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General Practice > Endo - T2DM > Flashcards

Endo - T2DM Flashcards

1
Q

Screening for T2DM

A

Screen every 3 years from age 40 or 18 is ATSI using AUSDRISK

If low risk <5% then repeat AUSDRISK 3 yearly

If high risk
- AUSDRISK >12
- Previous cardiovascular event
- Women with history of gestational diabetes
- Women with PCOS
- Patients on Antipsychotics
- People >/35 years originating from the Pacific Islands, Indian subcontinent of China
- People aged >/40 years with BMI >/30 of HTN
Then fasting BSL or HbA1c every 3 years

If high risk WITH impaired glucose then screening
every 12 months with fasting BSL or HbA1c

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2
Q

Diagnosis of diabetes in symptomatic patients

Symptoms suggestive of diabetes

Signs of insulin resistance

A 
lethargy, polyuria, polydipsia 
frequent fungal or bacterial infections
blurred vision 
loss of sensation 
poor wound healing 
weight loss

acanthosis nigricans commonly in neck and axillae
skin tags
central obesity
hirsutism

Screen patients with these signs with fasting BSL

IF single elevated FBG >/7 OR random >/11.1 in these patients then CONFIRM DIABETES

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3
Q

Diagnosis of diabetes in asymptomatic patients

A

FBG >/7 or random BSL >/11.1 confirmed by a second abnormal FBG on a separate day

HbA1c >/ 6.5% of two separate occasions

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4
Q

Fasting blood glucose screening and diagnosis algorithm

A

<5.5 diabetes unlikely

> /7 diabetes likely - confirm if symptomatic, or confirm with repeat if asymptomatic

5.5-6.9 diabetes possible –> OGGT

On OGGT
fasting flucose <6.1, two hour <7.7 = normal

fasting glucose 6.1-6.9 & two hour glucose <7.8 = impaired fasting glucose

fasting glucose <7 and & two hour glucose 7.8-11 = Impaired glucose tolerence

fasting glucose >/7, two hour >/11.1 = diabetes

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5
Q

Lifestyle modification for T2DM

EXERCISE

A

30 minutes or more of moderate physical activity on most, if not all days of the week

Patients on insulin or sulphonylureas should check their BGL before, during and after prolonged physical activity

  • If pre-exercise BGL is <5 they need to have additional carbohydrates
  • should carry rapid acting glucose source at all times

All diabetics need to wear correct supportive footwear and check their feet daily and after physical activity

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6
Q

Lifestyle modifications for T2DM

DIET

A

Eat plenty of vegetables, fruit, grains (wholegrain), lean meats, dairy with reduced fats
Drink plenty of water
Limit foods containing saturated fat, added salt, added sugars and alcohol

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7
Q

Lifestyle modification for T2DM

WEIGHT

A

Patients with impaired fasting glucose, impaired glucose tolerance or diabetes should lose 5-10% Total body weight

if BMI > 35 - bariatric surgery may be considered

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8
Q

Lifestyle modification for T2DM

SMOKING

ALCOHOL

A

Cease smoking

Alcohol in moderation as per the guidelines

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9
Q

Assessment of T2DM

History

A

Symptoms of hyperlglycaemia

  • polyuria
  • polydipsia
  • polyphagia
  • weight loss
  • nocturia

Sequelae of hyperglycaemia

  • malaise/fatigue
  • CV symptoms
  • neurological and autonomic symptoms
  • altered vision, bladder or sexual function
  • foot and toe numbness and pain
  • recurrent infections
  • GI dysfunction
  • dental hygiene and gingivitis

Predisposition to diabetes

  • age, family history, cultural group, overweight, physical inactivity, HTN
  • GDM
  • medications causing hyperglycaemia
  • haemochromatosis
  • family history of autoimmune disorders
  • pancreatic disease, cushing’s disease
  • OSA

General health check

  • SNAP, lipids, HTN, mental health
  • knowledge about diabetes and related complications
  • living situation
  • vaccination history
  • intercurrent illnesses
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10
Q

Assessment of T2DM

Physical

A

weight, BMI
waist circumference
BP, central and peripheral vascular systems
Absolute CV risk

