omission in order to lose weight (diabulimia).
Other medical conditions (such as hypothyroidism or pancreatitis).
Drug treatment (such as corticosteroids, diuretics, and sympathomimetic drugs [for example salbutamol]).

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17
Q

hyperglycaemia associated with hypokalaemia or hyperkalaemia ?

A

hypokalaemia

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18
Q

how diabetic ketoacidosis treated ?

A

IV infusion of soluble insulin, fluids (saline), potassium ( not if anuria)
continue established long acting insulin e.g. detemir or glargine
add glucose to infusion when blood glucose concentration fall below 14mmol
Continue insulin infusion until blood-ketone concentration is below 0.3 mmol/litre, blood pH is above 7.3 and the patient is able to eat and drink; ideally give subcutaneous fast-acting insulin and a meal, and stop the insulin infusion 1 hour later.

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19
Q

what are rapid acting analogue insulins ?

A

Humalog (insulin lispro) and Novorapid (insulin aspart)

glulisine (apridra)

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20
Q

what is onset of action and duration of action of insulin lispro and insulin aspart?

A

onset 15 min

duration 2-5 hours

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21
Q

name examples of short acting insulins ?

A

actrapid and humulin S

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22
Q

what is onset of action and duration of actrapid and humulin S?

A

onset of action of 30–60 minutes and a duration of action of up to 8 hours.

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23
Q

name intermediate acting insulins?

A

isophane, Humulin I®, Insuman Basal®, and Insulatard®

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24
Q

what is onset of action and duration of intermediate acting insulins ?

A

onset of action of approximately 1–2 hours, maximal effects between 3–12 hours, and a duration of action of 11–24 hours.

