PSA - diabetes

Question 1

metformin is the first line treatment for type 2 diabetes. How do you start treatment?

Answer 1

• Check eGFR - less than 30 treatment is contraindicated
• increase to total dose over 2 weeks
• if eGFR 45 dose should be reduced
• standard release is standard….. offer modified release if a patient experiences gastro side effects

Question 2

What is the second line treatment for T2DM?

Answer 2

-metformin still indicated:
add DPP-4 inhibitor “gliptins” (sitagliptin, vildagliptin, linagliptin) or,
add pioglitazone (if not contraindicated) or,
add sulfonylurea (gliclizide, glipizide)

-metformin contraindicated - mix two of the other first line options together

Question 3

When would a second line treatment of T2DM be indicated?

Answer 3

Hb1AC rises to 58mmol when being treated with one hypoglycaemic agent

Question 4

2 hypoglycaemic agents aren’t cutting it for a patient with T2DM. What ya gonna do doc?

Answer 4

triple (threat) treatment

• metformin, DPP-4 (“gliptins”), sulfonylurea (“zide”)
• consider starting subcut insulin

Question 5

What is the aim of insulin treatment?

Answer 5

• relieve symptoms of hyperglycaemia
• prevent hypoglycaemia
• prevent micro- and macrovascular complications
• enable patients to live a normal life with disease

Question 6

When are once daily basal regimens useful?

Answer 6

• oral hypoglycaemic resistant T2DM
• obese insulin insensitive T2DM
• people who can’t inject themselves
• do not require tight control
• have high glucose conc over night and in the morning

Question 7

What is the insulin recommended for once daily regimens?

Answer 7

human isophane

Question 8

In twice daily regimes there is mixed insulin, intermediate with short acting. What does the number are novomix 30 or humalog 25 mean?

Answer 8

it is the percentage of short acting insulin with in the mixture.

Question 9

What does the acronym INSULIN stand for?

Answer 9

Insulin only last a few minutes (change infusions quick)
Never omit regular insulin for T1DM (treat hypo first)
Self injection empowerment
Usual insulin (get them back to their normal dose asap)
Low blood glucose - treat all
Increase dose in times of illness
Narrow food-insulin gaps - know the onset of regimes

Question 10

When should you always refer to a diabetes specialist?

Answer 10

• urgent or elective surgery
• new onset diabetes
• DKA, HHS, HONK
• foot ulceration
• unable to manage self
• IV insulin >48 hours
• patient request
• parenteral or enteral feeding
• uncontrolled hyperglycaemia

Question 11

What are the indications for an insulin infusion?

Answer 11

• DKA & HHS
• Surgical procedures (for people with diabetes)
• ACS in diabetes patients
• post stroke hyperglycaemia
• high and variable hyperglycaemia (happens in actue illness especially sepsis)

Question 12

What sort of insulin is an a Variable Rate Insulin Infusion (VRII)? What are the considerations with a patients normal insulin regime?

Answer 12

• Short acting human insulin
• patients normal regime is stopped apart from long-acting insulins
• if long acting insulins are still being used this (may) varies the initial rate of the infusion

Question 13

What is the aim of a variable rate insulin infusion?

Answer 13

to attain near normoglycaemia

i.e. prevent hypeglycaemia or hypoglycaemia

Question 14

What considerations need to be made when prescribing a VRII?

Answer 14

• prescribe fluids and electrolytes at the same time
• prevent hypokalaemia
• prevent hypoglycaemia

Question 15

When and What do you do when stopping a VRII?

Answer 15

• When a patient is clinically stable and eating and drinking normally again
• in T2DM give oral hypoglycaemic medication before a meal and stop the infusion 30mins later

Question 16

What do you need to consider when restarting oral hypoglycaemic medication post VRII?

Answer 16

• metformin - check eGFR and start at pre-infusion does
• pioglitazone, sulfonylureas - be prepared with withhold a dose due to reduced food intake
• DPP-4 inhibitors and SLGT-2 inhibitors start after senior review

Question 17

What do you need to do when restarting SC insulin post VRII?

Answer 17

• ensure basal insulin is given prior to withdrawal VRII
• give normal short acting SC insulin pre meal and wait for 30 mins before withdrawing VRII
• be prepared to r/v pre illness insulin regime and get diabetes team input

Question 18

What is the weight based method of working out insulin require for a newly diagnosed T1DM (insulin naive) patient?

Answer 18

• 0.3 x weight (frail, old, CKD 4/5, hepatic failure, new T1DM)
• 0.5 x weight (all other adults)

Question 19

What is the recent VRII rate method of working out a patients insulin requirements?

Answer 19

most recent 6 hours requirement divided by 6
times by 20 (prevent hypoglycaemia)

BOTH METHODS CHECK LOCAL GUIDELINES

Question 20

Once you have worked out a patient’s 24hr insulin requirement how do you convert it to a tice daily regime?

Answer 20

• 60% in morning dose

- 40% in evening dose

Question 21

Once you have worked out a patients 24hr insulin requirement how do you convert that to a basal bolus regime?

Answer 21

• 50% of units to be given as the basal insulin at the evening meal time
• divide the rest evenly across breakfast, lunch and dinner given as rapid acting insulin