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- Question 1 of 15
1. Question
1. Insulin therapy remains essential in management of T2DM because long-term glucose control is necessary to prevent long-term complications. - Question 2 of 15
2. Question
2. Insulin therapy is indicated for use in which circumstances?
- Question 3 of 15
3. Question
3. Which statement is false? At diagnosis, short-term insulin therapy should be considered if:
- Question 4 of 15
4. Question
4. For high-risk and elderly patients, target PPG is:
- Question 5 of 15
5. Question
5. In the case of suboptimal glycaemic control using 3 antidiabetic agents, SEMDSA recommendations are to continue metformin and:
- Question 6 of 15
6. Question
6. Which statement is false?
- Question 7 of 15
7. Question
7. Which statement is false? Referral to an endocrinologist or specialist diabetes clinic is recommended when glycaemic targets are unmet:
- Question 8 of 15
8. Question
Case study
The CPD questions are based on applying the principles of insulin initiation in this Case Study.
Patient: Preesha, 50-year-old Indian female
Reason for visit
- A T2DM patient for 9 years
- Is currently expressing concern about her glucose control
- Her elder brother was referred to a nephrologist 3 months earlier with kidney problems and he is devastated; she is worried that the same thing could happen to her
- She has completely changed her lifestyle over the past 10 weeks, watching her diet and walking 30 minutes daily
- Preesha currently weighs 90kg, having lost 9kgs
Home readings for blood pressure
- 127/78mmHg
- Her blood tests were done a week prior
Current therapy
- Metformin 1g bid
- Vildagliptin 50mg bid
- Gliclazide MR 120mg once daily
- Atorvastatin 20mg daily
- Ramipril 10mg daily
Investigations
- HbA1c 8.3%
- FBG 9.8mmol/L
- Serum creatinine 77µmol/L
- eGFR 73ml/min/1.73m2
- LDL-cholesterol 1.82mmol/L
- Potassium 4.2mmol/L
- Albumin-to-creatinine ratio (ACR) 8mg/mmol
8. What is the HbA1c target for this patient?
View Expert Comment »
The new Clinical Guidelines Committee of the American College of Physicians recommends that patients with T2DM should be treated to achieve an A1c between 7% and 8%.
- Question 9 of 15
9. Question
9. What alternative therapies can be used to reach the desired target?
View Expert Comment »
While clinical considerations are always subject to patient preference, this patient is motivated to avoid target organ disease and she will benefit to a greater extent with insulin than any of the other antidiabetic agents, none of which would achieve the desired HbA1c lowering of >1.5%.
- Question 10 of 15
10. Question
10. The decision is to initiate insulin. Which insulin is preferable?
View Expert Comment »
The value of a basal insulin in this situation relates to less weight gain and less hypoglycaemia. In the ‘4-T’ trial, weight gain was lower than with biphasic insulin twice-daily and prandial insulin.
- Question 11 of 15
11. Question
11. What would be the starting dose of basal insulin at bedtime?
View Expert Comment »
The SEMDSA guidelines advise a starting dose of 10µ at bedtime, ensuring that patient support from the clinician or allied healthcare staff is available.
- Question 12 of 15
12. Question
12. On self-monitoring of her blood glucose following basal insulin (analogue), Preesha’s fasting blood glucose levels are shown below. Based on the SMBG what would you advise?
- Question 13 of 15
13. Question
After this intervention, Preesha is asked to monitor pre-breakfast and 2-hours after dinner levels for the next few days. Her chart now shows:
13. What in your view is the next best step?
View Expert Comment »
This profile demonstrates how the glucose levels fall overnight, suggesting that the problem is not a deficiency of basal insulin but rather a post-dinner rise in blood glucose. A step-up approach of adding a prandial short-acting insulin would work well.
- Question 14 of 15
14. Question
14. The following week her pre-breakfast levels are in single digits: Mon 5.6, Tues 7.1, Wed 6.5, Thurs 5.8. When do you want to see Preesha again
- Question 15 of 15
15. Question
Preesha comes for a consultation 3 months later. Her pre-breakfast levels are <8mmol/L on 54µ basal insulin, but her HbA1c is still above target at 7.9%.
15. Why is the HbA1c not yet at target?
View Expert Comment »
The most likely reason is that her PPG levels are high.
Preesha then refers to her diary and points out that she has been testing her blood glucose after lunch (her main meal everyday over the past week.) Her blood glucose after lunch is 10.3-13.2mmol/L. She has been doing this because she is not losing weight anymore and is in fact 1kg heavier and is concerned about this. Insulin intensification strategies are now needed.
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