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25
name all long-acting insulins ?
Lantus® (insulin glargine), Levemir® (insulin detemir), and Tresiba® (insulin degludec).
26
what is onset of action and duration of long-acting insulins ?
long-acting insulins have a duration of action of up to 24 hours; steady-state level achieved after 2–4 days to produce a constant level of insulin.
27
under what circumstances insulin requirements would be increased ?
infection or intercurrent illness stress or acidental or surgical trauma puberty pregnant 2 and 3 trimester
28
under what circumstances insulin requirements would be decreased ?
``` endocrine disorders: Addisons disease, hypotuitarism coeliac disease ( gluten intolerance ) ```
29
Patient asks you how to administer insulin ?
SC injection into buttocks, upper arm, abdomen or thigh
30
describe biphasic mixtures insulin regimen ?
short/rapid acting insulin PRE_MIXED with intermediate/long-acting insulin OD/BD before meals This regime suitable for patients who have difficulty with multiple regime, but not suitable for acutely ill patients as insulin requirements change
31
Which insulin regimen is recommended for adults with type 1 diabetes ?
Offer multiple daily injection basal-bolus insulin regimens as the first-line choice to all adults with type 1 diabetes. Offer twice-daily insulin detemir as the long-acting basal insulin therapy. Offer a rapid-acting insulin analogue injected before meals for mealtime insulin replacement (rather than rapid-acting soluble human or animal insulins)
32
for which patients groups is continuous subcutaneous infusion pump is recommended ?
type 1 diabetics who: suffer recurrent unpredictable hypoglycaemia glycemic control more than 8.5% despite optimised MIR children under 12 where MIR is not practical
33
which drugs enhance hypoglycaemic effect of insulin ?
ace inhibitors ( hyperkalaemia and hypoglycaemia linked) BB mask symptoms of hypoglycaemia alcohol
34
which drugs antagonise hypoglycaemic effects of insulin ?
corticosteroids, oral contraceptives, loop/thiazide diuretics
35
patient is dehydrated, has vomiting and diarrhoea, fever and has been advised to stop metformin, why is that ?
risk of lactic acidosis
36
why would gliflozins would need to be stopped if patient is dehydrated ?
they cause volume depletion
37
what is second line treatment of t2d ?
if initial treatment with metformin did not work consider dual therapy with one of the followings: metformin and a DPP‑4 inhibitor or metformin and pioglitazone or metformin and a sulfonylurea
38
what treatment options can you offer to type 2 diabetics who cannot tolerate metformin ?
if metformin is contraindicated or not tolerated, consider initial drug treatment with: a dipeptidyl peptidase‑4 (DPP‑4) inhibitor or pioglitazone or a sulfonylurea.
39
In adults with type 2 diabetes, if metformin is contraindicated or not tolerated and initial drug treatment has not continued to control HbA1c to below the person's individually agreed threshold for intensification, what dual therapy can be given ?
a DPP‑4 inhibitor and pioglitazone or a DPP‑4 inhibitor and a sulfonylurea or pioglitazoneand a sulfonylurea.
40
when can you not offer pioglitazone in adults with type 2 diabetes ?
``` heart failure or history of heart failure hepatic impairment diabetic ketoacidosis current, or a history of, bladder cancer uninvestigated macroscopic haematuria ```
41
what is MHRA warning regarding pioglitazone ?
Pioglitazone is associated with an increased risk of heart failure, bladder cancer and bone fracture.
42
what is MHRA warning regarding SGLT2 inhibitors?
- Risk of diabetic ketoacidosis - monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness - Increased risk of lower-limb amputation (mainly toes) - reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
43
patient comes into the pharmacy and presents with the following symptoms: severe pain, tenderness, erythema, or swelling in the genital or perineal area, accompanied by fever or malaise, which medicine can cause this?
Canagliflozin: Patients should be advised to seek urgent medical attention
44
what is advise regarding pioglitazone and insulin for healthcare professionals ?
cases of cardiac failure have been reported when pioglitazone was used in combination with insulin, especially in patients with risk factors for the development of cardiac failure if the combination is used, patients should be observed for signs and symptoms of heart failure, weight gain, and oedema pioglitazone should be discontinued if any deterioration in cardiac status occurs
45
what type of drug is metformin and how it works ?
biguanide: decreases liver glucoeneogenesis and increases peripheral use
46
why would you avoid metformin in tissue hypoxia ( myocardial infarction, acute heart failure, liver impairment and respiratory failure) and in renal impairment ( severe infection, dehydration, eGFR less than 30 ml/min) ?
because of lactic acidosis
47
what are other possible side effects of metformin apart from lactic acidosis ?
GI disturbances. V.N.D and weight loss, taste disturbance and reduced vitamin B12 absorption
48
what are the contraindications of metformin ?
general anaesthesia, iodine-containing contrast media
49
what are monitoring requirements for metformin ?
Determine renal function before treatment and at least annually (at least twice a year in patients with additional risk factors for renal impairment, or if deterioration suspected).
50
what patient counselling should you give for people on metformin ?
informed of the risk of lactic acidosis and told to seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia occur.
51
how does sulphonylurea work ?
augments insulin secretion
52
name short acting sulphonylurea?
gliclazide and tolbutamide
53
why short acting sulphonylureas may be better?