Eyes - visual acuity, retinopathy
Feet - sensation, circulation, skin condition, ulcers, abnormal bone structure
Peripheral nerves - Reflexes, sensation 10g monofilament, vibration 128Hz tuning fork
Urinalysis - ACR, MCS

Urine microalbumin
Lipids
HbA1c 3 monthly

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11
Q

Annual review for T2DM

A

system review

  • vascular
  • renal
  • eye
  • nerve
  • podiatric

HISTORY

  • review symptoms of hypoglycaemia, hyperglycaemia, and diabetes complications
  • SNAP
  • team care arrangements
  • immunisation

Visual acuity
Retinal screening 2 yearly, or yearly if symptomatic

CVS, CV risk assessment
Waist height WC 
Feet examination without shoes - pulses, monofilament
Psychological status 
Remind for dental review

Lipids
urine microalbumin

Assist with 
- registration for NDSS
GPMP and chronic disease management plan
Will need drivers licence assessment 
Add to recal system
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12
Q

Conditions that affect the HbA1c result

A

A condition that shortens the ESR will falsely lower the HbA1c

Abnormally low

  • haemolytic anaemia
  • recovery from acute blood loss
  • chronic blood loss
  • chronic renal failure

Abnormally high

  • Iron deficiency anadmia
  • splenectomy
  • alcoholism
  • steroid therapy, stress, surgery or illness in the past 3 months
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13
Q

Recommendations for self- monitoring of BSL

A

patients on insulin or sulphonureas
when monitoring hyperglycaemia arising from illness
with pregnancy and pre-pregnancy planning
when changes in treatment, lifestyle or other conditions require data on glycaemic patterns
when HbA1c is unreliable

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14
Q

Targets for self-monitored glycaemic control in T2DM

A

FBG 6-8
Preprandial 6-8
Postprandial 6-10

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15
Q

algorithm for T2DM treatment

A

first line - metformin unless contraindicated or not tolerated

IF HbA1c target not achieved in 3 months

Add SU, DPP-4i or SGLT2i

IF HbA1c target not achieved in 3 months

Consider triple oral therapy OR addition of GLP-1 RA OR insulin

IF on triple oral therapy, switch >/1 agent to GLP-1RA or insulin

If on GLP-1RA then change to OR add basal/premix insulin

If on basal insulin add SGLT2 inhibitor or GLP-1RA or basal/bolus or basal plus insulin

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16
Q

Risk factors for hypoglycaemia when on insulin

A 
inappropriate dose 
timing 
missed meals 
alcohol intake 
exercise 
weight loss 
treatment with sulphonylureas 
decreased insulin clearance (renal failure)
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17
Q

Managing cardiovascular risk in T2DM

A

All adults with T2DM should receive the max tolerated dose of statin irrespective of their lipids
Also should be on an ACE inhibitor or ARB as renally protective
Can add a calcium channel blocker as second antihypertensive in diabetics

BP target 130/80 for diabetes

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18
Q

Antithrombotic therapy in T2DM

A

all adults with T2DM and known prior CV disease should receive long-term antiplatelets unless a clear contraindication

If Hx of ischaemic stroke or TIA then low dose aspirin or clopidogrel or combo low dose aspirin and XR dipyridamole

If Hx of ACS and/or stent then for 12 months after event or procedure combo low dose aspirin and clopidogrel/prasugrel/ticagrelor

If Hx of coronary artery disease, but no acute event in the last 12 months then long term low dose aspirin or clopidogrel if intolerant to aspirin

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19
Q

Monitoring for diabetic retinopathy

A

dilated fundus examination
Visual acuity

At the diagnosis of diabetes and at least 2 yearly

Higher risk patients (poor glycaemic control, HTN, blood lipid control) annually
ATSIs annually

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20
Q

Non-proliferative diabetic retinopathy

A

retinal haemorrhages and exudates

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21
Q

Proliferative diabetic retinopathy

A

neovascularisation which may lead to severe complications and blindness

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22
Q

Risk factors for development and progression of diabetic retinopathy

A 
Existing diabetic retinopathy 
Poor glycaemic control 
Raised BP 
Duration of diabetes >10 years 
Microalbuminuria 
Dyslipidaemia 
Anaemia 
Pregnancy
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23
Q

