W6 Diabetes Mellitus (AG)

Question 1

Diabetes mellitus (DM)
What is the definition?

Answer 1

➢ DM is a group of metabolic disorders in which persistent Glucose is caused by deficient insulin secretion or by resistance to the action of insulin.
➢ This leads to the abnormalities of carbohydrate, fat and protein metabolism.
➢ Type 1 DM describes an absolute insulin deficiency in which there is little or no endogenous insulin secretory capacity due to destruction of insulin-producing β-cells in the pancreatic islets of Langerhans.

Question 2

What is the presentation of DM?
BM above what conc?

Answer 2

INC Glucose (above 11 mmol/L), ketosis, rapid weight loss, a BMI < 25 Kg/m2, age < 50 years, and a personal family history of autoimmune disease

Question 3

Initial Diagnosis
Patient presenting with hyperglycaemia AND 1 or more of which symptoms?: (7)

Answer 3

✓Polyuria (freq urination)
✓Polydipsia (excessive thirst)
✓ketosis
✓rapid weight loss
✓age of onset under 50 years
✓body mass index (BMI) below 25 kg/m2
✓personal and/or family history of autoimmune disease.

Question 4

Early Care Plan for Diabetes (for info)

Answer 4

1) Medical assessment to:
– ensure the diagnosis is accurate
– ensure appropriate acute care is given when needed
– review medicines and detect potentially associated disease
– detect adverse vascular risk factors
2) Environmental assessment to understand:
– the social, home, work and recreational circumstances of the person and their carers
– their lifestyle (including diet and physical activity)
– other relevant factors, such as substance use
3) Cultural and educational assessment to:
– find out what they know about diabetes
– help with tailoring advice, and with planning treatments and diabetes education
programmes
4) Assessment of their emotional wellbeing to decide how to pace diabetes education

Question 5

Initial Diabetes Assessment
What are the tests and questions to ask?

Answer 5

• acute medical history
• social, cultural and educational
  history, and lifestyle review
• complications history and symptoms
• diabetes history (recent and long
  term)
• other medical history
• family history of diabetes and
  cardiovascular disease
• medication history
• vascular risk factors
• smoking
• general examination
• weight and BMI
• foot, eye and vision examination
• urine albumin:creatinine ratio (ACR) and
  estimated glomerular filtration rate (eGFR)
• psychological wellbeing
• attitudes to medicine and self-care
• immediate family and social relationships, and
  availability of informal support.

Question 6

Individualised and culturally appropriate plan:
What are the factors?

Answer 6

• diabetes education, including dietary advice
• insulin therapy, including dosage adjustment
• self-monitoring avoiding hypoglycaemia and
  maintaining hypoglycaemia awareness
• family planning, contraception and pregnancy planning
• cardiovascular risk factor monitoring and management
• complications monitoring and management
• communicating with the diabetes professional team (how often and how to contact them)
• how often they will have follow-up appointments, and what these will cover

Question 7

Education and Information:
What is DAFNE?

Answer 7

• DAFNE stands for Dose Adjustment For Normal Eating.
• It aims to help adults with DM1 lead as normal a life as possible, whilst also maintaining blood G levels within healthy targets, to reduce the risk of long-term DM complications.

Question 8

Dietary Management

Answer 8

• Carbohydrate counting ✓
• Glycaemic index diets X
• Dietary advice: ✓
  -On healthy eating and balanced diet
  -Changing their insulin dosage to reduce G excursions when varying their diet.
  -Snacks (appropriate)
  -Modify nutritional recommendations to take account of associated features of DM,
  including: excess weight and obesity, underweight, disordered eating, hypertension,
  renal failure
• Physical activity: ✓
  -can reduce their enhanced cardiovascular risk in the medium and long term.
  -the effect of physical activity on blood glucose levels when hyperglycaemic and
  hypo-insulinaemic (there is a risk of worsening hyperglycaemia and ketonaemia)

Question 9

Blood Glucose Management
What Measurement to take?
Alternative monitoring methods? (3)

Answer 9

• Measure HbA1c levels every 3 to 6 months in adults with DM1.
• Measure HbA1c levels more often in adults with DM1 if their blood G control is suspected to be changing rapidly.
• Measure HbA1c using calibrated methods.
• Tell adults with DM1 their HbA1c results after each measurement and have their most recent result available at consultations.
• If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using 1 of the following:
  ➢ fructosamine estimation
  ➢ quality-controlled blood glucose profiles
  ➢ total glycated haemoglobin estimation (if abnormal haemoglobins)
  (if genetic issues and cant obtain HbA1c)

Question 10

Blood Glucose Management
Targets:
What is the target HbA1c level?
What is the higher target for pt who are prone to hypoglycaemic episodes?

