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pre-reg exam 2021 > Diabetes Mellitus And Hypoglycaemia > Flashcards

Diabetes Mellitus And Hypoglycaemia Flashcards

1
Q

What is type 1 diabetes mellitus?

A

Insulin deficiency

Pancreatic beta islet cells are destroyed causing insufficient insulin

Treat with insulin

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2
Q

What is type 2 diabetes mellitus?

A

Insulin resistance

Reduced insulin secretion/peripheral resistance to insulin

Treat with diet, oral antidiabetic drugs or insulin

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3
Q

What are the symptoms of diabetes mellitus?

A 
Polyphagia 
Polydipsia 
Polyuria
Weight loss
Fatigue
Blurred vision
Poor wound healing
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4
Q

When do you start reviews for children with diabetes?

A

After 12 years old or 5 years after diagnosis

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5
Q

Is diabetes a strong risk factor for cardiovascular disease?

A

Yes

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6
Q

When is a statin given as primary prevention in diabetes?

A

Type 1 diabetes
Type 2 diabetes with a 10 year cardiovascular risk score of > 10%

Low dose aspirin is not recommended for primary prevention
ACEi may have a role in preventing cardiovascular disease

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7
Q

What are the microvascular complications of diabetes mellitus?

A

Retinopathy - treat hypertension

Nephropathy - give ACEi/ARB

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8
Q

What happens when ACEi are used in diabetes?

A

Potentiates hypoglycaemic effects of antidiabetic drug and insulin, especially in renal impairment

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9
Q

Which nerves can be affected in diabetes mellitus?

A

Sensory, painful neuropathy

Autonomic neuropathy

Gustatory neuropathy

Neuropathic postural hypotension

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10
Q

What is used to treat diabetic foot?

A

Analgesics - oxycodone/morphine
Duloxetine, TCAs
Pregabalin, gabapentin, carbamazepine

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11
Q

What is used to treat autonomic neuropathy in diabetes mellitus?

A

Diabetic diarrhoea - codeine or tetracycline

Gastroparesis - erythromycin

Erectile dysfunction - sildenafil

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12
Q

What is the treatment for gustatory neuropathy in diabetes mellitus?

A

Sweating face, scalp, head and neck - antimuscarinic/antiperspirant

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13
Q

What is the treatment for neuropathic postural hypotension in diabetes mellitus?

A

Fludrocortisone and increased salt intake

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14
Q

When do insulin requirements increase in pregnancy?

A

In the second and third trimester

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15
Q

Why should you plan pregnancies in pre-existing diabetes?

A

Reduces risk of congenital malformations

Aim for HbA1c level below 48mmol/mol (6.5%)

Give 5mg folic acid daily to prevent neural tube defects

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16
Q

What insulin should be used when planning a pregnancy?

A

Longer acting is the first choice - isophane insulin
(glargine or detemir)

Continuous subcutaneous infusion pump

Increased risk of hypoglycaemia postnatal period - reduce insulin immediately after birth

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17
Q

What are the counselling points for pre-existing diabetes in pregnancy?

A

Hypoglycaemic risks in all pregnant women treated with insulin (especially in first treatment)

Carry fast acting form of glucose

For type 1 - glucagon if needed

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18
Q

How do you treat type 2 diabetes in pregnancy?

A

Stop all oral antidiabetic drugs except metformin, substitute with insulin

Metformin alone or with insulin

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19
Q

How do you treat type 2 diabetes in breast feeding?

A

Continue metformin or resume glibenclamide post birth

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20
Q

How do you treat gestational diabetes if fasting blood glucose < 7 mmol/L at diagnosis?

A

Dietary and exercise first line

Second line - metformin if blood glucose target not met in 1-2 weeks. Alternative insulin

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21
Q

How do you treat gestational diabetes if fasting blood glucose > 7 mmol/L at diagnosis?

A

First line insulin with or without metformin + dietary and exercise measures

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22
Q

How do you treat gestational diabetes when the fasting blood glucose is 6-6.9 mmol/L with hydramnios or macrosomia?

A

First line insulin with or without metformin

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23
Q

How do you treat gestational diabetes in women intolerant of metformin and do not want insulin?

A

Glibenclamide (from 11 weeks gestation; after organogenesis)

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24
Q

What are the symptoms of diabetic ketoacidosis?

