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Endocrine T2DM Flashcards

1
Q

TYPE 2 DIABETES is characterised by…?

A

Insulin resistance, later in life

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2
Q

Prediabeties is what mmol/L?

A

42-47mmol/mol

Can try prevent diabetes with lifestyle advice

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3
Q

Diabetes HbA1c?

A

48mmol/mol

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4
Q

DIABETES TREATMENT- pts with LOW CVD RISK

What 3 do you need to assess first?

A

HbA1c
Kidney function
Cardiovascular risk

AIM FOR INDIVDUALLY AGREED THRESHOLDS!

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5
Q

DIABETES TREATMENT- LOW CVD RISK

1st LINE?

A

METFORMIN

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6
Q

DIABETES TREATMENT- LOW CVD RISK

Metformin not working and
HBA1C> individually agreed threshold, what meds to add?

A

DUAL THERAPY
ADD IN…
DPP-4i (gliptin)
OR
Pioglitazone (not in HF)
OR
SU (Sulphonylurea- glic, glim, tolb)
OR
SGLT-2i (Flozins)

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7
Q

DIABETES TREATMENT- LOW CVD RISK

DUAL THERAPY not working..
HBA1C> individually agreed threshold, how to treat?

A

TRIPLE THERAPY by…
adding/swapping class of anti-diabetic
NOTE: DAPAG with PIOG not recommended, OTHER SGLT-2is fine

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8
Q

DIABETES TREATMENT- HIGH CVD RISK

Which pts high risk?

A

Established atherosclerotic CVD
HF
QRISK2>10%

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9
Q

DIABETES TREATMENT- HIGH CVD RISK

1ST LINE?
ONCE TOLERATED?
IF NOT TOLERATED?

A

1ST LINE? METFORMIN

ONCE TOLERATED? ADD SLGT-2i

IF NOT TOLERATED? ALONE SLGT-2i

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10
Q

why is sglt2i good in diabetes with high cvd risk?

A

cardio protective

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11
Q

DIABETES TREATMENT- HIGH CVD RISK

what to do if HBA1C> individually agreed threshold?

A

SAME AS DUAL+TRIPLE THERAPY FLASHCARDS!

avoid pioglitazone due to cvd risk

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12
Q

Patient w/ diabetes develops high risk CVD at any point what to do?

A

Consider SLGT-2i first.

EU marketing agency, recent approval for flozins in HF, draining effect.

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13
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

Patient can’t tolerate metformin due to side-effects?

A

Use MR preparations

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14
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

Patient can’t tolerate metformin MR? Treat w/…

BUT
When high risk of CVD?

A

Treat w/ DPP-4I/Pioglitazone/SU/SLGLT-2I

BUT
When high risk of CVD? SGLT-2i

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15
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

HbA1c above individually agreed threshold& Monotherapy not working?
Treat w/…

A

Treat w/…
DPP-4i+Piogltiazone
OR
DPP-4i+SU
OR
Pioglitazone+SU

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16
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

HbA1c STILL not controlled..?

A

INSULIN THERAPY!

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17
Q

METFORMIN (biguanide)

MOA?

A

Decreases gluconeogenesis+increases peripheral utilisation of glucose

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18
Q

METFORMIN SIDE-EFFECTS? LGV

A

Lactic acidosis (avoid if eGFR<30)
GI side-effects (increase dose slowly/give MR prep)
Can reduce vitamin B12

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19
Q

why can metformin -> lactic acidosis?

A

metformin blocks pyruvated carboxylases -> enz involved in gluconeogenesis, thus leading to accumulation of lactic acid

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20
Q

sick day rules apply to which classes of drugs?

A

diuretics
acei/ arb
metformin
nsaids
aglt2i

(all act on kidneys)

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21
Q

what to do if PATIENT ON METFORMIN experiences acute AKI?

A

stop!
due to increased risk of lactic acidosis

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22
Q

SULPHONYLUREAS
MOA?

S for secretion!

A

Stimulates insulin secretion from pancreatic beta cell

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23
Q

2 TYPES OF SULPHONYLUREAS? and examples pls

A

SHORT-ACTING- GT- gliclazide, tolbutamide, glipizide

LONG-ACTING- GG- glibenclamide, glimepiride

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24
Q

What are LONG-ACTING sulphonylureas associated with?

