Diabetes Flashcards

Question

A 78-year-old nursing home resident is admitted to the acute medical unit after being found collapsed in his room. A carer from the nursing home is present and reports that he has had regular 'hypos' recently. On admission he was drowsy and the blood glucose was 1.8 mmol/l. Following intravenous dextrose the patient's condition significantly improved. His medication on admission is as follows: * Metformin 1g bd * Gliclazide 160mg od * Pioglitazone 45mg od * Aspirin 75mg od * Simvastatin 40mg on What is the most appropriate action whilst awaiting review by the diabetes team? * Stop metformin * Stop pioglitazone * Stop gliclazide * Make no changes to the medication * Stop all oral antidiabetic medications

Answer 1

Neither metformin nor pioglitazone cause hypoglycaemia. The gliclazide dose is therefore responsible and should be stopped whilst awaiting diabetes review.

Answer 2

Insulin lispro

Answer 3

Correct answer: C E Sulfonylureas are commonly used second-line to metformin in type 2 diabetes mellitus. They are used in addition to metformin and hence there is no need to stop his current treatment. At standard (and starting) doses gliclazide is taken once a day. Hypoglycaemia is by far the most important side-effect that patients should be made aware of. This is particular relevant if the patient drives or operates machinery. No specific monitoring is required for patients taking sulfonylureas.

Answer 4

The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol NICE guidelines suggest a standard target of 48mmol/mol for patients managed by lifestyle and/or a single antidiabetic drug. The target may change to 53 mmol/mol if the patient is started on a second agent, or if they are receiving a medication that carries the risk of hypoglycaemia (e.g. sulphonylurea). Remember that there is a difference between target HbA1c and the HbA1c threshold for changing medications.

Answer 5

A further abnormal HbA1c. Asymptomatic patients with an abnormal HbA1c or fasting glucose must be confirmed with a second abnormal reading before a diagnosis of type 2 diabetes is confirmed This patient has presented to the GP with no symptoms of diabetes. NICE states that 'in an asymptomatic person, the diagnosis of diabetes should never be based on a single abnormal HbA1c or fasting plasma glucose level; at least one additional abnormal HbA1c or plasma glucose level is essential. If the second test results are normal, it is prudent to arrange regular review of the person.' As a result of the above NICE guidance, type 2 diabetes cannot be diagnosed in this patient with a single abnormal HbA1c. Therefore option 1 of no further testing can be ruled out. A fasting sample of greater than 7 mmol/l would be indicative of type 2 diabetes so option 3 can be ruled out. Random glucose levels of greater than 11mmol/l in patients that are symptomatic are indicative of type 2 diabetes mellitus and therefore both options 4 and 5 can be ruled out.

Answer 6

The correct answer is that the patient may be continued on metformin but that the gliclazide must be stopped. In the management of type 2 diabetes in pregnancy 'women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin'. While it is likely that the patient will be required to switch to insulin it is not an absolute requirement. Both gliclazide and liraglutide are contraindicated in pregnancy. Source: BNF (https://www.evidence.nhs.uk/formulary/bnf/current/6-endocrine-system/61-drugs-used-in-diabetes/612-antidiabetic-drugs

Answer 7

Diarrhoea Worsening of heart failure Hypoglycaemia **Overview of side effects:** Metformin: * Gastrointestinal side-effects * Lactic acidosis Sulfonylureas * Hypoglycaemic episodes * Increased appetite and weight gain * Syndrome of inappropriate ADH secretion * Liver dysfunction (cholestatic) Glitazones * Weight gain * Fluid retention * Liver dysfunction * Fractures Gliptins * Pancreatitis

Answer 8

In type 1 diabetics, a general HbA1c target of 48 mmol/mol (6.5%) should be used. Overview: HbA1c * should be monitored every 3-6 months * adults should have a target of HbA1c level of 48 mmol/mol (6.5%) or lower. NICE do however recommend taking into account factors such as the person's daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia Self-monitoring of blood glucose * recommend testing at least 4 times a day, including before each meal and before bed. * more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding Blood glucose targets * 5-7 mmol/l on waking and * 4-7 mmol/l before meals at other times of the day Type of insulin * offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults * twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative * offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes Metformin * NICE recommend considering adding metformin if the BMI \>= 25 kg/m²

Answer 9

She may drive if she has adequate awareness of hypoglycaemia. Must inform the DVLA. For group 1 vehicles, diabetic patients on insulin may drive if they have hypoglycaemic awareness All patients with diabetes who are treated with insulin MUST inform the DVLA about their medical condition. This patient has a well-controlled diabetes and there are no underlying concerns about her health. According to the DVLA she may drive if she has adequate awareness of hypoglycaemia. She should NOT switch to tablets. This would be medically dangerous and would risk her having episodes of diabetic ketoacidosis. Although patients with well-controlled diabetes on tablets need not inform the DVLA this patient is on insulin and should stay on insulin. OVERVIEW: * Until recently people with diabetes who used insulin could not hold a HGV licence. The DVLA changed the rules in October 2011. The following standards need to be met (and also apply to patients using other hypoglycaemic inducing drugs such as sulfonylureas): * there has not been any severe hypoglycaemic event in the previous 12 months * the driver has full hypoglycaemic awareness * the driver must show adequate control of the condition by regular blood glucose monitoring\*, at least twice daily and at times relevant to driving * the driver must demonstrate an understanding of the risks of hypoglycaemia * here are no other debarring complications of diabetes * From a practical point of view patients on insulin who want to apply for a Group 2 (HGV) licence need to complete a VDIAB1I form. * Other specific points for group 1 drivers: * if on insulin then patient can drive a car as long as they have hypoglycaemic awareness, not more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months and no relevant visual impairment. Drivers are normally contacted by DVLA * if on tablets or exenatide no need to notify DVLA. If tablets may induce hypoglycaemia (e.g. sulfonylureas) then there must not have been more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months * if diet controlled alone then no requirement to inform DVLA * \*to demonstrate adequate control, the Secretary of State's Honorary Medical Advisory Panel on Diabetes Mellitus has recommended that applicants will need to have used blood glucose meters with a memory function to measure and record blood glucose levels for at least 3 months prior to submitting their application

