block 34 week 3 Flashcards

Question

short acting insulin?

Answer 1

* a.k.a regular or soluble insulin * Usually injected subcutaneously 30 minutes before a main meal. * The time of peak action is about 1-3 hours (so the peak of blood insulin corresponds to the blood glucose rise after the meal) and duration of action is 4-8 hours

Answer 2

* Such as isophane and lente insulin are insoluble suspensions of insulin mixed with protamine and /or zinc ions * The onset of action is 1-2 hours, the time of peak action is about 4-12 hours and duration of action is up to 24 hours thereby providing background insulin cover

Answer 3

* These have set ratios of short-acting and isophane insulin premixed in the insulin vial or cartridge * The most common mixture is 30% short-acting and 70% isophane which is then injected twice daily before breakfast and before the evening meal

Answer 4

* Continuous subcutaneous insulin infusion (CSII) is an insulin delivery system where insulin is delivered subcutaneously at an adjustable constant (basal) rate (usually 1 unit/hour) and further boosts delivered at meal times - Mimics physiology most closely but requires high degree of training and motivation and is expensive.

Answer 5

- suitable for variable meal times and variable activity levels - insulin levels can be decreased/interested

Answer 6

*General principles are teaching the ability to estimate the carbohydrate content of meals and snacks and adjusting the dose of insulin to suit

Answer 7

* ABCDE - check airway, breathing, circulation and disability, endocrinology - measure glucose * recovery position * measure capillary BG - finger prick * establish venous access by inserting cannula * glucose, U&Es, FBC, amylase * check arterial blood gas for pH and oxygen status

Answer 8

* usually when BG is below 4 * Edinburgh Hypoglycaemia Scale

Answer 9

* if concious administer oral glucose - 5 dextrosol tablets or 3 teaspoonfuls of sugar in a drink or 150ml lucozade * follow w starchy snack e.g. biscuit * recheck blood sugar in 10 mins

Answer 10

–100 ml of 20% or 200 ml of 10% glucose intravenous (IV) over 15 minutes followed by a saline flush –1 mg intra-muscular (IM) glucagon can be given if IV access is delayed (the effect only lasts for 30 minutes and not always effective) - Recheck blood sugar in 10 minutes and repeat IV glucose if < 4 mmol/L

Answer 11

if IV access is delayed - effect only lasts 30 min

Answer 12

* If the BG is high then test for diabetic ketoacidosis (hyperglycaemia + ketones + arterial pH<7.3) * If this is not ketoacidosis, investigate for other causes of unconsciousness –e.g. alcohol intoxication, sepsis, stroke, deliberate/accidental drug overdose, etc

Answer 13

- Treat hyperglycaemia with IV insulin infusion and IV Normal Saline until able to eat and drink normally

Answer 14

*State of severe uncontrolled diabetes due to insulin deficiency *Diagnosed by presence of high blood sugars, ketone bodies (in blood and urine) and acidosis

Answer 15

- Usually precipitated by infection, missing or incorrect insulin injections and newly diagnosed diabetes

Answer 16

* medical emergency - needs admission for IV fluids and insulin replacement * Patients get nausea/vomiting, extremely dehydrated, hypotensive and hyperventilate

Answer 17

*Tight BP control (<135/85 or <130/80 if microalbuminuria coexists)

Answer 18

*Aspirin if over 40 and have 1 other CV risk factor

Answer 19

*Atorvastatin 20 mg if over 40, nephropathy or additional CV risk factor

Answer 20

- Stop smoking advise and encourage exercise and weight loss if needed

Answer 21

– Diabetic retinopathy – Diabetic renal disease nephropathy – Diabetic neuropathy

Answer 22

–Peripheral vascular disease –Coronary heart disease - Cerebrovascular disease

Answer 23

* Hyperglycaemia -> polyuria and polydispsia * poor utilisation of glucose by cells which can lead to: weight loss (but less commonly than in T1DM) and fatigue

Answer 24

- impaired glucose tolerance - impaired fasting glucose

Answer 25

* T1: symptoms appear more quickly * Type 2: develop more slowly, patient may not notice any symptoms

Answer 26

* type 1: diagnosis more likely under 40 * type 2: risk increases with age

Answer 27

* risk increases with ethnicity: You’re more at risk of developing type 2 diabetes if you’re white and over 40 * or over 25 if you’re African-Caribbean, Black African, Chinese or South Asian.

