MET3 Revision: Diabetes I Flashcards
A patient is diagnosed with DMT1 after an admission for DKA.
What is the insulin regime you should start them on post-admission? [1]
Twice-daily basal insulin detemir (long acting), insulin aspart (short acting) bolus with meals
Name 4 complications associated with untreated diabetes
skin infections – staphylococcal skin abcesses, oral or genital candidiasis
foot problems – ulcers or neuropathic pain
retinopathy – perhaps found on routine eye test
acute myocardial infarct / stroke– diagnosed whilst in hospita
State 4 methods for diagnosing diabetes [4]
Fasting plasma glucose (FPG) (note NOT a capillary glucose [ie. a fingerprick test])
Random plasma glucose (RPG)
75 gram oral glucose tolerance test (OGTT / 2hr PG)
Haemoglobin A1c (HbA1c, glycated haemoglobin)
NOTE: One diagnostic test is enough to diagnose diabetes w/ symptom
Impaired glucose tolerance can only be diagnosed using which diagonostic test?
FPG
2 hr PG
RPG
HbA1c
Impaired glucose tolerance can only be diagnosed using which diagonostic test?
FPG
2 hr PG
RPG
HbA1c
Which HLA is associated with DMT1? [2]
HLA DR3 & DR4
Describe what pancreatic diabetes is [1]
Name 4 causes of pancreatic diabetes [4]
Pancreatic diabetes:
* Severe disease of pancreas causes damage to B cells
Causes:
Acute / Chronic Pancreatitis
Trauma / Pancreatectomy
Neoplasia
Cystic fibrosis
Haemochromatosis / Thalassaemia – due to iron overload
Name 6 endocrine diseases known to cause diabetes [6]
Acromegaly (excess growth hormone)
Cushing’s syndrome (excess cortisol)
Glucagonoma (excess glucagon)
Phaechromocytoma (excess adrenaline)
Hyperthyroidism (excess thyroid hormone)
Conn’s syndrome (excess aldosterone hormone
State 5 causes of drug induced diabetes [5]
Glucocorticoids
b-blockers
Thiazide diuretics
Tacrolimus (used in transplantation – may cause “New Onset Diabetes after Transplantation” [NODAT])
Atypical anti-psychotics – eg. olanzapine, risperidone, clozapine
Name two congenital viral infections that may cause diabetes [2]
Congenital rubella
Cytomegalovirus
DMT2 is caused by a combination of which two physiological factors? [2]
Insulin resistance AND B-cell failure
Insulin resistance AND B-cell failure are exacerbated by hyperglycaemia:
What is this concept called? [1]
Explain the pathophysiology [2]
Glucose toxicity:
High levels of glucose lead to poorer b-cell function leading to reduced insulin secretion
therefore lowering glucose may actually help b-cell function
Describe how alpha and beta cell mass changes in diabetic patients [2]
b-cell mass is relatively preserved (50% at autopsies) - but function declines
a-cell population increased
Which factors contribute to metabolic syndrome? [6]
BMI > 30 kg/m2 , or:
Abdominal Waist Circumference – ethnic specific
Low HDL Concentration
Blood pressure
Fasting glucose
Triglyceride
Label the treatment choices for the DM patients with multi-morbidities for patients already on metformin management and HbA1c remains above 53
CVD:
A: SGLT-inhibitor
B: GLP-1
Heart Failure:
C: SGLT-inhibitor
D: GLP-1
CKD
E: SGLT-inhibitor
F: GLP-1
High CV Risk:
G: SGLT-inhibitor
H: GLP-1
Frail / elderly:
I DPP-inhibitor (low hypoglycaemia risk)
Obesity
A: SGLT-inhibitor
B: GLP-1
Which drugs are contraindicated for patients with DMT2 who might also be suffering from:
Heart Failure [2]
CKD [1]
Frail / elderly [3]
Obesity [2]
Heart Failure:
- Pioglitazone: causes oedema as an AE
- Saxagliptin: increase risk of HF
CKD [2]
- Caution with SUs
Frail / elderly [3]
- SGLT2i (hypoglycaemia risk)
- GLPs (hypoglycaemia risk)
- Caution with SUs (hypoglycaemia risk)
Obesity
- SUs (weight gain)
- Pioglitzaone (weight gain)
When are the following useful / recommended as an additional step to DM patient medication? [3]
Sulfonylurea [1]
Pioglitazone [1]
Repaglinide [1]
Sulfonylurea: (gliclazide, glimepiride): if rapid glucose lowering needed and hypos are not a concern
Pioglitazone: can improve lipids, useful for insulin resistance if no C/Is
Repaglinide: can be useful in shift workers/ irregular meal patterns
Sick day rules:
During an acute dehydrating illness, patients with diabetes should be advised to stop the SADMAN drugs, and restart once they have been eating and drinking normally for 24-48 hours.
