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S3 Case 4 - Endocrine > T2DM Care > Flashcards

T2DM Care Flashcards

1
Q

What is T2DM?

A

Insulin is secreted but not enough to overcome insulin resistance

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2
Q

What increased T2DM risk?

A

Obesity
Age
Family Hx
Gestational diabetes
Ethnicity
HTN

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3
Q

What are the presenting features?

A

NOT usually weight loss
No ketonuria
Onset over months

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4
Q

What is the fasting plasma glucose diagnosis?

A

> 7mmol/L

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5
Q

What is the 2hrs post-prandial glucose diagnosis?

A

> 11mmol/L

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6
Q

What is the HbA1c diagnosis?

A

> 48mmol/mol

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7
Q

What should diet be like?

A

Eat wide range of foods - fruit, veg + starchy foods
Keep sugar + fat to minimum
Do NOT skip meals

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8
Q

How much exercise?

A

30mins/day 5 days/week

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9
Q

What education is available?

A

DESMOND/XPERT

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10
Q

What is DESMOND/XPERT?

A

Prepare individuals to cope with disease
Help to make informed decisions about care
Help patients make behavioural changes

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11
Q

What are the benefits of weight loss?

A

Decreased insulin requirement
Decreased diabetes risk
Increase HDL
Decreased LDL, cholesterol + triglycerides
Decreased BP

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12
Q

What are the 3 treatment targets?

A

Lipids
BP
Blood glucose

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13
Q

What are the microvascular complications?

A

Cognitive impairment
Retinopathy
Neuropathy
Diabetic foot
Sexual dysfunction

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14
Q

What are the macrovascular complications?

A

Cerebrovascular disease
Coronary heart disease
Peripheral vascular disease

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15
Q

What is monotherapy?

A

Lifestyle management + metformin

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16
Q

What is dual therapy?

A

Lifestyle management + metformin + additional agent

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17
Q

What is triple therapy?

A

Lifestyle management + metformin + 2 additional agents

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18
Q

What is the MoA for Sulphonylureas + Meglitinides?

A

Stimulate pancreas + increase insulin production

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19
Q

What is the MoA for Biguanides?

A

Act on liver + cells to decrease glucose production

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20
Q

What is the MoA for Thiazolidinediones?

A

Act on liver + cells to reduce insulin resistance

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21
Q

What is the MoA for alpha-glucosidase inhibitors?

A

Acts in the gut to slow absorption of sucrose/starch

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22
Q

What is the MoA for DDP4-inhibitors?

A

Acts on pancreas + brain to increase the effects of incretin

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23
Q

What is the MoA for GLP-1 agonists?

A

Acts on pancreas + brain to increase the effects of incretin

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24
Q

What is the MoA for SGLT-2 inhibitors?

A

Acts in the proximal tubules of nephrons in kidney to inhibit sodium-glucose co-transporter 2 leading to increased glucose excretion

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25
Q

What is an example of Biguanides?

A

Metformin

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26
Q

What does metformin do?

A

Decrease hepatic glucose production
Increase insulin sensitivity
Improve peripheral glucose
Delay intestinal glucose absorption

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27
Q

What are the side effects of metformin?

A

N+V
Diarrhoea
B12 deficiency = slow titration to avoid

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28
Q

What are the cautions of metformin?

A

Stop if eGFR <30L/min

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29
Q

What are the contraindications of metformin?

A

Risk tissue hypoxia in renal function (acute HF, resp failure + liver failure)
If having general anaesthesia suspend at least 24hrs before

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30
Q

What is an example of Thiazolidinedione?

A

Pioglitazone

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31
Q

What does Pioglitazone?

A

Increase insulin sensitivity

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32
Q

What are the side effects of Pioglitazone?

A

Weight gain
Oedema
Anaemia
GI disturbances
Headaches
Dizziness
Liver toxicity = uncommon

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33
Q

What are the contraindications of Pioglitazone?

A

Hx HF
Haematuria
Previous/active bladder

34
Q

What are the cautions with Pioglitazone?

A

Elderly = increased risk of fracture
HF + bladder Ca
Increased risk of fractures
Bladder cancer risk
CV risk

35
Q

What is an example of sulphonylureas?

A

Gliclazide

36
Q

What does gliclazide do?

A

Increase insulin secretion

37
Q

What is the dose for gliclazide?

A

Oral up to TDS with meals

38
Q

What are the side effects of gliclazide?

A

Hypoglycaemia
GI disturbances
Weight gain
Rashes

39
Q

What are the contraindications of gliclazide?

A

Ketoacidosis
Acute porphyria
Severe hepatic impairment

40
Q

What are the cautions of gliclazide?

A

G6PD
Renal impairment may increase risk of hypos

41
Q

What is the dose of Pioglitazone?

