Endocrinology

Question 1

When should HbA1c be measured in adults with T2DM if unstable?

Answer 1

3-6 monthly until HbA1c is stable on unchanging therapy?

Question 2

When should HbA1c be checked once HbA1c level and blood glucose stable?

Answer 2

6 month intervals

Question 3

What is the target HbA1c in patients managed by lifestyle and diet alone OR taking a single agent not associated with hypoglycaemia (metformin, glipitin, SGLT2-i, pioglitazone)

Answer 3

48 (6.5%)

Question 4

What is the target HbA1c in patients on two or more oral agents (or any agent associated with hypoglycaemia) and do not meet criteria for 58-64mmol target?

Answer 4

53-57 mmol. If >58 mmol intensify drug treatment

Question 5

If patient is older (>60 year) or longer duration diabetes (>10 years) and any of the following apply:
- Tighter control will put them at higher risk of developing hypoglycaemia (falling, impaired awareness of hypos, people operating machinery as part of job)
- Intensive management will not be appropriate due to co-morbidities
- Moderate frailty
What is their target?

Answer 5

58-64 mmol

Question 6

What is the target for patients with severe frailty and/or not likely to achieve longer-term risk-reduction benefits (due to reduced life expectancy)

Answer 6

<75 mmol

Question 7

What is the first step of diabetes management?

Answer 7

Diet and lifestyle

Question 8

What is the first thing to consider when starting patient on diabetic medication?

Answer 8

Are they:
- High risk of CVD
- Chronic Heart failure
- Established atherosclerotic CVD, CKD or ACR >3

Question 9

What are the CV risk factors when deciding initial management?

Answer 9

HTN, dyslipidaemia, smoking, obesity, family history of premature CVD.

Question 10

If the patient has a HbA1c of >48 and is high risk of CVD what is the management? (age >40 and QRISK >10%, or Age <40 and >1 CV risk factors)

Answer 10

Metformin (if intolerant consider MR) before moving to next level.
- Then consider SGLT-2i as first line dual therapy OR
- Second line to achieve HbA1c target. Dapagliflozin has the strongest primary prevention data

Question 11

If the patient has chronic heart failure or established artherosclertic CVD?

Answer 11

Metformin (if intolerate, consider trial of MR)
When metformin tolerability confirmed + SGLT-2i)

Question 12

If a patient has established artherosclertic CVD which medication is appropriate alongside metformin for diabetes?

Answer 12

Empagliflozin and Canagliflozin

Question 13

If a patient has established Chronic HF which medication is appropriate alongside metformin for diabetes?

Answer 13

Dapagliflozin and Empagliflozin

Question 14

If the patient has a HbA1c of >48 and has CKD (ACR >3mg/mol and eGFR 25-75) what is the management?

Answer 14

Metformin (if intolerant, consider trial of MR)
AND
Maximum tolerated ARB or ACEi
+ SGLT2
If not at glycaemic target and eGFR <45 additional antihyperglycaemic agents will be required

Question 15

If the patient has a HbA1c of >48 and has CKD (ACR >3mg/mol and eGFR 25-75) what is the medication used?

Answer 15

Metformin + SGLT2
- For CKD = Dapagliflozin and Canagliflozin has the strongest data

Question 16

What is the next step in management if the patient is not at high risk of CVD, HF, or has established atherosclerotic CVD or CKD w/ ACR <3

Answer 16

Metformin - (consider MR before movign to next level)

Question 17

What is the next step in management after metformin if the patient is not at high risk of CVD, HF, or has established atherosclerotic CVD or CKD w/ ACR <3

Answer 17

Sitagliptin or Gliclazide or Pioglitazone or SGLT-2