Answer 10

Insulin If at the time of diagnosis of gestational diabetes, the fasting glucose level is \>= 7 mmol/l immediate insulin (plus or minus metformin) should be started This woman has gestational diabetes and should be started immediately on insulin (plus or minus metformin). Gestational diabetes is diagnosed with either a fasting plasma glucose level of \> 5.6 mmol/L, or a 2-hour plasma glucose level of \>/= 7.8 mmol/L. If at the time of diagnosis the fasting glucose is \> or = 7 mmol/L, as in this case, then insulin should be started immediately. Dietary advice is an important management step in any diagnosis of diabetes, but in this case the fasting glucose is greater than 7mmol/L and insulin needs to be started. Gliclazide would not be the correct option. Sulfonylureas are avoided in pregnancy as there is a risk of neonatal hypoglycaemia. Metformin may be started in gestational diabetes, but with a fasting glucose level \>=7mmol/L insulin is the most appropriate next step. Insulin and metformin can be used together in the management of gestational diabetes. The test results are conclusive for gestational diabetes as both the fasting glucose and the 2-hour glucose level are raised, there is no need to repeat the test.

Answer 11

Add insulin In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added This patient fulfilled the criteria for a diagnosis of gestational diabetes on her original OGTT at 25 weeks, due to a fasting glucose \> 5.6mmol/L. Her glycaemic control has been refractory to lifestyle modifications, and, most recently, the addition of metformin, as her fasting glucose has remained above 5.6mmol/L. At this stage, NICE advise that short-acting insulin should be added to her existing treatment. Although the patient's fasting glucose has improved slightly with the addition of metformin, her fasting glucose reading is still above the target range. As such, it would not be appropriate to continue with her current treatment, and risk the fetal and maternal complications of gestational diabetes. Changing metformin to modified-release metformin can be helpful in patients who do not tolerate metformin due to side-effects such as gastrointestinal upset, but would not have a role in improving glycaemic control in this patient. NICE advise that in the instance of persistent impaired glycaemic control, insulin should be added in conjunction with metformin, rather than substituted for it. Sulfonylureas such as glibenclamide should only be offered for patients who cannot tolerate metformin, or as an adjunct for patients who decline insulin treatment, and would not be the most appropriate next drug for this patient.

Answer 12

He may be able to apply for a HGV licence if he meets strict criteria relating to hypoglycaemia. Patients on insulin may now hold a HGV licence if they meet strict DVLA criteria

Answer 13

NICE recommend the following blood pressure target for type 2 diabetics: \< 140/90 mmHg

Answer 14

Diabetes sick day rules: 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. Patients with insulin-dependent diabetes who become unwell should continue with their normal insulin regime and ensure they check their blood sugars frequently (at least four hourly during the day). Stopping or reducing insulin whilst unwell would be very dangerous due to the risk of diabetic ketoacidosis. Checking blood sugars before each insulin dose would not be appropriate as it would require the patient to be titrating each insulin dose very carefully and this would also depend on how much they would be eating. This would not be practical or safe in this situation for Bernard. Doubling Bernard's normal insulin dose would put him at a significantly increased risk of hypoglycaemia, particularly when he is likely to have a reduced oral intake due to feeling unwell.

Answer 15

Increased risk of fractures. Glitazones - associated with fractures Important for meLess important Pioglitazone is a thiazolidinedione (also called the glitazones), which acts by reducing resistance to insulin, thus lowering blood glucose. It is a PPAR-γ agonist. It's classical side effects are: weight gain (rather than loss); fluid retention; liver dysfunction; and associated fractures. It is metformin that has the classical risk of lactic acidosis and gastric disturbances (diarrhoea rather than vomiting most commonly). Pioglitazone is not a subcutaneous medication, so would not have injection-site reactions.

Answer 16

DPP-4 inhibitors are useful in T2DM patients who are obese * A DPP-4 inhibitor could be added at this stage as they are weight neutral. The other medical options suggested would cause weight gain. * While a sulphonylurea would reasonable if it was just an elevated HbA1c, with her BMI there are better therapeutic options available. Sulphonylureas may also cause weight gain. * Pioglitazone causes weight gain. * With her HbA1c of 58mmol/mol and the patient reporting they feel they cannot modify their lifestyle more, continuing monotherapy is not advisable. * Insulin therapy is not appropriate at this stage as there are more medical options available. Insulin also has a side effect of weight gain.

