Diabetes

Question 0

What dietary aims should patients with T2DM have?

Answer 0

Reduce cholesterol, BMI and HbA1c
Reduce fats, especially polysaturated
Reduce salt
Reduce alcohol
Eat 5 fruit and veg a day

10kg weight loss in prediabetic stage reduces risk of later developing diabetes

Question 1

When is hba1c not used to diagnose diabetes?

Answer 1

T1DM
Patients with renal failure on EPO
Anaemia
Acute illness - blood sugar levels will rise
Antiviral drugs

Question 2

How is T2DM diagnosed?

Answer 2

One reading hba1c greater than 48 with symptoms

Two readings greater than 48 without symptoms, at least a month apart

If greater than 70, start oral treatment! If not, begin trial of lifestyle interventions

Question 3

When should low dose aspirin (75mg) be offered in diabetes?

Answer 3

If over 50 and BP is under 145/90

If under 50 and has significant risk factors

Question 4

How should microbuminuria be tests for in T2DM?

Answer 4

Early morning urinary albumin:creatinine ratio

> 2.5mg/mmol in men
3.5mg/mmol in women

Positive result should be repeated once or twice in the subsequent month

Question 5

How should microalbuminuria be managed?

Answer 5

Offer ACEI or ARBs
Maintain low blood pressure

In type two, prognostic of IHD

Question 6

Which t1dm patients should be started on statins?

Answer 6

All patients over 40 with diabetes for more than 10 years, or that have complications

Question 7

What regular reviews should patients with T2DM have?

Answer 7

Diet control - once a year
Cardiovascular risk estimation - annual
Renal complications - measure proteinuria, creatinine and eGFR
Retinopathy - annual screening
Neuropathy - annual foot check

General diabetic checks- twice a year

Question 8

How does metformin work?

Answer 8

Metformin is a biguanide

Reduces hepatic glucose production
Increases glucose uptake by cells
Delays intestinal glucose absorption

Reduces cholesterol and does not cause weight gain!

Question 9

What are the side effects of metformin?

Answer 9

Nausea
Diarrhoea

These usually pass within the first few days

Start with low dose and increase over weeks to 2g a day

If not tolerated, try modified release

Question 10

When is metformin contraindicated?

Answer 10

Renal failure - risk of lactic acidosis - renal function must be determined first!

Iodine containing scan contrast - stop using metformin

Question 11

How should metformin be taken?

Answer 11

Take with meals

500mg with breakfast for a week
Then 500mg with breakfast and dinner for a week
Then 500mg with breakfast, lunch and dinner

Question 12

How does gliclazide (sulphonylurea) work?

Answer 12

Increases insulin secretion from pancreatic B cells

Question 13

What are the side effects of gliclazide?

Answer 13

Nausea and vomiting
Diarrhoea
Constipation
Weight gain
Hypoglycaemia - patients must have regular food intake and not be on low carb diets

Rarely causes hepatitis and jaundice

Question 14

When should gliclazide not be used?

Answer 14

Acute porphyria
Ketoacidosis

Avoid in:
Patients who are overweight
Patients with irregular diets - increased risk if hypoglycaemics 
Elderly
Renal impairment
Hepatic impairment

Question 15

What hba1c level is needed to start insulin?

Answer 15

Hba1c greater than 58 mmol

Question 16

How does sitagliptin (DPP4 inhibitor) work?

Answer 16

Incretin hormones, such as GLP1 are secreted from l cells of the small intestine

These hormones increase insulin release from B cells

DPP4 inhibitors inhibit the enzyme, dipeptyl peptidase 4, which breaks incretins down

Question 17

What are the side effects of sitagliptin?

Answer 17

Can cause hypoglycaemia
May decrease appetite
GI disturbance
Upper respiratory tract infection

Rarely, pancreatitis

Question 18

What are the contraindications of sitagliptin?

Answer 18

Ketoacidosis

Reduce dose if renal impairment

Question 19

How does pioglitazone (glitazones) work?

Answer 19

Pioglitazone is an agonist for the PPARG receptor, which up regulates genes that increase insulin sensitivity of cells

Question 20

What are side effects of pioglitazone?

Answer 20

Weight gain
Hypoglycaemia
GI disturbances
Osteoporosis 
Fluid retention - oedema - HF?

Bladder cancer
Liver toxicity - assess liver function before!

Question 21

What are the contraindications of pioglitazone?

Answer 21

Heart failure
Patients with a history of bladder cancer
Patients with Undiagnosed haematuria
Patients at high risk of fracture

Question 22

How does exenatide work?

Answer 22

Exenatide mimics GLP1 to increase insulin secretion from the pancreas

This is an injectable drug

Question 23

What are the side effects of exenatide?

Answer 23

Hypoglycaemia
Nausea - delays gastric emptying
Pancreatitis

Question 24

When should exenatide be used?

Answer 24

For patients with T2dm previously uncontrolled with metformin and a sulphonylurea

Does not increase weight!

Use instead of insulin if:
BMI >35
BMI <35 and insulin not acceptable

Question 25

When should statin be considered in T2DM?

Answer 25

Considers simvastatin if :
Under 40 and with poor cardiovascular risk profile

Over 40 and cardiovascular risk greater than 20% over 10 years

Question 26

When and how should self monitoring be used in t2dm?

Answer 26

Offer to newly diagnosed patients on t2dm if on oral hypoglycaemics or insulin

Make plan of how blood glucose levels should be interpreted and what action should be undertaken

If blood glucose testing is not tolerated, use urine glucose testing