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PY6020 > Management of Diabetes > Flashcards

Management of Diabetes Flashcards

1
Q

How many amino acids are in insulin?

A

51

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2
Q

What 3 glucose homeostasis process occur in the body?

A

Glycogenesis: glucose –> glycogen

Glyconeogenesis: protein –> glucose

Glycogenolysis: glycogen –> glucose

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3
Q

What type of stress hormones can induce more glucose to be released/produced?

A
  1. Glucagon
  2. Adrenaline
  3. Glucocorticoids
  4. Growth hormone
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4
Q

What processes does insulin prevent from occuring?

A
  1. Gluconeogenesis
  2. Lipolysis
  3. Ketogenesis
  4. Glycogenolysis
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5
Q

What processes does insulin promote?

A
  1. Glucose uptake in muscles/adipose
  2. Glycolysis (respiration)
  3. Glycogenesis (glycogen formation)
  4. Uptake of ions (K+)
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6
Q

What should normal blood sugar levels be?

A

4-5.6mmol/L

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7
Q

What is the main difference between type 1 & type 2 diabetes?

A

Type 1: insulin dependent (genetics)

Type 2: non-insulin dependent (or insulin independent) (obesity/drug related)

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8
Q

What are the main features of someone diagnosed with type 1 diabetes?

A
  1. <50 years old
  2. Family history of it
  3. BMI <25kg/m^2
  4. Features like: hyperglycaemia, ketosis, rapid weight loss
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9
Q

At what age is type 2 diabetes most common in?

A

40-80 years old.

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10
Q

Why are diabetics more prone to candida infections?

A

Because they are excreting lots of sugar in their urine which is the appropriate environment for bacterial growth to occur.

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11
Q

What causes polyurea, thirst & weight loss in diabetes?

A
  1. Polyurea: osmotic diuresis, where too much glucose in the blood has to be excreted
  2. Thirst: loss of electrolytes/fluid
  3. Weight loss: fluid depletion/break down of muscle/fat due to insulin deficiency
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12
Q

What are the 3 investigations for diabetes?

A
  1. Fasting glucose test
  2. Random glucose test on 2 separate occasions
  3. OGTT - oral glucose tolerance test
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13
Q

How can the risk of CV events be lowered in diabetic patients?

A

Using an ACEi and a lipid regulating drug (Atorvastatin)

ACEi improves heart function + nephroprotective

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14
Q

How often should diabetics regularly get their bloods checked and what is specifically measured?

A

They should have a blood test every 3 months.
Their HbA1c is measured which is the % of haemoglobin that has sugar on it.
Since RBCs have a 3 month life span, this is why blood tests are done 3 months apart.

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15
Q

Why cant insulin be taken by mouth? Which route is it given it?

A

Because it includes amino acids which will be digested by the stomach.
Insulin is hence given by subcutaneous injection.

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16
Q

In which circumstances is insulin the 1st line treatment for?

A
  1. Type 1 diabetics
  2. Type 2 diabetics in which other methods have failed
  3. Temporarily during surgery
  4. In pregnant women, where everything else has failed
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17
Q

Which 2 type of insulin preparation are used for a basal-bolus regimen?

A

Basal: long-acting
Bolus: short acting

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18
Q

What are some examples of rapid acting human insulin analogues?
When are they taken?

A
  1. Insulin aspart - NovoRapid
  2. Insulin lispro - Humalog
  3. Insulin glulisine - Apidra
  • They are taken shortly before/after a meal
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19
Q

What are some examples of intermediate insulins?

When are they taken?

A

Isophane insulin - Humulin I, or Insulatard

They are taken twice a day for stable basal levels.

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20
Q

What are some examples of longer acting insulins?

When are they taken?

A
  1. Insulin glargine - Lantus, or Toujeo
  2. Insulin detemir - Levemir

They are taken the same time once a day

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21
Q

What are some examples of biphasic insulins (mixed)?

A
  1. NovoMix 30
  2. Humalog Mix 25 or Mix 50
  3. Humulin M3
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22
Q

What are some examples of insulin regimens?

A
  1. Basal-bolus
  2. Short acting (or rapid) mixed with intermediate acting
  3. Intermediate OD or BD
  4. Continuous infusion - from a pump
  5. Long acting on its own - for type 2 diabetics
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23
Q

Which patients would benefit from a CSII (continuous subcutaneous insulin infusion) pump?

A
  1. Those with type 1 suffering from multiple hypos
  2. Those with multiple injecting regimens
  3. Those with a HbA1c >8.5%
  4. Those where their injecting regimens is considered impractical/inappropriate
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24
Q

Which drug is mainly given to patients with a BMI >27kg/m^2?

A

DPP4 inhibitors (linagliptin, sitagliptin)

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25
Q

What do diabetic patients monitor themselves at home?