Answer 17

Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1

Answer 18

The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol Important for meLess important Patients with type 2 diabetes should be offered diet and lifestyle advice to achieve and help maintain their HbA1c target. For adults with type 2 diabetes managed either by lifestyle and diet (eg this patient) or by lifestyle and diet combined with a single drug not associated with hypoglycaemia (eg metformin), we should support the person to aim for an HbA1c level of 48 mmol/mol. Therefore, option 3 is correct. In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol or higher the NICE guidelines suggest that we should: Reinforce advice about diet, lifestyle and adherence to drug treatment Support the person to aim for an HbA1c level of 53 mmol/mol Intensify drug treatment. For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol. If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it.

Answer 19

Do not cause weight gain Hypoglycaemia is rare in patients taking dipeptidyl peptidase-4 inhibitors.

Answer 20

Continue normal insulin regime. Diabetes sick day rules: 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 Important for meLess important Insulin administration on sick days should be continued due to the risk of diabetic ketoacidosis. This patient is experiencing diarrhoea and vomiting and is at risk of electrolyte derangement, ketosis, and dehydration. It is important that she: Maintains good fluid intake (minimum of 3 litres in 24 hours) Consider taking sugary drinks to maintain carbohydrate intake as she is unable to tolerate solids Monitor blood glucose at least every 4 hours Ensure there are people in the house, patient has a mobile phone, or neighbours are aware that the patient is unwell in case of the patient becoming unconscious If the patient is unable to keep fluids down, diarrhoea is persistent, or there is severe derangement in ketone and/or blood glucose levels then the patient may require admission to hospital. Infection causes a stress response in the body with the increased release of cortisol and adrenaline which work against insulin, leading to increased glucose production in the body causing high blood glucose levels. As such, it is inappropriate to withhold insulin during illness. It would also be inappropriate to blindly double or half the insulin dose as this could cause hypoglycaemia. Metformin should be stopped during illness - this is due to the increased risk of lactic acidosis with dehydration.

Answer 21

Reducing the peripheral breakdown of incretins Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1 Reducing the peripheral breakdown of incretins such as glucagon-like peptide 1 is the correct answer. Sitagliptin belongs to dipeptidyl peptidase-4 inhibitors (DDP-4 inhibitors). They act by reducing the peripheral breakdown of incretins such as glucagon-like peptide 1. Incretins inhibit glucagon secretion, therefore increasing insulin secretion, subsequently reducing gastric emptying and reducing blood glucose levels. Act as glucagon-like peptide 1 agonists is an incorrect answer, this describes the mechanism of action of glucagon-like peptide-1 mimetics. The medication named, sitagliptin, is a DDP-4 inhibitor. which reduces the breakdown of GLP-1 and other incretins, rather than mimicking them. Therefore both GLP-1 mimetics and DDP-4 inhibitors have the same overall effect of inhibiting glucagon secretion and increasing insulin secretion. Act on ATP-sensitive K+ channels is incorrect. This describes the action of sulfonylureas, whereas the sitagliptin is a DDP-4 inhibitor. Sulfonylureas work by closing the ATP-sensitive K+ channel on pancreatic beta cells, depolarising the cell as potassium is unable to exit. This opens voltage-gated Ca2+ channels. The increase in intracellular calcium leads to insulin secretion. They can cause hypoglycemia and are associated with modest weight gain. Increasing insulin sensitivity is incorrect, as this describes the mechanism of action of biguanides. However, the medication named, sitagliptin is a DDP-4 inhibitor. Inhibiting sodium-glucose co-transport is incorrect, this describes the action of sodium-glucose co-transporter 2 inhibitors, whereas sitagliptin is a DDP-4 inhibitor.

Answer 22

Losartan An angiotensin II receptor blocker should be used first-line for black TD2M patients who are diagnosed with hypertension Hypertension in patients with diabetes is treated slightly different to those without. NICE advises use of an angiotensin-converting enzyme (ACE) inhibitor such as ramipril or an angiotensin II receptor blockers (ARB) such as losartan as a first line in all patients with diabetes, regardless of age. NICE also recommends in patients of black African or African-Caribbean to use an ARB in preference to an ACE inhibitor, hence losartan is the correct answer. Amlodipine is a calcium-channel blocker, it would be an appropriate first line medication in those of black African or African-Caribbean family origin without diabetes or those of other ethnic backgrounds aged over 55. Doxazosin is an alpha blocker and generally used as a fourth line antihypertensive. Indapamide is a thiazide diuretic and generally used as a third line antihypertensive.

Answer 23

Reduces the peripheral breakdown of incretins. Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1 The correct answer is that sitagliptin reduces the peripheral break down of incretins. Sitagliptin is one of the Gliptins (DPP-4 inhibitors) which reduce the peripheral breakdown of incretins such as GLP-1. Metformin increases peripheral insulin sensitivity and reduces hepatic gluconeogenesis. Sulfonylureas augment pancreatic insulin secretion. Increased insulin secretion can lead to hypoglycaemia. GLP mimetics, e.g. exenatide, augment pancreatic insulin secretion, suppress glucagon release, slow gastric emptying and promote satiety.

