Type 1 diabetes

Question 1

what is the advice from the DVLA regarding patients with diabetes + driving

Answer 1

• all drivers taking insulin (long term) must inform DVLA
• measure blood glucose before driving + every 2 hrs during driving
• Blood-glucose should always be above 5 mmol/litre while driving
• always have a supply of a fast-acting carbohydrate (sugary snack) in car
• if signs of hypoglycemia occur, stop car, have a snack + wait 45 mins before driving again

Question 2

why should patients with diabetes only drink alcohol in moderation + when accompanied by food

Answer 2

Alcohol can make the signs of hypoglycaemia less clear, and can cause delayed hypoglycaemia

Question 3

what does the HbA1c tell you

Answer 3

average plasma glucose over the previous 2 to 3 months and provides a good indicator of glycaemic control

• also a reliable predictor of microvascular and macrovascular complications and mortality (lower HbA1c = lower risk of complications/mortality)
• note: HbA1c test can be performed at any time of the day and does not require any special preparation such as fasting *

Question 4

when might an oral glucose tolerance test be used

Answer 4

• to establish gestational diabetes
• In patients who have less severe symptoms and a blood-glucose concentration that does not establish or exclude diabetes (e.g. impaired fasting glycaemia)

note: An oral glucose tolerance test involves measuring the blood-glucose concentration after fasting, and then 2 hours after drinking a standard anhydrous glucose drink

Question 5

what causes type 1 diabetes

Answer 5

the insulin-producing beta-cells (in the pancreatic islets of Langerhan) are destroyed which means the body produces little/no insulin

lack of insulin = hyperglycaemia

Question 6

what are the symptoms of diabetes

Answer 6

• increased thirst
• increased urination
• sudden unexplained weight loss
• increased vaginal infections
• sexual problems
• wounds that won’t heal
• numbing/ tingling in hands or feet
• blurred vision

Question 7

what is the target HbA1c for patients with type 1 diabetes

Answer 7

48 mmol/mol or lower

Question 8

what treatment do all patients with type 1 diabetes need

Answer 8

insulin

Question 9

describe Multiple daily injection basal-bolus insulin regimens in type 1 diabetes

Answer 9

• one or more injections of an intermediate/long acting insulin throughout the day as the basal insulin. then injections of short-acting insulin before meals

Question 10

describe the Mixed (biphasic) insulin regimen

Answer 10

a mixture of short-acting insulin + intermediate acting insulin.

The insulin preparations may be mixed by the patient at the time of injection, or a premixed product can be used.

Question 11

describe the Continuous subcutaneous insulin infusion (insulin pump)

Answer 11

regular or continuous amount of insulin (usually in the form of a rapid-acting insulin analogue or soluble insulin), delivered by a programmable pump and insulin storage reservoir

• insulin pumped through subcutaneous needle or cannula

Question 12

what is the first line insulin treatment choice in type 1 diabetes

Answer 12

multiple daily injection basal-bolus insulin regimen.

using:
- Twice-daily insulin detemir (Levemir) should be offered as the long-acting basal insulin therapy.
- Short acting insulin also used before meals, examples
insulin aspart (Novorapid, Fiasp), insulin lispro (Humalog), Insulin glulisine

if Levemir not tolerated, can give Once-daily insulin glargine (Lantus/ Toujeo /Abasaglar)

• note: a twice-daily mixed insulin regimen should be considered if first line not possible*

Question 13

when is Continuous subcutaneous insulin infusion (insulin pump) therapy used

Answer 13

should only be offered to patients who suffer disabling hypoglycaemia or who have high HbA1c concentrations (69 mmol/mol [8.5%] or above) with multiple daily injection therapy

Question 14

what can affect the blood glucose of a diabetic

Answer 14

• food
• exercise
• infection
• stress
• accidental or surgical trauma (increases insulin required)
• renal or hepatic impairment (decreases insulin required)
• endocrine disorders e.g addison’s disease (decreases insulin required)
• pregnancy (increases insulin required)

note insulin/ antidiabetics may need to be adjusted in these occur

Question 15

name some examples of intermediate-acting insulins

Answer 15

isophane insulin + biphasic isophane insulin

Humulin, Insulatard

Question 16

name some examples of short-acting insulins

Answer 16

• insulin aspart (Novorapid, Fiasp)
• insulin lispro (Humalog)
• Insulin glulisine

Question 17

name some examples of long-acting insulins

names start with: LLTT

Answer 17

insulin detemir 
insulin degludec (can be combined with liraglutide)
insulin glargine (can be combined with lixisenatide)

(Levemir, Lantus, Toujeo, Tresiba)

Question 18

name examples of biphasic (pre-mixed) inuslins

Answer 18

biphasic insulin aspart
biphasic insulin lispro

(Novomix, Humulin M3, Humalog Mix)

Question 19

what causes diabetic ketoacidosis (more common in type 1 diabetes)

Answer 19

• when insulin levels become dangerously low, this causes glucose levels to rise (hyperglycaemia). The body can no longer use glucose effectively, so the body starts using fat as an energy source. This causes ketones to be released which make the blood acidic.

acidic blood causes symptoms of diabetic ketoacidosis (DKA)

Question 20

what are the symptoms of diabetic ketoacidosis

Answer 20

• rapid weight loss
• nausea or vomiting
• abdominal pain
• fast and deep breathing
• sleepiness
• a sweet smell to the breath (like pears)
• a sweet or metallic taste in the mouth
• different odour to urine or sweat

note DKA most commonly occurs in type 1 diabetics but can also occur in type 2 diabetes (more commonly in patients taking SGLT2 inhibitors)

Question 21

what are the 2 classes of short-acting insulins

Answer 21

short-acting insulins made up of:

• Soluble insulin (can be given I.V, S/C, I.M)
• rapid-acting insulin (e.g Novorapid, Fiasp, Humalog)

Question 22

what is the most common use for soluble insulins

Answer 22

soluble insulin given (via I.V) in diabetic emergencies e.g. diabetic ketoacidosis and perioperatively
- can also be given before meals

note: when soluble insulin is given I.V the results are instant (within a few mins). when soluble insulin is given S/C it takes 30-60 mins

Question 23

why is it important NOT to extract insulin from insulin pen devices

Answer 23

If insulin extracted from a pen or cartridge is of a higher strength, it can lead to a significant and potentially fatal overdose

Question 24

how do you prevent insulin overdose (based in insulin device use)

Answer 24

The words ‘unit’ or ‘international units’ should not be abbreviated.

Specific insulin administration devices should always be used to measure insulin i.e. insulin syringes and pens.

Insulin should not be withdrawn from an insulin pen or pen refill and then administered using a syringe and needle.

Question 25

why should patients make sure they rotate injection sites when using insulin

Answer 25

• to prevent deposits of amyloid protein under the skin (cutaneous amyloidosis)
• to prevent lipodystrophy (fatty deposits at injection sites)

Question 26

why should diabetics not inject into lumpy areas of skin

Answer 26

may reduce the effectiveness of insulin

if patients change from injecting into lumpy areas, to unaffected areas, this may cause hypoglycaemia

Question 27

what is the target fasting blood glucose

Answer 27

4–7 mmol/litre before meals at other times of the day

Question 28

what is the target blood glucose after meals

Answer 28

5–9 mmol/litre at least 90 minutes after eating