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Hello, everybody, thanks very much for joining in on time. We'll give it a few more minutes, and then we'll begin with today's session. Okay, thank you very much for everyone. Has joined on time for today's session. We'll be starting the diabetes management section for the PS. A prep course. My name is Dr Chang, one of the ones who is currently at Milton Keen's University Hospital. Again. Same disclaimer as per the previous sessions, or a bunch of doctors who have prepared cause to help aid your PS a revision. Make sure they always consult your university for the exam related questions. Always consult that the NFL medicines complete for upstate information on drugs and prescriptions before we begin today's session. I just want to quickly correct an error that I had made in the last session. So it's the question with regard to the lady who was on the HRT patch and she didn't want any withdrawal bleeds. I believe that I did a bit more background research just to make sure, and you actually give them an estrogen and a progesterone. But you give them that kind of constantly so they don't have that eastern only period. And, um, that's the preparation you should give. As someone rightfully said in the comments, uh, you need to give them the progestin to make sure that they're protected against endometrial hyperplasia and cancers. So have corrected the slides. Um, and, uh, those are loaded onto last week's session. So today we're going to be talking about the different types of medication that can be used. So we'll do a quick run through in terms of all the diabetes medications. And essentially I'll be highlighting the key components. So the key fact that you'll need to know when you go into your TSA exam and then we'll quickly go through the management for how to capture someone who's hypoglycemic and how to adjust. Uh, the drug doses when they are hyperglycemic. Just a quick question before we begin is the audio and, um, screen sharing. Okay, if someone wouldn't mind just popping a quick message in the chat so that they can hear Perfect. Yes, all the sessions should be recorded and automatically uploaded. All the previous sessions will also have been recorded and uploaded on to the respective, um uh, events. Okay, so let's quickly run through the types of medication that can be used in diabetes management. So this was a child that I found while doing some research for this. You can see that it's quite complicated. All the information you need is on this image here, essentially. But there's a lot to kind of pick out when you're looking at this chart. And so we're going to try and simplify this down into the key components that you need to know specifically for your PS PSA assessment. Um, everything else that we go through in today's session, you should be able to revert back to this slide, and it should make a bit more sense once we've gone through today's session. And this is also another session slide that I think Imperial likes to use in terms of when they give us teaching in terms of how to manage Type two diabetes. So you can refer to either one of these slides, and they should give you quite a lot of detail just to reassure you guys. You don't need to know to this much this level of detail, but it's just for reference for you guys to look back after the session. So in terms of first line options for Type two diabetes. That's what we're going to be focusing on for now. Um, if someone comes in to the clinic and they've been complaining of diabetes symptoms saying they have polydipsia polyphagia area, you know the usual stuff. The first line that we often do is we aim for lifestyle optimization, and that includes foods educated the patient, um, exercise and trying to promote weight loss for around 6 to 8 weeks, obviously encouraging them to cut down on smoking and alcohol and then managing alternative cardiovascular risk factors such as BP and cholesterol. The reason why I've added this is because this could sometimes be in the multiple choice questions where it's about giving patient advice. Someone comes in with a high HBA one C, and the question could be, what's the first line option that you would give in that case if they have not had any previous intervention so far? The first line would be diet weight, uh, weight loss and exercise for at least a good 6 to 8 weeks. That's about two months or so, and you also want to set a target HBA one c so the standard target. Um, HBA one c for someone who's printed for the first time should be about 48 millimeters per month. And that's the magic number to remember for the first line option. If they've had 6 to 8 weeks of weight loss management and the HBA one c still isn't well controlled, there's a separate cut off for that. And that's the cutoff that we use for when we start managing them medically. So if the HBA one c is above 53 despite, um, trial of exercise and dieting and that's when most of the time we'll start you on metformin the standard dose that you would start off with the metformin 500 mg Oh d and this is increased in terms of 500 mg increments, so it can go from 500 mg to 500 b. I. D 500 t. I. D. S. And then the maximum dose that you can give them is 2 g total, so it could be 1 g twice a day or it could be 1 g in the morning, 500 at lunch, 500 at dinner. The main thing to take away is the side effect for metformin. A lot of patients will complain that they have GI disturbance. So we're talking about nausea, diarrhea, that kind of stuff. And sometimes the PS PSA could ask you, a patient has come in. They've tried metformin, but they've got a lot of side effects and they can't tolerate it. What would be the next step in management? And most people would think to switch to maybe a sulfonylurea an SGLT two inhibitor. But the actual best practice answer is to consider a modified release tablets. So this is similar to the, um, opioid uh, session that we talked about earlier with regard to the immediate release and modified release. The first thing that you prescribed would be immediate release metformin. But if they can't tolerate it, you should try the modified release tablets first and see if they can tolerate those side effects better. If not, then that's when you would consider escalating them to the second line options. It's just a quick, um, back, uh, quick