GP

Question 1

Type 2 Diabetes mx

Answer 1

Diabetes is diagnosed as a HbA1c > 48, Fasting >7 or random glucose >11.1
- 1 +ve result with sx, 2x if no symptoms

First line management is lifestyle, education (DESMOND, X-pert programmes)
- exercise, reduce intake of sugar, low GI foods, reduce alcohol, stop smoking, weight loss, screening

If HbA1c > 48 start metformin 500mg OD, each week increase by 500 to max of 2g

If HbA1c >53 then start then add DPP4, SGLT2, pioglitazone, SU

If still >53 - triple therapy

If still not enough - insulin

Drugs

• Biguanide - metformin
• SU - gliclazide - weight gain, hypo
• SGLT2 - (dapagliflozin) Improve weight, cardio and renal protective (not work if eGFR <60), no hypo
• TZT (pioglitazone) - contraindicated with haematuria – weight gain, no hypo
• DPP4 - (-gliptin) not improve weight, use in liver or renal failure, no hypo
• GLP-1 - (-tide) third line, only use if already on triple therapy, weight loss, no hypo

HbA1c aims

• If insulin/ SU - aim 53
• If others aim 48

Consequences of diabetes

• Microvascular - neuro, nephropathy (peripheral, autonomic e.g. gastroparesis, erectile dysfunction), retinopathy
• Macrovascular - ischaemic heart disease, stroke, PVD

Annual review

• Take a hx, ask about how managing, sx, SE of tablets
• Depression and anxiety
• Qrisk to look for CV disease - cholesterol, BP, BMI
• Do a blood glucose measurement - HbA1c
• Diabetic retinopathy screen
• Foot exam - check sensation, for ulcers, do ABPI
• Ask about autonomic SE including erectile dysfunction, gastroparesis
• Nephropathy - early morning first pass urine specimen for ACR, also do creatinine level for eGFR

Question 2

AF management

Answer 2

Ix: Pulse, ECG, Bloods, ECHO, TFT

Tx:

If present with collapse - O2, fluid, airway adjunct, emergency cardioversion

If new, young, reversible, HF - Cardiovert with DC or amiodarone

If paroxysmal - pill in pocket or catheter ablation

Long term:
Rate - BB, CCB or digoxin
Rhythm - BB, flecainide, amiodarone

CHADVAS vs HASBLED
Chadvas >1 in m or >2 in female - need anticoag
Hasbled >3 - at risk of bleeding
- DOAC or warfarin