ENDOCRINE- DIABETES MELITUS Flashcards
1
Q
What is diabetes mellitus?
A
Metabolic disorder characterised by hyperglycaemia.
2
Q
What are two types of DM?
A
TYPE 1
TYPE 2
3
Q
What is type 1 DM caused by?
A
Deficiency
autoimmune destruction of pancreatic beta- islet cells
4
Q
What is type 2 diabetes caused by?
A
Unhealthy life style
e.g poor diet, High BP, cholesterol
5
Q
What is treatment for type 1 diabetes?
A
Insulin
6
Q
What is treatment for type 2 diabetes?
A
Anti-diabetics or Insulin if needed.
7
Q
What are 3 symptoms of type 2 diabetes?
A
Unexplained weight loss
numbness
feeling very thirsty
8
Q
What are 8 symptoms of diabetes melitus?
A
Hyperglycaemia
Polyuria
Polydipsia (thirst)
Polyphagia (excess appetite)
Poor wound healing
Fatigue
Weight loss
Blurry vision
9
Q
What are 6 diabetic complications
A
Diabetic retinopathy
Diabetic nephropathy
Peripheral neuropathy
Stroke
Heart attack
Diabetic foot
10
Q
What are 2 diabetic complications which are macrovascular?
A
Stroke
Heart attack
11
Q
What are 3 diabetic complications which are mIcrovascular?
A
Diabetic retinopathy
Diabetic nephropathy
Peripheral neuropathy
12
Q
What does microvascular complications mean?
A
disease affecting small vens
13
Q
What does macrovascular complications mean?
A
disease affecting arteries
14
Q
What is treatment for cardiovascular disease for primary + secondary prevention?
A
Low dose statin - primary prevention
low dose aspirin - secondary
15
Q
What is potential treatment option for diabetic retinopathy?
A
Treat HTN
16
Q
What is potential treatment option for diabetic nephropathy?
A
Treat HTN
Low dose ACEi/ARB
17
Q
What is potential treatment option for diabetic neuropathy pain?
A
Neuropathic pain meds - analgesia, TCA, anti-epileptic
18
Q
What is tx for erectile disfunction?
A
Sildenafil
19
Q
What is diabetic ketoacidosis?
A
Serious complication of diabetes that can be life-threatening.
20
Q
What are 5 risk factors to diabetic ketoacidosis?
A
Stress
Severe dehydration
Not eating
Surgery
illness
21
Q
What are 10 symptoms of diabetic ketoacidosis?
A
Electrolyte imbalance (K+).
increased ketones in blood + urine
Weight loss
Polyuria
Dehydration + extreme thirst
N+ V
Diabetic coma
Abdo pain
Convulsions
FRUITY breath
22
Q
When should fluids be given?
A
Especially in shock - restore normal volume
If not shock - rehydrate + maintain
23
Q
When to NOT give potassium in diabetic ketoacidosis?
A
Do NOT give if anuric- no urine.
24
Q
What is insulin regimen for diabetic ketoacidosis?
A
Continue LONG acting insulin
25
When to add in glucose for diabetic ketoacidosis?
When glucose is <14mmol/L
26
When to continue treatment of insulin in diabetic ketoacidosis?
If blood ketones <0.3 mmol/L
Blood pH > 7.3 = eat + drink
27
If Blood pH > 7.3, what to do?
Eat + drink
28
When to stop insulin in DKA?
1hour after S/C fast acting insulin + meal
29
MOA of insulin?
Lowers BG level by increasing uptake of skeletal muscle + adipose tissue
supresses hepatic gluconeogenesis
30
What is indication of insulin?
T1 +T2 DM
31
What are the 3 routes of insulin?
SC
IV
IM
32
What are the 3 conditions which require increased insulin level?
Infection or illness
Surgery or trauma
Puberty, pregnancy (2nd or 3rd trimester)
33
What are the 3 conditions which require decrease in insulin level given?
Reduced food intake , physical activity
Renal impairment
Endocrine disorders e.g addison's disease
34
What is a MAIN SE of insulin?
Hypoglycaemia
35
What is usual Insulin administration route + sites?
SC injection
Abdomen, thighs, buttocks, upper arm.