bit of background information from metformin. So the mode of action itself is to increase insulin sensitivity, and it also reduces the release of glucose. And this is a medication that does not cause hypoglycemia. There are some risks that you need to know of. The main one is lactic acidosis. So if someone was acutely unwell, if they were dehydrated, if they were at risk of a k I, you would hold metformin off and again the GI side effects that we talked about, which typically settled fast. But if they can't tolerate it, switched to the EMR. There are some contraindications that you should be aware of. Uh, if they have a reduced really function of less than 30 if they have liver failure or liver cirrhosis, some sort of hepatic disease, or if they have severe advanced heart failure, um, from the red box down here, the main thing to take away, though, would be the risks more than the contraindications, but just to keep an eye out for those. So let's say that the patient's been on metformin and the HBA one C is still above 53. This is when we need to start thinking about second line options that we can add on top of the metformin. Um, one of them is your classic SGLT two inhibitors, and these are your guaifenesin so the most common ones in practice would be empagliflozin dapagliflozin, and these will prevent renal glucose reabsorption. So as your blood gets filtered through the kidneys and uh, actually L t two inhibitors will stop the kidneys from reabsorbing the glucose, which means you'll have glycose area. The side effect of having an SGLT two inhibitor is that the patients will often experience weight loss, which is actually a good side effect more than a bad side effect. For most of these patients, the main risks that you need to be aware of are you t i s because they've got glycosuria. They're going to be more prone for urinary tract infections. And there is this thing called you glycemic ketoacidosis that you should also be aware of. So what this means is is essentially very similar to diabetic ketoacidosis. So in DKA of the three components high blood sugar, high ketones and acidotic blood pH. However, new glycemic ketoacidosis basically DKA without the d, so the sugars will be normal. But there's a lot of raised ketones and various acid, so that's just a important risk to be aware of. And SGLT two inhibitors are commonly being used in heart failure management more and more in everyday practice, so it's just a bit of a clinical side note. Let's talk about DPP four inhibitors now, so these are your glip times. See what your sitagliptin and your linagliptin, and these will prevent the breakdown of GLP one. So just two roughly recap. What GLP one does is it enhances insulin secretion, and it inhibits, um, glucagon release. And so, if you prevent the breakdown of GLP one, then your body is going to be able to enhance insulin secretion further. And these are typically often used in either those who are elderly or those who are obese in body habits. Some of the second line options that we commonly see is, or actually less commonly, would be your so finally areas. So this is glipizide is your very common classical, uh, sulfonylurea that you may see in the PS PSA questions. This one is one of the more important ones to be aware of, because the mode of action is that it stimulates insulin secretion from the pancreas directly. So you have two side effects which are important. You've got your weight gain, but more importantly, there's a risk of hypoglycemia. Um, so for now, your ears in day to day practice are becoming less fashionable because there are alternative medications as the ones that we've talked about previously. And some of the other ones that we talked about, which are better microvascular outcomes. And obviously there's also the risk of a patient having a hypoglycemic episode. So when you start a patient on SULFONYLUREA is, you need to inform them. Um, it's always carry around a bit of sugar, a bit of that extra glucose boost, just in case you do experience a hypoglycemic episode. And then we also have the GLP one analog. So these are your drugs that end in type. So you got your semaglutide and your exenatide These, uh, promote insulin secretion with your meals. So it kind of mimics your, uh, body's natural hormonal response as to when you have meals. And it's got the additional benefit of quite a good efficacy in terms of weight loss. So that's a one of the side effect profiles GLP one analog. The main thing to be aware of is that this is actually a third line option, so we typically don't usually give GLP one analog unless you've tried a few of the other second line options, and the important thing is that it's given as a subcutaneous injection. So if you have a PS a prescribing question and the patient is saying that they are needle phobic, for example, but you need to, um, add on another medication, then you you should stay away from your GLP one analog, and you should obviously stay away from your insulin because those are both injectable medications. Just a few more second line options. These ones are less commonly used nowadays, so you've got your thiazolidinedione. Uh, these are the ones that end in glitazone, so the two main ones are, in fact, that to only ones, I think, which are licensed for diabetes or were licensed for diabetes. Medication is your pioglitazone and your rosiglitazone. Just a side note that Road's Glitazone actually is no longer used in diabetes management because it was shown through certain studies that there's an increased risk of cardiovascular events, and those risks actually outweighed the benefits of managing the diabetes, so rosiglitazone is no longer used anymore. Pioglitazone is the only thiazolidinedione that's used, and this one is another medication that increases the body's sensitivity to insulin main contraindications that you need to be aware of our heart failure and bladder cancer and also those who have history of DKA. Uh, so the way I like to remember it is, um, pioplitazone. It begins with a P. So it's contraindicated for those who have bladder cancer. And then, uh, because of this fact that rosiglitazone was withdrawn because of the cardiovascular risks. You also don't use pioglitazone in patients with heart failure, so it's a bit of a dubious way. But it's how I remembered the contraindications