A

prolonged/sometimes fatal cases of hypoglycaemia
AVOID IN ELDERLY

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25
Q

SULPHONYLUREAS- SIDE-EFFECTS?

A

High risk of hypoglycaemia
AVOID in:
Acute porphyria
Hepatic/Renal failure
(sulpHonyluRea)

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26
Q

PIOGLITAZONE
MOA?

P for less peripheral!

A

Reduces peripheral insulin resistance

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27
Q

PIOGLITAZONE

AVOID IN which pts?

A

history of HF

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28
Q

PIOGLITAZONE

There’s an increase risk of Bladder cancer therefore report what..?

A

review safety+efficacy after 3-6months
stop treatment if patient responds inadequately

REPORT…
Haematuria (blood in urine)
Dysuria (painful urination)
Urinary urgency

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29
Q

increased risk what 3 with Pioglitazone?

A

bladder cancer
bone fractures
liver toxicity

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30
Q

inc risk of liver tox with pioglitazone so report what?

A

nausea
vom
abdominal pain
fatigue
dark urine develop

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31
Q

DPP-4i
MOA?

increases one, decreases the other

A

Increases insulin secretion+lowers glucagon secretion

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32
Q

DPP-4i

Can cause..?

A

Pancreatitis
Discontinue if symptoms of acute pancreatitis occur…
- persistent, severe abdominal pain

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33
Q

DPP-4i EXAMPLES?

A

ALIOGLIPTIN
LINAGLIPTIN
SAXAGLIPTIN
SITAGLIPTIN
VILDAGLIPTIN (hepatotoxic)

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34
Q

SLGT-2iS

MOA?

A

Inhibits SLGT2 in renal proximal convoluted tubule (more urine, glucose, infection)

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35
Q

SGLT-2iS

MHRA WARNINGS? DKAKFaGLLA

MONITOR RENAL FUNCTION!

A
  • DIABETIC KETOACIDOSIS
    MONITOR KETONES if treatment interrupted-> surgery/illness
  • FOURNIER’S GANGRENE
  • CANAGLIFLOZIN only: risk of lower-limb amputation (mainly toes)
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36
Q

SGLT-2iS

what causes volume depletion and how to correct?

A

Due to lots of urination, loss of water

Correct hypovolaemia (reduced volume of circulating blood in body) before starting treatment

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37
Q

what to monitor with SGLT-2i?

A

renal function

38
Q

SGLT-2iS EXAMPLES?

A

CANAGLIFLOZIN
DAPAGLIFLOZIN
EMPAGLIFLOZIN

39
Q

GLP-1 AGONIST
MOA?

GLP-1 receptor

A

BINDS TO GLP-1 RECEPTOR
Increases insulin secretion,
suppresses glucagon secretion
slows gastric emptying

40
Q

GLP-1 AGONIST

EXAMPLES? -tides

A

DULAGLUTIDE
EXENATIDE
LIRAGLUTIDE
LIXISENATIDE

41
Q

GLP-1 AGONIST SIDE-EFFECTS?

A

SEMAGLUTIDE!!! ozempic

ACUTE PANCREATITIS (same as DPP4i)- persistent, severe abdominal pain

DEHYDRATION- risk, due to GI SEs, take precautions to avoid fluid depletion

42
Q

OTHER ANTIDIABETICS

ACARBOSE?

A

Delays digestion+absorption of starch+sucrose

high risk of GI side-effects- reduce dose?

43
Q

OTHER ANTIDIABETICS

MEGLITIDES (Nataglinide/Repaglinide)?

A

Stimulates insulin secretion

Stressed? Change to treatment w insulin to maintain glycaemia control

44
Q

which of the following SEs NOT associated w pioglitazone

HF
bladder cancer
bone frax
liver tox
pancreatitis

A

pancreatitis

45
Q

which antidiabetics assoc with:
weight gain

A

Pioglitazone+Sulphonylureas (gliclazide)+Insulin

46
Q

which antidiabetics are weight neutral

A

metformin
DPP4i (gliptins)

47
Q

which antidiabetics asociated w weight loss

A

GLP-1+SGLT-2i
glutides

48
Q

4 diabetic complications

A

CV disease
diabetic nephropathy
diabetic neuropathy
visual impairment

49
Q

WHAT DRUG IS CONSIDERED IN ALL TYPE 1 PATIENTS to prevent treat CVD?