Answer 28

* the main cause of morbidity/mortality is a 2-4x excess risk of cardiovascular disease - This is at least partly due to a higher prevalence of cardiovascular risk factors (e.g. hypertension, hyperlipidaemia) in diabetes patients

Answer 29

* Hypertension with antihypertensives * Hyperlipidaemia with lipid lowering agents e.g. statins - Prothrombotic tendency with anti-platelets.

Answer 30

*Since obesity is a major contributory factor to the development of type 2 diabetes, ways of preventing/treating obesity - Lifestyle changes are likely to be the most effective treatments

Answer 31

* Increases the risk of developing a range of serious diseases, including heart disease and cancers. * Associated with the development of long-term health conditions, placing demands on social care services. * Significant economic impact on the NHS and wider economy.

Answer 32

* Multicomponent interventions including community settings * Dietary intervention * Physical activity * Behavioral change strategies * Medications - Bariatric surgery

Answer 33

* Symptoms such as polydipsia, polyuria, blurred vision, unexplained weight loss, recurrent infections, and tiredness

Answer 34

* Signs such as acanthosis nigricans (a skin condition causing dark pigmentation of skin folds, typically the axillae, groin, and neck), which suggests insulin resistance.

Answer 35

* HbA1c of 48mmol/mol * fasting glucose level of 7 * random plasma glucose of 11.1mmol in the presence of symptoms or signs

Answer 36

* If the person is asymptomatic, do not diagnose diabetes on the basis of a single abnormal HbA1c or plasma glucose result. * Arrange repeat testing, preferably with the same test, to confirm the diagnosis. If the repeat test result is normal, arrange to monitor the person for the development of diabetes, the frequency depending on clinical judgement.

Answer 37

* at least 2 and both need to show hyperglycaemia - 1 can't be normal * one abn result needed if symptomatic, two needed if asymptomatic

Answer 38

* under 18 * ppts of any age suspected of having type 1 diabetes * symptoms of diabetes for less than 2 months * People taking medication that may cause hyperglycaemia (for example long-term corticosteroid treatment). * People with acute pancreatic damage, including pancreatic surgery. * end stage renal disease * HIV

Answer 39

* autoimmunity is the main factor in the destruction of beta cells * It is thought that genetically susceptible individuals may develop autoantibodies that target the beta-cells in response to an external trigger (e.g. viral infection). Up to 85% of patients with T1DM are found to have circulating autoantibodies.

Answer 40

* The anti-glutamic acid decarboxylase (anti-GAD) antibody, an enzyme found within beta cells of the pancreas, is most commonly identified.

Answer 41

* obesity and inactivity accounts for over 80% of the risk * poor diet - low fibre, high glycaemic index * low birth weight * meds * PCOS * history of GDM

Answer 42

* chronic panc * monogenic diabetes * cushings * drugs - steroids, antidepressants

Answer 43

* Usually younger, lean, european * not generally inherited * autoimmune condition * insulin deficient, always need insulin * presence of ketosis more likely

Answer 44

* genetic factors - HLA-DQ * autoimmunity: autoantibodies to glutamic acid decarboxylase

Answer 45

* environmental@ e.g. exposure to cows milk, enteroviruses, vitamin D deficiency

Answer 46

* mostly older, overweight, all racial groups * strong familial tendency * no autoimmunity * partial insulin def, insulin resistance

Answer 47

sedentary lifestyle, excessive food intake

Answer 48

decreased birth weight, thrifty phenotype

Answer 49

strong familial tendency

Answer 50

* prev of 0.25% in the UK * usually occurs in children but can present at any age

Answer 51

* insulin deficiency * high stress increases glucagon and cortisol levels -> decrease action of insulin * increased hepatic glucose production * inc ketogenesis

Answer 52

* ketone bodies -> vomiting and acidosis

Answer 53

osmotic diuresis

Answer 54

a few eeks

Answer 55

* secreted in response to glucose * glucose picked up by GLUT2 receptors * leads to release of stored insulin granules

Answer 56

* decreases hepatic glucose production * increases peripheral glucose uptake by muscles

Answer 57

* Lifestyle advice can help patients achieve sustained weight loss, better physical fitness, improved diet and ultimately improved glycaemic control. * high fibre, low-index carbohydate and controlling intake of high fat foods

Answer 58

* exercise - exercise daily with at least 150 minutes of moderate intensity activity over a weekly period.al

Answer 59

* Patients should be encouraged to reduce alcohol consumption and stop smoking. * Alcohol increases weight and may exacerbate or prolong hypoglycaemia induced by antidiabetic medications.

