Diabetes - Treatment

Question 1

What type of insulin (i.e. human or analogue) is most commonly used by type 1 diabetics and why?

Answer 1

Analogue, because it has a lower risk of hypoglycaemia

Question 2

What is an example of a short-acting human insulin?

Answer 2

Actrapid

Question 3

What is an example of a long-acting human insulin?

Answer 3

Insulatard

Question 4

What are 2 examples of short-acting analogue insulins?

Answer 4

Novorapid (insulin aspart) and Humalog (insulin lispro)

Question 5

What are 2 examples of long-acting analogue insulins?

Answer 5

Lantus (insulin glargine) and Levemir (insulin determir)

Question 6

Which has a shorter duration of action- human or analogue insulin?

Answer 6

Analogue

Question 7

Patients with type 1 diabetes should be given an insulin to carbohydrate ratio and should be educated to match their prandial insulin dose to what 3 things?

Answer 7

Carbohydrate intake, pre-meal glucose and anticipated exercise

Question 8

Do fingerprick blood glucose levels taken before meals inform about the long or short acting insulin dose?

Answer 8

Long-acting

Question 9

Do fingerprick blood glucose levels taken after meals inform about the long or short acting insulin dose?

Answer 9

Short-acting

Question 10

Explain what is meant by the basal bolus regimen of giving insulin?

Answer 10

A long-acting insulin is given before bed, and short-acting insulin doses are given with each meal

Question 11

In a bi-daily insulin regimen, what type of insulin is given at the two daily doses?

Answer 11

A mixture of short and intermediate acting insulin

Question 12

How fast acting is isophane insulin?

Answer 12

Intermediate-acting

Question 13

What type of insulin is given in a once daily insulin regimen? When should this dose be given?

Answer 13

An intermediate-long acting insulin is given before breakfast

Question 14

When is a once daily insulin regimen used?

Answer 14

In type 2 diabetics, in conjunction with oral hypoglycaemic agents

Question 15

Explain what is meant by continuous SC insulin infusion?

Answer 15

A rapid acting insulin is infused continuously, boluses are given with meals

Question 16

When is IV insulin used?

Answer 16

In acute illness and fasting patients

Question 17

If a patient is being given IV insulin and their blood glucose is > 12mmol/L, what should be checked?

Answer 17

Ketones

Question 18

What effect does insulin therapy have on weight?

Answer 18

Weight gain

Question 19

What is the name for a lump of fat which accumulates under the skin at the site of many SC injections of insulin? How can this complication be avoided?

Answer 19

Lipohypertrophy, this can be avoided by regularly changing the injection site and using new needles daily

Question 20

What is the major potential risk of insulin treatment?

Answer 20

Hypoglycaemia

Question 21

What gets replaced in a pancreas transplant for type 1 diabetes?

Answer 21

Pancreatic islet cells

Question 22

Which oral hypoglycaemic agent has the following mechanism of action: helps to increase insulin sensitivity and decrease hepatic gluconeogenesis?

Answer 22

Metformin

Question 23

Metformin is the first line pharmacological treatment for type 2 diabetes because it does not cause what two things?

Answer 23

Weight gain and hypoglycaemia

Question 24

What is the most common side effect of metformin?

Answer 24

Gastrointestinal upset

Question 25

Which oral hypoglycaemic agent can cause a metallic taste in the mouth as a side effect?

Answer 25

Metformin

Question 26

Why should metformin be avoided in those with severe liver disease or renal failure?

Answer 26

Risk of lactic acidosis

Question 27

What are the contraindications to the use of metformin?

Answer 27

CKD, and periods of time where there is tissue hypoxia (e.g. post-MI)

Question 28

It is recommended that metformin should be stopped if the creatinine is greater than what, or the eGFR is less than what?

Answer 28

Creatinine > 150 / eGFR < 30

Question 29

Is metformin safe to use during pregnancy and breastfeeding?

Answer 29

Yes

Question 30

When should metformin be taken in relation to food?

Answer 30

After food

Question 31

Gliclazide and glibenclamide are examples of which class of oral hypoglycaemic agents?

