Insulin and Hypoglycaemics and Endocrine Flashcards

1
Q

as a rule, all insulin is given via what route?

A

s/c

except for sliding scales using short-acting insulin - Actrapid® or NovoRapid® - given by IV infusion

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2
Q

what kind of insulin is Novomix 30®

A

a combination of short and medium acting insulin

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3
Q

what is first line Tx for T1DM?

A

standard-release metformin

(gradually ↑ dose over several weeks to minimize the risk of adverse effects - GI)

if intolerable, consider modified-release metformin

monitor renal function before and during treatment with metformin

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4
Q

CIs and cautions for metformin?

A

At risk of LACTIC ACIDOSIS:

  • DKA
  • eGFR <30 (standard) , <45 (modified)
  • acute dehydration, fasting, infection, shock (renal function)
  • HF, resp failure, recent MI, shock (tissue hypoxia)
  • hepatic insufficiency, alcohol intoxication/addiction

ELECTIVE SURGERY:

  • discontinue 48 hrs before if GA, spinal, or peridural anaesthesia
  • Tx restarted >48 hrs following surgery/ resumption oral nutrition + if normal renal function

CAUTION:

  • CKD
  • elderly people (↑ risk of lactic acidosis)
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5
Q

max daily dose of metformin?

A

2g

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6
Q

if metformin not tolerated/CI?

A

sulfonylurea (GLICLAZIDE)

OR

  • gliptin (dipeptidyl peptidase-4 inhibitor)
  • pioglitazone
  • Na+-glucose cotransporter 2 inhibitors (SGLT-2i)
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7
Q

2nd line Tx for T2DM?

A

metformin/gliclazide + gliptin/pioglitazone

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8
Q

3rd line Tx for T2DM?

A

met + glicla + gliptin/pioglitazone
consider insulin therapy

if 3rd line unaffective, consider adding in glucagon-like peptide-1 (GLP-1) mimetic

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9
Q

if creatinine is >150, what drug to use as 2st line in T2DM?

A

gliclazide

beware metformin if renal impairment, or overweight

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10
Q

sulfonylurea S/Es?

A

↑ weight
hypos
avoid in renal or liver impairment

(BNF says also common: abdo pain, D, N)

RARE:
SIADH
BM suppression (↓↓↓all bc)
liver damage (cholestatic)
peripheral neuropathy
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11
Q

what time of day to take gliclazide?

A

mornings (to avoid overnight hypos)

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12
Q

define a hypo?

A

< 4 mmol/litre

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13
Q

how to Tx a hypo if patient is conscious?

A

oral glucose 10-20g

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14
Q

how to Tx a hypo if patient is unconscious?

A
  • 75ml glucose 20% IV (15 g) for an unconscious patient in hospital
  • or 50ml (10g)
  • or 100ml (20g bc 20%)

(also IM glucagon, but not ideal for patients who are anticoagulated + IV is more readily available)
- if glucagon ineffective after 10 mins give 20% glucose IV

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15
Q

diagnosing a DKA? (3)

A

VBG pH < 7.3
glucose > 11
serum ketones >3, urine 2+

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16
Q

Tx DKA?

A
  • BP<90 500ml NaCl STAT
  • BP>90 1 litre in 1 hr, then in 2/4/8
  • K+ ↓ with Tx, therefore add 40mmol per litre if <5.5: measure at 60 minutes, 2 hours, and 2 hourly
  • IV insulin mixed with NaCl to 1 unit/mL, given at fixed rate of 0.1 units/kg/hour (eg 50 units in 50ml)
  • established S/C long-acting insulin (detemir or glargine) should be continued during Tx*

monitor:

  • BM - aim ↓ 3mmol/L/h, when <14 start 10% glucose
  • ketones - aim ↓ 0.5 mmol/L/h
  • pH - aim >7.3

Continue insulin infusion until ketones< 0.3, pH >7.3, able to eat and drink, S/C fast-acting insulin and a meal, and stop infusion 1hr later.

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17
Q

Tx HHS?

A

● hyperglycaemia (usually >35 mmol/L)
● hyperosmolar: osmolality >340 mmol/L (calculated by (x2 Na + x2 K) + urea + glucose)
● non-ketotic

18
Q

Tx HHS?