A

Low-dose atorvastatin, offer to:
40+years
diabetic 10+years
nephropathy/other CVD factors

50
Q

what drug class REDUCES CVD risk

A

ACEi
regardless of age
or ARB in afro-carribean

51
Q

what is diabetic nephropathy

A

deterioration of kidney func

52
Q

DIABETIC COMPLICATIONS

pts with DIABETIC NEPHROPATHY causing proteinuria (protein in urine)
TREATMENT?

53
Q

WHAT DRUG CAN POTENTIATE HYPOGLYCAEMIA EFFECT OF ANTIDIABETIC DRUGS/INSULIN?

A

ACE-i (risk of HYPERkalaemia)
can affect clearance of drugs thus inc risk

54
Q

diabetic complications
PAINFUL PERIPHERAL NEUROPATHY treated with what
what about diabetic foot?

A

antidepressants/gabapentin/pregabalin
Diabetic foot? treat pain+manage infection

55
Q

how is AUTONOMIC NEUROPATHY with diabetes tx?

A

treat diarrhoea w/ codeine/tetracyclines

56
Q

how is NEUROPATHIC POSTURAL HYPOTENSION w diabetes tx?

A

increase salt intake/fludrocortisone (mineralocorticoid causes fluid retention)

57
Q

how is GUSTATORY SWEATING w diabetes tx?

A

antimuscarinic- propantheline bromide

58
Q

how is ERECTILE DYSFUNCTION w diabetes tx

A

Sildenafil

59
Q

how is VISUAL IMPAIRMENT w diabetes tx

A

Yearly eye tests

60
Q

DIABETEIC KETOACIDOSIS- SEVERE HYPERGLYCAEMIA

SYMPTOMS? PTP(B)DLC

A

Polyurea
Thirsty
Pear drop breath smells (ketones) - key giveaway. other symptoms overlap w drunk
(B) Deep/ fast breathing
Lethargic
Confusion

61
Q

DKA- checking blood sugar levels

What do you do if…

PATIENT DISPLAYS SYMPTOMS OF DKA?

BLOOD SUGAR LEVELS >11mol/L?

A

PATIENT DISPLAYS SYMPTOMS OF DKA? Check blood sugar levels

BLOOD SUGAR LEVELS >11mol/L? Check ketone levels (urine/ blood)

62
Q

DKA- ketone levels

0.6-1.5mmol?
1.6-2.9mmol?
3mmol?

A

0.6-1.5mmol? slight risk (retest in 2hrs)
1.6-2.9mmol? increased risk (contact GP)
3mmol? medical emergency

63
Q

DKA- TREATMENT

systolic BP<90?

Once BP>90? Give what

A

BP<90? RESTORE VOLUME W/ 500ml IV NaCl 0.9%

Once BP>90? GIVE MAINTENANCE IV NaCl 0.9%

64
Q

in DKA, Start IV insulin mixed w/ NaCl, administer at a rate so that
ketone conc. falls at?
blood glucose conc. falls at?

A

ketone conc: 0.5mmol/L/hr
Blood glucose conc: 3mmol/L/hr

65
Q

DKA- TREATMENT

What do you do when blood glucose <14mmol/L?

A

Give IV glucose 10%
as were trying to keep BG from falling too much while trying to lower ketone levels

66
Q

DKA- TREATMENT
blood glucose <14mmol/L.

Continue insulin till..
ketone<
ph>?

A

Continue insulin till..
ketone <3 mmol/L
&
pH>7.3

When patient is able to eat, give fast-acting insulin w/ meal

Finally, stop treatment 1hr after food

67
Q

INSULIN DURING SURGERY

ELECTIVE (minor w/ good glycaemic control) day before what changes to make?

A

Reduce OD long-acting dose by 20%, rest as usual

68
Q

INSULIN DURING SURGERY

ELECTIVE (major/poor glycaemia control)

DAY BEFORE?

ON THE DAY?

A

DAY BEFORE?
Reduce long-acting dose by 20%- rest as usual

ON THE DAY?
Reduce long-acting dose by 20%- stop other insulin till patient eating
IV infusion of KCL+Glucose+NaCl
Variable rate IV insulin (soluble human) in NaCl 0.9 given via pump

69
Q

elective major surgery/ poor glycaemic control, how often bg measurements taken and what to give if bg drops belwo 6mmol/L

A

Hourly blood glucose measurements for first 12hrs
Give IV glucose 20% if blood glucose dips <6mmol/L

70
Q

INSULIN- POST SURGERY

When do you convert back to SC insulin?