What do the SADMAN drugs refer to? [6]
State why need to stop each of the SADMAN drugs [6]
SGLT2 inhibitors: (risk of DKA)
ACE inhibitors: (risk of AKI)
Diuretics (risk of AKI)
Metformin (risk of lactic acidosis)
ARBs (risk of AKI)
NSAIDs (risk of AKI)
DPP4 inhibitors have a risk of causing which pathology? [1]
Pancreatitis
What BP in DM patients would indicate BP treatment? [1]
What BP for a diabetic patient would indicate BP treatment if they have kidney, eye or CV disease ? [1]
BP persistantly over 140 / 90 mmHG
BP persistantly over 130 / 80 mmHG & kidney, eye or CV disease
What drug, dose and administration would you give to DMT2 patients with no CVD, but Qrisk score of greater than 10% to modify their lipid levels? [1]
What drug, dose and administration would you give to DMT2 patients with known CVD modify their lipid levels? [1]
If not achieving target, which drugs should be prescribed modify their lipid levels? [2]
Diabetic patients with no CVD, but Qrisk score of greater than 10%:
- Arvostatin, 20mg daily
Diabetic patients with known CVD:
- Arvostatin, 80mg daily
No response:
- Ezetimibe
- PCSK9 inhibitors
When should you provide statins for DMT1 patients? [2]
- Anyone who has has DMT1 for over 10 years
- Statins for anyone with complications (eyes / neuro etc
Describe the physiological effect for long term diabetic management of having tight glycaemic control [2]
Microvascular complications reduced
Macrovascular complications has no effect
Which conditions are HbA1c may be invalid for when assessing diabetic conditions? [2]
May be invalid in haemoglobinopathy or anaemia (reduced red blood cell survival)
How can patients using insulin therapy assess their glycaemic control? [1]
What are pre-prandial and post-prandial glucose level aims? [2]
Self monitoring of blood glucose (SMBG):
Pre-prandial aim: 4-7 mmol/L
Post-prandial aim: 5-9 mmol/L
Name this [1]
Which Ptx populations can use it? [4]
Intermittently Scanned Continuous Glucose Monitoring (Freestyle Libre)
▪ Can be used in most people with T1D
▪ Consider in people with T2D if they are on
twice daily or more insulin therapy
▪ AND have recurrent hypos or severe hypos or hypo unawareness
▪ OrLearningdisability/Cognitiveimpairment
DMT2 Management:
- MoA of Metformin? [3]
- Acts by activation of the AMP-activated protein kinase (AMPK)
- Increases insulin sensitivity / improving insulin resistance
- Decreases hepatic gluconeogenesis
- inhibits glucose absorption in the gut
State 2 advantages of sulfonylureas
State 3 disadvantages of sulfonylureas
Advantage:
Oral
Cheap
Disadvantage
Hypoglycaemia
Weight gain
Testing glucose if driving
Describe the MoA of Acarbose [2]
Blocks disaccharidase in the GI tract
Reduces absorption of glucose }
Name 3 advantages of glitazones for diabetic control
Generally well tolerated
Oral / once daily
Cheap - ~ £2.00 per month
HbA1c reduction 10-15 mmol/mol
Little hypoglycaemia
Name 4 disadvantages of glitazones (thiazolidinediones) [4]
Oedema (avoid in HF)
Weight gain 3-5 kg
Fractures in post menopausal women
Query around cause of bladder cancer
ELBOW
Edema
Liver failure
Bladder cancer
Osteoporosis
Weight gain
Describe the physiological effect of GLP-1 [4]
Glucose-dependently stimulates insulin secretion and decreases glucagon secretion:
Delays gastric emptying
Decreases food intake and induces satiety
Stimulates B-cell function and preserves or increases B-cell mass in animal models (stimulating insulin release)
Name a daily [1] & weekly [2] injectable GLP-1 drug
Liraglutide – daily injection
Dulaglutide – weekly injection
