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Endocrine > Rx of DM > Flashcards

Rx of DM Flashcards

1
Q

What does type 1 always require

A

Insulin as no pancreatic tissue left

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2
Q

If on insulin what happens to BG control

A

Can be less strict due to risk of hypoglycaemia

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3
Q

How do you treat type II

A

Diet + exercise to restore insulin sensitivity
Oral meds
Metformin = 1st line
Can step up to insulin if still not controlled

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4
Q

How do you monitor DM

A

Self monitoring of BG only if risk of hypo
Trend in HbA1c = most important value every 3-6 months
If stable = then leave on drug
If rising = add in drug

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5
Q

What should target HbA1c be in type I

A

48

Depends on other factors / risk of hypo

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6
Q

How often should you monitor blood glucose on insulin

A

4x daily

Before each meal and before bed

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7
Q

What should target BG levels be

A

5-7 on waking

4-7 before meals

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8
Q

How do you treat type I

A

Insulin

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9
Q

What do you consider adding if high BMI >25

A

Metformin

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10
Q

What can you test for in type I

A

GAD Ab

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11
Q

How do you deliver insulin

A

SC
Insulin pump = continuous infusion + bolus at meals
IV insulin if acutely unwell

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12
Q

What is important in SC

A

Rotate sites to prevent lipodystrophy which will cause erratic absorption

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13
Q

What are SE of insulin

A

Hypoglycaemia
Lipodystrophy
Weight gain

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14
Q

What should people on insulin have

A

Glucagon kit for emergency

Education about signs of hypoglycaemia

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15
Q

What drug reduces hypo awareness / insulin sensitivity

A

Beta blocker

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16
Q

What sources of insulin is there

A

Analogue
Human sequence
Porcine

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17
Q

What duration of action of insulin is there

A

Rapid acting
Short acting ‘actarapid’ - use as basal bolus
Intermediate acting ‘isoprene’ - use in pre-mix with long acting
Long acting ‘determir’ - use once or 2x daily
Mixed

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18
Q

What is most common insulin regimen

A

2x daily insulin determir (LA)
+- rapid acting insulin analogue 30 mins before meal
Basal bolus - 4x B,L,T, B

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19
Q

What must patient work out

A

Insulin to CHO ratio

Initially 1 unit for 10g of carb

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20
Q

What is the future of type I

A

Full closed loop pump with internal glucose monitor
Donor transplant
Bionic pancreas

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21
Q

What does patient education encompass

A

Team based
DIANE - Diabetes Insulin Adjustment and Normal Eating
Online - DM UK / myDMmyway / carb counting apps
Group education
Sick day rules
Hypoglycaemia awareness
How to administer insulin
How to monitor glucose / ketones / finger prick glucose
CHO counting
Exercise advise

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22
Q

Who is involved in DM team

A 
Patient
DSN
Practice nurse
GP
Diabetes doctor
Podiatrist
Dietician
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23
Q

Lifestyle measures in DM

A 
High fibre, low glycemic index CHO 
Control fats
Weight loss 
Exercise
Stop smoking 
Manage CVS disease risk 
- High dose statin for cholesterol 
- BP meds 
Regular foot care 
Advise DVLA
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24
Q

What is HbA1c targets in DM II

A

Aim 48

Aim 53 if on drugs that cause hypo / frail / reduced LE

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25
Q

What is 1st line oral drug in DM type II

A

Metformin

Titrate as high as patient tolerates or change to MR

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26
Q

When would you start sulphonyurea instead of metformin

A

If osmotic symptoms or present with weight loss or if metformin CI

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27
Q

When would you add another agent

A

If HbA1c >58 / trend increasing

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28
Q

What agents do you add

A

Any - look at SE

Not GLP-1

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29
Q

When do you add thiazodiole

A

If hypo a concern

No CCF

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30
Q

When do you add DDP-IV

A

If hypo / weight gain a concern

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31
Q

When do you add SGLT -2

A

If hypo or weight gain a concern

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32
Q

If HbA1c still >58

A

Add another agent OR

Consider insulin + metformin

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33
Q

If triple therapy not tolerated or not effective AND BMI >35

A

Metformin + sulphonyurea + GLP-1 - all 3

Last resort

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34
Q

What is the action of metformin

A

Increases insulin sensitivity
Decrease hepatic gluconeogenesis
Increase peripheral utilisation of glucose

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35
Q

How do you take metformin

A

Oral

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36
Q

What are SE and when is it CI

A 
Lactic acidosis
CI in eGFR <30
Consider stopping if eGFR <45
Risk of b12 albsorption
GI upset

CI
CKD
Recent MI / AKI / sepsis as may cause lactic acidosis as state of hypoxia
Iodine containing contrast (stop 48 hours after)
Alcohol abuse

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37
Q

What are advantages

A

Weight neutral
No hypo risk
Safe in pregnancy
Improved CVS outcomes

38
Q

What are examples of sulphonylurea drugs

A

Gliclazide

Glibenclamide

39
Q

How do sulphonyurea drugs work

A

Augement insulin secretion by stimulating beta cells so increase insulin and C-peptide

Useful in MODY

40
Q

How do you take

A

Oral

41
Q

What are SE

A

Risk of hypo so BG testing required - present nausea / sweaty / dizzy etc.
Weight gain
Increased appetite

Rare
Hyponatraemia due to inapproriate ADH 
Hepatic failure / cholestasis
Bone marrow suppression
Neuropathy
42
Q