Answer 10

• Aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long-term vascular complications.
• Agree an individualised HbA1c target.
• Take into account factors such as their daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia.
• Ensure that aiming for an HbA1c target is NOT accompanied by problematic hypoglycaemia.
• Document the proportion of adults with DM1 who reach an HbA1c level of 53 mmol/mol (7%) or lower (this is higher target)

Question 11

Blood Glucose Management
HbA1c measurement: (for info)

Answer 11

• Glycated haemoglobin (HbA1c) forms when RBCs are exposed to G in the plasma. The HbA1c test reflects average plasma G over the previous 2-3 months

Monitoring:
➢ HbA1c is a reliable indicator of microvascular and macrovascular complications.
➢ In DM1 it should be measured every 3-6
months.
➢ In DM2 every 3-6 months until stable on
medication and then reduced to every 6 months.

Question 12

Blood Glucose Management
Monitoring:
What is the target?
How often to monitor?
What should patients aim for? (4)

Answer 12

A target of 48 mmol/mol (6.5%) or lower is recommended in T1DM. Blood G
concentration should be monitored at least four times a day, including before each
meal and before bed.

Patients should aim for:
➢ a fasting blood-glucose of 5-7 mmol/L on waking
➢ 4-7 mmol/L before meals
➢ 5-9 mmol/L at least 90 minutes after eating
➢ at least 5 mmol/L when driving

Question 13

Blood Glucose Management
What is CGM?
What are the 2 types?
What to consider about patients before CGM? (4)

Answer 13

Continuous Glucose Monitoring
* Offer adults with DM1 a choice of real-time continuous glucose monitoring (rtCGM) or intermittently scanned continuous glucose monitoring (isCGM) (is CGM, commonly referred to as ‘flash’), based on:

➢their individual preferences,
➢needs,
➢characteristics, and
➢the functionality of the devices available.

Question 14

Blood Glucose Management:
Self-monitoring of capillary blood G - Frequency of self-monitoring of blood G
(for info)

Answer 14

• Advise patients to routinely self-monitor their blood G levels, and to measure at least 4 times a day (including before each meal and before bed).
• Support them to measure at least 4 times a day, and up to 10 times a day:
• if their target for blood G control, measured by HbA1c level, is NOT reached
• if they are having more frequent hypoglycaemic episodes
• if there is a legal requirement to do so, such as before driving during periods of
  illness before, during and after sport
• when planning pregnancy, during pregnancy and while breastfeeding
• if they need to know their blood G levels more than 4 times a day for other
  reasons (e.g. impaired hypoglycaemia awareness, or they are undertaking high-
  risk activities)

Question 15

Enable additional blood G measurement (>10 times a day) for adults with DM1 who are using capillary blood G monitoring if this is necessary because of? (2)

Answer 15

• the person’s lifestyle (for example, they drive for long periods of time, they undertake high-risk activities or have a high-risk occupation, or they are travelling) or
• impaired hypoglycaemia awareness.

Question 16

Blood Glucose Management
Blood glucose targets?

Answer 16

1) Advise adults with DM1 to aim for:
- a fasting plasma glucose level of 5 to 7 mmol/L on waking, and
- a plasma glucose level of 4 to 7 mmol/Lbefore meals at other times of the day.
2) Advise patients who choose to measure after meals to aim for a plasma G level of 5 to 9mmol/L at least 90 minutes after eating.
3) Agree bedtime target plasma G levels.
Take into account the timing of their last meal of the day and the related insulin dose, and
ensure the target is consistent with the recommended fasting level on waking

Question 17

Blood Glucose Management
Empowering people to self-monitor blood glucose (for info)

Answer 17

• Teach self-monitoring skills at the time of diagnosis and the start of insulin therapy.
• When choosing blood glucose meters:
• take the needs of the adult with DM1 into account
• ensure that meters meet current ISO standards.
• Teach adults with DM1 how to measure their blood G level, interpret the results
  and take appropriate action. Review these skills at least annually.
• Support adults with DM1 through structured education on self-monitoring of blood
  G.

