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114 Cards in this Set

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What is the NHMRC definition of diabetes mellitus?
A heterogenous condition characterised by hyperglycaemia, disturbances of CHO, fat and protein metabolism associated with relative deficiencies in insulin action or secretion.
What are the 3 main types of diabetes?
- Type 1 diabetes (Insulin dependent, juvenile-onset).
- Type 2 diabetes (non-insulin dependent, traditionally adult onset).
- Gestational diabetes.
Diabetes is the __ leading cause of death.
7th
What percentage of health cost does diabetes have on the Australian healthcare system?
3%
Epideimologically, diabetes increases in prevalence with age. True or false?
True.
What are the risk factors for diabetes?
- Obesity and/or inactivity.
- High saturated fat diet.
- Age.
- Ethnicity.
- Waist > 100cm in men, 90cm in women.
- Low birth weight or diabetes in pregnancy.
- Stress.
- Lack of exercise.
- Excess alcohol, smoking, and some drugs.
- Sleep deprivation.
- High fat, sugar diet.
What are the dietary recommendations to prevent diabetes?
- Low fat.
- Low GI.
- ?Dairy foods.
- Green leafy vegetables, fruit and berries, olive oils, ?margarine, poultry.
List substances that could possibly influence diabetes.
- Cinnamon.
- Alcohol.
- Coffee.
- Metformin.
List complications (macrovascular and microvascular) that can occur with diabetes.
Macrovascular:
- Heart, brain and peripheral vascular disease.

Microvascular:
- Peripheral neuropathy.
- Retinopathy.
- Nephropathy.
At the time of diagnosis of diabetes, 1 in 3 to 1 in 20 of patients have what complication?
Microvascular disease.
What is the annual incidence of dialysis/transplants needed for diabetic patients?
1.2%.
What is the annual incidence of heart attacks, stroke or amputation in diabetic patients?
2-5%.
What are the common co-morbidities of diabetes?
- Hypertension (55%).
- Hypercholesterolaemia (53%).
- Coronary heart disease (30%).
- Obesity (44%).
What self-help device is used to help influence the behaviour of a diabetic?
Pedometer.
How frequently should high risk populations be screened for diabetes?
Every 3 years.
At what age should ATSI, PI, Indian and Chinese populations start being screened for diabetes?
Age 35 and above.
Which CVD patients should be screened for diabetes?
AAAAALL OF THEM
If a patient has a BMI > 29, hypertension or a family history of diabetes, at what age should they be screened for diabetes?
Age 45 and above.
At what age should an overweight patient with PCOS be screened for diabetes?
AAAAANY AGE
Everybody, regardless of physical health, should be screened for diabetes after age 55. True or false?
True!
At what age should a patient with a past medical history of gestational diabetes be screened?
Any age.
How frequently should a patient be screened for diabetes if they have an impaired glucose tolerance or impaired fasting glucose result?
Every year.
At what blood sugar level is considered normal in both fasting and random blood glucose tests?
5.5mmol/L.
At what range of a fasting blood glucose result should an OGTT be ordered?
5.5-6.9mmol/L.
At what range of a random blood glucose result should an OGTT be ordered?
5.5-11mmol/L.
At what fasting blood glucose level can a diagnosis of diabetes be likely?
> 7.0mmol/L.
At what random blood glucose level can a diagnosis of diabetes be likely?
> 11mmol/L.
On an OGTT, what result is needed for a diagnosis of diabetes?
11mmol/L.
On an OGTT, what result range would indicate impaired glucose tolerance?
7-11mmol/L.
List the GP's role in managing diabetes.
- Diagnosis/Screening.
- Optimising care and coordinating chronic disease management.
- Regular review.
- Detection and minimisation of complications.
- Education, lifestyle and behaviour modification.
In a diabetic patient, how frequently should the HbA1c be checked?
1-4 times a year (depending on compliance and current stage of disease).
What needs to be checked twice a year in a diabetic patient?
BP, BMI and feet.
What needs to be checked annually for a diabetes patient?
BSL, urine, lipids, medications, SNAP review.
What needs to be checked biannually for a diabetes patient?
Eye check.
What do you check for at the legs for a diabetic patient?
- Foot check for neuropathy.
- Ankle/brachial BP and pedal pulses for vasculopathy.
What does an aspirin every day do for a diabetic patient?
- Reduced major cardiovascular events by 28%.
- The benefits > harms if more than CVD 3% risk in 5 years (but take care in patients > 70).
List medications used to control diabetes and CVD risk.
- Aspirin.
- ACE-I.
- Statin.
- Biguanides (metformin).
- Sulphonylureas (e.g. glibenglamide).
- Insulin.
- Glitazones (e.g. rosiglitazones).
- Alpha glucosidase inhibitor (acarbose).
Differentiate the features of Type 1 and Type 2 diabetes.
Type 1:
- Young (generally).
- Rapid onset.
- Ketosis prone.
- Insulin deficient.
- Recent weight loss.