Answer 60

* Wash your hands. * Put a lancet into the lancet device so that it’s ready to go. * Place a new test strip into the meter. * Prick your finger with the lancet in the protective lancing device. * Carefully place the subsequent drop of blood onto the test strip and wait for the results.

Answer 61

* placed on the back of the upper arm * worn externally by the user, allowing glucose information to be monitored using a mobile app * offered to all people with T1D or insulin treated type 2 diabetes who are living with a learning disability and are recorded on their GP learning disability register.

Answer 62

* CGM is a small device that sticks to the skin. It measures glucose levels continuously throughout the day and night and can show trends in glucose levels over time. * The information is available instantly when a patient looks at the reader. Importantly, it can alert the user if the glucose goes too high or too low.

Answer 63

standard release metformin

Answer 64

* if they have chronic HF or established atherosclerotic CV disease offer an SGLT2 inhibitor

Answer 65

* Gradually increase the dose of standard-release metformin over several weeks to minimise the risk of gastrointestinal side effects in adults with type 2 diabetes. * If an adult with type 2 diabetes experiences gastrointestinal side effects with standard‑release metformin, consider a trial of modified‑release metformin

Answer 66

* CVD/ atherosclerosis: SGLT2 inhibitor * if not, use DPP4 inhibitor, pioglitazone, sulfonurea, SGLT2 inhib

Answer 67

* they have had a previous episode of DKA * they are unwell with intercurrent illness * they are following a very low carbohydrate or ketogenic diet.

Answer 68

* doctors can work with DSN to provide education and training to patients * medication manegement - monitoring adherence, assessing for side effects * patient support

Answer 69

* Doctors can refer patients to podiatrists for regular foot screenings, risk assessments, and preventive interventions. * patient education * collaboratiev care to address both medical and podiatric concerns

Answer 70

* nutritional assessments - provide individualized dietary recommendations for individuals with diabetes, taking into account their medical history, lifestyle, and treatment goals. * meal planning * nutrition education

Answer 71

Doctors and dietitians collaborate to integrate nutrition therapy into the overall diabetes management plan

Answer 72

hypoglycaemia and hyperosmolar hyperglycaemic state (HHS).

Answer 73

* diabetic retinopathy * Other disorders include cataracts and ocular palsies. * When diagnosed with T2DM, GPs should immediately refer for eye screening.

Answer 74

* Persistent damage to the retina leads to areas of ischaemia and release of angiogenetic factors such as vascular endothelial growth factor (VEGF). * This promotes new formation of vessels that are weak and friable. * This leads to complications including haemorrhage, fibrosis and retinal detachment.

Answer 75

* Photocoagulation is used to manage proliferative disease. * The aim of photocoagulation is to burn holes within the ischaemic retina to prevent the release angiogenesis factors (e.g. VEGF), which stimulate new vessel formation.

Answer 76

* The earliest sign of diabetic nephropathy is the presence of microalbuminuria, which can be assessed with an albumin:creatinine ratio (ACR). * An ACR 3 - 30 mg/mmol is suggestive of microalbuminuria

Answer 77

* A1: < 3 mg/mmol, normal or mild increase * A2: 3 - 30 mg/mmol, moderately increased * A3: > 30 mg/mmol, severely increased

Answer 78

* microalbuminuria is a marker of systemic microvascular damage and patients shoild be treated w an ACEi or ARB even in the presence of normotension

Answer 79

* Chronic kidney disease (CKD) in diabetes is evidenced by a persistently low eGFR < 60 mmol/L and/or an ACR persistently > 3 mg/mmol/L. * Offer an SGLT2 if ACR > 30 mg/mmol

Answer 80

- symmetrical poluyneuropathy - mononeuropathy - diabetic amyotrophy - autonomic neuropathy

Answer 81

typically a peripheral neuropathy that occurs in the leg secondary to loss of vibration, pain and temperature sensation.

Answer 82

damage to a single cranial or peripheral nerve (e.g. third nerve palsy).