What are advantages

A

Rapid onset

43
Q

What do you avoid in

A

Pregnancy
Breast feeding
Hepatic failure

44
Q

What are examples of thiazolidinediones (Glitazone)

A

Pioglitazone

45
Q

What is the action

A

Reduce peripheral insulin resistance

46
Q

How do you take

A

Oral

47
Q

What are SE

A 
Weight gain
Fluid retention 
Anaemia 
Heart failure
Osteoporosis / fractures
Bladder cancer
Liver impairment so monitor LFT before Rx and regularly
48
Q

What are advantages

A

No hypo

49
Q

Who do you avoid in

A

HF due to fluid retention

Bladder cancer

50
Q

How do DDP-4 inhibitors work (siptagliptin)

A

Inhibit DDP-4
Increase insulin secretion
Decreased glucagon secretion by increasing incretin

51
Q

How do you take

A

Oral

52
Q

What are SE

A

GI Sx
Pancreatitis
Careful in eGFR

53
Q

What are advantages

A

Reduce hypo

Weight neutral

54
Q

How do SGLT-2 inhibitors work

A

Inhibit SGL2
Reduce glucose reabsorption in kidney
Increase kidney

55
Q

How do you take

A

Oral

56
Q

What are SE

A 
Require eGFR of 60
Amputation
Increased fungal and UTI due to glycosuria 
Can get normoglycemia ketoacdiosis
Postural hypo due to diuresis
Polyuria
57
Q

When is it CI

A

EgFR <60

Pregnancy

58
Q

What are advantages

A

Weight loss as increased urine loss
Decreased hypo
CVS risk

59
Q

What does GLP-1 agonist do

A

Activates GLP-1 in small intestine to increase insulin
Suppress glucagon
Slows gastric emptying

60
Q

How do you take

A

SC injection

61
Q

What are SE

A

N+V

Pancreatitis

62
Q

When is it CI

A

eGFR <30

63
Q

What are advantages

A

Weight loss
HbA1c control
Use with insulin

64
Q

What are symptoms of uncontrolled

A 
Increasing thirst and urination
Blurred vision
Fatigue
Increased hunger
Tingling / pain / numbness
Slow healing of guts
65
Q

How do you manage RF

A

BP
Statin
Lifestyle

66
Q

Lifestylee

A 
Diet
Weight loss
Physical activity
Reduce alcohol 
Smoking cessation
67
Q

What is target BP if no end organ damage and if end organ damage

A

140/80 = no damage

130 / 80 if mage

68
Q

What is 1st line in DM

A

ACEI as renoprotective

69
Q

What should you be aware of

A

Autonomic neuropathy may lead to postural Sx

Avoid BB as cause insulin resistance

70
Q

When do you offer statin

A

CVS risk >10%

71
Q

When is this different

A

DM type I with see below
CKD = offer to all
Hx familial hyperlipidaemia

72
Q

When do you consider statin in type 1

A

> 40
DM >10 years
Nephropathy
Other CVD RF

73
Q

How do you follow up statin

A

Full lipid profile

74
Q

DM and work

A

Can’t work in armed forces / police / fire

75
Q

DM and Ramadan

A

Eat meals with long acting CHO
Check BG if feel unwell
Switch doses or times of meds

76
Q

What are sick day rules

A

Increase BG monitoring to every 4 hours
Drink 3L of fluid
Drink sugary drinks if can’t eat
Continue oral meds / insulin even if can’t eat due to risk of DKA as illness often requires extra insulin despite reduced food
Corrective dose of insulin if sugar or ketones raised

77
Q

What is exception to rule

A

Metformin

Should be stopped if dehydrated due to risk of renal impairment

78
Q

Why do you continue meds if not eating

A

Stress = increased cortisol

79
Q

When do you admit to hospital

A 
Serious underlying illness
Can't keep fluid down
Persistent diarrhoea
Significant ketones despite Rx
BG >20 despite insulin
Lack of support at home
A child or pregnant
80
Q

DVLA and type 1 /2

A

Can drive if no hypo in 12 months
Still have awareness
Regular BG monitoring
No complications

81
Q

Do you need to inform DVLA

A

Only if on insulin

82
Q

Risks of surgery and DVLA

A

Increased risk of infection if poorly controlled

83
Q

If poor control or on insulin what happens

A

Require variable rate IV insulin infusion +

K supplementation

84
Q

If on oral med / diet controlled

A

Omit medication and monitor BG

85
Q

What do you get when Dx with DM

A 
BG measured
BP and BMI measured
Lipid measures
Eye, foot and kidney screen annual
Smoking cessation support
Education
Emotion and psych support
86
Q

What do you do if on metfromin and having contrast CT

A

Stop for 48 hours after

87
Q

Common errors insulin prescribing

A

Never omit dose
Always use insulin unit and don’t abbreviate
Use insulin syringe
Follow sick day rules

88
Q

4 Rights to insulin prescribing

A

Right insulin
Right dose
Right time
Right way

89
Q

What are the 4 doses of insulin

A

100 = most common (100 units in 1ml)
200
300
500

90
Q

What is important to remember

A

Any >100 must be given in device they are supplied with

NEVER draw out to be put into syringe

91
Q

Where do you store insulin

A

Fridge

92
Q

Cntrol

A

Tight needed in young to prevent complications

In elderly less tight as don’t want to fall

Endocrine (17 decks)

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