A

Oral OD (does NOT needed to be taken with meals)

42
Q

What is the dose of metformin?

A

Oral up to TDS with meals

43
Q

What is an example of Meglitinides?

A

Repaglinide
Nateglinide

44
Q

What does Nateglinide do?

A

Increase insulin secretion with a rapid onset + short duration of action

45
Q

What are the side effects of Nateglinide?

46
Q

What are the cautions with Nateglinide?

A

Elderly
Malnourished

47
Q

What is the off note of Nateglinide?

A

Can be used alone or in combo with metformin

48
Q

What is the dose of Nateglinide?

A

Oral TDS with main meals (within 30mins before meal)

49
Q

What is an example of DPP4 inhibitors?

A

Sitagliptin

50
Q

What does sitagliptin do?

A

Increase insulin secretion
Decreases glucagon secretion

51
Q

What is the dose for sitagliptin?

A

Oral OD (does NOT have to be with meals)

52
Q

What are the side effects of sitagliptin?

A

GI
Weight neutral
Headache
Nasopharyngitis
Rash
Pancreatitis
Joint pain

53
Q

What are the cautions of sitagliptin?

A

Renal impairment = dose reduced
Moderate to severe HF
Hx pancreatitis

54
Q

What are the contraindications of sitagliptin?

A

Ketoacidosis

55
Q

What is an example of SGLT-2 inhibitors?

A

Dapagliflozin

56
Q

What does dapagliflozin do?

A

Increase urinary excretion of glucose

57
Q

What are the side effects of dapagliflozin?

A

Dyslipidaemia
UTI
Thrush
Nausea
Constipation
Ketoacidosis
Lower limb amputations/fractures

58
Q

Which SGLT-2 increases risk of amputation?

A

Canagliflozin

59
Q

What are the contraindications of dapagliflozin?

A

SGLT2 discontinued if eGFR <45
>60

60
Q

What are the cautions of dapagliflozin?

A

Renal impairment
Hx HTN
Elderly
CVD
Vol depletion - eg. loop diuretics

61
Q

What is an example of a GLP-1?

A

Liraglutide

62
Q

What does liraglutide do?

A

Increase insulin secretion
Reduce glucagon secretion
Reduce gluconeogenesis
Slow gastric emptying

63
Q

What is the does of liraglutide?

A

Up to OW - S/C injection (does NOT have to be with meals)

64
Q

What are the side effects of liraglutide?

65
Q

What is the cautions with liraglutide?

A

Elderly
Risk of thyroid tumours?
Pancreatitis

66
Q

What are the contraindications of liraglutide?

A

Ketoacidosis
Severe GI disease
eGFR <30

67
Q

When may insulin be introduced?

A

Transiently in special circumstances - eg. surgery
Inadequate control
Offer high dose

68
Q

What is the dose for SGLT-2

69
Q

What are the Sick Day rules?

A

If vomiting, diarrhoea, fevers, sweats or shaking
STOP taking…
ACEi
ARBs
NSAIDs
Diuretics
Metformin
SGLT-2
Acarbose

70
Q

Which medications must be reviewed on Sick Days?

A

Sulphonylureas/meglitinides = not eating may be at risk of low = consider decreasing dose/stopping
GLP-1/DPP4’s = medical advice if severe abdominal pain
Pioglitazone = medical advice if SoB

71
Q

What family planning is needed?

A

Folic acid 5mg OD
Refer to pre-natal/gestational diabetes clinic ASAP
Many medications teratogenic

72
Q

What are precipitating factors of HHS?

A

Pneumonia
UTI
Cerebrovascular disease
MI
Trauma
Inadequate fluid intake

73
Q

When do you rehydrate fast for HHS?

A

AKI
Consequence of profound dehydration

74
Q

When do you rehydrate slowly for HHS?

A

Initial severity
Elderly
HF

75
Q

How is fluid loss estimated for HHS?

A

Between 100-220ml/kg

76
Q

How do you diagnose HHS?

A

Marked hypovolaemia
Serum osmolarity >320
Marked hyperglycaemia
Without hyperketonaemia
Without significant acidosis

77
Q

What are the treatment goals for HHS?

A

Normalise osmolarity
Replace fluid + electrolyte abnormalities
Normalise blood glucose

78
Q

How do you monitor osmolarity in HHS?

A

0-6hrs = check every 1hr
6-12hrs = check every 2hrs
12-24hrs = every 4hrs (if not improved every 2hrs)

79
Q

How do you monitor blood glucose?

A

0-6hrs = every hr
6-12hrs = every hr
12-24hrs = every hr

80
Q

How do you monitor clinical status?

A

Cardiac
Urine output
Establish IV access

81
Q

How do you monitor precipitating factors?

A

Review for sepsis, foot infection, treatment omission, vulnerable person + vascular event

S3 Case 4 - Endocrine (17 decks)

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