Type 2 diabetes:
- Middle aged (generally).
- Slow onset.
- Not prone to ketosis.
- Insulin resistant.
- Overweight.
- Strong family history.
How does one confirm diagnosis of Late onset Autoimmune Diabetes in Adults (LADA)?
Testing for glutamic acid decarboxylase (GAD) antibodies can confirm the diagnosis.
What are the characteristics of a typical patient with Late onset Autoimmune Diabetes in Adults (LADA)?
- Young (30-40 years).
- Lean.
- Personal and/or family history of other autoimmune disease.
How does one confirm diagnosis of Late onset Autoimmune Diabetes in Adults (LADA)?
Testing for glutamic acid decarboxylase (GAD) antibodies can confirm the diagnosis.
What are the characteristics of a typical patient with Late onset Autoimmune Diabetes in Adults (LADA)?
- Young (30-40 years).
- Lean.
- Personal and/or family history of other autoimmune disease.
What symptoms do you ask about in the history for suspected diabetes?
- Polyuria.
- Polydipsia.
- Polyphagia.
- Weight loss.
- Nocturia.

- Malaise/fatigue.
- Altered vision.
What factors predisposes an individual to diabetes?
- Age over 40 (type II).
- Family history.
- Cultural group.
- Overweight.
- Physical inactivity.
- Hypertension.
- Obstetric history of large babies or gestational diabetes.
- Medication causing hyperglycaemia.

- Family or personal history of autoimmune disease (for Type 1).
What general symptoms reviews do you need to do for suspected diabetes?
- Cardiovascular symptoms.
- Neurological.
- Ophthalmic.
- Bladder and sexual function.
- Foot and toe problems.
- Recurrent infections (especially urinary and skin).
What are the risk factors for diabetic complications?
- Personal or family history of CVD.
- Smoking.
- Hypertension.
- Dyslipidaemia.
What examinations do you need to elicit for suspected diabetes?
- Weight/waist.
- CVS: BP (lying and standing), peripheral neck and abdominal vessels.
- Eyes: Retinopathy, cataracts, visual acuity.
- Feet.
- Peripheral nerves.
- Urinalysis.
What aspects of the feet do you need to examine?
- Sensation and circulation.
- Skin condition.
- Pressure areas.
- Interdigital problems.
- Abnormal boney architecture.
What aspects of the peripheral nerves is it important to examine?
- Tendon reflexes.
- Sensation (touch and vibration).
What do you need to look at on urinalysis?
- Albumin.
- Ketones.
- Nitrites and/or leukocytes.
What do you need to look for in terms of renal function?
- Plasma urea and creatinine.
- Microalbuminuria.
How frequently are you recommended to do an ECG for a diabetic over the age of 50 with at least one other vascular risk factor?
Every 2 years.
When should you do TFTs for a diabetic?
- Family history.
- Clinical suspicion.
What are the short and long-term aims of diabetes management?
Short term:
- Relief of symptoms and acute complications.