Answer 83

a spectrum of disease affecting the lumbosacral plexus leading to symmetrical pain, weakness and wasting of the proximal muscles of the leg.

Answer 84

- a spectrum of conditions related to damage of the autonomic nervous system - Some of the major autonomic neuropathies include postural hypotension, gastroparesis (delayed gastric emptying leading to vomiting), diarrhoea, bladder dysfunction and erectile dysfunction.

Answer 85

* secondary to the combination of peripheral neuropathy and poor vascular supply. * Due to loss of sensation and poor blood supply, patients are at risk of a number of complications including diabetic ulcers, secondary infection (e.g. cellulitis, osteomyelitis), skin necrosis and eventually amputation.

Answer 86

* results from loss of sensation and subsequent repeated micro-trama to the foot - traditionally mid foot * Microtrauma in the presence of poor peripheral blood flow leads to remodelling, swelling and distortion of the whole joint.

Answer 87

* diabetes is a major RF for atherosclerosis

Answer 88

* diagnosis based on Whipple's triad * Low blood glucose concentration * Symptoms of hypoglycaemia * Reversal of symptoms when blood glucose concentration is restored to normal

Answer 89

insulin and sulphonylureas

Answer 90

* acute diabetic emergency that occurs in patients with type 2 diabetes - life threatening * HHS occurs insidiously over several days with dehydration and metabolic disturbances that are more extreme than diabetic ketoacidosis (DKA).

Answer 91

* Hypovolaemia * Hyperglycaemia (> 30 mmol/L) * Mild or absent ketonaemia (blood ketones < 3 mmol/L) * High osmolality (> 320 mOsm/kg)

Answer 92

* Patients are usually elderly with multiple co-morbidities, and as a result may be very unwell. * HSS usually occurs in the elderly but is increasingly recognised in younger ppts

Answer 93

* In HHS, the relative lack of insulin is coupled with a rise in counter-regulatory hormones (e.g. cortisol, growth hormone, glucagon) that leads to a profound rise in glucose. * bc a certain level of insulin is retained, this prevents the development of ketosis that epitomises DKA * However, the level of insulin is inadequate to prevent profound hyperglycaemia. * The excessive glucose leads to massive osmotic diuresis within the kidneys with the loss of essential electrolytes such as sodium and potassium. * As water is lost, there is profound dehydration and reduced circulating volume, resulting in hyperosmolarity and marked hyperglycaemia * The increase in osmolality increases compensatory mechanisms such as release of anti-diuretic hormone (ADH) and stimulation of thirst.

Answer 94

* However, if this cannot compensate for the renal water loss (e.g. elderly patients with co-morbidities) then hypovolaemia develops with progression to acute kidney injury, electrolyte disturbances, hypotension and coma.

Answer 95

* The hyperosmolar state of the condition leads to hyperviscosity that increases the risk of arterial and venous thrombosis (e.g. stroke, DVT).

Answer 96

* Most cases are from a new diagnosis of type 2 diabetes * Infection * High-dose steroids * Myocardial infarction * Vomiting * Stroke * Poor treatment concordance

Answer 97

* Polydipsia * Polyuria * Nausea * Vomiting * Muscle cramps * Weakness * Altered mental status * Seizures * Coma

Answer 98

* dehydration * hypotension & tachycardia * decreased urine output * decreased concious level and coma * focal neurology signs

Answer 99

The diagnosis of HHS is based on identification of characteristic features including marked hyperglycaemia, raised serum osmolality, and mild/absent ketonaemia.

Answer 100

* Normalise osmolality * Normalise blood glucose * Replace fluid and electrolytes * Prevention of arterial/venous thrombosis * Prevention of complications & foot ulceration

Answer 101

* more common w T1D but can also occur w T2D

Answer 102

* DKA results from an absolute or relative deficiency of insulin, leading to increased hepatic glucose production, decreased peripheral glucose utilization, and enhanced lipolysis with subsequent ketone body formation

Answer 103

* Driven by insulin deficiency which can be caused by inadequate insulin therapy, illness, or stress. * The most common precipitating factors of DKA are infection, missed insulin doses and myocardial infarction.

Answer 104

- hyperglycaemia - ketosis - metabolic acidosis

Answer 105

* hyperglycaemia: Increased gluconeogenesis and glycogenolysis in the liver, combined with decreased glucose utilization in peripheral tissues, result in hyperglycemia.