for pioplitazone. There are some drugs which are under the meglitinide, um, these ones. So the ones on this side you don't really need to know too much about because I don't think they're as commonly used in practice usually. But you're, um, ones that end in a glipizide. So you're repaglinide and you're nateglinide. These are medications that stimulate insulin secretion, and you've got some alpha glucose. Today's inhibitors. Uh, this is your acarbose medication, and what Acarbose does is it inhibits the enzymes which break your carbohydrates down into sugars. So what the Acarbose should do is when you've had a meal. It should slow down the break down of carbohydrates and should therefore increase your blood sugar level is a bit more slow. So those are the main, um, oral medications. Other than your GLP one agonists, I'll just quickly shoot over to see if there are any questions. Okay, so here's our first question. Then you've been bleeped to review uh, metformin, a 62 year old man who was found by the nurses to be drowsy during the evening drug around you perform a quick 80 assessment on him and you get the following results results. So his airways patent and there's no evidence of obstruction. His respiratory is 18 per minute and his SATs 98% on room air. His pulse is a bit fast. At 1 25 his BP seems okay. It's 1 25/87. His GCS is 11. Pupils are equal and reactive to light. His his abdomen is soft and nontender and his BMS are 2.6. Uh, he's got a past medical history of Type two diabetes, hypothyroidism and PMR. So which of the following medications is most likely to be the cause of that should be his drowsiness. Is it A prednisolone is a b glimepiride, is it? See levothyroxine d liraglutide or e metformin. So if you guys want to have a look at this question, you can load of your B n f if you want and answer in the chat on metal A, B, C, D or E. Okay, Yeah. Give you guys a few more seconds, see if anyone has any other answers we got be. So far, we've got d. Okay, Uh, so the answer to this question was e glimepiride. Uh, when I first looked at this question, I straightaway looked at the regular time and thought, Okay, that's an insulin. Um, I'll jump to that answer, but your appetite is actually one of the long acting insulins. If we have a look at what GLIMEPIRIDE actually is sometimes with the TNF type in glimepiride, let's have a look here. You can see here. It tells us that it's actually a sulfonylurea. And as I mentioned on the previous slides, SULFONYLUREA is our one of the common, uh, oral anti diabetic drugs, which can cause hypoglycemic episodes. So it's out of the following, uh, the most likely medication to be the cause of the drowsiness because of the lower blood sugars is be glimepiride, uh, sulfonylurea. So this is a question that I've taken straight from the PSSA. Um, what questions? So let's say this came with my PS exam. How would I break this question down? So the first thing I would look Okay, so this is a patient information question. Let's have a look at what's in the case presentation. So you've got someone who has known diabetic Type two diabetes. They're on metformin titrated up to 1 g twice a day. So there are the maximum dose of metformin, and the HBA one C is still a bit high above 53. They've remained hypoglycemic despite dietary modification lifestyle advice for over the last three months, she is advised, I had glucoside 80 mg or lead to her existing prescription. So let's have a look at the options here we've got either glipizide may need to be increased temporarily during illness. We've got quickly. Side will be stopped once the diabetes is under control. Got glipizide will help to prevent weight gain. Got regular dipstick test will determine the need to adjust the dose of glipizide and we have She should carry a source of should refer at all times. So what do you guys think? The answer is A, B, C, D or E. Okay, very good. So pretty much all of you have gone to E, which is the correct answer. Um, let's go through the other options really quickly. So, typically before surgery or during illness, Um, I think during illness, you probably carry on the glipizide dose. But before surgery typically hold it off because again of that risk of hypoglycemic episodes, the patient is going to be more by mouth before surgery. They're going to have low blood sugars. If her diabetes was brought under control on glipizide. That will tell us that the GLICLAZIDE has been working, and that addition of the medication is what brought the glucose levels down so you wouldn't stop it. You could carry it on. If the diabetes is under control. Sulfonylurea is actually have a side effect profile of causing weight gain and in terms of, um, monitoring the patient rather than urine dips, you would look at the HBA one c is you would ask the patient to do bms at home and that is what you would base in terms of addressing the dosage. So, as you said, because there's a risk of hypoglycemic episodes, E is the correct answer to this question. Okay, so let's move on to insulin therapy now. So this is typically, um, started in Type two diabetics if the HBA one C is above 58 despite having maximum non insulin treatment. And, of course, insulin is also what we give to patients with Type one diabetes. So there are a few different types of insulin regimes that can be given. We've got just the basal, which means that we give the patient a long acting insulin, and it's typically given over once a day or twice a day. We have the biphasic, which contains both long acting and short acting insulin, and this is typically given twice a day with meals. And then we have your classical basal bolus regime. So this is the basal regime mentioned with the addition of short acting insulin with every meal a few of the common long acting insulins. To be aware of that we see in clinical practice, you've got your, uh, nph insulin, your insulin glargine and also your insulin detonate. And in terms of short acting insulin, I think the only one that can think of off the top of my head is your nerve records. So when someone is on insulin therapy, we've gotta have a target. Fasting PM In hospitals, the range is typically around 6 to 10. We've got to remember that when a patient in hospital, we're not trying to perfect their blood sugar levels. But we're just trying to make sure that