Question 18

Sites for self-monitoring of blood glucose?

Answer 18

Monitoring blood G using sites other
than the fingertips CANNOT be
recommended as a routine alternative
to conventional self-monitoring of
blood G

Question 19

Type 1 diabetes - insulin therapy
Where is insulin injected?

Answer 19

Injections: Insulin should be injected into a body area with plenty of subcutaneous
fat—usually the abdomen (fastest absorption rate) or outer thighs/buttocks (slower
absorption compared with the abdomen or inner thighs).

Question 20

What are the types of insulin therapy?

Answer 20

1) Multiple daily injection basal-bolus insulin regimens: one or more separate injections of
intermediate-acting insulin or basal insulin alongside multiple bolus short-acting insulin
before meals - flexibility to tailor insulin with carbohydrate load of each meal
2) Mixed (biphasic regimen) - one to three insulin injections of short-acting mixed with
intermediate-acting insulin
3) Continuous subcutaneous insulin infusion - regular continuous pump

Question 21

What is Lipo-hypertrophy?

Answer 21

• A lump of fatty tissue under your skin
• Can occur due to repeatedly injecting into the same small area. This can be minimised by using different injection sites in rotation. Injection sites should be checked for signs of
  infection, swelling and bruising

Question 22

Insulin regimens:
Which to offer to new T1DM patients?

Answer 22

• Offer multiple daily injection basal–bolus insulin regimens as the insulin
  injection regimen of choice for all adults with type 1 diabetes.
• Do NOT offer adults newly diagnosed with DM1 non-basal–bolus insulin regimens (that is, twice-daily mixed, basal only or bolus only)

Question 23

Insulin Therapy
Long-acting insulin: Treatment steps
What to offer and alternatives? (4)

Answer 23

• Offer twice-daily insulin detemir as basal insulin therapy.
• Consider 1 of the following as an alternative basal insulin therapy to twice-daily insulin detemir :
  1) An insulin regimen that is already being used by the person if it is meeting their agreed treatment goals (such as meeting their HbA1c targets or time in target glucose range and minimising
  hypoglycaemia)
  2) once-daily insulin glargine (100 units/ml) if insulin detemir is not tolerated or the person has a strong
  preference for once-daily basal injections
  3) once-daily insulin degludec (100 units/ml) if there is a particular concern about nocturnal hypoglycaemia
  4) once-daily ultra-long-acting insulin such as degludec (100 units/ml) for people who need help from a carer or healthcare professional to administer injections.
• There is a risk of severe harm and death due to inappropriately withdrawing insulin from pen devices (NHS England’s patient safety alert)

Question 24

Long-acting insulin: Things to consider (for info)

Answer 24

• When starting an insulin for which a biosimilar is available, use the product with the lowest acquisition cost.
• Ensure the risk of medication errors with insulins is minimised (risk of medication error with high strength, fixed combination and biosimilar insulin products.
• Consider other basal insulin regimens only if the regimens above do not meet their agreed treatment goals. When choosing an alternative insulin regimen, take account of:

1) the person’s preferences
2) comorbidities
3) risk of hypoglycaemia and diabetic ketoacidosis
4) any concerns around adherence
5) acquisition cost.

• When prescribing, ensure that insulins are prescribed by brand name

Question 25

Rapid-acting insulin: What to consider?

Answer 25

• Offer rapid-acting insulin analogues that are injected before meals, rather than rapid-acting soluble human or animal insulins, for mealtime insulin replacement for adults with DM1.
• Do NOT advise routine use of rapid-acting insulin analogues after meals for adults with DM1.
• If an adult with DM1 has a strong preference for an alternative mealtime insulin, respect their wishes and offer the preferred insulin

Question 26

Mixed Insulin: What to consider?