Answer 106

* ketosis: Insulin deficiency promotes lipolysis, releasing free fatty acids that are converted to ketone bodies (β-hydroxybutyrate and acetoacetate) in the liver * High levels of ketone bodies lead to ketonemia and ketonuria.

Answer 107

* metabolic acidosis: Accumulation of ketone bodies causes an increase in the anion gap metabolic acidosis.

Answer 108

* ketosis presents as characteristic sweet, fruity, or acetone odour on the breath.

Answer 109

fluid resus, begin insulin therapy

Answer 110

* endocrinologists - They provide expertise in adjusting insulin therapy, managing electrolyte imbalances, and addressing underlying factors contributing to DKA.

Answer 111

* diabetic specialist nurses - DSNs play a crucial role in educating patients about diabetes self-management, including insulin administration, blood glucose monitoring, and lifestyle modifications. They also provide support and guidance during hospitalization and after discharge.

Answer 112

* GP - ongoing diabetes management, preventative care, regular monitoring of blood glucose levels

Answer 113

- Patients classically exhibit polyuria, polydipsia, and profound weakness, with notable signs including - Kussmaul breathing, dehydration, and a distinct acetone odour on the breath.

Answer 114

* fluid replacement - isotonic saline * insulin - IV infusion * correction of electrolyte disturbance - potassium * long-acting insulin should be continued, short-acting insulin should be stopped

Answer 115

* ketonaemia and acidosis should have been resolved within 24 hours * If this hasn't happened the patient requires senior review from an endocrinologist * patient should be reviewed by diabetes specialist nurse prior to discharge

Answer 116

* shock and denial * fear and anxiety - prospect of managing a chronic condition * stress - managing the demands of diabetes care such as monitoring blood glucose levels. adhering treatment regimes, making lifestyle adjustments * grief and a sense of loss of their pre-diagnosis lifestyle * increased risk of depression * anger and frustration - resentful towards their body or towards others who don't understand their challenges

Answer 117

* family dynamics - as it can often require adjustments in daily routine, meal planning and lifestyle habits * peer relationships - Individuals with type 1 diabetes may face social challenges in peer interactions, such as concerns about disclosing their condition, managing blood glucose levels in social settings, and addressing misconceptions or stigma related to diabetes

Answer 118

* school/ work envir - concerns around accomodations. stigma, discrimination * social activities e.g. sports might need planning and consideration of diabetes * emotional wellbeing - isolation, depression, low self esteem * stigma and discrimination

Answer 119

* glucose level of below 3.3mmol

Answer 120

- excess insulin - sulfonylureas - hypoglycaemia

Answer 121

* excess of insulin - Most commonly this is from exogenous, injectable insulin used in the management of type I or type II diabetes mellitus. * Levels of insulin may be higher than necessary if the patient has taken too much insulin, or has used the same amount of insulin whilst not eating enough or skipping a meal or snack

Answer 122

* Sulfonylureas (e.g. gliclazide) act by increasing the secretion of insulin from β-cells. ] * Hypoglycaemia is a common adverse effect, especially when starting this medication or increasing dose.

Answer 123

* Hypoglycaemia is more likely to occur in diabetics who have a viral illness, have drunk alcohol, exercised more than usual or have just started or changed dosage of a new medication.

Answer 124

IGF-1, lithium, pentamidine

Answer 125

* alcohol consumption - most commmon non iatrogenic cause of hypo * This is due to its inhibitory effect on gluconeogenesis and glycogenolysis.

Answer 126

* sweating * shaking * hunger * anx * nausea * tremor * palpitations

Answer 127

* Weakness * Vision changes * Confusion * Dizziness

Answer 128

* landmark clinical trial * demonstrated the importance of intensive glycemic control in preventing or delaying the development of diabetes-related complications in individuals with type 1 diabetes. * The DCCT provided robust evidence that maintaining blood glucose levels as close to normal as possible significantly reduces the risk of long-term complications of diabetes, such as retinopathy, nephropathy, and neuropathy.

Answer 129

* The trial demonstrated that achieving lower hemoglobin A1c (HbA1c) levels through intensive insulin therapy was associated with better outcomes.