36
What is an MHRA warning regarding insulin injection?
Risk of cutaneous amyloidosis at injection site
Different to lipodystrophy
37
What 4 counselling points to tell patient on insulin to prevent lipodystrophy + cutaneous amyloidosis on injection site?
Rotate injection site
Check site for reactions - infection, swelling, bruising, lipodystrophy
Do NOT miss meals , avoid strenuous exercise
Recognise warning signs of hypOglycaemia
38
What does the NHS improvement of safety alert regarding insulin talk about?
Severe harm and death withdrawing insulin from pen devices - can cause overdose.
39
How should insulin be prescribed?
Prescribe doses in units or international units.
overdose due to abbreviations = X
40
What 2 items need to be handed to a patient on insulin?
Insulin passport
Patient information booklet
41
What is insulin best stored at?
Fridge 2-8 degrees
42
Where to keep insulin after opened?
Keep room temperature, use by <28days.
43
What to do if insulin is frozen?
Discard
44
What does prandial mean?
Insulin secreted in response to glucose spikes after meals
45
What does basal insulin mean?
Insulin is secreted 24 hours a day
slow and long acting
46
What are the 2 types of insulin?
Bolus
Basal
47
What is bolus insulin split into ?
Rapid acting analogue
Short acting
48
What 2 activities is basal insulin split into ?
Intermediate acting
Long-acting analogue
49
What is short acting soluble insulin made from?
Human e.g. actrapid, humalin
Beef/pork - unacceptable religions
Route - SC + IM (IV is surgery/emergency)
50
When is bolus short acting insulin given?
15 to 30 mins before meals
Eat before 30 mins has past to avoid hypoglycaemia
51
What are 3 bolus rapid acting insulin analogues and their brands?
Aspart- novorapid
Glulisine- apidra
Lispro - humalog
52
What is route of bolus rapid acting insulin?
SC or IV in emergency
53
When is rapid acting bolus insulin given?
Just before meals
Lower risk of hypoglycaemia before meals + nocturnal
54
What is onset of bolus short actin insulin?
30-60 MINS to work
Peak 1 to 4 hrs
Duration up to 8 hrs
55
What is bolus rapid acting insulin onset?
15 mins to work
56
What is bolus rapid acting insulin duration?
2-5 hours
57
What is basal intermediate acting insulin example?
Isophane (NPH)
58
What is a common SE of Isophane (NPH)?
Allergic reaction
59
What is route of Isophane (NPH)
always IM
60
Why is Isophane (NPH) NOT given iv?
Thrombosis can happen
61
What is frequency of isophane?
BD
62
What are 5 long acting analogue basal insulin names/brands?
Degludec - tressiba - ultra
Determir - levemir (OD + BD)
Glargine (Lantus)
Protamine zinc (iv cause thrombosis)
Zinc insulin
63
What is frequency of long acting basal insulin?
Take OD same time each day
64
What is onset of basal intermediate acting insulin?
1-2 hrs
Peak - 3 to 12 hrs
Duration - 11 to 24 hrs
65
What is duration of basal long acting insulin?
up to 36 hrs
66
What insulin regimens are given via multiple injections? (basal-bolus)
short or rapid acting (before each meal)
intermediate or long acting - OD/BD
67
When is short or rapid acting bolus insulin given?
Before meals
68
What frequency is intermediate or long-acting basal insulin given?
OD or BD
69
What is the pros and cons of multiple injection insulin regime?
Flexible
More injecting
70
What is patient counselling for multi injection insulin regimen?
Match insulin dose to carb intake.
71
What are biphasic insulin options?
Short OR rapid acting
Mixed with
Intermediate acting (BD before meals)
72
What is counselling point for biphasic insulin regimen?
Regulate carb intake to match dose, BEFORE meal
Check insulin container + proportions
73
What is SC infusion of insulin?
Continuous soluble insulin delivered by infusion pump
either short or rapid acting
74
What insulin regimen is given for T1 diabetics as first line?
Multiple injections
of rapid acting (before meal) + detemir (BD)
{Basal-bolus or biphasic}
75
What is an alternative to multiple injection insulin regimen for T1?
Biphasic regimen BD
76
What 3 cases can SC infusion of insulin be used in?