A

same as DKA except less fluids and only use insulin if glucose isn’t ↓ by 5mmol
risk of thrombosis so LMWH

19
Q

basic Tx of DM (1 + 2)? (4)

A

1) education and dietary/exercise advice
2) CV risk factor management: aspirin + simvastatin
3) annual review of complications: ACR (nephropathy), retinopathy, etc
4) blood glucose-lowering therapy

20
Q

is okay to use oral hypoglycaemic drugs in T1DM?

A

no! insulin, normally long acting

21
Q

blood glucose lowering therapy in T2DM?

A

HbA1c ≥48 (after trial of diet and exercise):

1) metformin (or if ↓/normal weight or creatinine >150 gliclazide)
2) then ↑ dose to max tolerated
3) then + gliclazide, or gliptin (DPP-4 inhibitor if already on gliclazide
4) then + insulin

22
Q

1st line in TDM overweight patients (as it causes appetite suppression)?

A

metformin

23
Q

is metformin okay to use in renal impairment?

A

avoid in those with a creatinine >150 μmol/L due to the risk of lactic acidosis

24
Q

1st line in T2DM if normal/underweight?

A

sulfonylureas

25
Q

first line IV treatment of hypoglycaemia?

A

glucose 20% (50-100ml)

  • delivers between 10–20 g of glucose
  • infusion rates <20 mins are optimal

(glucose 10% 100-200ml is suitable alternative)

26
Q

Tx: BM goals in adults and kids?

A

In adults: 4 and 9 mmol/litre for most of the time (4–7 mmol/litre before, < 9 after meals)

In children: 4 and 10 mmol/litre for most of the time (4–8 mmol/litre before, <10 mmol/litre after meals)

27
Q

what’s the most important consideration in creating an insulin regime?

A

strenuous efforts should be made to prevent it from falling below 4 mmol/litre

28
Q

if a patient is hyperglycaemic in the evening on their existing regimen of Humulin (biphasic isophane insulin) due to corticosteroids?

A

an increase in the usual insulin dose of 10% would be an appropriate way to manage a transient rise in blood glucose caused by corticosteroids
*****it is preferable to adjust the existing regimen, rather than add in an additional insulin prescription

29
Q

how much generally to increase units of insulin by to achieve BM target?

A

2-4 units sensible

30
Q

important prescribing info to give with metformin?

A

take with meals bc of bad GI S/E

check GFR

31
Q

effect of beta-blockers in DM?

A

reduce hypoglycaemic awareness

32
Q

Tx hypothyroidism?

A
  • ↓ starting dose in elderly/IHD
  • if CVD, severe ↓thyroidism or patients>50 years (starting dose 25mcg od)
  • others started on 50-100mcg od
  • following a change in dose TFTs checked after 8-12 weeks
33
Q

S/E levothyroxine?

A

hyperthyroidism: due to over treatment
reduced bone mineral density
worsening of angina
atrial fibrillation

34
Q

levothyroxine interactions?

A

iron, calcium carbonate

absorption of levothyroxine reduced, give at least 4 hours apart

35
Q

therapeutic goal of levothyroxine therapy?

A
  • ‘normalisation’ of TSH
  • normal TSH value 0.5-2.5 mU/l
  • preferable to aim for a TSH in this range
  • The TSH should be monitored carefully, aiming for a low-normal value
36
Q

women with established hypothyroidism who become pregnant?

A

should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy

37
Q

what constitutes the basal and the bolus in basal-bolus insulin regimes?

A

BASAL:

  • intermediate (isophane)
  • long-acting (determir:Levemir) or (glargine:Lantus)

BOLUS:

  • rapid (aspart: NovoRapid) or (lispro: Humalog)
  • soluble short-acting insulins - Actrapid, Humulin S
38
Q

regarding time of surgery?

A

DM should be first on list!

39
Q

gliclazide in pregnancy?

A

hypo risk (never given!)

40
Q

metformin

A

always continued (in BF too!)

41
Q

1st line if ↑ weight?

A

metformin

42
Q

1st line if ↓weight?

A

gliclazide