PSA - diabetes Flashcards
metformin is the first line treatment for type 2 diabetes. How do you start treatment?
- 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
What is the second line treatment for T2DM?
-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
When would a second line treatment of T2DM be indicated?
Hb1AC rises to 58mmol when being treated with one hypoglycaemic agent
2 hypoglycaemic agents aren’t cutting it for a patient with T2DM. What ya gonna do doc?
triple (threat) treatment
- metformin, DPP-4 (“gliptins”), sulfonylurea (“zide”)
- consider starting subcut insulin
What is the aim of insulin treatment?
- relieve symptoms of hyperglycaemia
- prevent hypoglycaemia
- prevent micro- and macrovascular complications
- enable patients to live a normal life with disease
When are once daily basal regimens useful?
- 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
What is the insulin recommended for once daily regimens?
human isophane
In twice daily regimes there is mixed insulin, intermediate with short acting. What does the number are novomix 30 or humalog 25 mean?
it is the percentage of short acting insulin with in the mixture.
What does the acronym INSULIN stand for?
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
When should you always refer to a diabetes specialist?
- 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
What are the indications for an insulin infusion?
- 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)
What sort of insulin is an a Variable Rate Insulin Infusion (VRII)? What are the considerations with a patients normal insulin regime?
- 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
What is the aim of a variable rate insulin infusion?
to attain near normoglycaemia
i.e. prevent hypeglycaemia or hypoglycaemia
What considerations need to be made when prescribing a VRII?
- prescribe fluids and electrolytes at the same time
- prevent hypokalaemia
- prevent hypoglycaemia
When and What do you do when stopping a VRII?
- 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
What do you need to consider when restarting oral hypoglycaemic medication post VRII?
- 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
What do you need to do when restarting SC insulin post VRII?
- 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
What is the weight based method of working out insulin require for a newly diagnosed T1DM (insulin naive) patient?
- 0.3 x weight (frail, old, CKD 4/5, hepatic failure, new T1DM)
- 0.5 x weight (all other adults)
What is the recent VRII rate method of working out a patients insulin requirements?
most recent 6 hours requirement divided by 6
times by 20 (prevent hypoglycaemia)
BOTH METHODS CHECK LOCAL GUIDELINES
Once you have worked out a patient’s 24hr insulin requirement how do you convert it to a tice daily regime?
- 60% in morning dose
- 40% in evening dose
Once you have worked out a patients 24hr insulin requirement how do you convert that to a basal bolus regime?
- 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