Answer 130

* DCCT established HbA1c targets for individuals with type 1 diabetes, with the goal of reducing levels to below 7% to minimize the risk of complications. * This set a benchmark for glycemic control that has since been widely adopted in clinical practice

Answer 131

* A diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged. * People with diabetes are advised to avoid sugar-sweetened beverages (including fruit juice). * carb counting

Answer 132

* The risk of developing the condition is as high as 75% if both parents have suffered from the condition. * Certain ethnicities (e.g. Asian/African) have a 2-4x increased risk of developing the condition.

Answer 133

* inactivity and obesity account for the majority of the risk * Poor dietary habit (low fibre, high glycemic index diet) * Low birth weight * Medications * Polycystic ovarian syndrome * History of GDM

Answer 134

* An inability of peripheral tissue to respond to insulin leads to hyperglycaemia, which in turn causes hyperinsulinaemia. * In the early stages of insulin resistance, abnormal regulation of glucose occurs following a meal in the post-prandial state. * This is termed impaired glucose tolerance (IGT). * IGT is a major risk for the future development of frank diabetes and cardiovascular disease.

Answer 135

* High levels of glucose during the fasting state (between meals) can also occur with insulin resistance, which is termed impaired fasting glucose (IFG). * IFG itself is another risk factor for the development of frank diabetes.

Answer 136

- hba1c 42-47 - IFG and IGT are often collectively referred to as ‘pre-diabetes’ as they are significant markers for the future development of the condition if no intervention occurs to reduce risk (e.g. lifestyle and diet modifications).

Answer 137

* As hyperglycaemia develops, the beta cells within the Islets of Langerhans must secrete more insulin to deal with the increase in glucose leading to hyperinsulinaemia. * These high levels of insulin are still inadequate to restore glucose homeostasis. It is thought that high glucose levels (and lipids) are toxic to beta cells leading to a depletion in their cellular mass. This is termed glucotoxicity

Answer 138

* reflects the average blood glucose concentration over a three month period (the average survival time of an erythrocyte) * increases as blood glucose levels increase * diabetes >48mmol * 42-47mmol = pre-diabets

Answer 139

* conditions interrupting erythryopotein like (e.g. EPO use, iron-deficiency), haemoglobin structure (e.g. haemoglobinopathies), glycation (e.g. CKD, alcoholism), or red cell survival (e.g. haemolysis, splenectomy) will effect the level of HbA1c.

Answer 140

* should be approx 4-6mmol

Answer 141

* diabetes can be made if the fasting glucose levels are ≥ 7 mmol/L on two separate readings in a patient who is asymptomatic or a single reading if the patient is symptomatic

Answer 142

* fasting glucose level between 6-6.9 mmol/L are said to have impaired fasting glucose (IFG), which is a marker of pre-diabetes and increases the risk of developing overt diabetes.

Answer 143

* not used for diagnosis * A random blood glucose level ≥ 11.1 mmol/L is indicative of diabetes

Answer 144

* Patients with a high random plasma glucose should be assessed for potential complications (e.g. HHS, DKA) and concurrent illness.

Answer 145

* Concurrent illnesses can increase plasma glucose levels as part of the normal physiological stress response. * Patients with high levels should undergo further testing (e.g. HbA1c or fasting glucose levels).

Answer 146

* The oral glucose tolerance test (OGTT) measures the ability of the body to deal with a glucose load over a two hour period. * use has largely been replaced by Hba1c

Answer 147

Levels greater than 11 mmol/L at 2 hours are suggestive of diabetes.

Answer 148

Levels ≥ 7.8 mmol/L but < 11.1 mmol/L are suggestive of impaired glucose tolerance (IGT)

Answer 149

* the oral glucose tolerance test is usually reserved for assessment of gestational diabetes

Answer 150

* education * lifestyle advice * medication * monitoring for complications

Answer 151

* Biguanide * lowers blood glucose levels through inhibition of hepatic gluconeogenesis whilst increasing peripheral insulin sensitivity and enhancing peripheral uptake of glucose.

Answer 152

* Standard release metformin * Aim for HbA1c < 48 mmol/mol, increasing dose as needed

Answer 153

* All patients with T2DM should be started on metformin unless contraindicated (e.g. CKD, those at risk of lactic acidosis, poorly tolerated).