Disabling, unpredictable hyperglycaemia
Poor glycemic control - HBA1C > 8.5% even after multiple injecting
Children under 12 - if MIR (MULTIPLE insulin regimen) impractical
77
What is 1st line insulin regimen for T2 diabetics if basal only?
Human isophane
78
When is Human isophane given in t2 diabetics?
OD or BD
79
What is pro and con of insulin pen?
easy to use
Residual insulin = not used
80
What is 1st line insulin regimen for T2 diabetics if multiple injection + biphasic used?
Human isophane
+
Human short acting (before meals)
81
What are 3 types of insulin devices?
Insulin pen
Pump
Syringe
82
What is pro and con of insulin pump?
Provides continuous basal + patient activated bolus
Con = only for certain t1 diabetics.
83
What is pro and con of insulin pump?
Less popular in children
84
What are SICK day rules?
Sugar - check BMs every 3-4 hrs until normal
Insulin = never stop itW
Carbs - normal meal pattern, replace meals with carb drinks, 3L fluid, get medical help if vomiting.
Ketones - check blood + urine ketones every 3 to 4 hrs
85
What must you never stop in sick day rules?
never stop insulin
86
When to check ketones in sick day rules + when to get medical help regarding ketones?
Ketones - check blood + urine ketones every 3 to 4 hrs.
If urine ketone > 2 OR blood ketone > 3mmol/L
87
What drug class can mask the symptoms of hypoglycaemia?
Beta blockers
88
What 3 drug classes can cause hypoglycaemia?
ACEi
ARB (cause hyperkalaemia)
Antidiabetic drugs
89
What 3 drug classes can antagonise insulin?
Corticosteroids
Antipsychotics
Thiazides
90
Which 2 antipsychotics can antagonise insulin?
Clozapine
Olanzapine
91
What should be given during major procedure, emergency or poor glycemic control for diabetic patient?
Sliding scale - soluble human insulin
Measured hrly based on BMs
Stop other insulins except long acting one - 80% dose given.
Continue until patient E +D + stable
92
What to give diabetic patient about to have minor procedure?
Adjust usual insulin
93
How are anti-diabetic drugs given?
nearly all given orally
94
What are the 4 oral hypoglycaemic drugs?
Sulphonylureas
GLP1 agonist
Gliptins - DPP4 inhbitors
Meglitinides
95
What 2 drugs are insuline sensitizers?
Metformin
Pioglitazone
96
What is MOA of metformin?
Causes less hepatic gluconeogenesis
Increases peripheral use
97
What is metformin used in 1st line for?
T2 Diabetes
98
Can metformin be used in pregnancy + breastfeeding?
Yes -safe
99
What other condition is metformin used unlicensed as?
PCOS
100
What is a deficiency in patients using metformin + is a MHRA alert?
B12 deficiency - check + monitor level
101
What are 3 SEs of metformin?
1. GI disturbances- N, V, D
2. Lactic acidosis
3. Low B12 level
102
What counselling points for metformin?
Take with or after meal or food.
Report signs of lactic acidosis
103
What 2 criteria to avoid giving metformin?
When renal impairment, eGFR <30ml/min.
Tissue hypoxia
104
What are 4 signs of AKI risk?
Severe infection , sepsis,
shock, dehydration
105
What are 4 signs of tissue hypoxia?
Acutr HF
Respiratory failure
MI
liver impaired
106
What is MOA of sulphonylureas?
Increased insulin secretion
107
What are 5 signs of lactic acidosis?
Dyspnoea
cramps
abdo pain
hypothermia
asthenia
108
What is name of long acting sulphonylurea?
Glimepiride
109
What 2 sulphonylureas are good in elderly or RI as they are short acting?
Gliclazide
Tolbutamide
110
What are 5 SEs of sulphonylureas? (JAW)
Hypoglycaemia - treat in hospital
HypOnatraemia
Weight gain
Jaundice
Allergic dermatitis
111
What is an interaction between ARB/ACEI and sulphonylurea going to cause?
Hypoglycaemias
112
What interacts with sulphonylureas to cause hypoglycaemia?