A 
Severe hyperglycaemia 
High blood ketones
Fruity breath
Dehydration
Polyuria 
Nausea and vomiting
Convulsions
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25
Q

How do you treat diabetic ketoacidosis?

A

Soluble insulin
Fluids
Potassium do not give if anuria

Continue established long acting insulin
Add glucose to infusion when below 14 mmol/L
Continue until patient able to eat and drink and blood pH above 7.3

Give SC fast acting insulin and meal. Stop infusion one hour later

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26
Q

Do you need to notify the DVLA in diabetes mellitus?

A

Yes, but not in diet controlled diabetes

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27
Q

What are the complications of diabetes mellitus that can affect driving?

A

Visual complications, renal and limb complications

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28
Q

When should you notify the DVLA if you have diabetes mellitus?

A

If on any medication
2 episodes of severe hypoglycaemia in past 12 months (1 if group 2)
Impaired awareness
Disabling hypoglycaemia while driving

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29
Q

When do you need to monitor glucose levels in regards to driving?

A

No more than 2 hours before driving and every 2 hours for long journeys

Those on insulin, sulphonylureas, glinides

Record readings at least twice a day even when not driving

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30
Q

What levels should your glucose be before driving?

A

5 mmol/L take carbohydrate before driving

< 4 mmol/L do not drive

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31
Q

What do you do if hypoglycaemia occurs during driving?

A

Stop and switch off engine

Fast acting sugar then long acting carbohydrate

Wait 45 mins after levels return to normal

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32
Q

What is insulin?

A

Polypeptide hormone responsible for the metabolism of carbohydrates, fat and protein

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33
Q

What are the types of insulin?

A

Human insulin - soluble human

Human insulin analogues - rapid and long-acting

Beef/pork insulin - soluble animal

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34
Q

What are the short acting soluble insulins?

A

Human soluble
Beef/pork

Bolus insulin - take 15-30 minutes before a meal. Consume meal within 30 minutes to avoid hypoglycaemia

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35
Q

What are the rapid acting analogue insulins?

A

Lispro - humalog

Aspart - novorapid

Glulisine - apridra

Lower risk of hypo before lunch + late dinner, then soluble
Alternative to soluble in emergency

Bolus insulin - take immediately before or after meal

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36
Q

What are the intermediate acting insulins?

A

Isophane

Never give IV = thrombosis

Protamine causes allergic reactions

Basal insulin - take BD in conjunction with soluble insulin

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37
Q

What are the long acting analogue insulins?

A

Glargine - lantus
Detemir (OD/BD) - levemir
Degludec - tresiba
Protamine zinc - never give IV (thrombosis), don’t mix with soluble (binds in syringe)

Basal insulin - take OD at same time each day to cover 24 hour period

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38
Q

When is insulin used?

A

Type 1 diabetes
Type 2 diabetes
Surgery, when hospitalised for an illness or DKA

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39
Q

When are insulin requirements increased?

A

Infections or illness
Stress/trauma
Puberty
Pregnancy 2nd and 3rd trimester

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40
Q

When are insulin requirements decreased?

A

Endocrine disorders

Coeliac disease

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41
Q

Where do you administer insulin?

A

SC injection to buttocks, upper arm, abdomen or thigh

IV reserved for urgent treatment

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42
Q

What is a multiple injection regimen?

A

Short/rapid acting insulin before meals

plus intermediate/long acting OD or BD

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43
Q

What is a biphasic mixtures regimen?

A

Short/rapid acting insulin pre mixed with intermediate/long acting insulin OD/BD before meal

For patients who have difficulty with or prefer not to use MIR
Not for acutely ill patients

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44
Q

What is a long/intermediate acting regimen?

A

OD/BD with or without short/rapid acting insulin before meals

Long acting insulin not for Type 2 unless in certain criteria

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45
Q

When is a continuous subcutaneous infusion used?

A

Type 1 diabetes in certain criteria

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46
Q

What is the first line treatment for type 1 diabetes?

A

Multiple injection regimen

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47
Q

What is the treatment for type 2 diabetes?

A

Isophane insulin OD or BD + short acting soluble insulin as a biphasic or multiple injection regimen

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48
Q

What is a continuous subcutaneous infusion pump?

A

Delivers basal insulin and patient activated bolus doses at meal times

Must be highly motivated to monitor blood glucose regularly

Not recommended in type 2 diabetes

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49
Q

Who is a continuous subcutaneous infusion pump recommended for?