Answer 31

Sulfonylureas

Question 32

When may sulfonylureas be used as a first line treatment for type 2 diabetes?

Answer 32

In patients who are intolerant of metformin, or those who are significantly underweight

Question 33

Which oral hypoglycaemic agent has the following mechanism of action: increases pancreatic insulin secretion by binding to an ATP-dependent potassium channel on the cell membrane of pancreatic beta cells?

Answer 33

Sulfonylureas

Question 34

What are the two major adverse effects of sulfonylureas?

Answer 34

Hypoglycaemia and weight gain

Question 35

Due to the risk of hypoglycaemia, sulfonylureas should be avoided/given with caution in who?

Answer 35

The elderly/frail

Question 36

Sulfonylureas may cause which electrolyte abnormality?

Answer 36

Hyponatraemia (secondary to SIADH)

Question 37

Bone marrow suppression, hepatotoxicity and peripheral neuropathy are all relatively rare side effects of which oral hypoglycaemic agent?

Answer 37

Sulfonylureas

Question 38

Are sulfonylureas safe to use in pregnancy and breastfeeding?

Answer 38

No

Question 39

Exenatide and liraglutide are examples of which class of drug?

Answer 39

GLP-1 analogues

Question 40

What effect do GLP-1 analogue drugs have on weight?

Answer 40

Weight loss

Question 41

Which oral hypoglycaemic agents cause weight gain?

Answer 41

Sulfonylureas and thiazolidinediones

Question 42

Which oral hypoglycaemic agents risk hypoglycaemia?

Answer 42

Sulfonylureas and thiazolidinediones

Question 43

Which oral hypoglycaemic agent has the following mechanism of action: agonist to the PPAR-gamma receptor, working by reducing peripheral insulin resistance?

Answer 43

Thiazolidinediones

Question 44

Pioglitazone is an example of what class of oral hypoglycaemic agent?

Answer 44

Thiazolidinediones

Question 45

What blood test should be monitored regularly in those taking thiazolidinediones?

Answer 45

LFTs

Question 46

What is the major contraindication to the use of thiazolidinediones and why?

Answer 46

Heart failure - due to the adverse effect of fluid retention

Question 47

How and when should exenatide (a GLP-1 analogue) be given?

Answer 47

As SC injection, 60 minutes before the morning and evening meals

Question 48

What is the main advantage of liraglutide over exenatide?

Answer 48

It is only given once daily

Question 49

What is the main adverse effect of GLP-1 analogue drugs?

Answer 49

Nausea/vomiting (usually resolves by 6-8 weeks)

Question 50

Which class of type 2 diabetes drug comes with an increased risk of developing pancreatitis and pancreatic cancer?

Answer 50

GLP-1 analogues

Question 51

Vildagliptin and sitagliptin are examples of which class of oral hypoglycaemic agent?

Answer 51

DDP-4 inhibitors (Gliptins)

Question 52

What effect do DDP-4 inhibitors (gliptins) have on weight?

Answer 52

Weight neutral

Question 53

Canagliflozin and dapagliflozin are examples of which class of oral hypoglycaemic agent?

Answer 53

SGLT-2 inhibitors

Question 54

Which oral hypoglycaemic agent has the following mechanism of action: works in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion?

Answer 54

SGLT-2 inhibitors

Question 55

What effect do SGLT-2 inhibitors have on weight?

Answer 55

Weight loss

Question 56

What is the major adverse effect of SGLT-2 inhibitors?

Answer 56

Urinary and genital infections

Question 57

SGLT-2 inhibitors will be of no use in individuals with an eGFR of less than what?

Answer 57

60ml/min

Question 58

How often should HbA1c be monitored in type 1 diabetics?

Answer 58

Every 3-6 months

Question 59

How often, and when, should self-monitored testing of blood glucose be done in type 1 diabetics?

Answer 59

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

Question 60

On average, for type 1 diabetics, what should their blood glucose target be when monitoring it throughout the day?

Answer 60

4 - 8mmol/L

Question 61

What is the insulin regimen of choice for all adult type 1 diabetics?

Answer 61

Multiple daily injection basal bolus regimen

Question 62

What is the basal insulin regimen of choice for all adult type 1 diabetics?

