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Yr 5 - Endocrine & Metabolic > Diabetes Revision > Flashcards

Diabetes Revision Flashcards

1
Q

What is the ideal blood glucose conc?

A

4.4 - 6.1 mmol/l

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2
Q

Is insulin an anabolic or catabolic hormone?

A

Anabolic

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3
Q

Insulin reduces blood sugar levels in what 2 ways?

A

1) Causes cells in body to ABSORB glucose from blood and use it as FUEL

2) Causes muscle & liver cells to ABSORB glucose from blood and STORE it as GLYCOGEN

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4
Q

Is glucagon a catabolic or anabolic hormone?

A

Catabolic

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5
Q

Glucagon INCREASES blood sugar levels in what 2 ways?

A

1) glycogenolysis –> tells liver to break down stored glycogen into glucose

2) gluconeogenesis –> tells liver to convert proteins & fats into glucose

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6
Q
A
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7
Q
A
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8
Q

Example of fluid resuscitation in DKA management:

A

1st hour –> 1L of 0.9% saline

For the remaining time –> 0.9% sodium chloride 1L with potassium chloride

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9
Q

When there is doubt about whether a patient has type 1 or type 2 diabetes, what 2 investigations can be done?

A

1) Serum C-peptide

2) Autoantibodies

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10
Q

What are the 3 types of autoantibodies in T1D?

A

1) Anti-islet cell antibodies
2) Anti-GAD antibodies
3) Anti-insulin antibodies

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11
Q

How often is HbA1c monitored in T1D?

A

Every 3 to 6 months

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12
Q

What does HbA1c measure?

A

Glycated haemoglobin –> how much glucose is attached to the haemoglobin molecule

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13
Q

What is a closed loop system in T1D management? What is it a combination of?

A

AKA an artificial pancreas

1) continuous glucose monitor
2) an insulin pump

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14
Q

What are the macrovascular complications of diabetes?

A

1) Coronary artery disease

2) Peripheral ischaemia –> poor skin healing and foot ulcers

3) Stroke

4) HTN

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15
Q

What are the microvascular complications in diabetes?

A

1) Peripheral neuropathy

2) Retinopathy

3) Nephropathy (particularly glomerulosclerosis)

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16
Q

What is the main kidney disease seen in diabetes?

A

Glomerulosclerosis

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17
Q

Infection-related complications of T1D & T2D?

A

1) UTIs
2) Pneumonia
3) SSTIs, particuarly in the feet
4) Fungal infections, particularly oral and vaginal candidiasis

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18
Q

Pathophysiology of T1D vs T2D?

A

T1DM –> autoimmune destruction of beta cells of pancreas

T2DM –> resistance to insulin due to repeated exposure

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19
Q

What HbA1c indicates pre-diabetes?

A

42-47

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20
Q

What HbA1c level indicates diabetes?

A

≥48

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21
Q

To confirm a diagnosis of T2D, when is the HbA1c repeated?

A

Repeated after 1 month to confirm the diagnosis (unless there are symptoms or signs of complications).

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22
Q

What is the HbA1c target for new type 2 diabetics?

A

48 mmol/mol

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23
Q

What is the HbA1c target for patients requiring MORE THAN 1 antidiabetic medication?

A

53 mmol/mol

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24
Q

Give stepwise medical management of T2D

A

1st line –> metformin

2nd line –> dual therapy: add sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor

3rd line –> triple therapy (with metformin and two of the second line drugs) or insulin therapy

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25
Q

Management of T2D patients with existing CVD or HF?

A

1) Settle them on metformin

2) Add SGLT-2 inhibitor (e.g. dapagliflozin)

N.B. NICE suggest considering an SGLT-2 inhibitor in patients with a QRISK score above 10%.

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26
Q

When triple therapy fails in T2D, and the patient’s BMI is above 35 kg/m2, what can you do?

A

there is the option of switching one of the drugs to a GLP-1 mimetic (e.g., liraglutide).

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27
Q

What are the 2 notable side effects of metformin?

A

1) GI symptoms e.g. diarrhoea

2) Lactic acidosis (e.g. 2ary to AKI)

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28
Q

Mechanism of action of SGLT-2 inhibitors?

A

1) The sodium-glucose co-transporter 2 protein is found in the proximal tubules of the kidneys –> acts to reabsorb glucose from the urine back into the blood.