A

Type 1 diabetics who…

Suffer recurrent unpredictable hypoglycaemia
Glycaemic control > 8.5%
Children under 12

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50
Q

What are the side effects of continuous subcutaneous infusion pump?

A

Hypoglycaemia - don’t miss meals
Lipodystrophy
Local injection site reactions

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51
Q

What are the counselling points for a multiple injection regimen in regards to food?

A

Must adjust insulin dose to carbohydrate intake

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52
Q

What are the counselling points in relation to food for a biphasic, fixed dose regimen?

A

Must regulate and distribute carbohydrate intake through the day to match regimen

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53
Q

What are the medications that interact with insulin that then enhance insulins hypoglycaemic effect?

A

ACEi (hyperkalaemia + hypoglycaemia linked)

Beta blockers masks symptoms of hypoglycaemia

Alcohol

54
Q

What are the medications that interact with insulin that then antagonise insulins hypoglycaemic effect?

A

Corticosteroids
Oral contraceptives
Loop/thiazide diuretics

55
Q

What are the sick day rules?

A

SICK

Sugar - check levels every 3-4 hours, still monitor even when feeling better until controlled

Insulin - never stop taking insulin

Carbs - maintain normal meal pattern, 3 L fluid, urgent help if drowsy, can’t keep fluids down, persistent vomiting or diarrhoea

Ketones - check ketones every 3-4 hours, if 2+ or >3mmol/L immediately see GP

56
Q

Do you stop metformin or gliflozins if you are sick?

A

Stop metformin if dehydrated due too increased risk of lactic acidosis

Consider stopping gliflozins if dehydrated as they cause volume depletion

57
Q

What are the NPSA alerts regarding insulin?

A

Prescribe as unit

Never give IV syringe for SC injection as can cause overdose

Check injection technique

Check insulin container, pen and needle size

Store in fridge, when opened store at room temp and use by 28 days

If left outside fridge at 15-30 degrees > 48 hours - discard

If frozen must discard

58
Q

What are the conversion rates for beef to human insulin?

A

Reduce dose by 10%

59
Q

What are the conversion rates for pork to human insulin?

A

No dose change

60
Q

What are the insulin requirements for type 1 diabetes the night before surgery?

A

Usual insulin

61
Q

What are the insulin requirements for type 1 diabetes on the day of surgery?

A

IV glucose with potassium

IV soluble insulin with NaCl piggy backed onto infusion

62
Q

What are the insulin requirements for type 1 diabetes after surgery once they start eating and drinking?

A

SC before breakfast and stop IV 30 minutes after

63
Q

What is the first line treatment for type 2 diabetes?

A

Lifestyle advice

64
Q

When do you consider drug treatment in type 2 diabetes?

A

If HbA1c rises to 48 mmol/mol consider monotherapy

If HbA1c rises to 58 mmol/mol consider dual therapy

65
Q

What is the first line drug treatment for Type 2 diabetes if HbA1c target is 48 mmol/mol?

A
  1. Standard release metformin

2. Consider MR if not tolerated

66
Q

What is the first line drug treatment for Type 2 diabetes if metformin is not tolerated if HbA1c target is 48 mmol/mol?

A

DPP - dipeptidyl peptidase 4 inhibitor

Or

Pioglitazone

67
Q

What is the first line drug treatment for Type 2 diabetes if metformin is not tolerated if target HbA1c is 53 mmol/mol?

A

Sulfonylurea

68
Q

If HbA1c has risen to 58 mmol/mol in type 2 diabetes what are the treatments available?

A

Metformin + DPP

Or

Metformin + sulphonylurea

Or

Metformin + pioglitazone

Or

Metformin + SGLT (sodium glucose cotransporter 2 inhibitors)

69
Q

If HbA1c has risen to 58 mmol/mol in type 2 diabetes what are the treatments available if metformin is contraindicated?

A

DPP + pioglitazone

DPP + sulphonylurea

Pioglitazone + sulphonylurea

70
Q

What are the triple therapy regimes that can be given to type 2 diabetics if the HbA1c is 58 mmol/mol?

