T2DM pharm

Question 1

Dietary advice for T2DM

Answer 1

encourage high fibre, low glycaemic index sources of carbohydrates
include low-fat dairy products and oily fish
control the intake of foods containing saturated fats and trans fatty acids
limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
discourage the use of foods marketed specifically at people with diabetes
initial target weight loss in an overweight person is 5-10%

Question 2

HbA1c target - with just lifestyle measures

Answer 2

48mmol/mol

Question 3

HbA1c target - lifestyle measures + metformin

Answer 3

48 mmol/mol

Question 4

HbA1c target - includes any drug which may cause hypoglycaemia

Answer 4

53mmol/mol

Question 5

1st line agent if HbA1c > 48mmmol/mol

Answer 5

metformin

Question 6

Options HbA1c has risen to 58mmol/mol already on metformin

Answer 6

sulfonylurea
gliptin
pioglitazone
SGLT-2 inhibitor

Question 7

Criteria for GLP1 mimetic

Answer 7

if triple therapy is not effective, not tolerated or contraindicated then consider combination therapy with metformin, a sulfonylurea and a glucagon-like peptide1 (GLP1) mimetic if:

BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or

BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities

Question 8

Should metformin be continued when starting insulin

Answer 8

Yes

Question 9

Example of GLP-1 mimetic and how does it work

Answer 9

Exenatide

Increases insulin secretion and inhibits glucagon secretion

Question 10

what is a potentially beneficial effect of GLP-1 mimetics

Answer 10

Typically result in weight loss

Question 11

How is exenatide usually given

Answer 11

Exenatide must be given by subcutaneous injection within 60 minutes before the morning and evening meals. It should not be given after a meal.

Question 12

Major adverse effect of GLP-1 mimetics

Answer 12

Nausea and vomiting

Link to severe pancreatitis

Question 13

How do DPP-4 inhibitors work

Answer 13

dipeptidyl peptidase-4, DPP-4 inhibitors increase levels of incretins (GLP-1 and GIP) by decreasing their peripheral breakdown

Question 14

When do NICE recommend use of DPP-4 inhibitors

Answer 14

NICE suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated or the person has had a poor response to a thiazolidinedione

Question 15

Adverse effects of DPP-4 inhibitors

Answer 15

GI problems
Dizziness
Peripheral oedema
Pancreatitis

Question 16

How do SGLT-2 inhibitors work

Answer 16

SGLT-2 inhibitors reversibly inhibit sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.

Question 17

Examples of SGLT-2 inhibitors

Answer 17

Examples include canagliflozin, dapagliflozin and empagliflozin.

Question 18

Important adverse effects of SGLT-2 inhibitors

Answer 18

urinary and genital infection (secondary to glycosuria). Fournier’s gangrene has also been reported
normoglycaemic ketoacidosis
increased risk of lower-limb amputation: feet should be closely monitored

Question 19

Key potential beneficial side effect of SGLT-2 inhibitors

Answer 19

Weight loss

Question 20

Metformin mechanism of action

Answer 20

increases insulin sensitivity
decreases hepatic gluconeogenesis
may also reduce gastrointestinal absorption of carbohydrates

Question 21

Adverse effects of metformin

Answer 21

gastrointestinal upsets are common
reduced vit b12 absorption
lactic acidosis with severe liver disease or renal failure

Question 22

Metformin contraindications

Answer 22

CKD(review)
Periods where there is tissue hypoxia(MI, AKI, severe dehydration)
iodine-containing x-ray contrast media

Question 23

Advice regarding stopping metformin in imaging procedures using iodine-containing contrast

Answer 23

metformin should be discontinued on the day of the procedure and for 48 hours thereafter

Question 24

Fasting glucose and HbA1c which indicate pre diabetes

Answer 24

a fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk

Question 25

Mx of pre diabetes

Answer 25

Lifestyle modification: weight loss, increased exercise, change in diet at least yearly follow-up with blood tests is recommended NICE recommend metformin for adults at high risk

Question 26

What are the two main types of impaired glucose regulation

Answer 26

impaired fasting glucose (IFG) - due to hepatic insulin resistance impaired glucose tolerance (IGT) - due to muscle insulin resistance patients with IGT are more likely to develop T2DM and cardiovascular disease than patients with IFG

