40 Questions
What is crucial for a patient to know about their disease?
The disease, its clinical manifestations, complications, and treatment
What is the recommended course of action if HbA1c is less than 1.5% above target?
Start monotherapy
When should insulin therapy be initiated?
If initial HbA1c is above 10% with catabolic manifestations
What is the maximum dose of metformin?
2550 mg
What is a rare complication of metformin therapy?
Lactic acidosis
Why should metformin be taken with or after meals?
To avoid GIT upset
What is the primary concern when using sulphonylureas?
Hypoglycemia
What is a possible complication of metformin?
GIT disturbance
What is Glibenclamide classified as?
First generation sulphonylurea
Why is it recommended to start with a small dose of metformin and increase gradually?
To avoid GIT upset
What is recommended for patients taking metformin with low Vitamin B12 levels?
Prescribing Vitamin B12 supplements
In which patients should Glibenclamide be avoided?
Elderly patients above 60 years
What is the maximum daily dose of Glibenclamide?
20 mg
What is the advantage of Gliclazide over Glibenclamide?
Less risk of hypoglycemia
In which patients should Glimepiride be used with caution?
Patients with EGFR less than 60 ml/min
What is the starting dose of Gliclazide?
30 mg
What is the primary characteristic of diabetes mellitus?
Chronic hyperglycemia due to defect of insulin action or secretion
Which of the following autoimmune diseases is NOT associated with type 1 diabetes?
Rheumatoid arthritis
What is the recommended screening strategy for thyroid dysfunction in patients with type 1 diabetes?
Routine screening for all patients with type 1 diabetes
What is the criteria for testing for T2DM in children and adolescents?
Overweight plus any 2: family history of type 2 diabetes, race/ethnicity, signs of insulin resistance or conditions associated with insulin resistance
What is the key to better compliance for patients with diabetes?
Health education
What is the age of initiation for screening for T2DM in children and adolescents?
10 years or at onset of puberty
What is the term used to describe the condition of insulin resistance?
Diabesity
What is the diagnosis of diabetes based on?
American Diabetes Association Standards of Medical Care in Diabetes
What is the benefit of liraglutide in the treatment of diabetic patients with cardiovascular risk factors?
Proven benefit in reducing cardiovascular risk, especially atherosclerotic disease
What is the indication for insulin therapy in Type 2 diabetic patients?
Uncontrolled Type 2 patients on two or more oral drugs with HbA1c more than 8.5%
What is the starting dose of premixed insulin for an 80 kg Type 2 patient?
40 units daily divided into two doses
What is the preferred starting dose of insulin in prepubertal and adolescent patients?
0.7 unit per kg per day
What is the insulin regimen suggested for a 7-year-old child recently diagnosed with Type 1 diabetes?
Basal-bolus regimen with rapid-acting analogue and long-acting analogue
What is the calculation for the starting dose of insulin in a 20 kg child?
0.5 unit per kg per day
What is the schedule for premixed insulin doses in an 80 kg Type 2 patient?
25 units before breakfast and 15 units before dinner
What is the benefit of GLP-1 receptor agonists in the treatment of diabetic patients?
Decreases satiety and weight
What is the maximum daily dose of Amaryl beyond which there is no increase in efficacy but only an increased risk of hypoglycemia?
6mg
What is the mechanism of action of TZDs in the treatment of type 2 diabetes?
Acting on PPAR gamma receptors in liver and adipose tissue
What is the benefit of using DPP-4 inhibitors in the treatment of type 2 diabetes?
They have a glucose-dependent mechanism of action with less incidence of hypoglycemia
What is the mechanism of action of SGLT-2 inhibitors in the treatment of type 2 diabetes?
They act by inhibiting 90% of glucose reabsorption in the first segment of the proximal convoluted tubule
What is the proven benefit of Empagliflozin, an SGLT-2 inhibitor, in the treatment of type 2 diabetes?
It has a proven effect in reducing the risk of cardiovascular disease
What is a common side effect of SGLT-2 inhibitors that can be prevented by keeping the genitals clean and dry?
Mycotic vaginal infection
What is a contraindication for the use of TZDs in the treatment of type 2 diabetes?
Heart failure
What is the precaution that should be taken when starting a patient on SGLT-2 inhibitors, especially in type 1 diabetes patients, to avoid euglycemic ketoacidosis?