Answer 154

* Monitor renal function, consider modified-release preparations if develop adverse GI effects

Answer 155

* Consider dual antidiabetic therapy if HbA1c rises > 58 mmol/L * Metformin in combination with a second antidiabetic agent: * Sulfonylurea (SU) * Dipeptidyl peptidase-4 inhibitor (DPP-4i) * Pioglitazone * Sodium–glucose cotransporter 2 inhibitor (SGLT-2i)

Answer 156

* Aim for HbA1c < 53 mmol/mol

Answer 157

* Consider triple antidiabetic therapy or an insulin-based regimen if HbA1c > 58 mmol/mol * Metformin, DPP-4i and SU * Metformin, pioglitazone and SU * Metformin, pioglitazone/SU, and SGLT-2i

Answer 158

* In patients on triple antidiabetic therapy and ongoing poor glucose control, consider further intensification * Consider combination treatment with metformin, SU and glucagon-like peptide-1 (GLP-1) mimetic

Answer 159

* DPP-4i or pioglitazone or SU * Aim for HbA1c < 48 mmol/mol or < 53 mmol/mol if treatment with a SU

Answer 160

* If HbA1c rises > 58 mmol/mol consider a combination of: * SU and pioglitazone * SU and DPP-4i or * Pioglitazone and DPP-4i

Answer 161

* Consider an insulin-based regimen if HbA1c > 58 mmol/mol

Answer 162

* use should be considered early in the management of patients w T2DM * usually considered in patents with poor glycemic control despite dual antidiabetic with metformin and another agent. * not appropriate when there's sig risk of hypogylacemia

Answer 163

* In general, patients are offered an intermediate-acting insulin therapy such as NPH in the initial stages. * If glycemic control is particularly bad (e.g. HbA1c > 75 mmol/L) patients may be started on mixed insulin (intermediate and short-acting).

Answer 164

* Long-acting insulin is usually reserved for patients where hypoglycaemia is a problem with NPH insulin or the patients rely on carers for help with their injections.

Answer 165

aim HbA1c < 48 mmol/mol

Answer 166

aim HbA1c < 48 mmol/mol

Answer 167

aim HbA1c < 53 mmol/mol

Answer 168

aim HbA1c < 53 mmol/mol

Answer 169

* patients should be regularly reviewed and complications assessed on at least an annual basis. * During each clinic review, patients should have their BMI checked, smoking status clarified and assessed for any psychosocial issues (e.g. anxiety/depression).

Answer 170

Every 3-6 months, patients should have their HbA1c checked and management changed accordingly

Answer 171

annual retinal screening and eye check

Answer 172

renal function (eGFR) and albumin:creatinine ratio (ACR)

Answer 173

assessment for peripheral neuropathy, autonomic neuropathy, full examination including footwear, monofilament assessment of neuropathy, vascular assessment +/- dopplers.

Answer 174

primary/secondary prevention strategy with optimisation of blood pressure and lipids.

Answer 175

ACE inhibitors/A2RBs are first-line regardless of age

Answer 176

* TFT, LFT, U&E, CXR prior to treatment * TFT, LFT every 6 months

Answer 177

fluid retention

Answer 178

heart failure - Thiazolidinediones

Answer 179

bladder cancer -

Answer 180

genital infections, diabetic ketoacidosis

Answer 181

GI upset, lactic acidosis

Answer 182

nausea, vomiting, pancreatitis

Answer 183

weight gain, hypoglycaemia, lipodystrophy

Answer 184

high phosphate

Answer 185

- Tertiary hyperparathyroidism usually occurs after prolonged secondary hyperparathyroidism - the glands become autonomous, and so produce excessive PTH even after the cause of hypocalcaemia has been corrected; - -this then causes the hypercalcaemia that typifies tertiary hyperparathyroidism.

Answer 186

- high PTH - Ca2+ normal or low

Answer 187

In secondary hyperparathyroidism there in hyperplasia of the parathyroid glands in response to chronic hypocalcaemia (or hyperphosphataemia) and is a normal physiological response

Answer 188

P for primary, phosphate is low

Answer 189

seConDary for calcium, calcium is low, vitamin D is low

Answer 190

TerTiary = viTamin D and phosphaTe are low

Answer 191

The most common endogenous cause of Cushing's syndrome is a pituitary adenoma (also known as Cushing's disease)

Answer 192

Hypercalcaemia is the most common metabolic complication in patients with cancer - treated w iV N saline