A

Metformin + sulphonylurea + DPP

Metformin + sulphonylurea + pioglitazone

Metformin + sulphonylurea + SGLT

Metformin + pioglitazone + SGLT

Or consider insulin regime

71
Q

If a type 2 diabetic needs help injecting, has a lifestyle restricted by hypos, would otherwise need BD NPH insulin, that is the insulin treatment regime?

A

Give insulin detemir or glargine

Continue metformin

72
Q

If a type 2 diabetic does not need help injecting, doesn’t have a lifestyle restricted by hypos, would not otherwise need BD NPH insulin, what is the insulin treatment regime?

A

NPH insulin OD/BD

+ short acting insulin

73
Q

If a patient with type 2 diabetes prefers injecting before meals, their blood glucose rises before meals or hypoglycaemia is a problem, what is the insulin regime?

A

Short acting insulin analogue

74
Q

What do you do if a patient is type 2 diabetic and triple therapy fails?

A

Metformin + sulphonylurea + GLP-1 mimetic

75
Q

What is metformin?

A

Biguanide

76
Q

What is the mechanism of action of metformin?

A

Decreases liver gluconeogenesis and increases peripheral use

77
Q

What are the side effects of metformin?

A

Lactic acidosis
GI disturbances
Weight loss, rarely hypoglycaemia, taste disturbance and reduced vitamin B12 absorption

78
Q

When should you avoid metformin?

A

Renal impairment

Tissue hypoxia

79
Q

How do you reduce GI side effects of metformin?

A

MR

With or after meal

Increase dose gradually

80
Q

What are the contraindications of metformin?

A

General anaesthesia

Iodine containing contrast media

81
Q

What is the mechanism of action of the sulphonylureas?

A

Augments insulin secretion

82
Q

What are the short acting sulphonylureas?

A

Gliclazide

Tolbutamide

83
Q

When are gliclazide and tolbutamide preferred?

A

Lower risk of hypos
Elderly
Renal impairment

84
Q

What are the long acting sulphonylureas?

A

Glibenclamide

Glimepiride

85
Q

Which sulphonylurea is preferred in pregnancy?

A

Glibenclamide in 2nd and 3rd trimester

86
Q

What are the side effects of sulphonylureas?

A

Hyponatraemia - glipizide, glimepiride

Sulphonylurea induced hypoglycaemia

Weight gain
Jaundice
Hypersensitivity

87
Q

What are the patient counselling points for sulphonylureas?

A

Recognise symptoms of hypos

Always carry sugary snack

Never miss meals

88
Q

What other medications interact with sulphonylureas to cause an increased risk of hypos?

A

Warfarin

ACEi

89
Q

What is the interaction between sulphonylureas and NSAIDs?

A

Reduced renal excretion

90
Q

What is the mechanism of action of pioglitazone?

A

Reduces peripheral resistance

91
Q

When does NICE suggest you should continue pioglitazone?

A

If HbA1c reduced by 0.5% within 6 months

92
Q

What are the side effects of pioglitazone?

A

Heart failure
Bladder cancer
Hepatotoxicity

93
Q

What conditions are pioglitazone contraindicated in?

A

Heart failure
Bladder cancer
Uninvestigated macroscopic haematuria

94
Q

What are the counselling points for pioglitazone?

A

Report haematuria, dysuria, urgency

Report signs of liver toxicity. STOP if jaundice

95
Q

What are the SGLT2 inhibitors? (Gliflozins)

A

Canagliflozin
Dapagliflozin
Empagliflozin

96
Q

What is the mechanism of action of SGLT2 inhibitors?

A

Inhibits sodium glucose co transporter 2 in renal proximal tubule to reduce glucose reabsorption and increase urinary excretion

97
Q

What are the side effects of the SGLT2 inhibitors?

A

Life threatening atypical DKA

Volume depletion

Increased risk of lower limb amputation

98
Q

What are the counselling points for SGLT2 inhibitors?

A

Stop and test for ketones if DKA suspected
Report DKA symptoms
Report postural hypotension and dizziness

MHRA - report skin ulceration, discolouration, new pain

99
Q

What is the MHRA warning fit canagliflozin?

A

Increased risk of lower limb amputation

100
Q

What are the DPP4 inhibitors?

A 
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Vildagliptin
101
Q

What is the mechanism of action of the gliptins?

A

DPP4 breaks down hormone incretin

Incretin is made by the gut in response to food to increase insulin secretion and lower glucagon secretion

102
Q

What are the side effects of the DPP4 inhibitors?