ARB/ACEi
113
MOA of pioglitazone?
reduces peripheral resistance
114
What class is pioglitazone?
thiazolidinediones
115
What is 6 SEs of pioglitazone? (HHBB)
Heart failure
Bladder cancer
Hepatotoxicity
weight gain
Bone issues
visual impairment
116
What are 3 MHRA warnings of pioglitazone?
Monitor signs of HF- oedema
Report blood in urine, dysuria, urgency
Report signs of liver disorder- jaundice, dark urine, abdominal pain, vomiting
117
Which antidiabetic drug causes weight gain?
pioglitazone
+
Gliclizide
118
What is a contraindication of pioglitazone?
Uninvestigated macroscopic haematuria
119
What is MOA of SGLT2 inhibitors?
Inhibits sodium glucose co- transporter 2
Increased excretion of glucose
120
What diabetic drug is NOT to be used in HF patients?
Pioglitazone
121
What are 4 SEs of SGLT 2 inhibitors? (FARV)
Fournier's gangrene
Atypical Diabetic Ketoacidosis - weight loss
Recurrent UTIs
Volume depletion
122
List 4 SGLT inhibitors?
Dapagliflozin
Canaglifozin
Emagliflozin
Ertugliflozin (uncertain +Ve cardio effect)
123
What is Fournier's gangrene + what antidiabetic drug causes it?
Necrosis of groin
Caused by SGLT2 inhibitors- 'flozins'.
stop using if happens
124
What is 5 patient counselling points for SGLT2 inhibitors?
Report DKA signs, test ketones.
Monitor ketones if drug is stopped.
Hydrate yourself - report postural hypotension/dizziness
Report severe pain, red tender genitals and fever.
125
What SGLT 2 inhibitor is NOT to be used in TYPE 1 DM?
Dapagliflozin (5mg)
126
What can canagliflozin increase the risk of happening + what is a counselling point for this drug ?
Lower limb amputation - toes
Report skin ulcers, new pain, discolouration.
127
What are 6 signs of DKA which can be caused by SGLT2 inhibitors?
N + V
Abdo pain
Weight loss
urine smell different
fruity breath
sleepiness
128
What 2 things do if DKA suspected by SGLT2 inhibitors?
Stop tx in this case. (and if had major surgery)
Test for raised ketones.
129
MOA of DPP4 inhibitor?
Inhibit dipeptidylpeptidase- 4
Increases incretin = increased insulin secreted.
130
List 5 DPP4 inhibitors?
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Vildagliptin
131
What are 2 SEs of DPP4 inhibitors? (PH)
Pancreatitis
Hepatotoxicity
132
Which DPP4 inhibitor has a higher risk of hepatotoxicity?
Vildagliptin
133
Which anti-diabetic drug class has a lower risk of hypoglycaemia compared to sulphonlyreas?
DPP4 inhibitors
134
Is weight gain associated with DPP4 inhibitors?
NO
135
What are 2 counselling points for DPP4 inhibitors?A
Report severe abdo pain
Report signs of liver disorder
136
MOA of GLP1 agonist?
acts on incretin receptors - increase insulin secretion
137
List 4 examples of GLP1 agonist?
Dulaglutide
exenatide
lixisenatide
Liraglutide
semaglutide
138
What is frequency of GLP1 agonist?
Taken OD
139
When is GLP1 agonist used?
When other methods have failed
for patients who have a BMI of 35 kg/m2 or above (adjusted for ethnicity) + specific psychological or medical problems associated with obesity;
or
BMI less than 35 kg/m2 and for whom insulin therapy would have significant occupational implications,
or
if the weight loss with drugs would benefit.
140
What are 2 MHRA warning about GLP1 agonists?
Fake versions being made- be vigilant about hypoglycaemia + report to yellow book
DKA report when insulin rapidly reduced so should carefully go down.
141
What other effect does GLP1 agonist have on body?
Weight loss + improved cardiovascular outcomes
142
What is a risk with GLP1 agonists which is linked to GI effect?
Dehydration
143
Which GLP1 agonist is linked to increased heart rate?
Liraglutide
144
What GLP1 agonist to avoid in end stage renal disease?
semaglutide
145
What is route of GLP1 agonist?
SC
146
What 2 GLP1 agonists is not stored in fridge?
