Endocrine

Question 1

What is diagnostic criteria for type 2 diabetes?

Answer 1

○ Random glucose >= 11.1
○ Post OGTT glucose >= 11.1
○ Fasting glucose >= 7
○ HbA1c >= 48 (6.5%)
1 result needed if symptomatic, 2 if no symptoms

‘Pre-diabetes’:
IFG (impaired fasting glucose) -fasting glucose between 6.1 and 7
IGT (impare

Question 2

When can’t HbA1c be used?

Answer 2

○ Children and under 18s
○ Pregnancy (and up to 2 months postpartum)
○ Diabetes symptoms for less than 2 months
○ Acutely unwell
○ On medication that may cause hyperglycaemia eg long-term corticosteroids
○ Acute pancreatic damage
○ End-stage renal disease
○ HIV infection

Question 3

What are the individualised HbA1c Targets?

Answer 3

• Lifestyle including diet management — 48 mmol/mol (6.5%).
• Lifestyle including diet combined with a single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%).
• Drug treatment associated with hypoglycaemia (such as a sulfonylurea): 53 mmol/mol (7.0%).

Question 4

How often should HbA1c be checked?

Answer 4

HbA1c should be measured at 3–6 monthly intervals initially until stable on unchanging antidiabetic treatment, and then every 6 months to ensure adequate blood glucose control.

Question 5

If a patient suddenly has a significant increase in HbA1c, what diagnosis do you need to consider and what investigation should be requested?

Answer 5

Pancreatic cancer
CT scan

Question 6

What is the stepwise approach to drug therapy?

Answer 6

○ Step 1: Metformin (unless CI)
● + SGLT-2i eg dapagliflozin added afterwards if CVD or heart failure
○ Step 2: Metformin + Gliptin / Pioglitazone / Sulfonylurea / SGLT-2i
○ Step 3: Triple oral therapy OR insulin
○ Step 4: Consider GLP-1 eg exenatide

Question 7

DPP-4 inhibitors ‘Gliptins’ - examples, C/I & cautions

Answer 7

• Examples: Linagliptin , Sitagliptin, Alogliptin, Saxagliptin, Vildagliptin
• C/I Ketoacidosis, Hepatic impairment, Heart failure
• Cautions: Renal impairment, Pancreatitis history, Heart failure, Elderly

Question 8

DPP-4 inhibitors ‘Gliptins’ - side effects & monitoring

Answer 8

• Side effects (vary but include)
  ○ GI eg constipation, diarrhoea, gastritis, dyspepsia, reflux, vomiting
  ○ Acute pancreatitis
  ○ Liver eg hepatitis, hepatic failure
  ○ Neurological eg headache, dizziness, tremor
  ○ Skin eg pruritus, angioedema, rash, urticaria
  ○ MSK eg back pain, arthralgia, myalgia
  ○ Increased infection risk
  Monitoring
  ○ Before starting: Check liver and renal function
  ○ Ongoing: check either renal, liver function or both (depends on which drug)

Question 9

What are the monitoring requirements for Linagliptin?

Question 10

What are the monitoring requirements for Sitagliptin?

Question 11

How to treat a new Type 2 diabetic who presents with osmotic symptoms

Answer 11

• Commence patient initially on gliclazide
• Closely monitor, review after 2-4 weeks
• Switch to metformin once ostmotic symptoms resolve

Question 12

Which patients need to do finger prick blood glucose monitoring?

Answer 12

• Patient on insulin
• Patient with evidence of hypoglycaemic episodes.
• Patient taking a drug that may increase the risk of hypoglycaemia while driving or operating machinery (such as a sulfonylurea).
• Patient pregnant or planning a pregnancy.
• If driving blood sugar should be checked before driving and every 2 hours thereafter

Question 13

Diabetic DVLA rules