Question 27

Definition of impaired fasting glucose

Answer 27

a fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

Question 28

Definition of impaired glucose tolerance

Answer 28

impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Question 29

What should patients with IFG be offered

Answer 29

people with IFG should then be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn't have diabetes but does have IGT

Question 30

Example of a sulfonylurea

Answer 30

Gliclazide

Question 31

Sulfonylureas mechanism of action

Answer 31

Sulfonylureas bind to and close ATP-sensitive K+ (KATP) channels on the cell membrane of pancreatic beta cells, which depolarizes the cell by preventing potassium from exiting. This depolarization opens voltage-gated Ca2+ channels. The rise in intracellular calcium leads to increased fusion of insulin granules with the cell membrane, and therefore increased secretion of mature insulin

Question 32

Side effects of sulfonylureas

Answer 32

Abdominal pain; diarrhoea; hypoglycaemia; nausea | Weight gain

Question 33

Which conditions cause lower than expected levels of HbA1c

Answer 33

Sickle cell anaemia GP6D deficiency Hereditary spherocytosis

Question 34

Which conditions cause higher than expected levels of HbA1c

Answer 34

Vitamin B12/folic acid deficiency IDA Splenectomy

Question 35

What is hyperosmolar hyperglycaemic state

Answer 35

Very high blood glucose levels (often over 40 mmol/L) develop as a result of a combination of illness, dehydration and an inability to take normal diabetes medication due to the effect of illness Characterised by severe hyperglycaemia with marked serum hyperosmolarity, without evidence of significant ketosis

Question 36

Characteristic features of HHS that differentiate it from DKA

Answer 36

Hypovolaemia. Marked hyperglycaemia (30 mmol/L or more) without significant hyperketonaemia (<3 mmol/L) or acidosis (pH>7.3, bicarbonate >15 mmol/L). Osmolality usually 320 mosmol/kg or more

Question 37

Illnesses which can precipitate HHS

Answer 37

``` MI Infections Strokes Hyper/Hypothermia Pancreatitis PE ```

Question 38

HHS symptoms

Answer 38

Signs of gross dehydration Focal or global neurological dysfunction Generalised weakness + visual impairment Nausea and vomiting(less than dka) Confusion Seizures

Question 39

IX in HHS

Answer 39

Urinalysis shows marked glycosuria with normal or slightly elevated ketones Capillary glucose Serum osmolarity usually >320mmol/L ABG

Question 40

Initial general measures in HHS mx

Answer 40

A-E NG tube if impaired consciousness and risk of aspiration Consider transfer to HDU Alert acute med/diabetic team

Question 41

Main principles of HHS management

Answer 41

Measure osmolality to monitor response to treatment IV 0.9% NaCl Low-dose IV insulin only once blood glucose no longer falling with iv fluids alone Monitor for complications(fluid overload, cerebral oedema) Prophylactic anticoagulation

Question 42

Complications of HHS

Answer 42

``` Ischaemia or infarction VTE ARDS DIC Rhabdymylosis Cerebral oedema ```

Question 43

How can serum osmolality

Answer 43

it can be estimated by 2 * Na+ + glucose + urea

Question 44

criteria for bariatric surgery

Answer 44

BMI 40-50 | Other conditions such as T2DM and HTN

Question 45

What is whipple's triad

Answer 45

should be present in cases of true hypoglycaemia: hypoglycaemic symptoms, accompanying low blood glucose concentration, and resolution of symptoms after raising the blood glucose concentration to normal

Question 46

When should fast-acting carbohydrates be used via mouth for mx of hypoglycaemia

Answer 46

Any patient with a blood-glucose concentration less than 4 mmol/litre, with or without symptoms, and who is conscious and able to swallow

Question 47

Mx of hypoglycaemia which does not respond to fast-acting carbohydrates

Answer 47

intramuscular glucagon or glucose 10% intravenous infusion Thiamine supplementation in alcoholics

Question 48

When is glucagon not appropriate

Answer 48

Ineffective in patients whose liver glycogen is depleted(should not be used in anyone who has fasted for a prolonged period or has adrenal insufficiency) Glucagon may be less ineffective in patients taking a sulfonylurea

Question 49

Why is glucose 50% not recommended

Answer 49

it is hypertonic, thus increases the risk of extravasation injury, and is viscous, making administration difficult

Question 50

Mx of hypoglycaemia if unresponsive to glucagon

Answer 50

glucose 10% intravenous infusion, or alternatively glucose 20% intravenous infusion should be given.