Long term:
- Achievement of appropriate glycaemia.
- Reduction of risk factors.
- Identification and treatment of chronic complications.
How frequently should a diabetic see an ophthalmologist?
Every 2 years.
What would an ophthalmologist look for in a diabetic consultation?
- Fundal examination (dilated pupils).
- Presence of cataracts needs to be checked.
Who should be referred to an endocrinologist?
- Anybody with Type I diabetes.
- Pregnant women with established diabetes or gestational diabetes.
- People with Type II diabetes and uncontrolled hyperglycaemia or with significant complications.
Foot complications account for what percentage of hospital bed days occupied by diabetic patients?
50%.
What is the typical waist circumference for an overweight male and an obese male?
Overweight male: 94-102cm.
Obese male: >102cm.
What is the typical waist circumference for an overweight female and an obese female?
Overweight female: 80-88cm.
Obese female: >88cm.
What percentage of the total energy intake should comprise of carbohydrates with a low GI index and high in fibre?
50%.
What percentage of the total energy intake should comprise of fat with a low GI index and high in fibre?
Less than 30%.
What percentage of the energy should protein contribute to?
10-20% of total energy.
Low level aerobic exercise in diabetics has what benefits?
- Improved glucose tolerance as insulin sensitivity increases.
- Increased energy expenditure resulting in weight loss.
- Increased feeling of well being.
- Increased work capacity.
- Improved blood pressure and lipid profiles.
All people requiring insulin need to ________ their carbohydrate intake and/or
_________ their insulin before exercise.
All people requiring insulin need to increase their carbohydrate intake and/or
decrease their insulin before exercise.
Diabetes exercising need to take what with them?
Refined carbohydrates.
What might occur 6-12 hours after exercise if diabetics aren't careful?
Delayed hypoglycaemia.
What is the suggested initial schedule for blood glucose testing in a patient newly diagnosed Type II diabetic?
How frequently can it be reduced down to once control is established?
3-4 blood glucose tests daily.

Once control is established, it can be just 1-2 times daily, 2-3 days a week.

In the elderly, 1-2 days a week may be sufficient.
What needs to be done at the 3-4 monthly routine review?
- Review SNAP profile.
- Review self-monitoring.
- Foot symptoms and signs.
- Other symptoms.
- BP.
- Weight, height.
- Urinalysis.
- HbA1c (every 6 months).
What needs to be done every 6 months at least?
- BP.
- Height/weight/waist measurements.
- Foot exam.
What needs to be done at least once a year?
- HbA1c.
- Blood lipids.
- Microalbuminuria.
- SNAP.
- Medication review.
- Self care education.
- Podiatrist referral.
What needs to be done every two years?
Ophthalmologist referral.
When should you vaccinate a diabetic patient for pneumococcus (describe for non-ATSI and ATSI populations)?
Non-Aboriginal and Torres Strait Islanders:
- < 65 – single dose and revaccinate age 65 or after 10 years whichever later.
- > 65 – single dose and revaccinate 5 years later

Aboriginal and Torres Strait Islanders:
- < 50 – single dose and revaccinate age 50 or after 10 years whichever later.
- > 50 – single dose and revaccinate 5 years later.
When should the tetanus booster be given?
Booster at age 50 (unless booster has been given within
10 years).
What referrals may be done for a diabetic patient?
- Opthalmologist: Every 2 years.
- Dietician, podiatrist: If problem occurs that requires review.
- Pharmacist (Home Medications Review).
When can anti-diabetic medication be used early in diagnosis (i.e. without a 6 week trial of healthy living)?
- Symptomatic at initial diagnosis.
- Blood glucose level is very high (>20mmol/L).
How does metformin work?
- Reduces hepatic glucose output.
- Reduces insulin resistance.
- Promotes weight loss.
What is the only absolute contraindication in metformin use?

In what people should it be used with caution?
Absolute contraindication:
- Renal impairment.