2) SGLT-2 inhibitors block the action of this protein, causing more glucose to be EXCRETED in the urine

3) Loss of glucose in the urine lowers the HbA1c, reduces the blood pressure, leads to weight loss and improves heart failure

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29
Q

What protein do SGLT-2 inhibitors block the action of?

A

Sodium-glucose co-transporter 2 protein –> this protein acts to reabsorb glucose from the urine back into the blood.

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30
Q

Give some side effects of SGLT-2 inhibitors

A

1) Glycosuria (glucose in the urine)

2) Increased urine output and frequency

3) Genital and urinary tract infections (e.g., thrush)

4) Hypoglycaemia (when used with insulin or sulfonylureas)

5) Diabetic ketoacidosis, notably with only moderately raised glucose

6) Lower-limb amputation may be more common in patients on canagliflozin (unclear if this applies to the others)

7) Fournier’s gangrene (rare but severe infection of the genitals or perineum)

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31
Q

What class of drug is Pioglitazone?

A

thiazolidinedione

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32
Q

Mechanism of pioglitazone?

A

It increases insulin sensitivity and decreases liver production of glucose.

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33
Q

What are the notable side effects of Pioglitazone?

A

1) Weight gain

2) Heart failure

3) Increased risk of bone fractures

4) Small increase in risk of bladder cancer

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34
Q

What is the most common sulfonylurea?

A

Gliclazide

35
Q

Mechanism of Sulfonylureas?

A

Sulfonylureas stimulate insulin release from the pancreas.

36
Q

What are the 2 notable side effects of Sulfonylureas?

A

1) Weight gain

2) Hypoglycaemia

37
Q

What are incretins?

A

Hormones released by GI tract

They are secreted in response to large meals and act to reduce blood sugar

38
Q

Via what 3 mechanisms can incretins reduced blood sugar?

A

1) Increasing insulin secretion
2) Inhibiting glucagon production
3) Slowing absorption by the GI tract

39
Q

What is the main incretin?

A

Glucagon-like peptide-1 (GLP-1).

40
Q

what are incretins inhibited by?

A

An enzyme called dipeptidyl peptidase-4 (DPP-4).

41
Q

How can incretins be used in T2D management?

A

1) DPP-4 inhibitors (i.e. stopping inhibition of incretins)

2) GLP-1 mimetics (i.e. mimicking action of incretin)

42
Q

Give 2 examples of DPP-4 inhibitors

A

1) sitagliptin

2) alogliptin

43
Q

What are the 2 notable side effects of DPP-4 inhibitors?

A

1) Headaches
2) Low risk of acute pancreatitis

44
Q

Give 2 examples of GLP-1 mimetics?

A

1) exenatide

2) liraglutide

45
Q

How are GLP-1 mimetics given?

A

SC injection

46
Q

Which GLP-1 mimetic can be used for weight loss in non-diabetic obese patients?

A

Liraglutide

47
Q

When are ACEi started in the following scenarios (in terms of albumin-creatinine ratio):

1) CKD without diabetes

2) CKD with diabetes

A

1) ACR >30 mg/mmol

2) ACR >3 mg/mmol

48
Q

In patients with CDK and T2D, what is given when the ACR is above 30 mg/mmol (i.e. in addition to the ACEi)?

A

SGLT-2 inhibitor

49
Q

Gastroparesis is one complication of T2D.

What is the medical management?

A

Prokinetic drugs e.g. domperidone or metoclopramide

50
Q

What are the 4 pharmacological options for neuropathic pain (e.g., diabetic neuropathy) in T2D?

A

1) Amitryptiline

2) Gabapentin

3) Duloxetine

4) Pregabalin

51
Q

What is the principal feature of diabetic nephropathy?

A

Proteinuria

52
Q

Define microalbuminuria

A

There is albumin present in urine (indicates kidney damage).

53
Q

What ACR defines proteinuria?

A

≥30 mg/mmol

54
Q

What ACR defines microalbuminuria?

A

≥3 mg/mmol

55
Q

In all patients with confirmed nephropathy (including those with microalbuminuria alone) and type 1 diabetes, what medication should be started?

A

ACEi –> and titrated to FULL DOSE

56
Q

What should be offered to all adults with type 2 diabetes and CKD with an ACR over 30mg/mmol who are taking the highest tolerated dose of ACE inhibitor or ARB?