Answer 24

Add sitagliptin. TD2M already on 2 drugs - if HbA1c \> 58 mmol/mol then triple therapy with one of the following combinations should be offered: metformin + gliptin + sulfonylurea metformin + pioglitazone + sulfonylurea metformin + sulfonylurea + SGLT-2 inhibitor metformin + pioglitazone + SGLT-2 inhibitor OR insulin therapy should be considered Important for meLess important The correct answer is to add sitagliptin. The NICE guidelines suggest that patients with HbA1c \> 58 mmol/mol already on two drugs should be either offered a third drug or insulin therapy should be considered. Given that she is afraid of needles, insulin therapy should be avoided if possible. Hence a third drug should be added, either an SGLT-2 inhibitor, a gliptin, or pioglitazone, given that she is already taking metformin and gliclazide (a sulfonylurea). Since she has a past medical history of recurrent urinary tract infections, SGLT-2 inhibitors should be avoided as they increase the chances of developing them. Pioglitazone is rarely prescribed, so the correct option is to add sitagliptin. Adding exenatide is incorrect since this drug belongs to the class of GLP-1 mimetics. This class of drugs should be added only if the patient cannot tolerate triple therapy and they have a BMI greater than 35. In this case, none of these two conditions is true, making the option incorrect. It is incorrect to stop all the drugs and start insulin. This patient clearly stated that she is afraid of needles, and since there are other options we should take into account the patient's preference. Stop gliclazide and prescribe sitagliptin is incorrect as the NICE guidelines suggest that drugs should not be stopped and substituted but added together to work synergically. You could potentially add a gliptin but you should not stop the other drugs. Stop metformin and prescribe pioglitazone is incorrect as the NICE guidelines suggest that drugs should not be stopped and substituted but added together to work synergically. You could potentially add pioglitazone but you should not stop the other drugs.

Answer 25

Metformin increases the risk of lactic acidosis - suspend during intercurrent illness eg. diarrhoea and vomiting Important for meLess important Increase dose ramipril. Incorrect. Although his blood pressure is a little high today, it is not the priority and might increase risk of electrolyte disturbance whilst he is unwell - you may even consider suspending it. Blood pressure could be reviewed when he is feeling better. Double the dose of lansoprazole. Incorrect, no indication for this. Suspend ramipril. Incorrect. Blood pressure is a little high, and there is no evidence of acute electrolyte disturbance. Suspend metformin. Correct answer - metformin is associated with an increased risk of lactic acidosis and therefore should be suspended when there is risk eg. dehydration, sepsis, CT with contrast, renal failure, heart failure; particularly if the patient is frail or elderly. Reduce dose paracetamol to 500mg. Incorrect. Dose might be reduced when patient has a low body weight. Increase dose bisoprolol. Incorrect. No indication for increasing bisoprolol here.

Answer 26

At least 4 times a day, including before each meal and before bed In type 1 diabetics, recommend monitoring blood glucose at least 4 times a day, including before each meal and before bed

Answer 27

Patient to be started on insulin. If at the time of diagnosis of gestational diabetes, the fasting glucose level is \>= 7 mmol/l immediate insulin (plus or minus metformin) should be started Important for meLess important This patient has a fasting glucose level ≥ 7.0 mmol/L - she needs to be started on insulin (plus or minus metformin). If her fasting plasma glucose level was \< 7.0 mmol/L, trial of diet and exercise with review in 1-2 weeks would be appropriate. She must be seen in a joint antenatal and diabetic clinic within a week of diagnosis. Statins are contraindicated during pregnancy. The British National Formulary (BNF) advises to stop taking statins 3 months before attempting to conceive as there have been incidents of congenital abnormality reported which may be attributed to reduced cholesterol synthesis possibly affecting foetal development. Sitagliptin is not recommended for use during pregnancy and breast-feeding. It is a DPP-4 inhibitor (this is an enzyme which acts upon incretin). Discuss (3)Improve

Answer 28

A second drug should be added in type 2 diabetes mellitus if the HbA1c is \> 58 mmol/mol Important for meLess important Reinforce lifestyle measures. Incorrect answer, although lifestyle advice should be reinforced, NICE advises if HbA1c is 58mmol/mol or higher on a single drug, 'intensify drug treatment.' Commence a second blood glucose lowering drug and reinforce lifestyle and diet measures. Correct answer, NICE advises if HbA1c is 58mmol/mol or higher on a single drug, 'intensify drug treatment, as well as revisiting lifestyle and dietary advice with the patient. Stop metformin and commence a more effective blood glucose lowering drug. Incorrect answer, unless metformin is contraindicated or not tolerated, it should be continued. Change to modified-release metformin. Incorrect answer, this can be done if a patient is experiencing gastrointestinal side effects on standard release metformin but will not improve blood sugar control. Increase dose of metformin. Incorrect answer, he is already on the maximum dose (1g BD).

Answer 29

Aim to drink at least 3L of fluid. Option 4 is the correct answer as patients should be encouraged to drink at least 3L of fluid over 24 hours. Patients should continue their normal insulin regimen but check their blood glucose more regularly, therefore options 1 and 2 are wrong. Main meals should not be substituted for sugary foods, if a patient is struggling to eat then they may take sugary drinks. Ketones should also be measured, but more frequently than what is being proposed in option 5, for example, every 3-4 hours or even more frequently depending on the readings. NICE Clinical Knowledge Summaries - Diabetes Type 1 https://cks.nice.org.uk/diabetes-type-1#!scenarioclarification:2 'Candidates gave generally good responses to questions concerning management of type 2 diabetes. However, type 1 diabetes caused difficulty and candidates are reminded in particular to review the management of type 1 diabetes during intercurrent illness, and sick day rules.'

Answer 30

ramipril Hypertension in diabetics - ACE inhibitors/A2RBs are first-line regardless of age

Answer 31

No change Since the publication of the 2015 guidelines, NICE recommend we only add another drug if the HbA1c has risen to \>= 58 mmol/mol (7.5%) at this stage.