Start with a low dose and increase gradually over 1-2 weeks
Study Notes
Diabetes Mellitus
- Diabetes mellitus is a metabolic disorder of multiple etiologies, characterized by chronic hyperglycemia due to defects in insulin action or insulin secretion.
- People with type 1 diabetes are at increased risk for other autoimmune diseases, such as thyroid disease, celiac disease, and pernicious anemia (vitamin B12 deficiency).
Criteria for Testing for T2DM in Children & Adolescents
- Overweight plus any 2 of the following:
- Family history of type 2 diabetes in 1st or 2nd degree relatives
- Race/ethnicity
- Signs of insulin resistance or conditions associated with insulin resistance
- Maternal history of diabetes or GDM
Strategies of DM Management
- Health education is key for better compliance and patient outcomes.
- Patient education should include:
- Understanding of the disease
- Alarming clinical manifestations of hypo or hyperglycemia
- Complications of the disease
- Information about medical treatment and types of insulin
- Instructions on insulin storage and injection places
- Fixing times for insulin and meals, and following dietary recommendations are important.
- Remind patients to perform self-monitoring of blood glucose (SMBG) for better optimization of blood glucose.
Anti-Diabetic Drugs
- Start monotherapy if HbA1c is less than 1.5% above target HbA1c.
- Start combination therapy if HbA1c is more than 1.5-2% above target.
- Consider metformin as the backbone of treatment for diabetes, unless contraindicated or not tolerated.
- Metformin dosing:
- Starting dose: 500mg with main meals, either once or twice
- Optimal dose: 1000mg, twice daily
- Maximum dose: 2550mg (up to 3000mg in some guidelines)
Sulphonylurea
- Classified into 3 generations:
- 1st generation: Gibenclamide (conventional sulphonylurea)
- 2nd generation: Gliclazide (less risk of hypoglycemia and weight gain)
- 3rd generation: Glimepride (more efficacy and less hypoglycemia)
- Take care of risk of hypoglycemia and weight gain.
- Glibenclamide:
- Starting dose: 2.5-5mg before breakfast, can be increased to twice daily dose
- Maximum dose: 20mg
- Gliclazide:
- Starting dose: 30mg before breakfast, can be increased by 30mg on a weekly basis
- Maximum dose: 120mg
TZDs
- One of the most potent insulin sensitizers, acting on PPAR gamma receptors in liver and adipose tissue.
- Can be used in treatment of fatty liver and polycystic ovary.
- Take care of cardiovascular risk:
- Avoid in heart failure
- No renal dose adjustment, but avoid in renal impairment due to risk of fluid retention
DDP4 Inhibitors
- Leader group in management of type 2 diabetes.
- Controls blood glucose in glucose-dependent manner with less incidence of hypoglycemia and weight neutral effect.
- Examples: Sitagliptin, Vildagliptin, Linagliptin, Saxagliptin, Alogliptin
SGLT2 Inhibitors
- One of the promising groups in treatment of type 2 diabetes.
- Act by inhibiting 90% of glucose reabsorption in the first segment of the proximal convoluted tubule.
- Examples: Dapagliflozin, Empagliflozin
- Has a proven cardioprotective effect, as seen in the EMPA-REG trial.
- Complications:
- Urinary tract infections due to glucosuric effect
- Mycotic vaginal infection
- Euglycemic ketoacidosis if used off-label in type 1 patients or started at high dose
GLP1 Receptor Agonist
- One of the promising drugs in diabetes.
- Controls blood glucose in glucose-dependent manner with less incidence of hypoglycemia and decreases satiety, leading to weight loss.
- Examples: Liraglutide, Dulaglutide, Semaglutide
Insulin Therapy
- Indications:
- Type 1 patients (IDDM)
- Uncontrolled type 2 patients on two or more oral drugs at maximum dose, with HbA1c > 8.5%
- Recently diagnosed type 2 patients with HbA1c > 10% or blood glucose > 300mg, especially if there is catabolic state or associated increased triglycerides level
- At hospital admission
- Insulin types:
- Premixed insulin
- Basal bolus regimen (MDI)
- Starting dose of insulin: 0.5 unit per kg per day, divided into two-thirds as morning dose and one-third as night dose.
- Example: 80kg type 2 patient, starting premixed insulin at 40 units daily, divided into 25 units before breakfast and 15 units before dinner.
This quiz covers the basics of diabetes mellitus, a metabolic disorder characterized by chronic hyperglycemia due to defects in insulin action or secretion.
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