Answer 62

Twice daily Levemir (insulin determir)

Question 63

NICE recommends the addition of what drug in type 1 diabetics with a BMI of 25 or more?

Answer 63

Metformin

Question 64

How often should HbA1c be checked in type 2 diabetics?

Answer 64

Every 3-6 months until stable, 6 monthly after that

Question 65

Complete the blanks: in type 2 diabetics, you can titrate up metformin and encourage lifestyle changes to aim for an HbA1c of (X), but should only add a second drug if the HbA1c rises to (Y)

Answer 65

X = 48mmol/mol, Y = 58mmol/mol

Question 66

What is the HbA1c target for type 2 diabetics on lifestyle, or lifestyle + metformin management?

Answer 66

48mmol/mol

Question 67

What is the target HbA1c for type 2 diabetics who are taking any drug that comes with a risk of hypoglycaemia?

Answer 67

53mmol/mol

Question 68

What is the first line pharmacological treatment for type 2 diabetes and when should it be offered?

Answer 68

Metformin: offer when HbA1c 48mmol/mol+ on lifestyle intervention only

Question 69

A second drug should be added to metformin in type 2 diabetic patients if their HbA1c has risen above what?

Answer 69

58mmol/mol

Question 70

What are the 4 options of second line drug class that can be offered to patients as second line therapy in addition to metformin, if HbA1c is 58mmol/mol or more?

Answer 70

Sulfonylureas, thiazolidinediones, DDP-4 inhibitors, SGLT-2 inhibitors

Question 71

What are the two treatment options that can be considered for type 2 diabetic patients who are on metformin plus one other oral hypoglycaemic agent yet still have an HbA1c of 58mmol/mol or more?

Answer 71

Add one more drug (triple therapy) or start insulin

Question 72

In those type 2 diabetic patients who can tolerate metformin, if triple therapy is not effective, not tolerated or contraindicated for any reason AND the patient has a BMI of > 35, a combination of what three drugs can be tried?

Answer 72

Metformin, sulfonylurea and GLP-1 analogue

Question 73

What targets must be met for treatment with a GLP-1 analogue to be continued in type 2 diabetic patients?

Answer 73

Reduction in HbA1c of 11mmol/mol and weight loss of at least 3%, both in 6 months

Question 74

In those type 2 diabetic patients who cannot tolerate metformin, if the HbA1c rises to 48mmol/mol on lifestyle interventions alone, one of what 3 drug classes can be considered as first line treatment?

Answer 74

Sulfonylurea, thiazolidinedione, DDP-4 inhibitor

Question 75

In those type 2 diabetic patients who cannot tolerate metformin, if one drug is started but the HbA1c remains at 58mmol/mol or more, what should be done?

Answer 75

Combine two drugs (sulfonylurea, thiazolidinedione, DDP-4 inhibitor)

Question 76

In those type 2 diabetic patients who cannot tolerate metformin, if two drugs are started in combination but the HbA1c remains at 58mmol/mol or more, what should be done?

Answer 76

Start insulin therapy

Question 77

What drug should always be continued alongside insulin therapy for type 2 diabetes (if the patient is already on the drug)?

Answer 77

Metformin

Question 78

What is the recommended insulin regime for type 2 diabetics starting insulin treatment?

Answer 78

Intermediate acting human insulin (isophane insulin) given once or twice daily

Question 79

If treatment for hypertension is required in a diabetic patient, what is the drug of choice?

Answer 79

ACE inhibitor or ARB

Question 80

Should anti-platelets be offered routinely to diabetic patients?

Answer 80

No

Question 81

What drug is typically used as primary prevention against hyperlipidaemia in diabetic patients?

Answer 81

Atorvastatin 20mg

Question 82

When should atorvastatin 20mg be given to type 1 diabetic patients?

Answer 82

This is started in most adult type 1 diabetics

Question 83

When should atorvastatin 20mg be given to type 2 diabetic patients?

Answer 83

If they have a 10 year CV risk > 10%

Question 84

How many units of insulin are usually found within 1ml?

Answer 84

100 units