Answer 26

• Consider a twice-daily human mixed insulin regimen for adults with DM1 if a multiple daily injection basal–bolus insulin regimen is not possible AND a twice-daily mixed insulin regimen is used.
• Consider a TRIAL of a twice-daily analogue mixed insulin regimen if an adult using a twice-daily human mixed insulin regimen has hypoglycaemia that affects their quality of life.

Question 27

Insulin Monitoring (for info)

Answer 27

• Since blood G concentration varies substantially throughout the day, ‘normoglycaemia’ cannot always be achieved throughout a 24-hour period without causing damaging hypoglycaemia.
• Patients should maintain a blood G concentration of between 4 - 9 mmol/L for most of the time (4–7 mmol/L before meals and <9 mmol/L after meals).
• While accepting that on occasions, for brief periods, the blood G concentration will be above these values; strenuous efforts should be made to prevent it from falling below 4 mmol/L.
• Patients using multiple injection regimens should understand how to adjust their insulin dose according to their carbohydrate intake.
• With fixed-dose insulin regimens, the carbohydrate intake needs to be regulated, and should be distributed throughout the day to match the insulin regimen.
• The intake of energy and of simple and complex carbohydrates should be adequate to allow normal growth and development but obesity must be avoided.

Question 28

What are the features of an insulin pen?

Answer 28

Cap, Needle, needle attachment point, insulin resevoir, dose adjustment dial, injection button, insulin cartridge, expiration label

Question 29

Insulin delivery (for info)

Answer 29

• For adults with DM1 who inject insulin, provide their preferred insulin injection delivery device.
• For adults with DM1 and special visual or
  psychological needs, provide injection devices or needle-free systems that they can use independently for accurate dosing.
• Offer needles of different lengths to adults with DM1 who are having problems such as pain, local skin reactions and injection site leakages.
• Advise patients to rotate insulin injection sites and avoid repeated injections at the same point within sites.
• Provide patients with:
  ➢ suitable containers for collecting used needles
  ➢ a way to safely get rid of these containers.
  ➢ Advice on safe use and disposal of sharps
• Check injection site condition at least annually, and whenever new problems with blood G control occur

Question 30

Sick Day Rules:
What does SICK stand for?

Answer 30

Illness and infections, as well as other
forms of stress, can raise your blood
glucose (sugar) levels to dangerously
high levels. As part of the body’s
defence mechanism for fighting illness
and infection, more glucose is released
into the blood stream.

Sugar- check bm every 2-3 hrs
Insulin- always take your insulin or can lead to DKA
Carbs- drink lots of fluids, if sugars are high, drink sugar-free liquids, if they are low, drink carb-containing drinks
Ketones- check your urine or blood ketones every 4hrs, take rapid-acting insulin if ketones are present

Question 31

Safety Info re insulin (for info)

Answer 31

• Insulin should not be extracted from insulin pen devices- can lead to huge medical errors if a higher strength is extracted (fatal overdose)
• The words ‘Unit’ or ‘International Unit’ should not be Abbreviated
• Risk of cutaneous amyloidoisis at injection site- advise pt to rotate injection site (d.d to lipodystrophy)

Question 32

What is a Insulin Passport?

Answer 32

• Insulin Passports and patient information booklets should be offered to patients receiving insulin.
• The Insulin Passport provides a record of the patient’s current insulin preparations and contains a section for emergency information

Question 33

Hypoglycaemia:
What is the definition?
Treatment for Blood-glucose greater than 4 mmol/L?
Treatment for Blood-glucose less than 4 mmol/L conscious and able to swallow?

Answer 33

Hypoglycaemia is a lower than normal blood-glucose concentration. It results from an
imbalance between glucose supply, glucose utilisation, and existing insulin concentration

1. treated with a small carbohydrate snack (slice of bread or meal)
2. • Fast-acting carbohydrate by mouth (lift liquid, 4-5 glucose tablets, 1.5-2 tubes of glucose 40% gel, 150-200 mL pure fruit juice, 3-4 heaped teaspoons of sugar in water.
     * Orange juice not given in low-potassium diet due to CKD, sugar in water not given in
     patient taking acarbose, chocolates and biscuits avoided if possible due to high fat
     content and delayed stomach emptying
     * If necessary, repeat treatment after 10-15 minutes up to 3 times.
     * Once blood-glucose is above 4 mmol/L - provide a long-acting carbohydrate

• If not response after 3 treatment cycles, should be treated with IM glucagon or glucose 10% IV
• Alcoholic patients should be given thiamine supplementation

Question 34

What are some symptoms of Hypoglycaemia?