Exenatide
lixisenatide
147
What are 3 SEs of GLP1 agonists? (GP-D)
GI disturbances - N+ V
pancreatitis
DKA
148
What to do if missed dose of Liraglutide?
Do not take after meal
If more than 12 hrs late, do not double dose, and take next one at the right time
149
What to do if missed dose of Lixisenatide?
If missed dose, inject within 1 hour before the next meal—do NOT give after a meal.
150
What to do if missed dose of Exenatide?
If -MR injection is missed, should be given asap, provided the next regularly scheduled dose is due in 3 days or more;
Then, patients can resume their usual once weekly dosing schedule.
If immediate release - continue to next dose.
151
What GLP1 agonist is reviewed 6 months to see weight loss?
Semaglutide
need at least 5 % weight loss- determine whether to continue.
Only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight.
152
What to do if missed dose of dulaglutide?
Should be given as soon as possible ONLY if there are at least 3 days until the next scheduled dose.
If less than 3 days left before the next scheduled dose,
+ the next dose should be taken at the normal time.
153
What 2 GLP1 agonists need contraception? (EL)
MR exenatide
Lixisenatide
154
What are 2 main SEs of acarbose? (DF)
Diarrhoea
Flatulence
155
What is MOA of acarbose?
Inhibits alpha glucosidase.
Decrease starch + sucrose absorption.
156
What drug does NOT help with flatulence when taking acarbose?
Antacids
157
What to do if patient experiences diarrhoea on acarbose?
Reduce dose OR stop
158
What is patient counselling point for acarbose?
Chew with first mouthful of food OR
swallow whole with little liquid immediately before food.
Carry glucose to avoid hypoglycaemia
159
When is acarbose given as treatment?
If other oral anti diabetic drugs fail.
Has poorer anti-hyperglycaemic effect.
160
Can pregnant women have acarbose?
NO
161
MOA of meglitinide?
Increase insulin secretion
162
List 2 meglitinides?
Nateglinide
Repaglinide
163
What are the 2 SEs of meglitinides? (HD)
Hypoglycaemia
Diarrhoea (common)
164
What is patient counselling on how to take meglitinides?
take 30 mins before main meal
165
What is 1st line treatment for T2 DM?
Metformin tablets
166
What is 1st line treatment for T2 DM if metformin causes GI issues?
Try MR version of Metformin
167
What diabetic drug regiment to give if patient has CVD (HF, CVD, QRISK >10%)?
Metformin + SGLT2
168
What is a risk of using metformin + SGLT2 inhibitors as part of T2 DM therapy?
Risk of DKA - especially in illness, episode or Keto diet.
169
What to give if CVD status develops during diabetic treatment?
Add or replace drug with SGLT2 inhibitor
170
If metformin Triple therapy does not work for DM, what should be given?
GLP1 agonist
OR insulin therapy with metformin only.
171
What is dual metformin therapy if patient does not have CVD risk/status?
Metformin + one of the below
( SU, PIO, DPP4) SGLT2 (if SU contraindicated)
172
When is SGLT2, given after metformin?
when sulfonylureas are contra-indicated or not tolerated, or if the patient is at significant risk of hypoglycaemia
173
What 2 drugs are stopped temporarily for sick day rules in T2 DIABETES?
Metformin
SGLT2 inhibitor
174
Why is metformin + SGLT2 inhibitor stopped in sick day rules?
Due to risk of AKI from lactic acidosis + volume depletion/dehydration risk.
175
What to do if diabetic patient is going to undergo major procedure in Type 2?
sliding scale insulin
Stop antidiabetics -except GLP1 agonist
176
What to do if diabetic patient is going to undergo Minor procedure (short fasting period) in Type 2?
Leave out anti-diabetic dose
Continue Pio, DPP4, GLP1 agonist
177
What 3 anti-diabetic drugs to stop in minor procedure?
SGLT2 = DKA
SU = hypoglycaemia if patient is fasting
Metformin - renal impairment = Lactic acidosis
178
What is Hba1c level for pregnant women?
Less than 48mmol/mol
179
What are 2 pregnancy planning things to monitor + do if patient is diabetic?