Relative contraindications:
- Hepatic disease.
- Cardiac disease.
- Heavy alcohol intake.
How do sulphonylureas work?
Stimulates insulin secretion.
How does acarbose work?
Inhibits the digestion of carbohydrates and thus slows the rate of delivery of glucose into the circulation.
In what patient would acarbose useful?
Useful when blood glucose values remain high after meals despite dietary modifications.
When is acarbose to be taken?
At the time of starting a meal and introduced gradually to minimise side effects.
What are the main side effects of acarbose?
- Flatulence.
- Abdominal discomfort.
Care is necessary in prescribing acarbose to what patients?
Those with:
- Renal impairment.
- Gastrointestinal disease.
How does repaglinide work?
Causes a rapid, transient increase in pancreatic insulin secretion.
What should repaglinide never be used in conjunction with?
Sulphonylureas.
Glitazones work by what mechanism?
An oral hypoglycaemic agent that reduces insulin resistance.
What drug class is thiazolidinediones from?
Glitazones.
True or false: Pioglitazone and rosiglitazone can be used with insulin or other oral anti-diabetic agents.
True.
Care is required when prescribing glitazones to what patients?
Those with:
- Cardiac failure.
- Liver dysfunction (liver enzymes should be monitored).
What could sulphonylureas do if given in excessive amounts?
Cause hypoglycaemia.
Why shouldn't repaglinide be used with sulphonylureas?
Because they both can cause hypoglycaemia.
What are the main side effects of metformin?
- Anorexia, nausea, vomiting.
- Diarrhoea, abdominal cramps,
flatulence.
- Lactic acidosis (if renal, liver or cardiovascular disease exist).
What are the main side effects of metformin?
- Weight gain.
- Symptomatic hypoglycaemia.
- Anorexia, nausea, diarrhoea,
skin rashes.
- Occasionally blood dyscrasias.
What are the main side effects of repaglinide?
- Symptomatic hypoglycaemia.
- Nausea, diarrhoea, constipation.
- Skin rashes, abnormal LFT
(Rare) hepatitis and/or jaundice.
What are the main side effects of glitazones?
- Increased subcutaneous fat and/or fluid.
- Decreased haemoglobin levels.
- Increased LDL cholesterol
(rosiglitazone).
- Abnormal liver function tests.
What are the main side effects of acarbose?
- Flatulence and abdominal bloating.
- Non response to carbohydrates if hypoglycaemic (need glucose).
- (Rare) liver abnormalities.
What non-diabetes medications might reduce blood glucose?
- Alcohol.
- Beta blockers.
- Sulphonamides.
- MAO inhibitors.
- Salicylates (in high doses).
- Gemfibrozil.
What non-diabetes medications might increase blood glucose?
- Adrenergic compounds.
- Oestrogens.
- Glucocorticoids.
- Thiazide diuretics (high dose).
- Phenytoin.
What are the optimal lipid profile goals for diabetes?
LDL < 2.5mmol/L.
Total cholesterol < 4.0mmol/L.
HDL > 1mmol/L.
Triglycerides < 2mmol/L.
What are the target BPs for diabetic patients with and without significant proteinuria?
< 130/85 for people with proteinuria < 1g/day.

< 125/75 for people with proteinuria > 1g/day.
In Type II diabetes, insulin therapy may help:
- Preserve pancreatic beta cell function.
- Improve insulin sensitivity and secretion.
- Reduces microvascular complications.
Metformin must never be initiated or must be ceased in patients with:
- Keto-acidosis or history of lactic acidosis.
- Severe renal impairment (creatinine clearance < 30 mL/min).
- Severe hepatic disease or alcohol abuse.
- Conditions associated with tissue hypoxia (e.g. respiratory or cardiac failure, severe infection,
trauma or myocardial infarction).
- Dehydration or undergoing surgery or contrast radiography (cease for 48 hours before and after procedures).
Destroy the following myth about insulin treatment for Type II diabetes with the facts!

Myth: Insulin increases insulin resistance.
Reality: Insulin reverses glucose toxicity and can reduce insulin resistance
Destroy the following myth about insulin treatment for Type II diabetes with the facts!

Myth: Insulin increases
cardiovascular risk.
Reality: Insulin did not increase cardiovascular risk in the UKPDS and it reduced
mortality risk following acute myocardial infarction in the DIGAMI study.
Destroy the following myth about insulin treatment for Type II diabetes with the facts!

Myth: Weight gain with insulin
is a risk.
Reality: The long-term benefits of insulin therapy outweigh the risks of modest
weight gain.
Destroy the following myth about insulin treatment for Type II diabetes with the facts!

Myth: Insulin frequently causes severe hypoglycaemia.
Reality: The incidence of severe hypoglycaemia is low and occurs less frequently
in type 2 compared to type 1 diabetes.
Destroy the following myth about insulin treatment for Type II diabetes with the facts!

Myth: Insulin therapy involves too many injections.
Reality: Insulin may be as simple as one injection at bedtime with concurrent
oral agents.
What is the recommended initial dosage of insulin prescribed for a patient with Type II diabetes where oral hypoglycaemics are not working well enough?
Start on 10 Units of intermediate-acting isophate insulin at bedtime. If patient is very thin, they often have greater insulin deficiency and may require a morning injection as well.
In patients with Type II diabetes, what fasting blood glucose level would you be aiming for?
4-6mmol/L.
Do not delay insulin therapy by more than _______ in patients for whom double or triple oral therapy no longer provides adequate glycaemic control.
2 months.
Glitazones are absolutely contraindicated in what?
Moderate to severe heart failure.
When added to therapy with metformin, a sulfonylurea or insulin, a glitazone reduces HbA1C by about ________.
0.5–1.5%.
If fasting blood glucose remains high after initiating 10 units of insulin in Type II diabetes, how would you titrate it up?
Increase it by 2 units every 1-2 weeks up to about 20 units.