Answer 34

Shaking or trembling
Fast HR
Extreme hunger
Sweating
Dizziness
Confusion, difficulty concentrating

Question 35

Hypoglycaemia treatment
Blood-glucose less than 4 mmol/L but unconscious, having seizures or are very aggressive:

Answer 35

• IM glucagon, if unsuitable or no response after 10 minutes then give IV glucose 10% or
  IV glucose 20%
• A long-acting carbohydrate should be given as soon as possible once the patient has
  recovered and their blood-glucose concentration is above 4 mmol/litre (e.g. two
  biscuits, one slice of bread, 200–300 mL of milk)

Question 36

Hypoglycaemia (for info)

Answer 36

• Hypoglycaemia caused by a sulfonylurea or long-acting insulin, may persist for up to 24–36 hours following the last dose, especially if there is concurrent renal impairment.
• Alcohol can make the signs of hypoglycaemia less clear, and can cause delayed
  hypoglycaemia; drink in moderations and when accompanied with food.
• Beta-blockers can also blunt hypoglycaemic awareness, by reducing warning signs
  such as tremor.

Question 37

Hypoglycaemia awareness and management:
What are the scoring tools?

Answer 37

Identifying and quantifying impaired hypoglycaemia awareness

• Assess hypoglycaemia awareness in adults with DM1 at each annual review.
• Use the Gold score or Clarke score to quantify hypoglycaemia awareness in adults with DM1,
  checking that the questionnaire items have been answered correctly.
• Explain to patients that impaired awareness of the symptoms of plasma G levels < 3 mmol/L is associated with a significantly increased risk of severe hypoglycaemia.

Question 38

Managing impaired hypoglycaemia awareness (for info)

Answer 38

• Ensure that adults with DM1 and impaired hypoglycaemia
  awareness have had structured education in flexible insulin therapy using basal–bolus regimens, and are following its principles correctly.
• Offer additional education focusing on avoiding and treating hypoglycaemia to patients who still have impaired
  hypoglycaemia awareness after structured education in flexible insulin therapy.
• Avoid relaxing individualised blood glucose targets to address impaired hypoglycaemia awareness.
• For adults with DM1 and impaired hypoglycaemia awareness who are using lower target blood glucose levels
  than recommended, encourage them to use the recommended targets.
• Review insulin regimens and doses, and prioritise ways to avoid hypoglycaemia in adults with DM1 with impaired hypoglycaemia awareness, including:
  ➢ reinforcing the principles of structured education
  ➢ offering an insulin pump
  ➢ offering real-time continuous glucose monitoring.
• If, despite these interventions, an adult with DM1 has impaired hypoglycaemia awareness
  that is associated with recurrent severe hypoglycaemia, consider referring them to a
  specialist centre

Question 39

Preventing and managing hypoglycaemia?

Answer 39

• Explain to patients that a fast-acting form of G is needed for managing hypoglycaemic
  signs/symptoms in people who can swallow.
• Patients who have a decreased level of consciousness because of hypoglycaemia (cannot safely take oral treatment) should be:
  ➢ given IM glucagon (IV G may be used)
  ➢ checked for response at 10 minutes, and then given IV G if their level of consciousness is not improving significantly
  ➢ then given oral carbohydrate when it is safe to administer it, and put under continued
  observation by someone who has been warned about the risk of relapse.
• Explain that:
  ➢ it is very common to experience some hypoglycaemic episodes with any insulin regimen
  ➢ they should use a regimen that avoids or reduces the frequency of hypoglycaemic episodes, while maintaining the most optimal blood G control possible.