it's an adequate level, Uh, that there is an adequate level of control. The patient isn't going to be eating the regular food that they will be at home. Uh, patient is going to be quite unwell. And so, rather than trying to aim for perfection, we got to make sure that it's well controlled. And then when they are sent back into the community, um, it'll be the GPS responsibility to then monitor and then find to the diabetes medication. The main thing to be aware of again with insulin is the risk of hypoglycemia and the fact that you require the use of needles to administer this medication. So in terms of hypoglycemia management, they're essentially two things that you need to think about at the beginning. Is the patient able to swallow or are they not able to swallow? If they are alert and they have the capability to swallow, then you can give them various different things. Depending on what's available in the ward, you could give them some juice like orange juice. You can give them oral glucose supplements. So, uh, quite often on the world that I'm working on, we would give them the oral glucose gel. Or you can just give them anything sugary. If you have things like jelly babies on the ward, any sort of sugary sweet you can give those to the patient. We typically don't give something that has high fatty content such as chocolate, because I think the fat contents actually interferes with bringing up the sugar levels quite quickly. So that's what you would do if the patient is alert. If the patient is not alert so essentially there unconscious and they don't have the capability to swallow, then you've got three different classical options. You have given them 100 mils of 20% glucose. You can give them 200 miles of 10% glucose, or you can give them glucagon intramuscularly. So the way I remember is it's 120 or 210 so those numbers are essentially interchangeable. Um, quite often the PS PSA questions will ask you, Would you give 5% or would you get 50%? You wouldn't get out Of those, 5% is too low of a glucose concentration, whereas 50% is too high. And it's actually very, very viscous. And it could cause irritation in the veins. Uh huh. The reason why there's an asterisks asterisk next to glucagon is because you need to be aware of certain caveats of Glucagon administration. It won't work well in those who are either malnourished. Those who are fasting say that they were due to have surgery or those who have liver disease, because the main mode of action is that it replenishes your glucose levels, Um, which is stored within the liver. The other thing you need to be aware of, which is a bit sneaky is that you It's not recommended to be given to patients who are on sulfonylurea, um, for the diabetes management. Once you've given them something, though, you want to recheck every 10 to 15 minutes until they reach that four millimoles per liter cut off? That should say so, not malls. And once they're active and alert, you would give them a long acting carbidopa hydrate to kind of bring up and sustain their glucose levels. So to summarize, if they're alert, give them something to drink if they're unconscious. If they have good IV access, give them some fluids. If not, give them a job of glucagon. But be aware that if they have liver disease or if there malnourished or if they're on sulfonylurea, you wouldn't give them a glucagon, uh, in terms of which one do you get First, would you give glucagon or would you give dextrose? This creature has been taken directly from the TNF, so what they say is if there is a hypoglycemic episode which has caused unconsciousness, it's a medical emergency. Um, those were unconscious or having seizures, or if they're aggressive, um, if they're receiving any insulin, then that should be stopped. And they should initially be treated with the glucagon again. As you said, if it's unsuitable because of the previously mentioned reasons, then you can give them your glucose. Sorry, 10%. Or give them glucose 20%. And it tells you the reasons why glucose 50% isn't good. So if you forget, you can always refer to the hypoglycemia treatment summaries, which is located on TNF. So, um, sometimes they might ask you which of the following medications is likely to get the cause of hypoglycemia is two of the main ones that I've been kind of drilling into your heads by now is the insulins, and the sulfonylurea is. These are typically the most likely cause of agents that you'll see in the, uh questions. And remember that if someone has a glycemic event, I have a hypo hypoglycemic event. It's because it's being caused by the dosage of the medication that was given before the event. So if someone had a hypoglycemic episode at six AM, it's not because of the dosage of the six o'clock or eight o'clock medications. It's because of the evening medications that were given the night before, and so when you need to modify the medication, you should be thinking about that previously given doses, which needs to be adjusted. If someone had a hypoglycemic episode due to basal the basal dose of insulin. If you need to modify the dose, then you just reduce it by 10 to 20%. If the hypoglycemic episode was due to a bolus insulin, then typically we would reduce it 2 to 4 units. And if it's due to a sulfonylurea, then you just need to reduce the dose. So your glyco sides are typically cut down by 40 mg. But different sulfonylurea zar prescribed two different doses, so make sure you check the TNF to see what the typical dose escalation or de escalation is for. Each of the Sulfonylurea is okay, so let's move on to the next question. Then, uh, one of the HDL has informed you that Miss Diabetes has had a fall on the ward. She was admitted following an episode of alcohol intoxication in terms of a past medical history. She has Type two diabetes and hypertension. She's on the glipizide. She is on metformin, and she's taking Ramipril for her hypertension. On examination, she's unresponsive. She's got very pale and clammy skin, and her BMS are 1.7. So which of the following is the most appropriate treatment to administer? Uh, this patient based on the given information. Would it be two tubes of 40% glucose gel orally? Is it glucagon 1 mg I am? Is it 200 mL of 5% Glucose IV? Is it 200 mL of 10% Glucose IV, or is it 50 mL of 50% Glucose IV? So a, B, C, D or E if you guys want to pop