Hb1Ac level <48 mmol/mol
5mg Folic acid daily before conception until week 12
180
What 3 treatment options for diabetic patients who are pregnant?
Rapid acting insulin + Isophane insulin
Can continue long acting ones - e.g. glargine or determir
SC infusion - if hard to receive glycemic control using multiple injections
181
What is STOPPED in diabetic women who are pregnant?
Oral anti diabetic drugs other than metformin
Diabetic complications - ACEi/ARB + statin
182
What 3 drugs are not good in pregnant women with diabeties?
ACEi/ARB
statins- not for pregnancy
183
What is first line treatment for gestational diabetes if they have a fasting BM of less than 7mmol/L?
diet + exercise
If not work - metformin
(insulin if metformin not effective alone)
184
What is first line treatment for gestational diabetes if they have a fasting BM of MORE than 7mmol/L?
Insulin immediately with or - metformin (optional)
and
diet/exercise
185
What 2 drugs for diabetic patients who are breastfeeding?
Insulin
Metformin
186
What to give women with fasting plasma glucose of 6- 6.9 with complications such hydramnios or macrosomia?
Insulin tx + metformin (if you want).
187
What is hydramnios?
excess amniotic fluid
188
What is macrosomia?
big baby
189
What are some signs of hypoglycaemia?
Tingling lips
hunger
drowsy
palpitations
trembling
slurred speech
blurred vision
pale, clammy hands
Glucose < 4 mmol/L
190
What are 3 steps to avoid loss of hypoglycaemic awareness?
BB mask symptoms
Avoid frequent Hypos
Switch insulin- with specialist
191
What is treatment if blood glucose is > 4mmol/L?
Small carb snack or have next meal
192
What is treatment if blood glucose is < 4mmol/L?
15 to 20g fast acting sugar or Long acting carb
193
How many times to repeat fast acting glucose?
max 3 times - repeat after 15 mins
194
What are 5 examples of fast acting sugar?
60-80ml liquid glucose
4-5 glucose tabs
1.5 to 2 tubes glucose oral gel
3-4 heaped tsp of sugar in water
150 to 200ml fruit juice (avoid CKD)
195
What drug is 3-4 heaped tsp of sugar in water unsuitable in?
Acarbose
196
What juice to avoid in low K+ diet in CKD?
Orange juice
197
What is 2 long acting carb examples?
Two biscuits, 1 slice bread
200-300ml milk or next meal
198
What does HBA1C measure?
Glycaemic control in last 2-3 months
good in T2 DM
199
Who is HBA1C not effective for? (6)
T1 DM
pregnancy or less than 2mths PP
High DM risk + ill
Meds causing hyperglycaemia
HIV, end stage renal disease
acute pancreatic damage
200
What is normal range of hba1c?
below 42mmol/mol
201
What is prediabetic range of hba1c?
42-47
202
What is T2 DM range of hba1c?
between 48-58
203
What case is oral glucose tolerance test NOT suitable for?
Severe hyperglycaemia symptoms
204
What 2 cases are oral glucose tolerance test good in?
Gestational Diabetes
Impaired glucose tolerance- pre diabetics
205
How many times to monitor BMs in T1?
4 times before meals + bed
206
What is fasting BM levels in diabetics upon waking?
5-7
207
what is post prandial BM levels in diabetics 90 mins after eating?
5-9
208
What blood glucose should it be if a diabetic patient can drive?
Has to be at least 5
209
What is BP target for T1 DM?
<140/90 MMHG
210
What is BP target for T1 DM Albumin creatinine ratio >70?
<130/80 mm hg
211
What is BP target for T2 DM under 80?
<140/90 mm hg
212
What is BP target for T2 DM over 80?
<150/90 mmhg
213
What is total cholesterol limit in normal patients?
<5
214
What is total cholesterol limit in high risk patients?
<4mmol/L
215
What 4 cases should DVLA be notified in diabetes?
If on insulin
If hypoglycaemia = 2+ severe episodes in less than 1 year, disabling hypos while driving, impaired awareness
Group 2 vehicle - lorry
Diabetic complication -e.g. retinopathy
216
What to do when hypoglycaemia while driving?
Stop vehicle in safe place, switch off
Wait 45 mins after treatment
217
What is monitoring hypos while driving?