Question 40

If hypoglycaemia becomes unusually problematic or increases in frequency, review the following possible causes:

Answer 40

➢ inappropriate insulin regimens (incorrect dose distributions and insulin types)
➢ meal and activity patterns, including alcohol
➢ injection technique and skills, including insulin resuspension if necessary
➢ injection site problems
➢ possible organic causes, including gastroparesis
➢ changes in insulin sensitivity (including drugs affecting the renin–angiotensin system and renal failure)
➢ mental health problems
➢ previous physical activity
➢ lack of appropriate knowledge and skills for self-management.

Manage nocturnal hypoglycaemia (symptomatic or detected on monitoring) by:
➢ reviewing knowledge and self-management skills
➢ reviewing current insulin regimen, evening eating habits and previous physical activity
➢ choosing an insulin type and regimen that is less likely to cause low glucose levels at night.
- If early cognitive decline occurs in adults on long-term insulin therapy, then in addition to normal investigations consider possible brain damage from overt or covert hypoglycaemia, and the need to manage this.

Question 41

Symptoms of diabetic ketoacidosis?

Answer 41

DKA is a life-threatening condition caused by dangerously high blood sugar levels (common in T1 uncommon in T2)

Vomiting
Excessive thirst (polydipsia)
Dehydration
Urinating more frequently (polyruria)
Rapid breathing
Fruity smelling breath
Stomach pains/nausea
Drowsiness/reduced consciousness
Weight loss
Inc HR
Excessive tiredness

Question 42

How is DKA diagnosed ? (levels)

Answer 42

DKA is characterised by hyperglycaemia (blood glucose above 11 mmol/L or known diabetes mellitus), ketonaemia (capillary or blood ketone above 3 mmol/L or significant ketonuria of 2+ or more), and acidosis (bicarbonate less than 15 mmol/L and/or venous pH less than 7.3)

Question 43

Aim of treatment of DKA?
Treatment given?

Answer 43

To restore circulatory volume, correct
electrolyte imbalance and hyperglycaemia, clear ketones and suppress ketogenesis

• Initially: IV fluid replacement (sodium chloride 0.9%)
• followed by IV insulin (should continue to take their long-acting insulin at the usual dose)
• Potassium replacement and glucose administration to prevent hypokalaemia and hypoglycaemia depending on result

Question 44

Ketone monitoring and managing diabetic ketoacidosis
Management of DKA:

Answer 44

DKA management can be associated with mortality and morbidity. Therefore, the following should be considered when managing DKA:
➢ fluid balance
➢ acidosis
➢ cerebral oedema
➢ electrolyte imbalance
➢ that DKA can affect the results of standard diagnostic tests (white cell count, body
temperature, electrocardiogram [ECG])
➢ respiratory distress syndrome
➢ cardiac abnormalities
➢ precipitating causes
➢ infection management, including opportunistic infections
➢ gastroparesis

Question 45

Management of DKA

Answer 45

• Use isotonic saline for primary fluid replacement in adults with DKA, NOT given too rapidly except in cases of circulatory collapse.
• Do NOT generally use bicarbonate for managing DKA in adults.
• Give IV insulin by infusion to adults with DKA.
• When the plasma G concentration has fallen to 10 to 15 mmol/L in adults with DKA, give ** G-containing fluids** (not more than 2 litres in 24 hours) so that the insulin infusion can be continued at a sufficient rate to clear ketones (e.g., 6 units/hour, monitored for effect).
• Begin K+ replacement early in DKA in adults, with frequent monitoring for hypokalaemia.
• Do NOT generally use phosphate replacement when managing DKA in adults.
• In adults with DKA who have reduced consciousness, think about:
  ➢ inserting a nasogastric tube and
  ➢ monitoring urine output using a urinary catheter and
  ➢ giving VTE prophylaxis.
• To reduce the risk of catastrophic outcomes in adults with DKA, use continuous monitoring and frequent reviews that cover all aspects of clinical management

Question 46

Associated illness with T1DM:

Answer 46

• In adults with DM1 who have unexplained weight loss, assess for coeliac disease.
• Be alert to the possibility of other autoimmune diseases in adults with DM1 (including Addison’s disease and pernicious anaemia).
• Offer advice on monitoring for thyroid disease.