into the chat Oh, okay, so most of you guys are saying D, and that is indeed the correct answer. So the two suitable options would either be B or D. But then you've got in the history that she's been admitted following an episode of alcohol intoxication. So we need to think, under the assumption that the patient has, um, liver disease or some sort of liver pathology's undergoing. So they're going to be an unsuitable candidate for glucagon in terms of how fast to give the IV fluids, I think typically we would give them over 15 minutes, so we want to give it as a bolus quite quickly, too quickly, replenish the glucose levels. So if it was 200% 200 mils of 10% or 100 mils of 20%. I think both of them you would typically give between 10 to 15 minutes. I think if you if it was a prescription question both of those answers, we'll give you full masks, but you wouldn't want to give it slowly over an hour over eight hours. You want to give it to them quite rapidly, and this is just a bit more information with regards to giving glucagon in those with liver disease. So the main take away here is the manufacturer advisor is ineffective in those with liver glycogen depletion. So, for example, patients have fasted patients with chronic hypoglycemia, alcohol induced hypoglycemia, and it's also less effective in those taking the sulfonylurea. So again, this could all be backtracked and found on the TNF sites. In terms of hypoglycemia management, we're not going to be talking about DKA or H h h H s. Specifically, we're going to be talking about the clinical scenarios where someone's BMS are maybe 15.7 or 18.5. Um, these episodes of hypoglycemia not as urgent as the hypoglycemic episodes that we've talked about just now. So if someone is on metformin and that's all the wrong and they're a bit hypoglycemic. Then you would increase the dose by 500 mg, and you would increase up to the maximum dose if possible. If someone is on a different oral diabetic medication, then it's a fairly simple question. Can sort of TNF see what they recommend in terms of those escalations. And remember that different drugs, even if they're in the same drug class, may have different, um, dosage escalation levels. If they are on an insulin, then we've got to think about uptitrating the insulin doses. So if they're fasting, BMS are high. Then you want to increase the long acting insulin, typically about 10%. So if someone's BMS will measure in the morning and they were 17.6, remember, we need to change the evening dose because it's a long acting insulin that will have time overnight to kick in and then bring the VNS down. So if they're normal, BM dose evening dose was 44 units, then we add 10%. That's another four units on to that, so the next evening dose would therefore be 48 units. Remember that we wouldn't modify the morning dose because that's not that dosage is not going to be taking into effect overnight. So here is our next question. Uh, Mr Samad. Blue Tide presents to the GP with tingling in his hands and feet. He informs that he's been feeling a lot more thirsty in recent weeks, and he's waking up in the night to empty his bladder. Often again. He's got a past medical history of hypertension, and he's on Amlodipine. He is a bus driver, and he's been trying to lose weight with exercise and diet over the past six months to no effect. Heart rate is 78 his respirations 18 BP is 155 over 92 it's that's a 99 on room. Air is fasting. BM is high at 8.5 and it's random BMP. Also high at 15.6, is HBA. One C is also come back at 67. So if you guys could prescribe one medication to treat his hypoglycemia and if you could write as the full um, prescription. So the dose of the medication, the dose, the root and the duration, and if you want, just stick that into the chat for me okay? Yeah, yeah, yeah. Okay. Perfect. Very good. So this, um, was just to check to make sure that you're all concentrating and focus making sure you're not prescribing, uh, someone in the GP with a stat dose of act rapid or rapid insulin. So this is a patient come in. First presentation. They've already tried adequate weight loss and exercise over the past six months. So that's greater than 68 weeks. The HBA one C is over 53 so therefore, we want to start them on treatment just to make sure. Let's go through the TNF together. So as you mentioned, the first line medication would typically be metformin. So the full medication with the metformin hydrochloride. If we scroll down here, we can see type two diabetes mono therapy. We would start them off with the immediate release medicine, and it says here initially 500 mg once daily for at least one week. Those to be taken with breakfast. So to get the full marks, you would have had to said metformin hydrochloride 500 mg p 00. D. For at least one week, you can prescribe it as one week you prescribed two weeks, Ivan wouldn't matter as long as you prescribed it for at least 11 week. Yeah. So this is another question that we have taken directly from the PS A mark papers and I think the rest of the slides are essentially the same thing. So it's just to go through the questions together to show you how I would go through these questions or my thought process behind it and see if we all come up with the same answers or not. Okay, so we've got a IV fluid prescription just for one bag that is most appropriate to treat this patient's current condition. Okay, so what is the condition? So far, they've come in for an A k I. And he's sweaty, confused and drowsy. He's on metformin and he's on glipizide. So he's on the sulfonylurea already got red flags, got hypoglycemia buzzing, Um, in our heads. His heart rate is a bit fast. Blood pressure's fine. JVP is fine. Respirators. Fine. GCS is a bit low, and his finger print glucose shows that it's less than four is at 1.9. So if you guys want to think about what fluid you think would be the most suitable to prescribe and again over what you're Asian and what volume. And if you just want to pop it into the chat. So we've got an elderly gentleman who is an A k I. And he's having a hypoglycemic episode. He's confused and drowsy, and so he's probably not going to get have good oral intake. So just give him some fluids. Yeah, thank you. Okay, very good. So, uh, yeah, that's a very good answer. So you would give them either 10% extras at 200 mils, or you could