Answer 32

Admit for 2 doses IM steroids and monitor BMs closely, adjusting pump accordingly. Fetal fibronectin (fFN) is a protein that is released from the gestational sac. Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN Having a positive result means that the obstetric team can optimise everything, in case the lady does go into premature labour. This includes ensuring neonatal intensive care are aware, and administering steroids to help with neonatal lung maturity. As this lady is at high risk of premature labour, and is currently experiencing tightenings, it would be incorrect to discharge the patient without any further monitoring. Giving antibiotics may be indicated if she had spontaneously ruptured her membranes, however this history of watery discharge but no fluid seen on speculum examination and a closed os is not enough to initiate antibiotic therapy at this stage. As infection can be a precipitating factor for premature labour, swabs and urine cultures should be obtained to screen for infection and treat as appropriate. Administering steroids can cause hyperglycemia in diabetics, and therefore close attention should be paid to the blood glucose measurements. Hyperglycaemia in the mother can cause adverse outcomes for the fetus, which is why extra care must be taken. Hourly blood glucose measurements must be taken, and additional insulin given as required. If the blood glucose levels are hard to control in this way, a sliding scale should be started according to local protocol.

Answer 33

4 -7 mmol/l In type 1 diabetics, blood glucose targets: 5-7 mmol/l on waking and 4-7 mmol/l before meals at other times of the day

Answer 34

Pioglitazone can cause fluid retention and is therefore contraindicated in patients with heart failure.

Answer 35

Continue NovoMix 30 and check blood glucose every 2-4 hours Diabetes sick day rules state that a patient must not stop their insulin due to the risk of ketoacidosis. Concurrent illness will often raise blood sugars and demand for insulin will often rise. Most guidance suggests increasing the dose of mixed insulin by 2-4 units if blood sugars are above 10 mmol/L. He is already taking maximum dose of metformin. Further, metformin should be stopped if there is severe infection or dehydration. NovoMix is a biphasic insulin and so is not prescribed as a three times daily dose. Discuss (4)Improve

Answer 36

Glimepiride Metformin Pioglitazone

Answer 37

Add sitagliptin Pioglitazone is contraindicated by his history of bladder cancer and may contribute to his obesity. A DPP-4 inhibitor such as sitagliptin is therefore the best option. Exenatide generally causes weight loss and is therefore useful in obese diabetics but he does not meet the NICE body mass index criteria of 35 kg/m².

Answer 38

Commence insulin. In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added Important for meLess important Pregnant women with GDM should be advised to maintain their CBGs below the following target levels: fasting: 5.3mmol/L AND 1 hour postprandial: 7.8 mmol/L or 2 hours postprandial: 6.4 mmol/L If these targets are not met with diet, exercise and metformin, then insulin should be offered as add-on therapy. The only sulphonylurea that is advocated by the National Institute of Health and Clinical Excellence (NICE) is glibenclamide, which can be considered in women who decline insulin, or who cannot tolerate metformin initially, hence gliclazide is an incorrect option here. Note that the use of any sulphonylurea in GDM is an off-license indication. There is insufficient evidence to advise the safe use of gliptins in pregnancy, hence it is currently not recommended in GDM management. It would not be correct to continue the same management or de-escalate treatment by stopping metformin as the CBG readings are above target levels. Although fetal growth is currently normal, there are serious ongoing risks to both mother and fetus if glycaemic control is not achieved, including pre-eclampsia, pre-term labour, stillbirth and neonatal hypoglycaemia.

Answer 39

Add sitagliptin TD2M already on 2 drugs - if HbA1c \> 58 mmol/mol then triple therapy with one of the following combinations should be offered: metformin + gliptin + sulfonylurea metformin + pioglitazone + sulfonylurea metformin + sulfonylurea + SGLT-2 inhibitor metformin + pioglitazone + SGLT-2 inhibitor OR insulin therapy should be considered Important for meLess important As this patient has an HbA1c over 58 mmol/mol on two medications he requires triple therapy. The most suitable additional medication suggested in NICE guidance would be a gliptin such as sitagliptin as his medical history would contraindicate other options. Acarbose is an inhibitor of intestinal alpha glucosidases which delays the digestion of starch and sucrose. It does not appear in NICE guidance due to significant gastrointestinal side-effects this medication causes. Canagliflozin inhibits sodium-glucose co-transporter 2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion. It is contraindicated in active foot disease such as skin ulceration with a possible increased risk of toe amputation. Pioglitazone is a thiazolidinedione that reduces peripheral insulin resistance and is contraindicated in patients with active or previous bladder cancer.

Answer 40

Prescribe DPP-4 inhibitor A second drug should be added in type 2 diabetes mellitus if the HbA1c is \> 58 mmol/mol Important for meLess important The patient's HbA1c result shows that her glucose levels are not well controlled anymore, this could be due to tolerance, adherence or lifestyle issues. The next step would be to prescribe a second medication, be it a DPP-4 inhibitor, sulfonylurea or a SGLT-2 inhibitor, based on the patients needs and weighing up the risks and benefits of each. The standard dose of metformin is 500g daily which can be increased up to a maximum of 2g daily, divided into separate doses. She is already on 2g so cannot have her dose increased further. Thiazolidinediones such as pioglitazone should not be used in heart failure and are rarely used as first or second-line therapies. As her HbA1c levels exceed 58mmol/mol, another intervention is needed, in conjunction with reinforcing lifestyle and dietary advice. Insulin is retained for patients who do not respond to double or triple therapy.