Question 47

Control of Cardiovascular Diseases:

Answer 47

Aspirin
* Do NOT offer aspirin for the primary prevention of cardiovascular disease in adults with DM1.

Identifying cardiovascular risk - Assess cardiovascular risk factors annually, including:
* estimated glomerular filtration rate (eGFR) and urine albumin:creatinine ratio (ACR)
* smoking
* blood glucose control
* blood pressure
* full lipid profile (including high-density lipoprotein [HDL] and low-density lipoprotein [LDL] cholesterol, and triglycerides)
* age
* family history of cardiovascular disease
* abdominal adiposity

Question 48

Interventions to risk and manage cardiovascular disease

Answer 48

• Lipid modification
• Give adults with DM1 who smoke advice on stopping smoking
• Advise adults who do not smoke never to start smoking
• Provide intensive management for adults who have had MI or
  stroke.
• For angina or other ischaemic heart disease, β-blockers should
  be considered.

Question 49

Blood pressure management:
What are the BP ranges?

Answer 49

• For adults with a urine ACR < 70 mg/mmol, aim for a clinic BP < 140/90mmHg.
• For adults with an ACR of 70 mg/mmol or more, aim for a clinic BP < 130/80mmHg.
• In adults aged 80 or more, whatever the ACR, aim for a clinic BP < 150/90mmHg.
• Start a trial of a renin–angiotensin system blocking drug as first-line therapy

Question 50

Complications of T1DM?

Answer 50

o Microvascular complications — retinopathy, nephropathy, and neuropathy.
o Macrovascular complications — cardiovascular disease (CVD), cerebrovascular disease, and peripheral arterial disease.
o Metabolic complications — diabetic ketoacidosis (DKA) and dyslipidaemia.
o Psychological complications — these include anxiety; depression; and eating disorders. In children and young people, behavioural and conduct disorders, family/relationship difficulties, and risk-taking behaviour (including non-adherence to recommended treatment).
o Increased risk of developing other autoimmune conditions — including thyroid disease, coeliac disease, Addison’s disease, and pernicious anaemia.
o Reduced quality of life.
o Reduced life expectancy.

Question 51

Miss Sarah Aikon, a 19 years old patient, was recently diagnosed with DM1. She visits your pharmacy for advice on monitoring her blood G levels.
How often should you suggest Miss Aikon tests her blood G?
A. At least once a day
B. At least twice a day
C. At least three times a day
D. At least four times a day
E. At least twice a week

Answer 51

=D
Before each meal and before you go to bed. You may need to test more often such as before and during driving, when you exercise, if you start to feel unwell (as part of sick-day rules) or if you have problems with hypos

Question 52

Miss Sarah Aikon, a 19 years old patient, was recently diagnosed with DM1. She visits your pharmacy for advice on monitoring her blood G levels.
Which of the following blood glucose levels taken 90 minutes after eating would be within an accepted range for Miss Aikon?
A. 1 mmol/litre
B. 2 mmol/litre
C. 4 mmol/litre
D. 8 mmol/litre
E. 10 mmol/litre

Answer 52

=D
(Between 5 and 9 mmol/L)

Question 53

For patients described select the most suitable starting dose of Tresiba from the list
above. Each option may be used once, more than once or not at all

Dose of Tresiba
A. 22.4 units
B. 15 units
C. 30 units
D. 28 units
E. 24 units
F. 27.2 units
G. 25.6 units
H. 10 units

Miss Sophie Ali is a 23-year-old woman with DM1. Despite taking Novorapid 4 units
before meals and Lantus 28 units once daily, she continues to have high G levels on
waking. Miss Ali’s pharmacist independent prescriber decides to switch her to Tresiba as
it has been shown to be longer acting and may provide her with better control

Answer 53

=A
Miss Ali’s basal insulin dose is Lantus 28 units once daily:
* 20% of 28 units = 5.6 units
* So, 28 units - 5.6 units = 22.4 units

For pt with T1DM, a dose reduction of 20% based on the prev basal insulin dose or basal component of a continuous subcut insulin infusion should be considered with subsequent individual dosage adjustments based on the glycaemic response.