lower risk of hypos and good to use in elderly and renal impairment
54
name long acting sulphonylureas?
glibenclamide and glimepiride, higher risk of hypos and should be avoided in elderly and renal impairment
55
what are the side effects of sulphonylureas?
hyponatraemia=glipizide, glimepiride hypoglycaemia= must treat in hospital as may persist for hours weight gain, jaundice, hypersesnsitivity reactions in first 6-8 weeks e.g. skin rashes
56
if a patient is on a suphonylurea and warfarin as well as ace inhibitors, what would be your concerns ?
increased risk of hypo's, thus important to counsel how to recognise symptoms of hypoglycaemia:
57
if a patient takes sulphonylurea and NSAIDs what are your concerns ?
NSAIDS reduce renal excretion, thus increasing risk of hypoglycaemia
58
how does pioglitazone work and to which drug class does it belong ?
Thiazolinedione, reduces peripheral resistance
59
patient counselling regarding pioglitazone ?
bladder cancer risk: report haematuria, dysuria, urgency | liver toxicity: report nausea, vomiting, abdominal pain, dark urine, itching
60
How does Gliflozins (SGLT-2) inhibitors work?
inhibits sodium glucose co-transporter 2 in renal proximal tubule to reduce glucose reabsorption and increase urinary excretion
61
give examples of SGLT-2 inhibitors?
Canagliflozin, dapagliflozin, empagliflozin
62
what are the side effects of SGLT-2 inhibitors?
life-threatening atypical DKA volume depletion constipation, thirst, polyuria, UTIs, genital infection Canagliflozin: risk of lower lim apmutation ( toes)
63
what counselling would you give to patients on SGLT-2 inhibitors?
- stop and test for ketones if DKA suspected: report any signs of DKA - report postural hypotension, dizziness - report skin ulceration, discolouration, new pain
64
how does GLIPTINS ( DPP-4 inhibitors) work?
breaks down hormone incretin. incretin is made by the gut in response to food to increase insulin secretion and lower glucagon secretion
65
Give examples of DPP-4 inhibitors?
``` alogliptin linagliptin saxagliptin sitagliptin vidagliptin ```
66
what are the side effects of DPP-4 inhibitors ?
pancreatitis (report persistent, severe abdominal pain) | with vidagliptin: liver toxicity
67
How does meglitinides ( glinides) work ?
stimulate insulin secretion
68
name some meglitinides?
nateglinide | repaglinide
69
what are the side effects of meglitinides?
hypoglycaemia | hypersensitivity reactions: raches, urticaria, pruritus
70
what side effect repaglinide can cause?
visual disturbances
71
what side effects can nateglinide cause?
abdominal pain, constipaiton, diarrhoea, nausea, vomiting
72
how should you counsel patients who are on meglitinides?
take 30 min before main meal, rapid onset and short duration of action
73
how does acarbose work ?
inhibits intestinal aplha-glucosidase enzymes and delays digestion/absoprtion of starch and sucrose
74
what are the side effects of acarbose ?
flatulense which improves with time and antacids not help | diarrhoea: reduce dose or withdraw
75
what patient counselling should you provide for people who take acarbose ?
``` chew with first mouthful of food or swallow whole with little liquid immediately before food carry glucose ( not sucrose) if taking insulin or sulphonylureas and acarbose to counteract hypos. ```
76
how does GLP-1 receptor agonists work ?
binds to and activates GLP-1 receptors to increase insulin secretion, suppress glucagon secretion and slows gastric emptying. Prevents weight gain. SC injection. Do not administer after a meal
77
give examples of GLP-1 receptor agonists ?
exenatide, albiglutide, dulaglutide, liraglutide, lixisenatide
78
what are the side effects of GLP-1 receptor agonists ?
pancreatitis
79
if a patient misses a dose of GLP-1 lixisenatide ?
inject within 1 hour of next meal
80
if a patient misses a dose of exenatide ?
continue with next schedule dose
81
if a patient misses a dose of dulaglutide, albiglutide ?
inject within 3 days of next weekly dose
82
What contraception should be in place when on GLP-1 receptor agonists ?
``` should use contraception MR exenatide ( 12 weeks after stopping) lixisenatide, albiglutide ```
83
what should HBA1C blood test results be to diagnose type 2 diabetes ?
6.5% ( 48mmol) or above
84
what should be blood glucose target concentrations before meals and after meals ?
before meals: 4-7 mmol | after meals: < 9 mmol
85
what should be Hba1C in diabetic patients ?
6.5 to 7.5 % ( 48-59 mmol/l) or less
86
what should ne Hba1C if diabetic patient is at high risk of arterial disease ?
less than 6.5%
87
for diabetic patient what should be their BP target ?
140/80 without complications | 130/80 with complications
88
what antihypertensive treatment is first line for diabetic patients ?
ACE
89
what antihypertensive treatment is first line for diabetic patients who are afro/carribean ?
both: ace and diuretic or CCB first line
90
what are cholesterol targets in people with diabetes ?
normal patients: less than 5 mmol/l | high risk patients e.g. diabetes less than 4 mmol/l
91
what blood glucose levels would indicate hypoglycaemia ?
less than 4 mmol/l
92
what are the symptoms of hypoglycaemia ?
hunger, pale skin, tingling lips, sweating, chills, clammy, palpitations, drowsiness, slurred speech, shakiness, blurred vision, confusion, difficulty concentrating
93
how should you treat hypoglycaemia ?
10-20 g of glucose or sucrose if needed repeat after 10-15 min so can give coco-cola, lucozade energy drink, sugar lumps, sugar 2-4 tsp, ribena 19 ml to be diluted + provide long acting carbohydrate to sustain blood glucose: sandwich, avoid chocolate/biscuits: fat delays glucose absorption. if sulphonylurea induced hypoglycaemia then must be treated in hospital because it can persist for long time

Endocrine system (6 decks)

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