Answer 41

Prescribe short-acting insulin only Gestational diabetes is treated with short-acting, but not longer-acting SC insulin. This woman has been trialled on both lifestyle modifications for 2 weeks, and then metformin for 2 weeks, and neither of these has led to improvement of her gestational diabetes. The next step in her treatment should be to offer short-acting insulin, alongside education on how to dose insulin in accordance with meals. Glibenclamide is an oral hypoglycaemic agent which is a second-generation sulfonylurea. It decreases blood glucose by increasing insulin secretion. It may be associated with increased birth weight, macrosomia, and neonatal hypoglycemia when compared with insulin. For that reason, it is only given if insulin fails to offer adequate glycaemic control, or if insulin is refused or contraindicated. Therefore, in this scenario, it is not the correct answer. Gliclazide is an oral hypoglycaemic agent which is not recommended for use in pregnancy. It is unsure or not whether it may cross the placenta, and there is a risk of neonatal hypoglycemia. Therefore, it is not the correct answer. Gliclazide and glibenclamide together is not the correct answer. Gliclazide is not recommended in pregnancy, and glibenclamide should only be offered as the next step after insulin management has failed. Both of these drugs together may also precipitate maternal hypoglycaemia. Prescribing short-acting and long-acting insulin is not the correct answer. Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia. Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman.

Answer 42

Continue metformin and add insulin. In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added Important for meLess important This question is assessing your knowledge of the management of gestational diabetes. This patient would have been trialled with exercise and dietary changes over a 2-week period as her initial fasting blood glucose was below 7mmol/L. It is apparent that she has failed this trail and she has been started on metformin monotherapy. Insulin therapy was not previously started as her fasting blood glucose was below 7mmol/L. NICE guidelines advise that in the event targets aren't met on metformin monotherapy, then insulin should be commenced and lifestyle changes reiterated. This means that continuing metformin and adding insulin to this patients management is the correct answer. Continuing metformin and adding gliclazide is in an incorrect answer as it is preferable to avoid the use of gliclazide during pregnancy. Increasing the dose of metformin is an incorrect answer as her fasting blood glucose levels are now \>7mmol/L and the commencement of insulin therapy is required. Stopping metformin and commencing insulin is an incorrect answer as it would go against current NICE guidance which recommends continuing metformin if tolerated. The patient in this scenario has no tolerance issues with metformin. High dose folic acid is an incorrect answer. High dose folic acid may reduce the risks of foetal spinal cord defects but it will not improve her diabetic control.

Answer 43

The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol Important for meLess important The standard HbA1c target in type 2 diabetes mellitus is 48 mmol/mol for those taking a signal drug not associated with hypoglycaemia (in this case metformin). For those taking more than one medication or a single medication associated with hypoglycemia then the target would be 53 mmol/mol.

Answer 44

**Start metformin modified release** Gastrointestinal side effects are common with metformin and can occur in up to 20% of patients. As such we should start at a low dose of 500mg once daily and up titrate the dose slowly whilst monitoring for side effects. In this case, it appears the patient has been struggling with the symptoms ever since starting the medication (rather than when the dose was increased). The modified release variant of metformin appears to have a better gastrointestinal side effect profile and is recommended in patients experiencing those side effects as a second-line treatment. As he is taking the metformin three times daily we can assume he is on the immediate-release formulation. The modified release variant is usually given once daily (rarely twice daily). As such he should be switched to the modified-release formulation of metformin, before trying anything else. **The correct answer is: Start a sodium-glucose transport protein 2 (SGLT2) inhibitor27%** At first glance there may be more than one correct answer - this is something you will come across in the exam where multiple answers may appear correct, but you are asked to select the most appropriate one. He is on the maximum dose of metformin. Second-line options are a combination of metformin with another oral treatment. Insulin and the GLP-1 injectables, as well as pioglitazone, are usually reserved for those not controlled with the other treatment options. Also know that pioglitazone should not be used in heart failure. Whilst gliclazide is probably one of the most effective oral agents, it also carries the greatest risk of hypoglycaemia - something you really want to avoid in a lorry driver! Gliptins may be another option but are probably the least effective drug and should only be used if there is no better alternative. This only leaves a sodium-glucose transport protein 2 (SGLT2) inhibitor (the 'gliflozins'). The added benefit is that they appear to improve cardiovascular outcomes and reduce the admission rates for patients with heart failure - an extra benefit in this case. They do carry a small hypoglycaemia risk, but much less so than gliclazide. We should also warn patients about the small risk of DKA even at relatively low blood sugar levels. They should be used with caution in patients with renal impairment and the elderly. **The correct answer is: Start a glucagon-like peptide-1 (GLP-1) receptor agonist** Again, this question appears to have more than one correct answer at first glance. You may consider starting/adding a gliptin, insulin, a GLP-1 receptor agonist or pioglitazone as the next step. NICE recommends the following step wise approach to managing type 2 diabetes: Start with lifestyle modifications, then add metformin Add second oral drug to metformin If this fails, NICE recommends triple therapy with either Metformin + gliclazide + gliptin/glifozin/pioglitazone or Metformin + pioglitazone + glifozin or Insulin +/- other drug If triple therapy fails, we may consider a GLP-1 receptor agonist like Exenatide (GLP-1 receptor agonist should be limited for people with obesity). As we can see, this man was already on triple therapy. Replacing Dapagliflozin with a gliptin would unlikely improve his HbA1c significantly (remember that gliptins are one of the least effective drugs). He has heart failure, so pioglitazone is contraindicated. He is significantly overweight and has already struggled with hypos. As such we should really hold off giving him insulin at this stage. Starting him on a GLP-1 receptor antagonist like Exenatide would be the best option here - it carries almost no risk for hypoglycaemia, may result in weight loss and is recommended by NICE. Currently, this class of drug is one of the most expensive diabetic drugs on the market. He would need to achieve an 11 mmol/mol (1%) reduction in HbA1c AND 3% weight loss in the first 6 months in order for it to be continued.