give them 20% extras at 100 mils the duration. You've got to make sure that you specifically write down a duration. Typing in bolus wouldn't give you a, um, anything adequate in the duration drop down box? I think so. You've got to specify a specific time. So, like you said, 10 to 15 minutes should typically be a suitable time in terms of the prescription. Here we have a bit of a more lengthy question, but again, to save time, how would I go through this? Okay, question says, like the most appropriate decision with regards to the morning dose of insulin based on these based on these data. So already I'm thinking, Okay, this is probably someone who is either hyper or hyperglycemic. And their morning dose needs to be changed because the evening dose has been a bit low. So even I can skip the case presentation and the on examination part straight away. I can jump straight to the investigations. You can see that is also her fasting. Glucose is six prior to breakfast and 18 prior to evening meal. So it's a bit high in terms of the evening meal, so you probably want to increase the morning dose. Let's scroll up here. You can see that they're on the five basic isofl insulin on Humulin n free. They're taking 20 units subq twice daily. So you're taking 20 units in the morning and 20 units in the evening. So we want to increase the morning dose because the evening dose, because the evening fasting blood glucose has been on the low side. So out of these options, which ones are the most suitable? Well, in terms of adjusting the morning dose, we don't want to cut it down because that will cause the evening blood sugars to go up more option B, C and D are all increases in terms of the dosage option E to stop the subcutaneous insulin and start variable rate insulin infusion would be very extreme for someone who's just got a one off high, uh, blood glucose reading. So we said earlier that we need to increase the dose by 10% and they're probably 20%. So after these three options, the best option would be options. See here to increase up to 22 units. Subcutaneously. Okay. Okay. Here we have a similar sort of lengthy question. Um, this time I'll be quiet and I'll let you guys answer this one. So if you want to have to read through this question and then pop your answers in the chance Yeah, sure. Yeah. A, B, C, D or E. So the answer for this one is indeed be. Remember, if we look at these blood glucose levels here, we can see that at six o'clock, so six PM in the evening There, blood glucose is a bit high. So what this tells us is that their morning long acting insulin isn't high enough to bring their glucose down at the evening time. So therefore we need to give them a stronger morning dose. We can see that at breakfast they have 44 units, so 10% and 44 would be a number 4.4. So that increases the dose up to 48 units, which is the second option here. Okay, so this question I've added because it's pretty similar to one of the other previous questions that we've had. But my question specifically to you is, why is the first option wrong? So we got a six year old gentleman who's coming with diabetic gastroparesis. Uh, he is on a biphasic nova mix, um, mixture of 24 units at breakfast and 24 units in the evening. He was given his morning dose of insulin. Today, despite being near by mouth at 12 noon, he's found sweating and unconscious by the nurses. His finger prick capillary glucose is 1.3 millimeters. That's very low. So my question is out of these five a b c d e. Which one is the correct answer? And then the second part is why is a incorrect Okay, so you got people saying that be is the correct chancellor. Mhm. So I would agree out of B, C, D and E B would be correct. So I've told you that a is not the correct answer. Can anyone in the chat tell me why? Very good, Benita. Very good. So the question specifically says that he's near by mouth and he's being investigated for he's nearby because being investigated for diabetic gastroparesis. So what does this tell us? He's in a fasting state, which means very likely that his glycogen stores have been depleted. So, as you mentioned earlier, your glucagon 1 mg I am would not be a suitable prescription for this gentleman because it's unlikely to have an adequate response. So here is another question. No, sorry, we've done that. We did this question earlier. Um, it's the one that we I typed up early. Okay, so this is a bit of a more trickier question, which I thought would quickly cover. Um, we've got 20. In fact, how would I How would I go for this question? Okay, so it's a management option question at this stage. We got 22 year old who's come in with a 24 hour history of generalized tiredness and lethargy. Um, they are on a biphasic Humulin 20 in the morning, 22 in the evening. They appear drowsy. Skin tag is reduced. Temperature is a bit high. Heart rate is borderline normal. Um, so the temperature is normal. Heart rate is normal. BP is a bit low. Respiratory quite high, actually. The auction. So that's a 90 for breathing air, which is ever so slightly worrying for a 22 year old. Your analysis shows ketones two plus glucose free plus weight is 60. The white cells, a bit raised sodium. Potassium are are bordering along the low and high ends. Your ear is a bit high. Creatinine is a bit high. Their finger prick glucose is 28 so that's very high. The P 02 is ever so slightly low. T C E 02 is quite low. Okay, so they're a bit acidotic and they're hydrogen. Ion is a bit high. Bicarb is a bit low. They've already been given a bit of fluid. So based off of this information, you should be able to come up with a diagnosis and based on the diagnosis, you should be able to give the right prescription. Okay, Very good, guys. So, indeed, this was an episode of diabetic ketoacidosis very common in the young population of type one diabetes. So you can see we've got the three elements here. We've got the diabetic part because the finger prick glucose is high. We've got the keto part because your analysis shows that they've got raised Keto, and we've got the acid of spot because their pH is very, very low in terms of managing them, the first thing you want to do is give them very good fluid resuscitation. Uh, and you follow the typical DKA protocol, which we won't get into in today's session. But it's basically giving them good food, um, resuscitation