[GP] Type 2 Diabetes

Question 1

what is T2DM characterised by?

Answer 1

insulin resistance and insufficient insulin production

Question 2

how do you diagnose T2DM?

Answer 2

HbA1c (≥48mmol/mol or 6.5%) or fasting blood glucose (≥7mmol/L)

Question 3

what do you do if a pt is asymptomatic?

Answer 3

repeat test and if normal, pt should be followed up

Question 4

what do you do if a pt is symptomatic?

Answer 4

one test is sufficient, but need to rule out other causes of hyperglycaemia (e.g. trauma, infection)

Question 5

what are the modifiable risk factors for T2DM?

Answer 5

• obesity
• inactivity
• high glycaemic diet
• drug therapy (e.g. steroids, statins)

Question 6

what are the non-modifiable risk factors for T2DM?

Answer 6

• FHx
• hx of GDM
• black/Asian
• low birthweight
• metabolic syndrome
• PCOS

Question 7

what would you start pt on if lifestyle mx fails and HbA1c ≥48mmol/mol (6.5%)?

Answer 7

metformin

or DDP-4i / Pioglitazone / SU

Question 8

what would you do if HbA1c remains ≥58mmol/mol (7.5%) despite starting metformin?

Answer 8

ADD DDP-4i / Pioglitazone / SU / SGLT-2i

Question 9

what would you do if HbA1c remains ≥58mmol/mol (7.5%) despite being on metformin + DDP-4i / Pioglitazone / SU / SGLT-2i?

Answer 9

ADD DDP-4i / Pioglitazone / SU / SGLT-2i
OR 
commence insulin
OR
consider GLP-1 (with metformin and SU)

Question 10

what diet and exercise advice would you give a T2DM pt?

Answer 10

• low glycaemic index (fruit/veg/pulses/fish)

- 2.5 hour of exercise per week

Question 11

how often should you follow up a newly diagnosed T2DM pt?

Answer 11

HbA1c every 3-6 months – until stable on treatment then 6 monthly

Question 12

what HbA1c level is aimed for if pt is on lifestyle and metformin?

Answer 12

48mmol/mol (6.5%)

Question 13

what HbA1c level is aimed for if pt is on hypoglycaemic meds?

Answer 13

53mmol/mol (7.0%)

Question 14

when do you offer blood sugar self-monitoring?

Answer 14

• on insulin
• having hypoglycaemic episodes
• high risk occupation e.g. machinery operator, driving
• pregnant

Question 15

how do you screen for complications in T2DM?

Answer 15

annual:

• retinopathy screen
• nephropathy screen (ACR and eGFR)
• foot problems (check sensation with 10g monofilament and assess ABPI)
• cardiovascular risk (BP, smoking, lipids, FHx of CVD, BMI, glycaemic control)

Question 16

what are the features of Hyperosmolar Hyperglycaemic State (HHS)?

Answer 16

• hypovolaemia
• hyperglycaemia (glucose ≥30mmol/L)
• NO ketosis
• NO mild acidosis
• serum osmolality >320 mosmol/kg
• usually older pt

Question 17

how do you manage HHS?

Answer 17

1. fluid replacement: IV NaCl 0.9%
2. if significant ketonaemia: commence fixed rate insulin infusion (0.05unit/kg/hr) BUT if no ketones: do not commence until blood glucose ceased to fall following fluid resuscitation
3. replace K+ if needed (as in DKA)
4. rule out infective causes
5. VTE prophylaxis
6. care for pressure areas

Question 18

ankle swelling, erythema, loss of foot sensation and T2DM. dx?

Answer 18

Charcot arthropathy

Question 19

metformin and CKD. mx?

Answer 19

stop metformin if eGFR <30

Question 20

insulin and driving. mx?

Answer 20

T1: DVLA must be informed and pt must be able to record CBG every 2h

Question 21

when do you consider starting insulin?

Answer 21

if triple therapy (3x oral medication) is still not controlling HbA1c

Question 22

what does HHS need to be treated with?

Answer 22

IV fluids and sometimes FRII