A
  1. Blood glucose levels using a finger-prick blood sample

2. Urine testing for ketones

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26
Q

What ratio is measured nowadays which monitors for diabetic nephropathy?

A

Albumin/creatinine ratio (ACR)

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27
Q

What should HbA1c levels normally be?

A

<48mmol/mol (6.5%)

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28
Q

What is the HbA1C target for type 2 diabetics?

A

53 mmol/mol (7%)

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29
Q

What factors must be done/checked before a diabetic can drive?

A
  1. Must take regular breaks
  2. Bring treats if hypo occurs
  3. If reading is >5mmol/L, then it is ok to drive
  4. Regularly check blood sugar levels
  5. If reading is <4mmol/L, treat hypo & wait 45mins before you drive
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30
Q

What type of diet do you encourage for type 2 diabetics in order to lose weight?

A

High fibre, low glycaemic index sources of food e.g. fruit, vegetables, whole grains & pulses. Include low-fat dairy products & oily fish.

31
Q

What type of diet reduces major CV events?

A

Mediterranean diet

32
Q

When should oral anti-diabetic drugs be given?

A

When the patient fails to respond to diet/exercise for at least 3 months

33
Q

What are the main oral anti-diabetic class of drugs?

A
  1. Biguanides - metformin
  2. Sulphonylureas - gliclazide, glipizide
  3. DPP4 inhibitors - linagliptin, sitagliptin (ending in -gliptin)
  4. Thiazolidinediones - pioglitazone
  5. SGLT-2 (sodium-glucose cotransporter 2) inhibitors - dapagliflozin (ending in -flozin)
  6. GLP-1 AGONIST (liraglutide, exenatide)

___________________________
DONT MEMORISE THESE, and never pick them in an MCQ question

  1. Alpha-glucosidase inhibitors - acarbose (not very used)
  2. Post prandial regulators - nateglinide, repaglinide
34
Q

What is the mode of action of biguanides (e.g. metformin)?

A

They decrease gluconeogenesis & increase glucose uptake by muscles.

35
Q

What is the dosing for metformin?

A

500mg OD for 7 days, then BD for 7 days, then TDS thereafter.
Dose is titrated to minimise side effects

36
Q

What advantageous side effect can metformin cause in overweight patients?

A

It can aid in weight loss (careful not to let it cause anorexia)

37
Q

What organ function should be good when using metformin?

A

Kidney function, since lactate can build up & cause lactic acidosis.

38
Q

How do sulphonylureas (e.g. gliclazide, glipizide) work?

A

They stimulate insulin secretion by blocking K+ channels in B cells.

39
Q

What 2 side effects can occur when using sulfonylureas?

A
  1. Further weight gain - so avoid using in overweight patients
  2. Hypoglycaemia
40
Q

Can sulfonylureas be used in patients with renal or hepatic impairment?

A

No.

41
Q

How do thiazolidinediones (e.g. pioglitazone) work?

A

They enhance receptor sensitivity, reducing insulin resistance & lowering blood sugar levels.

42
Q

What conditions should you NEVER give pioglitazone with?

A
  1. Heart failure/history of HF - pioglitazone can increase this & cause oedema/weight gain
  2. Hepatic impairment - pioglitazone can cause liver toxicity
  3. Diabetic ketoacidosis
  4. History or current bladder cancer - risk can increase when using pioglitazone
43
Q

How do DPP4 inhibitors (e.g. sitagliptin, linagliptin) work?

A

They delay GLP-1 deactivation (by inhibiting DPP4 enzyme), so insulin secretion increases after meals.
Glucagon secretion is also reduced.

44
Q

How do GLP-1 agonists (e.g. liraglutide, exenatide) work?

A

They promote insulin release via incretins in the stomach, and decrease glucagon release.

45
Q

What effects of GLP-1 agonists can patients benefit from?

A
  1. Delayed gastric emptying - most commonly used to help with weight loss
  2. CV protection - this is why it is used for high risk CV patients
  3. Available as modified release (and oral)
46
Q

How do SGLT-2 inhibitors (e.g. dapagliflozin) work?

A

They inhibit renal reabsorption of glucose, so it is urinated out.

47
Q

What condition is a patient taking dapagliflozin more at risk of?

A

Candida infections (e.g. thrush), because high levels of glucose are being passed in urine making it an ideal location for bacterial growth.

48
Q

Can SGLT-2 inhibitors be used in patient with CVD?

A

Yes because it is a very potent drug which can reduce fluid build up.

It is the recommended option for CV patients.

49
Q

What specific condition can a patient be at risk of when taking dapagliflozin?

A

Diabetic ketoacidosis.
This is because insulin secretion is not involved in dapagliflozin’s mode of action. Lipids are metabolised instead, which can cause ketone build up = DKA occurs

50
Q

What should a patient do if they develop Fournier’s gangrene while taking an SGLT-2 inhibitor?