and then to give them a fixed rate insulin infusion, which typically 0.1 unit per kilo per hour. And that is in line with our option e. Okay, so here we have another similar question. And again, I want you guys to think about what you would do in terms of managing the medication. So this is probably one of the trickier, trickiest types of diabetes related questions you would get in the PSSA. So let you guys read through the question and then see what you guys say for the answers. What? Yeah. Okay, so we've got some people say, e, we've got some people saying, D see if anyone else has any different answers. Okay? Okay. So it seems like most of you are pretty on top of it, actually. And you seem to know most of the stuff that I'm quite impressed. Uh, so the main take away from this question is again we've got another patient who is in diabetic ketoacidosis. Uh, we established earlier that the main insulin management is for a fixed rate of insulin infusion. But this question also assess is your knowledge in terms of what do we do with the other diabetic medication? So in the drug history, we can see that they're on Humulin n s, which is a type of a fact acting sorry, fast acting insulin. And they're on Atlantis, which is the long acting insulin. So the options all here stating, you know, do you stop both the long acting and the short acting or do you stop the short acting only And what the TNF and what, uh, evidence based research has shown is that you should carry on with the long acting. But you should stop with the short acting, which pretty much all of you have actually got correct here. So most of you said I have a d or E. We can look and see that you would stop the soluble insulin, which is the short acting one you could carry on the insulin glargine, which is the long acting one. And then we got fixed rate versus variable rate. As you said, you give it at a fixed rate, um, which is the option e that was shown here. So the rate is fixed at 0.1 unit per kilo per hour. And that's the typical, um, management for the episode. So d k. To summarize, stop any short acting insulins carry on their usual long acting insulins, give them lots of fluid and start them on a fixed rate insulin infusion. This is the information that is given on the TNF again. The main take away man. The main take a point from the set of slides here is to carry on with the long acting insulin and stop the short acting one which, in fact, most of you got correct anyways, and it should say it. Here it is. Patients who normally take long acting insulins should continue their usual doses throughout treatment. So someone's asking. The chat is variable rate only for surgical patients. Um, yes. To the best of my knowledge, the only time I've seen variable rate infusions is for those who are surgical patients. We don't We don't use it in anything else off the top of my head. The main thing to remember is for insulin. It's fixed rate for surgery. You would give them variable rates based off of their blood glucose levels, so that pretty much brings us to the end of the session here. What I've done is I've added some hyper link for you guys. Um, these are the main treatment summaries, which I would recommend that you either get familiar with, have a read for a day, or even if not, just be aware that they do exist so that if in your exams you do forget something, you'll be able to jump to these treatments summaries, and they should give you plenty of detail in terms of what you need to know. For diabetes management, I have added a really quick summary with regards to what to do, um, in surgery. So this is all taken again from the diabetes surgery Medical illness part. If someone is having a major elective surgery or if they have poor glycemic control or if they have, um, the risk of missing one more than one meal or the risk of renal injury, then in these patients you would commence them on a variable rate insulin infusion. And if insulin is required and if it's given, then you would stop pretty much most of the other medications for major elective surgeries, your acarbose. But tonight, SULFONYLUREA is, um, sort of a, uh, the drug classes for the people to be or DPP four s and SGLT two. So, essentially, if someone's having a major elective surgery, um, for most of the day, you start them on variable very insulin, and you typically stop most of the medications. Uh, they stayed on that page that GLP one receptor agonists can be carried on as normal. And if they're having a minor surgical procedure, and it only requires a short period where they have to fast so example, just one. This meal then. Usually you can just monitor modify the dosages of the diabetic drugs that they're on rather than switching them to a variable rate insulin infusion. This is a lot of information there, and I haven't seen any questions either in the practice, um, papers or in the real paper or in any of the question banks where they ask you specifically how to modify drugs during surgery. So I think it's a bit advanced. Um, I've added some slides just for you guys to have a look for if you want to, Um, and I've added the link below in the notes for the source. For this, this essentially summarizes what you would typically do in patients who are surgical candidates. You can see it's very complicated, and this isn't something that is located on the TNF, either. So I don't think you need to worry about how to manage a surgical patient In terms of diabetes medication. I've added these slides more just for context. Your purposes for educational purposes. If anyone is was interested in what you would do so you can have a look at these slides. But it's not something I would, um, spend any time revising, and that brings us to the end of our session for today. So thank you very much. Everyone who stayed till the end. Um, just a quick shout out for AMSA. We are currently recruiting tutors for our paces course. It's going to be run from the middle of November early December, and it's a great opportunity for you to get involved with Amitiza to get some teaching experience for our portfolios. You'll get certificates and feedback, Um, which is all provided through the metal platform, The sessions themselves or one hour. I'm sorry. It's zoom tutorials on a 6 30 Monday evening, and, as I said, it will be starting between mid November