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PSA Prep Course -Diabetes DR CHANG KIM FY1 1Disclaimer We are a group of F1 doctors preparing this course to help prepare/as a supplement for your PSA. Please do not use this as your sole source of revision. None of the patients/cases are based on real-life scenarios, and any similarities are coincidental. Some drug concentrations/preparations may have been changed for ease of calculations, and may not resemble real-life clinical practice. Always consult your university for exam-related queries and support, and the BNF/Medicines Complete for up-to-date information on drugs and prescriptions. 2Learning Objectives Types of Medication ◦Insulins ◦Non-Insulins Prescription Management ◦Hypoglycaemia ◦Hyperglycaemia 3Types Of Medication 4IAPT: improving access to psychological therapies DESMOND: Diabetes Education and Self Management for Ongoing and Newly Diagnosed 56 First Line Options Lifestyle optimisation Metformin Patient education Metformin 500mg OD Diet, exercise, weight loss for 6-8/52 Can be increased to 2g total Smoking/alcohol Side effect: GI disturbance BP/cholesterol management Set target HbA1c If side effects occur, consider MR tablets Standard target HbA1C is 48mmol/mol, start treatment if HbA1c >53 Usual scheme is 500mg OD, then 500mg BD, then 500mg TDS, can go up to maximum 2g per day. 7Metformin MOA: increases insulin sensitivity & reduces release of glucose Does not cause hypoglycaemia Risks: Contraindications: Lactic acidosis eGFR <30 ◦ Hold if acutely unwell, dehydrated, AKI Liver failure/cirrhosis GI side effects which settle fast Severe advanced heart failure 8 Second Line Option SGLT2 inhibitors DPP-4 inhibitors -gliflozins ◦ Empagliflozin, dapagliflozin -gliptins ◦ Sitagliptin, linagliptin Prevent renal glucose reabsorption Prevents the breakdown of GLP-1 SE: weight loss Often used in elderly and obese Risks: UTIs, euglycaemic ketoacidosis patients SGLT2i’s commonly used in HF management If HbA1c still above 53mmol/mol despite first line treatment, the addition of a second line treatment is recommended. As SGLT2 inhibitors increase urinary excretion of glucose, there is an increased risk of UTIs due to glycosuria. Euglycaemic ketoacidosis: think DKA without the D Increased evidence base showing SGLT2i decrease risk of HF in T2DM, and decreases risk of major cardiovascular events in pts with HF/T2DM GLP-1 enhances insulin secretion and inhibits glucagon-release in a glucose- dependent manner 9 Second Line Options Sulphonylureas GLP-1 analogues ◦ E.g. Gliclazide -tides Stimulates insulin secretion from ◦ E.g. semaglutide, exenatide pancreas Promotes insulin secretion with meals SE: weight gain, hypoglycaemia Added benefit of weight loss Less fashionable as alternatives have better macrovascular outcomes Third line option Given as a SC injection Sulphonylureas will stimulate the pancreas to secrete insulin regardless of the blood glucose levels, therefore patients are at risk of hypoglycaemic episodes. GLP1 analogues are often not used until later down the line, if multiple oral medications have not been effective. Common question stems will state “the patient does not want any injections”, in which case you should not be prescribing GLP1 analogues or insulin. GLP1 analogues are being used more frequently in practice due to lower costs and macrovascular benefits. 10 Second Line Option Thiazolidinediones Meglitinides -glitazone -glinide ◦ Pioglitazone, rosiglitazone ◦ Repaglinide, nateglinide Increases insulin sensitivity Stimulates insulin secretion CI: HF, bladder Ca, HX of DKA Alpha-glucosidase inhibitors ◦ Acarbose Rosiglitazone withdrawn due to increased Inhibits enzymes which break carbs cardiovascular risks outweighed benefits down to sugars Pioglitazone not common used Meglitinides are similar to sulphonylureas 11 You are bleeped to review Matt Foreman, a 62-year-old man who was found by the nurses to be drowsy during the evening drug round. You perform an A to E assessment, with the following results: PMH: T2DM, hypothyroidism, polymyalgia rheumatica Which of the following medications is most Airway patient, no evidence of obstruction likely to be the cause of her drowsiness? RR 18/min, sats 98% on room air A. Prednisolone 10mg PO OD Pulse 125/min, BP 125/87 mmHg B. Glimepiride 5mg PO TDS before meals GCS E3 V4 M4, PEARL C. Levothyroxine 126 mcg PO OD Abdo SNT, BM: 2.6 mmol/L (>4) D. Liraglutide 0.6mg SC OD E. Metformin MR 1g PO BD Answer: B. Glimepiride is a SU, which has the SE of causing hypoglycaemia. 12E. Sulphonylureas have the side effect of causing weight gain It can cause hypoglycaemia and so needs to be stopped on the day of any surgery. It will unlikely be stopped if the diabetes is well controlled as that is the likely reason the diabetes is controlled Regular monitoring would typically be done with BM monitoring and HbA1c. 13Insulin Therapy Started if HbA1c >58 mmol/mol Long acting insulins: despite maximum non-insulin ◦ NPH insulin (Humulin I) treatment ◦ Insulin Glargine (Lantus/Abasaglar) ◦ Insulin Detemir (Levemir) Basal: long-acting insulin given Target fasting BM: 6-10mmol/L OD/BD Biphasic: contains LA & SA insulin given BD with meals Risk of hypoglycaemia, use of needles Basal-bolus: Basal + SA bolus doses with meals 14 Hypoglycaemia Management Alert Unconscious Juice 100ml 20% glucose Oral glucose 200ml 10% glucose