Semaglutide – weekly injection or oral tablet
Name 4 advantages of GLP-1 analogues [3]
Weight loss
Reduce CV risk
HbA1c reduction 10 / 30 mmol/mol
One weekly injection
Name 4 disadvantages of GLP-1 analogues [4]
Injection
Cost ~ £73.00 per month
Needs some nursing
GI side effects
?? Pancreatitis risk
Name 4 disadvantages of using SGLT-2 inhibitors [4]
- UTIs / Thrush
- Euglycaemic DKA (rare) - get DKA but at normal glucose levels
- Care in acute illness
- £ 36
Describe an overview of the drug pathway for glycaemic management of DMT2
- HbA1c above 48 at diet and lifestyle alone: condiser Ptx CV risk or CV disease
- If Ptx has low CV risk: metformin first line
- If Ptx has high CV risk or CV disease: metformin AND gliflozin
- If HbA1c continued not to be controlled: dual oral therapy
- If HbA1c continued not to be controlled: triple oral therapy
What is rescue therapy prescribed for symptomatic hyperglycaemia? [2]
- Consider insulin or sulfonylurea
- Review when glucose control achieved
How do you chose between GLP-1 analogue versus insulin for DMT2 after triple oral therapy has not controlled HbA1c? [1]
GLP-1:
- BMI > 35
Insulin:
- BMI < 35
Describe when insulin is released in a normal person [2]
Biphasic:
- Short-lived, rapidly generated meal-related insulin peaks
- Low, steady, basal insulin profile
Name indications for insulin therapy for DMT2 patients [5]
▪ inadequate glycaemic control on tablets
▪ contraindications to tablets
▪ symptomatic hyperglycaemia
▪ pregnancy
▪ infection / foot ulcers
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State the three different types of insulin regimens
Once-daily / twice-daily intermediate- or long-acting (basal) insulin
Once-/ twice-/ three-times daily premixed insulin
Basal–bolus therapy
Describe the dosing regimen of twice daily insulin [2]
Two injections:
First injection (contains both):
- Short acting acts on breakfast
- Long acting works on lunch
Second injection:
- Short acting acts on dinner
- Long acting works in background
Describe basal bolus therapy regime for insulin
3 injections of rapid acting, 1 injection of long acting: mimics normal physiology
A man sees his GP for a review of his type 2 diabetes. He is on metformin at the maximum tolerated dose. His latest HbA1c is 64 mmol/mol.
His GP starts him on gliclazide and plans to repeat the HbA1c in 3 months’ time.
What is the patient’s new target HbA1c? [1]
The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol
Pioglitazone is contraindicated in which type of cancer? [1]
Bladder cancer
Name three anti-VEGF medications used to treat diabetic retinopathy [3]
ranibizumab, bevacizumab & Aflibercept
Name two corticosteroids used to treat diabetic retinopathy [2]
Which
Triamcinolone
Dexamethasone implant can also be used, particularly in refractory DME
Describe how you would treat mild-moderate hypokalaemia (2.5-3.4) and severe hypokalaemia (< 2.5) [2]
Mild to moderate hypokalaemia 2.5 - 3.4 mmol/l:
- oral potassium provided the patient is not symptomatic and there are no ECG changes.
Severe hypokalaemia (< 2.5mmol/l) or symptomatic hypokalaemia:
- should be managed with IV replacement.
- If there are no contraindications to fluid therapy (e.g. volume overload, heart failure) potassium should be diluted to low concentrations as higher concentrations can be phlebitic.
- The infusion rate should not exceed 20mmol/hr
A second drug should be added in type 2 diabetes mellitus if the HbA1c is > [] mmol/mol
A second drug should be added in type 2 diabetes mellitus if the HbA1c is > 58 mmol/mol