early December. So if you are interested, please fill out this form here, or you can scan the QR code for the recruitment. And if you could kindly provide feedback with the second, uh, QR code down here, but that brings us to the end of the session. Hopefully that has clarified some of the more confusing aspects when it comes to diabetes management for the PSA, And if you have any questions, please do feel free to shoot them into the chat. Yeah, Okay, I will stay online for the next five minutes or so, just in case anyone does have any of the burning questions. But if not, thank you very much, everybody. And I hope you enjoy the rest of your Saturday. So when do you give dextrose versus Glucose IV? Um, that's a good question. I think it doesn't, um, off the top of my head, it's basically, um it depends on what your trust has. So in terms of real life practice, it just depends on what is available in the wards. Um, some, I guess some trust will have extra. Some will have glucose. Different hospitals might use different types of sugars. Either way, it doesn't matter too much to answer your question in terms of the in terms of the say specifically for purposes of the PAS exam, let's just drop on too. Let's have a look at it. So, as I always say in every session, I always like to have the PS a platform open because that can tell you. Okay, so we have glucose. 10%. 20% is an option. Um, let's see if texture so dextrose isn't an option here. So for the purpose of the PAS exam, you would prescribe glucose 10% or 20% in real life practice. It could be depending on whatever your water is available. What they have in stock. But for PS A exam purposes, Glucose is there, and you can see it won't even let you have pictures. Dexterous isn't even an option that you can prescribe. Could you please explain again how and when you would change the dose when the blood glucose is out of range? Okay. Are you talking about, uh, hyperglycemic episodes or hypoglycemic episodes or just want a quick summary on everything again? Yeah, sure thing. Let me change the doses. Okay, This is in terms of hypoglycemic episodes. So if someone has had a drop in their blood sugars because the doses of the medications are too strong, um, if it was due to the basil so if it was due to long acting insulin, we would typically reduce the dose by 10 to 20%. If it was due to the short acting insulin, then you probably just cut it down by 2 to 4 units. And if it was due to, for example, a sulfonylurea because That's the only other medication that we've covered today, which causes hypoglycemia. You would reduce the dose, and you check the TNF for that. So it was liquid side. We can see that they recommend for dating milligrams daily, and you would adjust it typically by 40 mg dose is it's got to the bottom. Let's have a look at other stuff in our area. So it was glipizide, so you can see it's a different dose here. So if they were on this medication, I would probably cut them down by 2.5 mg until their blood sugars are well controlled. Of course, in real life clinical practice, you wouldn't just change these medications. You would also have to think about what is the actual trigger, what the underlying cause that has caused this episode. And you need to treat, um, the cause of the hypoglycemic episode because it's probably not just going to be because of this one off dosage issue, if that makes sense. So in terms of hypoglycemia, the basil you would cut it down by 10 to 20%. Uh, let's just say 10% for clarity and elbows, and then you cut down by about two units in terms of hyperglycemia, UH, same principle, it was something like metformin. You would increase by 500 mg, and it's noted quite clearly how it will be prescribed. So you start them on 500 mg once a day, then you'll start them 500 mg twice a day. So in the first meal, I mean 500 mg three times a day, breakfast, lunch and evening meal, and then maximum would be 2 g a day. If it's a different medication. Like you said, you can just consult the specific drug. And what dose increments. They recommend that if it's to do with insulins, you would increase the long acting insulin, typically by 10%. So to make it really simple, uh, instruments you can reduce by the basal one. You can reduce or increase by 10% the bolus ones. You would modify them by units of two. If it's a medication, then um so if it's an oral medication, have a look at the TNF and see what they recommend again to kind of like this back with clinical practice. If you did have a patient who was quite who was having fluctuance blood sugars are if they If you're having any difficulties with managing their diabetes, what you can actually do is you would just put in a referral to the diabetes specialist nurse, and they will review the patient. And I'll document very clearly how you should, uh, modify their medication doses based on their PMS. So in real life practice, you have a lot of systems. The diabetes specialist nurses are excellent and what they do and they'll give you, they'll clear. Document the recommendations in terms of titrating up titrating down the doses for the PSSA. Just remember 10% if it's a basal two units with the bolus and anything else, Just look at the TNF. Hopefully that answered your questions. So the target glucose that you should aim for typically I think is, uh here we go, Um, typically around 6 to 10. Um, but I think off the topic. Sometimes we we aim for 6 to 15. If it's, um, an elderly patient. Um, I'll have a look just to make sure specifically what they recommend. But I think that the typical target fasting the end of 6 to 10, and there's a bit more leniency when it comes to sorry when it comes to elderly patients, when do we prescribe? I am glucagon. Uh, so as we covered in this session here. So if they're unconscious, Um, what the TNF recommends is giving glucagon first thing in patients who were unconscious. The only, uh, conditions where it's unsuitable would be is if they're either on a sulfonylurea or if they have, um, any of these any cause where the liver glycogen is depleted. So anyone who's been fasting, anyone who has adrenal insufficiency, chronic hypoglycemia, alcohol induce hypoglycemia again, All this has been recorded in today's session. And so you should have access to the recordings once the session is over. No worries. You're welcome.