A

Pancreatitis

Vildagliptin - liver toxicity

103
Q

What are the counselling points of the gliptins?

A

Report severe, persistent abdominal pain

STOP and report nausea and vomiting, abdominal pain, dark urine, fatigue, pruritis, jaundice - vildagliptin

104
Q

What is the mechanism of action of meglitinides?

A

Stimulates insulin secretion

105
Q

What are the meglitinides?

A

Nateglinide

Repaglinide

106
Q

What are the side effects of the meglitinides?

A

Hypersensitivity reactions
Flatulence
Diarrhoea

Nateglinide - abdominal pain, constipation, diarrhoea, nausea, vomiting

Repaglinide - visual disturbance

107
Q

What are the counselling points for the meglitinides?

A

Avoid hypoglycaemia especially when driving

30 mins before main meal - rapid onset and short duration of action

Flatulence improves with time, antacids do not help

If diarrhoea occurs withdraw or reduce dose

Chew with first mouthful of food or swallow whole with little liquid immediately before food

Carry glucose

108
Q

What are the GLP 1 agonists?

A 
Exenatide
Albiglutide
Dulaglutide
Liraglitide
Lisisenatide
109
Q

What is the mechanism of action of the GLP 1 agonists?

A

Binds to and activates GLP1 receptors to increase insulin secretion, suppress glucagon secretion and slows gastric emptying

110
Q

What are the side effects of GLP 1 agonists?

A

Pancreatitis

111
Q

What are the counselling points of the GLP 1 agonists?

A

STOP if severe persistent abdominal pain

Do not administer missed dose after meal

Use contraception

112
Q

What are the counselling points for a missed dose for lixisenatide?

A

Inject within 1 hour of next meal

113
Q

What are the counselling points for a missed dose for exenatide?

A

Continue with next scheduled dose

114
Q

What are the counselling points for a missed dose for dulaglutide and albiglutide?

A

Inject within 3 days of next weekly dose

115
Q

How long should you use contraception for after stopping MR exenatide?

A

12 weeks

116
Q

What tests are done to diagnose type 2 diabetes mellitus?

A

HbA1c blood test > 6.5%

Oral glucose tolerance test

117
Q

What monitoring is needed for type 2 diabetes?

A

Urinalysis - ketones, protein, glucose

Blood monitoring - ketones, glucose

118
Q

What are the fasting blood glucose targets in diabetes?

A

4-7 mmol/L

119
Q

What are the non-fasting blood glucose targets for diabetes?

A

< 9 mmol/L

120
Q

If diabetics are at high risk of arterial disease what is their target HbA1c?

A

< 6.5%

121
Q

What is the HbA1c target for diabetics?

A

6.5-7.5%

122
Q

What are the hypertension blood pressure targets in diabetics?

A

Without complications 140/80

With complications 130/80

Diabetic first line is ACEi, African/Caribbean should have ACEi + diuretic or CCB first line

123
Q

What are the cholesterol targets in diabetics?

A

< 4 mmol/L

124
Q

When do you need to use primary prevention of CVD in diabetics?

A

Type 1

Type 2 and 10 year CVD risk > 10%

125
Q

What level blood glucose is classed as hypoglycaemia?

A

< 4 mmol/L

126
Q

What are the symptoms of hypoglycaemia?

A 
Hunger
Pale skin
Tingling lips
Sweating
Dizziness
Shakiness
Palpitations
Blurred vision
Drowsiness
127
Q

What is blunted hypoglycaemia?

A

Loss of warning signs in insulin treated patients

Too tight glycaemic control lowers level needed to trigger hypoglycaemic symptoms

Avoid frequent hypo episodes

Beta blockers mask symptoms

128
Q

What is used to treat hypoglycaemia in the community?

A

10-20g sugar, if necessary repeat after 10-15 mins

Coke - 100-200ml
Lucozade original - 55-100ml
Sugar lumps - 3-6
Sugar - 2-4 tsp
Ribera - 19ml

Long acting carbohydrate

129
Q

Is sulphonylurea hypoglycaemia treated in community?

A

No as episodes can persist for hours

130
Q

What is the treatment if a hypoglycaemic patient is unresponsive?

A

SC/IM glucagon

If unresponsive after 10 mins
IV glucose

pre-reg exam 2021 (79 decks)

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