A

an SGLT2 inhibitor

57
Q

What is the most importance management of kidney disease in diabetics?

A

Antihypertensives

58
Q

Presentation of diabetic autonomic neuropathy?

A

Cardiac e.g. resting tachycardia, postural hypotension, exercise intolerance

Genitourinary e.g. impotence, sexual dysfunction, urinary hesitancy, overflow incontinence

GI e.g. N&V, abdo distension, diarrhoea

59
Q

What is the main motor presentation of diabetic neuropathy?

A

Proximal motor (diabetic amyotrophy):

Severe pain and paraesthesiae in the upper legs, with weakness and muscle wasting of the thigh and pelvic girdle muscles.

60
Q

What class of drug is orlistat?

A

Pancreatic lipase inhibitor

61
Q

How long is orlistat usually used for in obesity?

A

<1 year

62
Q

What can you give if metformin is contraindicated:

a) if risk of CVD/HF
b) if no risk of CVD/HF

A

a) SGLT-2 inhibitor

2) DPP-4 inhibitor or Pioglitazone or Sulfonylurea (SGLT-2 may be used if certain NICE criteria met)

63
Q

4th line therapy in T2D?

A

If triple therapy not effective or tolerated, consider switching one of the drugs for a GLP-1 mimetic (if BMI >/= 35) or insulin (occupational implications)

64
Q

What is the 1st line treatment of peripheral neuropathy in diabetes?

A

Managed as neuropathic pain:

1st line: amitriptyline, duloxetine, gabapentin or pregabalin

If the first-line drug treatment does not work try one of the other 3 drugs.

65
Q

What is the 1st line insulin regime in children with T1D?

A

Multiple daily injection basal-bolus regimen

66
Q

What other condition should all patients with a diagnosis of T1D be screened for?

A

Coeliac disease

67
Q

Define impaired fasting glucose

A

6.1 - 6.9 mmol/l

68
Q

What is the Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea)?

A

53 mmol/mol

69
Q

At what point should a second drug (in combination with metformin) be added to T2D regime?

A

HbA1c ≥58

70
Q

What is Buerger’s disease?

A

An inflammatory vasculitis strongly associated with young people who smoke.

71
Q

When should you consider the addition of metformin to T1D management?

A

patients with T1D and BMI >25

72
Q

T2DM BP targets?

A

T2DM blood pressure targets are the same as non-T2DM.

If < 80 years:
- clinic reading: < 140 / 90
- ABPM / HBPM: < 135 / 85

73
Q

In type 1 diabetics, how often is it recommended to monitor blood glucose?

A

at least 4 times a day, including before each meal and before bed

74
Q

In type 1 diabetics, what are the blood glucose targets:

a) on waking
b) before meals at other times of the day

A

a) 5-7 mmol/l
b) 4-7 mmol/l

75
Q

At what eGFR is metformin contraindicated?

A

<30

76
Q

Diagnosis of T2 diabetes in symptomatic vs asymptomatic patients?

A

Symptomatic –> can diagnose after 1 reading

Asymptomatic –> an abnormal HbA1c or fasting glucose must be confirmed with a second abnormal reading

77
Q

What is a rare but important side effect of DPP-4 inhibitors?

A

Pancreatitis

78
Q

What 2 main factors cause diabetic foot disease?

A

1) Neuropathy

2) Peripheral arterial disease

79
Q

How can neuropathy lead to diabetic foot disease?

A

1) Loss of protective sensation (e.g. not noticing stone in shoe)

2) Charcot’s arthropathy

3) Dry skin

80
Q

Presentation of diabetic foot disease?

A

1) Neuropathy: loss of sensation

2) Ischaemia: absent foot pulses, reduced ABPI, intermittent claudication

3) Complications: calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, gangrene

81
Q

How often should patients with diabetes be screened for diabetic foot disease?

A

At least on an annual basis

82
Q

How are diabetic patients screened for diabetic foot disease?

A

1) screening for ischaemia: done by palpating for both the dorsalis pedis pulse and posterial tibial artery pulse

2) screening for neuropathy: a 10 g monofilament is used on various parts of the sole of the foot

83
Q

All patients who are moderate or high risk (I.e. any problems other than simple calluses) should be followed up regularly by who?

A

Local diabetic foot centre

84
Q
A

Yr 5 - Endocrine & Metabolic (7 decks)

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