Monitoring for diabetic eye disease

A

Visual acuity
Cataracts
Retinopathy

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24
Q

Autonomic neuropathy may result in

A 
orthostatic hypotension >20mmHg drop 
impaired gastric emptying
diarrhoea 
delayed/incomplete bladder emptying 
erectile dysfunction 
reduced vaginal lubrication 
silent ischaemia or MI
sudden unexpected cardiac/respiratory arrest 
difficulty recognising hypoglycaemia 
unexplained ankle oedema
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25
Q

Recommendations for diabetic peripheral neuropathy

A

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

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26
Q

Recommendations for nephropathy

A

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
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27
Q

Foot complications

A

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
28
Q

When to refer to MDT foot care

A

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)

29
Q

Symptoms of hypoglycaemia

A

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

30
Q

Signs of hyperglycaemic states

A

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

31
Q

Management of hypoglycaemic emergency

A

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

32
Q

Management of hyperglycaemic emergency

A

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

33
Q

Common co-morbidities associated with diabetes

A

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
34
Q

PCOS rotterdam diagnostic criteria

A

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
35
Q

Interventions for PCOS

A

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
36
Q

Pregnancy with pre-existing diabetes recommendations

A

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

37
Q

Pre-pregnancy planning in gestation DM

A

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

38
Q

medications contraindicated during pregnangy

A 
ACE inhibitors 
ARBs 
CCBs (except nifidipine) 
B blockers (except labetalol and oxprenolol) 
Statins

Seek advice for

  • thiazide like diuretics
  • methyldopa
  • spironolactone
  • moxonidine
39
Q

GDM facts

A

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

40
Q

Maternal complications fo GDM

A

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

41
Q

neonatal complications of GDM

A 
macrosomia 
growth restriction 
birth injury 
respiratory distress 
hypoglycaemia 
jaundice
42
Q

Screening for GDM

A

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

43
Q

Management of GDM

A 
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
44
Q

post partum GDM

A

OGGT at 6-12 weeks
Thereafter a HbA1c every 3 years

The lifetime risk of developing T2DM after GDM is 60%

45
Q

Sexual problems associated with diabetes

A

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
46
Q

T2DM and pre-planned surgery

A

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

47
Q

Medical assessment for T2DM for driving

A 
Therapeutic regimens 
Commercial or private driving standards 
Satisfactory control of diabetes 
Hypoglycaemia unawareness 
Recent severe hypoglycaemic event 
Co morbidities and end-organ damage
48
Q

T2DM and travel

A

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

49
Q

Factors affecting glycaemic control in patients with T2DM at end of life

A 
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

50
Q

Biguanides

Metformin

A

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

51
Q

Sulphonylureas

Gliclazide
Gipizide

XR
Gliclazide MR
Glibenclamide
Glimepiride

A

MOA - triggers insulin release in a glucose independent manner

contraindication - severe renal or hepatic impairment

precaution - hypoglycaemia

SEs - weight gain

52
Q

Dipeptidyl peptidase - 4 inhibitors

Alogliptin
linagliptin
saxagliptin
vidagliptin

A

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

53
Q

Thiazolidinediones

Pioglitazone
rosiglitazone

A

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

54
Q

Alpha 1 glucosidase inhibitors

Arcarbose

A

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

55
Q

Sodium- Glucose Co-transporter 2 inhibitors

Canagliflozin
Dapagliflozin
Empagliflozin

A

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

56
Q 
Glucagon-like peptie - 1 receptor agonist
Exanatide 
Exanatide XR 
Liraglutide 
Lixisenatide

SUBCUT injection

A

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

57
Q

Insulin

SUBCUT injection

A

MOA - directly activiates the insulin receptor

Precaution - dose adjust in mod-severe renal disease

SES - hypoglycaemia, weight gain

58
Q

How to start insulin BASAL

A

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

59
Q

How to start insulin PREMIX

A

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

60
Q

BASAL PLUS insulin intensification

A 
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

61
Q

patients at risk of hypoclycaemia

A

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

62
Q

Symptoms of hypoglycaemia

A 
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
63
Q

Rule 15 for hypoglycaemia

A

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

64
Q

T2DM DKA

A

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

65
Q

Hyperosmolar hyperglycaemic state

A

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

General Practice (4 decks)

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