ic13 and ic14 DM

Question 1

Effect of Insulin on Hba1c

Answer 1

2.5%

Question 2

Where is exogenous insulin metabolised?

Answer 2

Kidney

Question 3

Why should we rotate injection sites?

Answer 3

Prevent lipohypertrophy, bulging of adipose tissue

Question 4

List 3 rapid acting insulin

When should it be taken?

Answer 4

LAG
Lispro
Aspart
Glulisine

5 mins before meal

Question 5

What is an intermediate acting insulin?

What is the duration of action? How frequent should it be taken?

Answer 5

NPH

10-16hrs
2 injections a day

Question 6

List 2 long acting insulins

Answer 6

Detemir
Glargine (U-100)

Question 7

List a short acting insulin

Answer 7

Regular Actrapid

Question 8

List 2 ultra-long insulins

Answer 8

Degludec
Glargine U-300 (Toujeo)

Question 9

Which insulin is used for corticosteroid induced hyperglycemia?

Answer 9

NPH

Question 10

Which insulin is suitable to be mixed?

Answer 10

NPH + Rapid acting or Short acting

Long acting (Glargine, Detemir) cannot

Question 11

How many doses to take for pre-mix insulin?

When should pre-mixed insulin be administered? What is the exception?

Answer 11

2 doses

15 mins before meal, cos use rapid acting insulin

Except Mixtard, which uses regular insulin. Administer 30 mins before meal

Question 12

What to do with oral therapy if starting on insulin?

Answer 12

Metformin, SGLT2i
Continue

TZD - discontinue or reduce dose

Sulfonylurea
If patient is on basal insulin eg. glargine
Reduce SU dose by 50%
If patient is on PPG insulin or Premix insulin
Discontinue

DPP4i (eg. Sitagliptin, Linagliptin)
Discontinue if on GLP-1 agonist

Question 13

What are exceptions for insulin dose conversion?

Answer 13

When converting to detemir/glargine U-100, need to decrease glargine dose by 20%

Either when converting 2x NPH to U-100 or converting U-300 glargine to U-100 glargine

Question 14

What is the definition of Hypoglycemia? (blood glucose level)

Symptoms?

Answer 14

Hypoglycemia < 4

Blur vision
Sweating
Hunger
Confusion
Anxiety
Shaking
Rapid heartbeat
Dizziness
Headache
Weakness, fatigue
Irritability

Question 15

What to do when feeling symptoms of hypoglycemia?

Examples of 15g of carbs?

Answer 15

15-15-15
15g of carbs → Wait 15 mins → Check BG → Below 4 then another 15g of carbs

15g of fast acting carbohydrates
0.5 cup of fruit juice
5 pieces of hard candy
0.5 cup of soft drinks

Question 16

What are the adverse effects of Insulin? (2 points)

Answer 16

1) Hypoglycemia
2) Weight gain

Question 17

Stability of insulin if not refrigerated or opened

Answer 17

If not refrigerated or opened, 28 days

Question 18

What insulin dose to start for patients?

How to titrate insulin?

What is the limit of basal/total insulin?

Answer 18

0.2units/kg of NPH
If the patient is obese, start on 10 units at bedtime

If FPG not at goal, increase by 2 units every 3 days
If FPG > 10 consistently, increase by 4 units every 3 days

Limit: 0.5 units/kg

Question 19

What if Hba1c is not at goal but basal dose at limit OR FBG at goal?

Answer 19

Add prandial coverage for the biggest meal
4 units or 10% of basal insulin
(if patient hba1c <8%, can reward patient) Reduce basal insulin dose by 4 units or 10%

OR

If patient is on bedtime NPH 10 units, can split 2/3 in morning and 1/3 in evening

Question 20

Why shouldnt we increase total insulin to more than 0.5units/kg?

Answer 20

Overbasalisation, insulin will lose its effectiveness, can result in weight gain and hypoglycemia

Question 21

What is the first line treatment for T2DM?

If Hba1c still > 7 after Meformin, what drug to add on? Add on therapy considerations (best glucose lowering efficacy, elderly, promote weight loss)

Answer 21

Metformin

Best glucose lowering efficacy:
Insulin, GLP-1 agonist

For elderly (want to reduce hypo):
Avoid Insulin, SU

If want weight loss also:
GLP-1 agonist, SGLT2i

Question 22

If patient needs more glucose lowering effect than oral medications can give, which 2 injectables can be given?

Which is preferred, under what circumstance (4 points)

Answer 22

GLP-1 over Insulin

Insulin is considered if
1) Ongoing catabolism (weight loss)
2) Symptoms of hyperglycemia
3) A1c > 10%
4) BG > 16.7

Question 23

What to do when patient has high BG when waking up?

Answer 23

Check if its Dawn phenomenon (normal) or Somogyi effect

Check blood glucose at 2am, if its very low then its Somogyi, as body responds by releasing glucagon

Question 24

How does Diabetic Ketoacidosis (DKA) occur?

Signs of DKA? (4 points)

Answer 24

When body does not have enough insulin, body breaks down fat and produce ketones

Alert
BG>14 mmol/L
Ketones found in blood, urine
Patient has fruity breath

Question 25

Signs of Hyperglycemic Hyperosmolar State (HHS) (3 points)

Answer 25

Patient usually dehydrated, confused

BG > 33 mmol/L

Measure patient’s serum osmolality AKA solute within plasma eg. glucose, urea, sodium
Very high (> 320)

Question 26

BP target for DM patients

What is the first line antihypertensive for patients with DM

Answer 26

130/80

ACE/ARBs

Question 27

Who is elligible for primary prevention of ASCVD

Primary prevention for ASCVD

Target LDL

Answer 27

For 40-75yo

Use moderate statins eg. Atorva 10-20mg

1.8mmol/L

Question 28

What to use for secondary prevention for ASCVD

Target LDL

Answer 28

Use high intensity statin eg. Atorva 40-80mg

Can add Ezetimibe or PCSK9i

1.4mmol/L

Question 29

What 2 symptoms will patients with Diabetic kidney disease have?

Answer 29

T1DM
Albuminuria
Retinopathy

T2DM
only Albuminuria

Question 30

When not to use Finerenone?

Answer 30

When patient eGFR < 25 (same as Dapagliflozin)

Question 31

What are ASCVD risk factors?

Answer 31

LDL > 2.6

High blood pressure

Smoking

CKD

Albuminuria

Family history of premature ASCVD

Question 32

When should Aspirin be used for prevention of ASCVD

Answer 32

Secondary prevention (ASCVD already happened)

Primary prevention
50-70 yo with at least 1 ASCVD risk factor

Question 33

When should SGLT2i not be used?

Answer 33

when eGFR <20ml/min