Endo - T2DM Flashcards

Question

Recommendations for diabetic peripheral neuropathy

Answer 1

all patients should be screened for distal symmetric polyneuropathy starting at diagnosis and at least annually antidepressants (tricyclics, duloxetine, venlafaxine) use in painful diabetic peripheral neuropathy anticonvulsants (pregabalin and gabapentin) can be used is painful diabetic neuropathy Use the diabetic neuropathy symptom score then test pinprick, vibration with 128Hz, 10g monofilament, assess ankle reflexes Regarding treatment tricyclics are first line Gabapentin can provide relief in 30% of patients Pregabalin at 300-600mg PO daily can provide high level of benefit

Answer 2

Kidney status should be assessed by annual screening for albuminuria (urine albumin creatinine ratio) and annual eGFR Target HbA1c 7% Optimise BP control Use ACEinhibitor or ARB to protect against progression of kidney disease Encourage smoking cessation Refer to renal specialist when - eGFR <30 - persistent significant urine ACR >/30 - a sustained decreased in eGFR of >/25% OR a sustained decrease in eGFR of 15mL/min over 12 months - CKD with HTN that is hard to get to target despite at least 3 antihypertensives

Answer 3

Assess all diabetics feet and the risk of developing foot complications inspect feet for structural abnormalities, ulcerations, sensation 10g monofilament, peripheral arterial disease including feeling pulses and sending for ABI offer foot protection programs including podiatry reviews pressure reduction is required to optimise the healing of plantar foot ulcers When a foot ulcer is present: - refer to a vascular surgeon, high risk foot clinic or other appropriate MDT - sharp debridement of non-ischaemic wounds - in ischaemic ulcers, maintain a dry wound using dry, non-adherent dressing - in non-ischaemic ulcers, create a moist wound environment

Answer 4

Deep ulcers high risk foot with active ulcer ulcer not reducing in size after 4 weeks despite appropriate treatment absence of foot pulses ascending cellulitis suspected Charcot neuroarthropathy (unilateral, red, hot swollen, possibly aching foot)

Answer 5

Adrenaline activation - pale skin, sweating, shaking, palpitations and feeling of anxiety, dizziness Neuroglycopenic symptoms - hunger, change in intellectual processing, confusion, changes in behaviour, paraesthesia, coma and then seizures

Answer 6

severe dehydration, altered LOC, shock, ketotic breath in DKA

Answer 7

1mg glucagon IM or submit If IV access glucose 50%- 20mLs in adults, 10% in children call 000 for diabetic emergency when patient is alert and can swallow then give carbohydrates

Answer 8

Correct extracellular fluid deficit then slowly correct water depletion and hyperglycaemia, monitoring sodium and potassium closely give submit rapid acting insulin 0.1 units per kg look for underlying cause

Answer 9

Psychological - chronic pain - depression and anxiety - dementia macrovascular disease - HTN - heart failure - coronary disease - cerebrovascular disease - PVD - high risk foot issues microvascular disease - renal impairment and CKD - neuropathy, peripheral, autonomic - retinopathy metabolic disorders - dyslipidaemia - low testosterone in males - hepatic steatosis - joint issues - pancreatitis overweight and obesity related - OSA - osteoarthritis other - bacterial, fungal and viral infections - periodontal disease - arthritis - fractures - cancer

Answer 10

Oligo-ovulation or anovulation clinical and/or biochemical signs of hyperandrogenism polycystic ovaries and exclusion of - hyperthyrioidism - hyperprolactinaemia - congenital adrenal hyperplasia - androgen-secreting tumours - cushing's syndrome

Answer 11

Oligomenorrhoea and amenorrhoea - OCP with low estrogen dose - cyclic progrestins 10-14 days every 2-3 months - metformin Hirsutism - OCP - anti-androgen monotherapy (spironolactine or cyproterone acetate) should not be used without contraception - combination therapy of OCP and BD spironolactone OR OCP and cyproterone acetate for days 1-10 of OCP

Answer 12

Pre-pregnancy glycaemic control should be maintained as close to non-diabetic range as possible All women with diabetes should be prescribed high dose pre-pregnancy folate supplements All women with pre-gestational diabetes should be encouraged to achieve excellent glycaemic control Post-prandial glucose monitoring should be carried out in pregnant women with type 1/2 diabetes or gestational diabetes