Answer 193

C peptide levels, high in t2

Answer 194

T2DM initial therapy: if metformin is contraindicated + patient has a risk of CVD, established CVD or chronic heart failure → SGLT-2 monotherapy

Answer 195

* pregnancy * prolactinoma * physiological * polycystic ovarian syndrome * primary hypothyroidism * phenothiazines, metoclopramide, domperidone

Answer 196

* Insulin * Testosterone * Oestrogen

Answer 197

Exophthalmos is a specific feature of Grave's disease rather than generic hyperthyroidism - diplopia

Answer 198

- Hypercalcaemia with suppressed PTH is highly suspicious for malignancy (e.g. solid organ, or myeloma). - Alternative diagnoses which can cause this pattern include thyrotoxicosis.

Answer 199

- when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. - They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently

Answer 200

- Cerebral oedema - imp comp espec in young ppts

Answer 201

- deteriorating mental status/ level of consciousness, incontinence unexpected for age, - abnormal neurogenic respiratory pattern (e.g. grunting, abnormal tachypnoea, apnoea) and vomiting.

Answer 202

propanolol - non cardioselectibe

Answer 203

metformin in addition to insulin

Answer 204

Liver failure = triad of encephalopathy, jaundice and coagulopathy

Answer 205

Co-amoxiclav is a well recognised cause of cholestasis - gallstones

Answer 206

subacute (De Quervain's) thyroiditis. Usually self limiting - conservative management + ibuprofen

Answer 207

Carbimazole induces remission of Graves' disease and therefore is only needed for a period of 12-18 months usually.

Answer 208

duloxetine

Answer 209

AST: ALT > 2 suggests alcoholic hep

Answer 210

- Propylthiouracil for pregnant women in the first trimtester w hyperthyroidism instead of carbimazole - When the woman reaches 12 weeks (second trimester), so would be switched to Carbimazole, as Propylthiouracil can cause severe hepatic injury.

Answer 211

radioactive iodine is the treatment of choice

Answer 212

Closely monitor legs and feet of patients taking canagliflozin (SGLT2 inhibitors) for ulcers or infection - possible increased risk of amputation

Answer 213

beta blockers, propylthiouracil and hydrocortisone

Answer 214

* thyroid or non-thyroidal surgery * trauma * infection * acute iodine load e.g. CT contrast media

Answer 215

* fever > 38.5ºC * tachycardia * confusion and agitation * nausea and vomiting * hypertension * heart failure * abnormal liver function test - jaundice may be seen clinically

Answer 216

- Endoscopic intestinal biopsy, however, is the gold standard for the diagnosis of coeliac disease and should be offered to all adult patients if the diagnosis is suspected following serology. - Jejunal biopsy, as the duodenum and jejunum are the most affected portions of bowel in coeliac disease, while the ileum is not as affected (unlike in Crohn's disease),

Answer 217

TIBC is high in IDA, and low/normal in anaemia of chronic disease

Answer 218

Alcohol excess can mimic Cushing's disease

Answer 219

F - Fluids I - Insulin (Fixed rate 0.1u/kg/hr) G - Monitor glucose P - Monitor / give potassium I - Treat any underlying infections / triggers C - Monitor for signs of cerebral oedema K - Monitor ketones & pH

Answer 220

Pretibial myxoedema is an uncommon but specific feature in Grave's disease that is not seen in hyperthyroidism secondary to other causes

Answer 221

pioglitazone causes weight gan sulfonureas cause weight gain

Answer 222

SGLT2 inhibitors

Answer 223

An angiotensin II receptor blocker should be used first-line for black TD2M patients who are diagnosed with hypertension

Answer 224

non-alcoholic fatty liver disease

Answer 225

fasting > 7.0, random > 11.1 - if asymptomatic need two readings

Answer 226

stop drinking alcohol, and low sodium intake

Answer 227

Ferritin is low in iron deficiency anaemia but high or normal in anaemia of chronic disease

Answer 228

Neurological features of pernicious anaemia may include peripheral neuropathy, subacute combined degeneration of the spinal cord and neuropsychiatric disorders - more lkely w T1D bc both autoimmune

Answer 229

Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels are characteristic of autoimmune hepatitis

Answer 230

haemodialysis

Answer 231

The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol

Answer 232

DAMN AKI? Diuretics Aminoglycosides and ACE inhibitors Metformin NSAIDs.

block 34 week 3 Flashcards

(270 cards)