A

when patient can eat/drink

71
Q

INSULIN- POST SURGERY

when to restart BASAL-BOLUS REGIMEN?

A

with the first meal- IV insulin infusions carried on till 30-60mins after first meal-time short-acting insulin admin

72
Q

INSULIN- POST SURGERY

LONG-ACTING REGIMEN carries on at 20% reduced dose until when

A

pt leaves hospital

73
Q

INSULIN- POST SURGERY

BD REGIMEN when restarted?

A

Restart before breakfast/evening meal- IV insulin infusion carried on for 30-60mins after first SC insulin dose

74
Q

SICK DAY RULES

  • SUGAR LEVELS?
  • INSULIN?
  • CARBOHYDRATES?
  • KETONES?
A

SUGAR LEVELS? Check regularly (every 2-3hrs if needed)

INSULIN? Carry on taking, else -> DKA

CARBOHYDRATES? Keep eating+stay hydrated

KETONES? Check regularly, 4 hrly

75
Q

DIABETES- PREGNANCY/BREASTFEEDING

Risks to woman+foetus, risk reduced by effective blood-glucose control

A

effective blood-glucose control

76
Q

DIABETES- PREGNANCY/BREASTFEEDING

PLANNING FOR PREGNANCY - what to aim for?

A

hba1c < 48mmol/L
take folic acid 5mg

77
Q

FOLIC ACID

HIGH RISK OF NEURAL TUBULE DEFECTS?

A

diabetes, antiepileptics, previous child, smoking is just at risk factor

5MG OD
BEFORE CONCEPTION+TILL WEEK 12 PREGNANCY

78
Q

FOLIC ACID

LOW RISK OF NEURAL TUBULE DEFECTS?

A

400MCG OD

BEFORE CONEPTION+TILL WEEK 12 PREGNANCY

79
Q

WOMEN TAKING INSULIN MUST BE AWARE OF..?

A

HYPOGLYCAEMIA RISK
+
ALWAYS CARRY FAST-ACTING GLUCOSE

80
Q

DIABETES- PREGNANCY/BREASTFEEDING

x3 MEDICATION KEY POINTS?

A

Stop all antidiabetics, except metformin, replace w insulin
1st line long-acting insulin: isophane insulin*
Statins/ACE-i/ARBs-> discontinue
*Good blood glucose control before pregnancy w/ long-acting insulin analogues (detemir/glargine) calm to continue

81
Q

what is GESTATIONAL DIABETES

A

Developed during pregnancy, STOP treatment after birth

82
Q

GESTATIONAL DIABETES

Fasting BG<7mmol/L?

A
  1. Diet+Exercise.
  2. Metformin (unlicensed)
  3. Insulin
    IF REQUIREMENTS NOT MET IN 1-2 WEEKS!
83
Q

GESTATIONAL DIABETES

Fasting BG>7mmol/L?

A

diet, exercise, insulin!! +/- metformin

84
Q

GESTATIONAL DIABETES

Fasting BG 6-6.9mmol/L w/ complications?

macrosomia

A

Insulin +/- Metformin

85
Q

HYPOGLYCAEMIA- mmol/L?

86
Q

HYPOGLYCAEMIA- SYMPTOMS?

A

SWEATING
LETHARGIC
DIZZINESS
HUNGER
TREMOR
TINGLING LIPS
PALPITATIONS
EXTREME MOODS
PALE

87
Q

HYPOGLYCAEMIA- TREATMENT (conscious+can swallow)
with/without symptoms!

What 3 things could you give?

A

FAST-ACTING CARBS:

4-5 glucose tablets
3-4 heaped teaspoonfuls of sugar
150-200mL fruit juice
Repeat/ 15mins for 3 cycles

88
Q

HYPOGLYCAEMIA- TREATMENT (patient unconscious/swallow L)

What do you do now?

A

IM glucagon
unresponsive after 10mins?
IV glucose

89
Q

Why be careful with b-blockers?

A

Can mask the effects of hypoglycaemia

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