A

Seek emergency medical assistance & stop taking the drug.

51
Q

How are GLP-1 agonists (e.g. siraglutide, liraglutide) administered?

A

Subcutaneous injection once a week.

52
Q

What condition can arise if patients are on a GLP-1 agonist & insulin?

A

Diabetic ketoacidosis.

53
Q

What is the step-wise management of type 2 diabetic treatment?

A
  1. Diet + exercise for 3 months
  2. If above not worked, metformin given as 1st line
  3. If above intolerated/additional therapy needed, then give a DPP4 inhibitor (gliptins), or pioglitazone, or sulfonylurea (gliclazide, glipizide)
  4. If above intolerated, then give SGLT-2 inhibitor (dapagliflozin) only if they cannot have a sulphonylurea, or they are at risk of hypos.
  5. If triple therapy does not work, start insulin treatment
    - Remember do not give pioglitazone in CV patients, or sulfonylureas in overweight patients.
54
Q

What is the most common dual therapy for type 2 diabetes?

A

Metformin + a DPP4 inhibitor (gliptins)

55
Q

When would a GLP-1 agonist be initiated in a type 2 diabetic’s treatment?

A

If the person is intolerant to their triple therapy, and they have a BMI >35 kg/m^2

They would receive metformin + sulfonylurea + GLP-1 agonist

56
Q

What is the target blood pressure for a type 1 diabetic?

A

135/85 mmHg

57
Q

Why is an ACEi always given as treatment for hypertension in diabetes, regardless of ethnicity?

A

Because they have more benefits than just controlling blood pressure.

ACEi: Ramipril, others ending in -pril

58
Q

What is is the step 2 management for a patient with diabetes + hypertension?

A

ACEi PLUS: either a CCB, or a diuretic

CCB: Amlodipine, diltiazem, others ending in -pine
Diuretic: Indapamide

59
Q

What physiological response does hypoglycaemia cause?

A

Suppression of insulin secretion, & an increase in catecholamine secretion.

60
Q

What are the symptoms of hypoglycaemia?

A
  1. Sweating
  2. Shaking
  3. Anxiety
  4. Palpitations
  5. Weak
  6. Sudden hunger
  7. Further cognitive impairment - confusion, poor concentration, coma
61
Q

Which class of drugs can mask the symptoms of hypoglycaemia?

A

B-blockers

62
Q

What is the treatment of hypoglycaemia?

A

Instant glucose, e.g. a sugary drink or granulated sugar
A carbohydrate/snack is then given

If patient is unconscious, give glucagon gel or injection.
IV glucose given if patient does not respond to glucagon.

63
Q

How does diabetic ketoacidosis occur?

A
  1. Absence of insulin leads to lipolysis (fat broken down into energy)
  2. Fats get broken down into fatty acids & then ketones
  3. This causes metabolic acidosis
  4. This process is accelerated by cortisol, glucagon & catecholamine release
64
Q

What are the symptoms of DKA?

A
  1. Dehydration, dry tongue
  2. Deep rapid breathing (Kussmaul breathing)
  3. Ketone breath smell
  4. Low body temp.
  5. Abdominal pain
  6. Sunken eyes, low BP
65
Q

What blood/urine results do you expect of a person suffering from DKA?

A
  1. Blood glucose >20mmol/L
  2. Urine test for ketones/glucose
  3. Acidic blood
  4. Low K+ levels - due to absence of insulin
  5. Low bicarbonate levels
66
Q

How is DKA treated?

A

IV insulin infusion, fluids & K+ infusion

67
Q

What are the 3 microvascular complications in diabetes?

A
  1. Retinopathy
  2. Neuropathy
  3. Nephropathy
68
Q

How is diabetic nephropathy treated?

A

An ACEi is given, or an angiotensin-II receptor antagonist (even if BP is normal)

  • They all end in -sartan
69
Q

How is diabetic neuropathy managed?

A 
No treatment, only pain relief with:
1, Paracetamol
2. NSAIDs
3. Pregabalin 
4. Gabapentin 
5. Oxycodone, tramadol
70
Q

How do diabetic foot infections arise?

A

Neuropathy in the small vessels in the foot means wound healing is very slow. Small injuries to the foot can result in ulcers/infections in a diabetic.

71
Q

What is the 1st line antibiotic given for a diabetic foot infection?

A

Flucloxacillin 500mg-1g QDS 7/7

72
Q

What alternative antibiotics are given for a diabetic foot infeciton?

A
  1. Clarithromycin 500mg BD
  2. Erythromycin 500mg QDS (in pregnancy)
  3. Doxycycline 200mg on day 1, then 100mg OD
73
Q

How is a patients diabetes controlled during surgery (what is given instead of their oral medication)?

A

IV insulin infusion, K+ infusion, and glucose with KCl

PY6020 (22 decks)

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