Answer 45

Add on insulin therapy. In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added Important for meLess important This woman has gestational diabetes and hyperglycaemia associated with this can result in macrosomia, premature birth and stillbirth. It is therefore vital that glucose levels are brought under control as quickly as possible. NICE state that 'if blood glucose targets are not met with diet and exercise changes plus metformin, offer insulin as well'.1 Adding on insulin therapy is therefore the most appropriate thing to do. Sulfonylureas are not as effective as the metformin and insulin combination in pregnancy.² In addition, they have been shown to be teratogenic in animals. They are therefore not indicated in gestational diabetes. Stopping metformin would not be ideal as it increases sensitivity to insulin, something which is lacking during pregnancy. Instead, it is safe to continue metformin while adding insulin therapy. Sodium-glucose co-transporter-2 (SGLT-2) antagonists are also associated with teratogenic effects in animals. They are a very useful option for diabetes management in patients with congestive heart failure due to their diuretic effects. Continuing metformin alone for a further two weeks in spite of persistently high blood glucose will increase the risk of complications. Insulin should be added at this stage. ``` 1 NICE (2015). Diabetes in pregnancy: management from preconception to the postnatal period ² BMJ (2015). Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis. ```

Answer 46

Daily fasting, pre-meal, 1-hour post-meal and bedtime tests. Pregnant patients with type 1 diabetes should monitor their blood glucose levels closely. They should test their levels multiple times during the day. NICE NG3

Answer 47

METFORMIN Sulfonylureas (gliclazide) should be avoided when breastfeeding due to theoretical risk of neonatal hypoglycaemia. Exenatide, liraglutide, and sitagliptin should be avoided when breast feeding. Metformin is safe to use when breast feeding.

Answer 48

\< 140/90 mmHg * T2DM blood pressure targets are the same as non-T2DM. If \< 80 years: * clinic reading: \< 140 / 90 * ABPM / HBPM: \< 135 / 85 * Important for meLess important * The target blood pressure for patients with type 2 diabetes mellitus are no different from those without diabetes, regardless of whether they have end-organ damage.

Answer 49

No change in dose of insulin Diabetes sick day rules: 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. Admitting a patient to the hospital would only be indicated in a CURB score of 2 or greater. The dose of insulin should not be decreased as this would increase the risk of diabetic ketoacidosis. The dose of insulin should not be increased as this puts the patient at risk of hypoglycaemia. The dose of insulin should not be changed, but the patient should be advised to keep hydrated and frequently check their blood sugar levels.

Answer 50

Start an ACE inhibitor. Hypertension in diabetics - ACE inhibitors/A2RBs are first-line regardless of age. This patient has stage 1 hypertension as defined by NICE. He should however be treated because he has underlying diabetes. The first-line treatment for a patient aged \> 55 years is a calcium channel blocker. However, in patients with diabetes ACE inhibitors are used first-line due to their renoprotective effect.

Answer 51

Trial of diet and exercise for 1-2 weeks. Gestational diabetes: if the fasting plasma glucose is \< 7 mmol/l a trial of diet and exercise should be offered for 1-2 weeks Important for meLess important This patient is presenting with elevated fasting plasma glucose (6.8 mmol/L) and may have gestational diabetes. The most appropriate management for this is a trial of diet and exercise to attempt to control blood glucose without pharmacological intervention. The patient should be advised to eat a high fibre diet with minimal foods containing refined sugars. During this period, the patient will be asked to check their blood glucose regularly as there are significant risks to the foetus with gestational diabetes and the patient should contact their team if ongoing elevated readings despite lifestyle interventions. If this patient had initial fasting plasma glucose of 7 mmol/L or more, insulin should be started. The vignette shows a patient with initial fasting glucose lower than this (6.8 mmol/L), however, if her blood glucose is not controlled by diet or metformin, she will need insulin. If there is no improvement (or improvement is not to an adequate level) within 1-2 weeks, the patient should be started on metformin. If metformin is inadequate, the patient will then be started on insulin too. Women who are pregnant should not be aiming to lose weight. Women are advised to maintain a balanced diet, high in fruit, vegetables, and unrefined foods. This option is also incorrect as gestational diabetes is caused by insulin insensitivity which affects women across the BMI spectrum. It is inappropriate to advise the patient to only monitor blood glucose at home for 2 weeks without any interventions (such as diet and exercise). The patient has been flagged to have elevated blood glucose and this is unlikely to change without any lifestyle intervention. While it is part of the management, it is not an exclusive intervention that should be offered.

Answer 52

\< 135 / 85 mmHg T2DM blood pressure targets are the same as non-T2DM. If \< 80 years: clinic reading: \< 140 / 90 ABPM / HBPM: \< 135 / 85 The target blood pressure for patients with type 2 diabetes mellitus are no different from those without diabetes, regardless of whether they have end-organ damage.

