Wk 16: Diabetes complications

Question 1

What are the sick day rules?

Answer 1

• Insulin: inc monitoring
• SU: monitor hypo
• Fluids

W/hold:
- Metformin: lactic acidosis

• SGLT2i: DKA
• Restart: eating normally for 24 hrs + not acutely unwell

Question 2

What would you give a type 2 diabetic patient with cardiovascular risk factor?

Answer 2

• QRISK >10%: atorvastatin 20mg
• CKD stage 3 + confirmed urine microalbuminuria: atorvastatin 20mg OD

Question 3

What would you give a type 1 diabetic patient with cardiovascular risk factor?

Answer 3

Offer atorvastatin 20mg:

• > 40
• Diabetes >10yrs
• Establish nephropathy
• CVD risk factors

Question 4

When would you offer ACEi to a type 2 diabetic patient?

Answer 4

140/90

Question 5

When would you offer a ACEi to a type 1 diabetic patient?

Answer 5

• No albuminuria/metabolic syndrome - start >135/85
• Albuminuria/2 features of metabolic syndrome - start ≥130/80

Question 6

What is an indicator of diabetic nephropathy?

Answer 6

Microalbuminuria

Question 7

How do you test for ACR?

Answer 7

• Annually
• First pass morning urine
• 3: start ACEi + titrate to highest tolerated dose
• 3-30: consider + SGLT2i (dapagliflozin)
• > 30: + SGLT2i (dapagliflozin)

Question 8

What are the signs of diabetic ketoacidosis?

Answer 8

Triad w/ rapid onset:

• Glucose >11
• Ketone >3
• Bicarb <15 or pH <7.3

Question 9

What are the causes of DKA?

Answer 9

• Infection
• Inadequate insulin
• SGLT2i, corticosteroids

Question 10

How does DKA occur?

Answer 10

• Insulin deficiency + inc counter regulatory hormones
• Enhanced gluconeogenesis + glycogenolysis = hyperglycaemia
• Inc lipolysis + metabolism of FA = ketogenesis
• Metabolic acidosis
• Fluid depletion + electrolyte disturbance

Question 11

What is the treatment for DKA?

Answer 11

Fluid replacement:

• NaCl 0.9% IV w/ potassium chloride
• Blood glucose falls <14 add 10% glucose (prevent hypo)
• Consider red insulin to 0.05 when <14

Question 12

Why do you replace fluids when managing DKA?

Answer 12

• Correct hypotension
• Counteract osmotic diuresis
• Correct electrolyte imbalance
• Potassium prevent hypokalaemia

Question 13

What would you monitor in a patient with DKA?

Answer 13

• Hourly capillary glucose + ketones
• Bicarb + potassium: 60 mins, 2 hrs then 2 hrly
• U+E (4hrly) + FBC
• BP, pulse, temp, O2
• Further|: blood culture, ECG, CXR, MSU

Question 14

What happens to the insulin regimen during/before surgery?

Answer 14

• During = normal
• Day before: red dose LA to 80%
• If given in morning don’t red dose

Question 15

What are rules of metformin on the day of surgery?

Answer 15

• Am: if TDS omit lunchtime
• Pm: if TDS omit lunchtime

Question 16

What are rules of SU on the day of surgery?

Answer 16

• Am: omit, if BD take evening dose
• Pm: omit

Question 17

What are rules of pioglitazone, DPP4 + GLP1 on the day of surgery?

Answer 17

Take as normal

Question 18

What are the rules of SGLT2i on the day prior to/on the day of surgery?

Answer 18

Omit

Question 19

What would you offer an african/caribbean w/ hypertension + type 2 diabetes?

Answer 19

ARB