Answer 13

Optimise diet, physical activity and healthy weight Advise that nausea and vomiting in pregnancy may affect blood glucose control Aim for glycaemic control to be as close to normal range - the risk of fetal abnormalities increases with higher HbA1c levels at the time of conception and during the first trimester Recommend higher folate supplementation (5mg per day) starting 1 month prior to pregnancy and continuing 12 weeks into gestation to reduce the risk of neural tube defects Be aware that women treated for hypothyroidism may require high doses of thyroid hormone (~30% increase in TDD) Advise examination of the retina prior to conception and during each trimester for women with T1 and t2 DM Renal function should be assessed prior to pregnancy

Answer 14

``` ACE inhibitors ARBs CCBs (except nifidipine) B blockers (except labetalol and oxprenolol) Statins ``` Seek advice for - thiazide like diuretics - methyldopa - spironolactone - moxonidine

Answer 15

Defined as glucose intolerance that begins or is diagnosed first during pregnancy Usually develops in the late 2nd or early 3rd trimester Affects 9.6-13.6% of pregnancies

Answer 16

pre-eclampsia higher rates of caesarean section maternal brith injury PPH

Answer 17

``` macrosomia growth restriction birth injury respiratory distress hypoglycaemia jaundice ```

Answer 18

All pregnant women screened between 26-28 weeks gestation with non fasting glucose challenge women at high risk should be screened at the first opportunity early in pregnancy with repeat if negative screening at 24-28 weeks women whose levels are >/7.8 should have a formal fasting OGTT the RACGP preferred criteria for GDM fasting glucose >/5.5 2 hour plasma glucose or random >/8

Answer 19

``` nutritional therapy weight optimisation physical activity BSL monitoring Refer to exc phsy and dietician Aim for pre-prandial readings of 4-6 and postprandially <7 Metformin is used internationally, but not approved in Aus Insulin therapy ```

Answer 20

OGGT at 6-12 weeks Thereafter a HbA1c every 3 years The lifetime risk of developing T2DM after GDM is 60%

Answer 21

MEN Erectile dysfunction - 4 times more likely. Associated with macrovascular disease, pelvic neuropathy, or psychological cause Can consider supportive counselling and CBT for psychogenic ED Phosphodiesterase inhibitors can be useful BUT can NOT use with vasodilating nitrates as contraindicated due to hypotension ``` WOMEN decreased or total lack of interest in intimacy or sexual relations decreased or no genital sensation anorgasmia vaginal dryness increased genital infections ```

Answer 22

Will need pre-op clinic However, usually all glucose-lowering medications PO and injectable exenatide can be continued the day prior to surgery May be omitted on the day of surgery Can generally be recommenced when they eat post op Patients on insulin will require per-operative insulin and glucose insfusions

Answer 23

``` Therapeutic regimens Commercial or private driving standards Satisfactory control of diabetes Hypoglycaemia unawareness Recent severe hypoglycaemic event Co morbidities and end-organ damage ```

Answer 24

Medical consultation at least 6 weeks prior to proposed travel time Checking routine immunisation status and other medical conditions Covering letter from their doctor and extra food supplies, medication and monitoring equipment Get travel insurance advice All diabetes supplies including equipment needs to be carried on board in the hand luggage of the individual with diabetes Travellers name should appear on the prescription and labels NDSS card is accepted as primary proof that a person with insulin-treated diabetes needs to carry the medication and equipment with them Carry a letter from the attending doctor with medical diagnoses, prescribed medications and if insulin the delivery device