Answer 53

Fasting plasma glucose \>= 5.6 mmol/L Gestational diabetes can be diagnosed by either a: fasting glucose is \>= 5.6 mmol/L, or 2-hour glucose level of \>= 7.8 mmol/L '5678' Important for meLess important This patient has been diagnosed with gestational diabetes mellitus in her first pregnancy - she was at an increased risk of this due to her raised BMI and the presence of a first-degree relative with diabetes mellitus. Women with risk factors and no previous history of gestational diabetes mellitus undergo an oral glucose tolerance test at around 24 weeks. Gestational diabetes mellitus is diagnosed if the patient has fasting glucose above 5.6 mmol/L or 2-hour glucose above 7.8 mmol/L on either of these occasions. The correct answer is therefore fasting plasma glucose of above 5.6 mmol/L. A 2-hour glucose level above 5.6 mmol/L would not be diagnostic of gestational diabetes mellitus. The 2-hour glucose level needs to be above 7.8 mmol/L for diagnosis. Glucose of 6.4 mmol/L 2-hours after mealtime is one of the glucose targets for women with gestational diabetes mellitus so this answer is not correct. Glucose of 7.8 mmol/L 1-hour after mealtime is another glucose target for women with gestational diabetes mellitus so this is not the correct answer. Random plasma glucose tests are not part of the diagnostic process for gestational diabetes mellitus.

Answer 54

Fasting glucose 6.8 mmol/L on two occasions A 75g oral glucose tolerance test 2 hour value of 8.4 mmol/L would imply impaired glucose tolerance rather than impaired fasting glucose

Answer 55

Insulin plus or minus metformin If at the time of diagnosis of gestational diabetes, the fasting glucose level is \>= 7 mmol/l immediate insulin (plus or minus metformin) should be started Important for meLess important Insulin plus or minus metformin should be offered immediately to women with gestational diabetes mellitus (GDM) who have a fasting plasma glucose level of ≥7.0mmol/L at diagnosis. Lifestyle modification (diet and exercise) should be offered to women with GDM who have a fasting plasma glucose level \<7 mmol/L at diagnosis. Metformin should be offered to women with GDM if blood glucose targets are not met after 1-2 weeks using lifestyle modification. Glibenclamide should be offered to women with GDM who fail to achieve their blood glucose targets with metformin, or in those who decline insulin therapy. According to the BNF pioglitazone should be avoided in pregnancy. Animal studies suggested that pioglitazone was toxic in pregnancy.

Answer 56

Sitagliptin DPP-4 inhibitors are useful in T2DM patients who are obese Important for meLess important This questions is essentially asking about which drug to use in the second intensification of oral therapy in type 2 diabetes. The NICE guidelines state that in this case the next step would be a choice between a sulfonylurea (in this case gliclazide), pioglitazone or a DPP-4 inhibitor (in this case sitagliptin). The reason a choice is offered is to allow clinicians to apply the guidelines in the most appropriate way to tailor the drug choice to the patient and it is this skill that the question is testing. This man is morbidly obese, with a BMI over 50 m/kg², which would make you want to start a therapy which is less likely to cause weight gain. The only one of the three choices which is appropriate is sitagliptin in this respect as gliclazide would cause significant weight gain by increasing the levels of insulin present and pioglitazone acts to change glucose and lipid metabolism in such a way that an increase in peripheral adipose tissue is always expected. Sitagliptin works by essentially increasing satiety and the insulin response to high-glucose content foods and so is more helpful in patients who overeat. The best choice for a second intensification in non-obese patients would be a sulfonylurea such as gliclazide or glibenclamide as these are the most effective at reducing blood glucose, although they do come with the side-effect of hypoglycaemia which can be prolonged and quite severe. Therefore if the patient needs to avoid this, such as a professional driver, a different drug would be more appropriate. Additionally, an important contraindication to Pioglitazone is heart failure and for this reason it is rarely used now as some degree of heart failure is expected in those with ischaemic heart disease and this is a very common co-morbidity in type 2 diabetics.

Answer 57

Basal–bolus insulin regimen with twice-daily insulin detemir In newly diagnosed adults with type 1 diabetes, the first-line insulin regime should be a basal–bolus using twice‑daily insulin detemir

Answer 58

Discuss diet and exercise A HbA1c between of 42-47 mmol/mol is indicative of prediabetes. Patients with prediabetes should be actively encouraged to increase physical activity and lose weight and improve diet by increasing dietary fibre intake and reducing fat intake. Metformin can also be considered in patients with prediabetes, however, this would be started at 500mg OD. Patients diagnosed with prediabetes should have their HbA1c repeated at regular intervals as they are at high risk of developing diabetes.

Answer 59

Insulin. If at the time of diagnosis of gestational diabetes, the fasting glucose level is \>= 7 mmol/l immediate insulin (plus or minus metformin) should be started Important for meLess important When fasting glucose is \>7 mmol/L at the diagnosis of gestational diabetes insulin should be started immediately. This makes insulin the correct answer here. Advice on diet and exercise alone would be inappropriate here due to her high fasting glucose level. Advice should be given alongside insulin therapy. Although regular glucose monitoring is key to the management of gestational diabetes when fasting glucose \>7 mmol/L at diagnosis insulin should be started. Sulfonylureas such as gliclazide are contraindicated in pregnancy due to increased risk of fetal macrosomia. Metformin may be given alongside insulin in this case, but not as monotherapy.

Diabetes Flashcards

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