2 hrs before + every 2hrs in long journey
IF <4 mmol/L = NO DRIVING
218
What BM level should you not drive on?
IF <4 mmol/L = NO DRIVING
219
What 9 scenarios in which HBa1c Is not useful?
Had symptoms of diabetes for less than 2 months
a high diabetes risk + are acutely ill;
Tx with medication that may cause hyperglycaemia
Acute pancreatic damage
end-stage chronic kidney disease
HIV infection.
In T1 DM
Children
pregnancy + within 2 months post-partum
220
When is a fast acting carb given?
If blood glucose <4 mmol/L
221
What is order of T2 DM management?
1. Metformin
2. Metformin + DPP4 inhibitor, OR pioglitazone, OR sulfonylurea.
3. Metformin + consider SGLT2 inhibitors if sulfonylurea CI or hypoglycaemia risk
222
If dual therapy for diabetes does not work what 3 options possible?
1.Metformin + sulfonylurea, + either SGLT2 inhibitors
2. Metformin + pioglitazone, + either canagliflozin or empagliflozin;
3. Metformin + a DPP-4 inhibitor + ertugliflozin (only if a sulfonylurea or pioglitazone is not appropriate).
223
What 2 drugs are used as rescue medication if symptomatically hyperglycaemic at any point?
Insulin
Sulfonureas
224
Patients prescribed a single drug associated with hypoglycaemia should aim for what HbA1c level?
53mmol/mol
225
What eGFR to avoid starting dapagliflozin?
Avoid initiation if eGFR less than 15 mL/minute/1.73 m2.
226
What eGFR to avoid starting empagliflozin?
Avoid initiation if eGFR less than 20 mL/minute/1.73 m2.
227
Initial management dka?
intravenous fluid replacement,
then intravenous insulin;
patients who normally take long-acting insulin should continue their usual dose(s) throughout treatment.
K+ replacement + glucose administration may also be required to prevent subsequent hypokalaemia + hypoglycaemia, depending on potassium levels and blood glucose Levels.
228
What is T1 DM blood glucose before meals?
a blood-glucose concentration of 4–7 mmol/litre before meals at other times of the day
229
What 2 ultra long insulins can be given for T1 patients who struggle to inject?
insulin degludec, or insulin glargine 300 units/ml
230
What long acting insulin can be given if concerned about nocturnal hypos?
Insulin degludec
231
What is the 1st line insulin for T2 DM?
Nph - isophane
232
What 2 insulins can be considered as alternative to nph if patient needs carer to inject?
Detemir or glargine
233
What insulin to give if hba1c is 75 mmol or more?
NPH and short acting insulin
234
When to give metformin in gestational diabetes?
If below <7mmol/L and BM target not met within 1-2 of diet/exercise
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What are other risk factors for DKA?
Stopping/ inadequate insulin therapy
acute illness e.g MI and pancreatitis, new onset of diabetes, or stress (e.g. trauma, surgery)
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Major Risk factor of DKA and HHS?
both DKA and HHS is infection.
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3 features of HSS?
hypovolaemia
marked hyperglycaemia (blood glucose above 30 mmol/L without significant hyperketonaemia or acidosis)
hyperosmolality
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Symptoms of HSS?
dehydration due to polyuria and polydipsia, weakness, weight loss, tachycardia, dry mucous membranes, poor skin turgor, hypotension, acute cognitive impairment, and in severe cases, shock
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Initial tx for HHS?
IV fluid replacement, followed by IV insulin
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If metformin is contra-indicated or not tolerated, what to give?
SGLT2) inhibitor 1st line if Chronic HF or established atherosclerotic CVD.
Others: DPP-4) inhibitor, or pioglitazone, or a sulfonylurea as 1st-line.
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What to do if BMs still 58?
Add on further tx - dual
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What is BM target is 2 or more anti-diabetics given?
When two or more antidiabetic drugs are prescribed, a target HbA1c level of 53 mmol/mol (7.0%) is recommended for patients in which it is appropriate.
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What should fasting blood glucose be?
Less than 5.5 mmol/L
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What should non fasting blood glucose be?
Under 11.1 mmol/L