Answer 25

``` Stress response Organ failure Malignancy Chemotherapy Use of steroids Frequent infections Poor appetite Smaller meals Poor nutrition Cachexia Dehydration Difficulty taking medications Weight loss ``` Aim for BSL between 6-15

Answer 26

MOA - reduces hepatic glucose output, lowers fasting glucose levels Contraindication - renal impairment (eGFR <30) Severe hepatic impairment Precaution - suspend treatment during periods of altered renal function SEs - gastrointestinal, lactic acidosis, rare B12 deficiency

Answer 27

MOA - triggers insulin release in a glucose independent manner contraindication - severe renal or hepatic impairment precaution - hypoglycaemia SEs - weight gain

Answer 28

MOA - decreases inactivation of gluclose like peptide 1 --> increasing GLP 1s ability to stimulate beta cell insulin release and slows gastric emptying contraindication - pancreatitis precaution - nasopharyngitis Side effects - rash, pancreatitis

Answer 29

MOA - Peroxisome proligerator activated receptor agonists. Lowers glucose levels through insulin sensitsation Precaution - symptomatic heart failure SEs - fluid retention, heart failure, increased risk of non-axial fractures in women, increased risk of bladder cancer, weight gain

Answer 30

MOA - slows intestinal carbohydrate absorption and reduces post prandial glucose levels contraindicated - severe renal impairement (creat clearance <25ml/min/m2) precaution - GI disorders associated with malabsorption SEs - bloating, flactulence

Answer 31

MOA - inhibits sodium co-transporter to produce urinary glucose loss and decrease glucose levels contraindicated - diminished effecacy with eGFR <60 Precautions - avoid with LOOP diuretics SEs - dehydration, dizziness, genitourinary tract infections, ketoacidosis PBS subsidised for use with combination metformin, sulphonylurea or both

Answer 32

MOA - stimulates beta cell insulin release and slows gastric emptying Contraindication - Avoid if history of pancreatitis or pancreatic malignancy Precaution - dose adjust for mod-severe renal impairment, increased risk of pancreatitis Side effects - nausea, vomiting, weight loss Exenatide is PBS subsidised for use in combination with metformin, sulphonylurea or both Or with insulin

Answer 33

MOA - directly activiates the insulin receptor Precaution - dose adjust in mod-severe renal disease SES - hypoglycaemia, weight gain

Answer 34

Start basal insulin 10 units bedtime (if FBG is high) or morning 9if pre-dinner BGL high) Continue oral glucose lowering meds Then adjust insulin dose twice weekly indul FBG target is achieved 10 - increase 4 units 8-9.9 - increase 2-4 units 7-7.99 - no change or increase by 2 units 6-699 - no change 4-5.9 - decrease by 2 units <4 or if severe hypoglycaemic episode - decrease 2-4 units

Answer 35

Start 10 units immediately before of soon after the largest meal Continue metformin, consider tapering sulphonylureas Then titrate dose once or twice weekly 10 - increase 4 units 8-9.9 - increase 2 units 7-7.99 - no change or increase by 2 units 6-699 - no change 4-5.9 - decrease by 2 units <4 or if severe hypoglycaemic episode - decrease 4 units INTENSIFY to twice daily when - if evening BGL is high - if HbA1c is > target Then half the dose and given BD Once a week adjust both insulin doses independently Pre breakfast insulin in adjusted according to pre-dinner BGL and pre-dinner insulin is adjusted according to fasting BGL

Answer 36

``` Start rapid acting prandial insulin 4 units before the meal with the largest carbohydrate content Continue basal insulin at current dose Continue meformin Consider tapering sulphonlureas Monitor 2 hr postprandial BSL ``` Titrate dose every 3 days with 2hr post prandial BGL >/ 8 for 3 consecutive days - no change or increase by 2 nits 6-7.9 - no change 4-5.9 - decrease by 2 units <4 on any day - decrease by 2-4 units INTENSIFY when HbA1c is not at target after 3 months, add further prandial insulin dose to another meal starting at 4 units and titrate as above

Answer 37

elderly longstanding T2DM with CVD renal impairment and CKD monotherapy or combo therapy with insulin or long-acting sulphonylureas excessive alcohol intake beta blocker therapy participated in unaccustomed or vigorous exercise

Answer 38

``` ADRENERGIC trembling or shaking sweating hunger lightheadedness numbness around the lips and fingers ``` ``` NEUROGLYCOPAENIC lack of concentration weakness behavioural change tearfulness/crying irritability headache dizziness ```

Answer 39

if symptompatic or BSL <4 15g of quick acting carbohydrates wait 15 mintues and repeat BSL, if still low another 15g of quick acting carbohydrates Provide longer acting carbohydrates if a patient's next meal is >15 minutes away (sandwich, fruit, dry biscuits) Test BSL ever 1-2 hours for the next few hours IF THE PATIENT CANNOT SWALLOW 1mg glucagon IM or SUBCUT

Answer 40

can rarely happen with SGLT2 inhibitors can occur in T2DM when under stress - surgery, trauma, infections, high dose steroids Biochemical criteria BSL >11 venous pH <7.3 or bicarb <15 blood ketones presence - Abnormal >/0.5 severe >3

Answer 41

Severe hyperglycaemia >25, hyperosmolality, dehydration and a change in mental state with little or no ketosis