Something sugary Glucagon 1mg IM* Recheck every 10-15 minutes until >4 mmol/mol Once alert, give long-acting carbohydarate Glucagon will not work well in malnourished/fasting/liver disease patients, or those on sulphonylurea treatment 50% dextrose is too viscous and irritant 5% dextrose does not contain enough sugar 15Glucagon IM VS Dextrose IV 16Hypoglycaemia Management Likely causative agents: If due to basal insulin: ◦ Insulin, sulphonylurea ◦ Reduce dose by 10-20% Remember that glycaemic events are If due to bolus insulin: caused by the medication before the ◦ Reduce dose by 2-4 units event ◦ E.g. morning hypoglycaemia is due to If due to sulphonylurea: the evening medication ◦ Reduce the dose ◦ E.g. gliclazide down by 40mg 17 One of the HCA’s informs you that Mrs Dianne Beaties has had a fall on the ward. She was admitted following an episode of alcohol intoxication. PMH: T2DM, HTN. DH: gliclazide 80mg PO OD, metformin 500mg PO TDS, ramipril 5mg PO OD Which of the following is the most appropriate treatment based on the given data? On examination: Unresponsive A. 2 tubes of 40% glucose gel PO Pale clammy skin B. Glucagon 1mg IM BM: 1.7 mmol/L C. 200ml 5% glucose IV D. 200ml 10% glucose IV E. 50ml 50% glucose IV Answer: D. 10% glucose IV Patient does not have the capacity to swallow based on the examination. Glucagon is ineffective in patients whose liver glycogen is depleted. Therefore it should s hould not be used in anyone who has fasted for a prolonged period or has adrenal insufficiency, chronic hypoglycaemia, or alcohol-induced hypoglycaemia. Glucagon may also be less effective in patients taking a sulfonylurea; in these cases, intravenous glucose will be required. C. Too slow E. Concentration too strong 18BNF Treatment Summaries: Hypoglycaemia 19 Hyperglycaemia Management Not as an urgent issue has Insulin Up-titration hypoglycaemia* If fasting BMs are high ◦ Increase LA insulin by 10% Metformin ◦ Increase by 500mg E.g. If morning BM 17.6, normal evening dose was 44 units, increase Oral diabetic medication ◦ Consult BNF next evening dose to 48 units ◦ Different drugs have different dose escalations *We are talking in the region of mildly raised BMs/poorly controlled diabetes, not DKA/HSS. In hospital, you are aiming for good control, not best control, as major hypoglycaemias are more dangerous than hyperglycaemias Keep into account patient not on their usual diet, so likely BMs will increase once out of hospital and feeling better. Remember which dose you need to change. If a patient is consistently having high BMs in the evening and is on oral medication e.g. gliglazide, then the morning doses will be the ones that need to be changed. 20 Mr Sam Aglutide presents to the GP with tingling in his hands and feet. He informs you that he has been feeling a lot more thirsty in recent weeks and is waking up in the night to empty his bladder often. PMH: HTN DH: amlodipine 5mg OD SH: Bus driver, been trying to lose weight with exercise and diet over past 6 months to no effect. HR: 78 bpm, RR 18/min, BP 155/92, Sats 99% on RA Fasting BM: 8.5 mmol/L, random BM: 15.6 mmol/L. HbA1c: 67 mmol/mol Please prescribe 1 medication to treat his hyperglycaemia. Metformin hydrochloride immediate release 500mg PO OD 21Glucose Infusion 100ml 20% over 10 minutes 22C 23B 24 Why is A incorrect? Answer: B. 25metformin 26E 27D 28 Main take-away: carry on long- acting insulin throughout fluid and IV insulin treatment Given at a fixed rate based on body weight 29Important BNF Pages Treatment summaries ◦ Type 1 diabetes ◦ Type 2 diabetes ◦ Hypoglycaemia ◦ Diabetic hyperglycaemic emergencies ◦ Diabetes, surgery, and medical illness 30 TL;DR- Diabetes Medication During Surgery If major elective surgery, poor If elective minor surgical glycaemic control, risk of more than 1 procedures only require a short-fasting missed meal, or risk of renal injury, period (just one missed meal), it may be commence variable rate insulin possible to adjust antidiabetic drugs to infusion avoid a switch to a variable rate intravenous insulin infusion; normal If insulin is required and given, stop drug treatment can continue. acarbose, meglitinides, sulphonylureas, pioglitazone, DPP4is, SGLT2is. If more than one meal will be missed, or there is risk of AKI, metformin should GLP1RA can be carried on as normal be stopped when the pre-operative fast begins. Differs and recommended to follow trust guidelines 31https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/DiabetesUnit/5830-3- Diabetes-Management-of-diabetes-before-and-after-surgery-or-procedure.pdf 32https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/DiabetesUnit/5830-3- Diabetes-Management-of-diabetes-before-and-after-surgery-or-procedure.pdf 33 Recruitment Feedback& Next Session 🥼AMSA are recruiting PACES tutors! AMSA are recruiting tutors for mid November - early December This is a great opportunity to get some teaching experience on your portfolio with certificates and feedback provided for all Feedback that take part! Details:- 1 hour Zoom tutorial at 6.30pm on Mondays Mid Nov-early Dec Please fill out the form below by 6pm this Sunday if interested! https://forms.gle/MUZ5UA3WFPPrtXbK8 Not covered topics such as DKA/HSS Unlikely to appear in the exam, if it did then it is likely to be a question such as “X has come in with a DKA. Please prescribe the appropriate fluids”. 34
