BPJ 42 QUIZ FEEDBACK:
Asthma in children / Diagnosing diabetes / Initiating insulin
Dear Dr
This quiz feedback provides an opportunity to revisit the BPJ 42 (February, 2012) articles:
- Diagnosing and managing asthma in children
- The new role of HbA1c in diagnosing type 2 diabetes
- Initiating insulin for people with type 2 diabetes
There are now in excess of 25 interactive quizzes available which provide an ongoing opportunity for accumulating CME points. These are available from www.bpac.org.nz.
| 1. Which of these statements about wheeze in children are true? | Your peers | Answer |
| Wheezing in children aged under five years is always indicative of developing asthma at school-age | 1% |  |
| Wheezing in children aged under five years needs to be supported by a lung-function test to be diagnostic of asthma | 2% | |
| Wheeze without cough is unlikely to be asthma | 15% | |
| Acute onset of wheeze reduces the likelihood of a diagnosis of asthma | 42% |  |
| Interval symptoms of wheeze may occur in response to cold or damp air | 96% | |
Wheezing is common in children and is a useful sign for the diagnosis of asthma. However, it is not always indicative of asthma, particularly in a young child, where it is more likely to be a respiratory illness such as bronchiolitis.
Almost all respondents correctly identified that interval symptoms are often triggered by cold or damp air. However, less than half correctly stated that acute onset of wheeze reduces the likelihood of an asthma diagnosis. Acute onset of wheeze or breathing difficulty is most likely to be due to an inhaled foreign object, or a viral illness, and only rarely is it indicative of asthma.
It is not uncommon for children with asthma to have wheeze without a cough, however a cough without wheeze is very unlikely to be due to asthma. Many young children with wheeze will have resolution of their symptoms by the time they reach school-age. Lung-function testing in children aged under five years is unlikely to produce consistent or reliable results, therefore is not recommended for the diagnosis of asthma in this age group.
| 2. A child with a high likelihood of asthma should have which of the following: | Your peers | Answer |
| A chest x-ray to confirm the diagnosis | 1% | |
| A trial treatment of at least a SABA, starting immediately | 91% | |
| A trial treatment of at least a LABA, starting immediately | 1% | |
| Spirometry testing to assess severity of asthma | 2% | |
| Assessment of treatment response within two to three months | 91% | |
Further investigations such as spirometry or chest x-ray are unnecessary in a child with a high likelihood of asthma, based on history and examination. Asthma treatment should be commenced and response assessed within two to three months.
A SABA should be prescribed to all children with symptomatic asthma, regardless of severity. In children with a high likelihood of asthma, if symptoms are severe, an ICS may also be initiated early on. A LABA is not recommended as an initial treatment option, and should only be added to the treatment regimen if symptoms are not controlled with the SABA + ICS. N.B. LABA should never be prescribed without an ICS.
| 3. Which of the following statements about inhaled corticosteroids are true? | Your peers | Answer |
| It is unsafe for a LABA to be used without an ICS | 91% | |
| Children requiring two or more canisters of SABA per month should have an ICS added to their treatment plan | 91% | |
| Roughly: 200 mcg beclomethasone = 100 mcg budesonide = 100 mcg fluticasone | 12% | |
| The same type of device should be used for the child’s SABA and ICS | 82% | |
| Sodium chromoglycate is an acceptable first-line alternative to an ICS for regular preventer treatment in a child | 26% | |
Most respondents were aware that it is unsafe to use a LABA without an ICS, and that an ICS should be added to the treatment regimen if symptoms are uncontrolled with SABA alone, used at optimum doses.
A small number of respondents were caught out by the equivalent dosing of ICS. Roughly, 200 mcg beclomethasone = 200 mcg budesonide = 100 mcg fluticasone.
Most respondents correctly stated that the same inhaler device can be used for the SABA and ICS. However, one-quarter of respondents answered the final option incorrectly - sodium chromoglycate is an acceptable alternative to an ICS, however, it is not considered first-line as it requires frequent dosing making the medicine less acceptable, particularly in children. Montelukast may also be considered for initial preventer treatment, particularly in children aged under five years, but it is not funded.
| 4. HbA1c is considered superior to fasting plasma glucose for the diagnosis of diabetes because: | Your peers | Answer |
| There is no need for fasting prior to the test | 97% | |
| HbA1c is more accurate than fasting plasma glucose in people with anaemia | 2% | |
| HbA1c is less affected by daily lifestyle variations than fasting plasma glucose | 95% | |
| In an individual, the likelihood of discrepant tests is four times less with HbA1c than with plasma glucose | 80% | |
| HbA1c is more accurate during pregnancy than fasting plasma glucose | 2% | |
HbA1c is now the recommended test for the diagnosis of type 2 diabetes. One of the most significant advantages of HbA1c is the lack of need for fasting, which allows for opportunistic testing. HbA1c is associated with less day-to-day variations than fasting plasma glucose and has less intra-individual variation.
However, fasting glucose still remains a valuable test in the diagnosis of diabetes when HbA1c is not appropriate or cannot be used. HbA1c results may be falsely high in people with severe anaemia, therefore is less accurate than fasting plasma glucose in this situation.
HbA1c testing is not currently recommended for diagnosis of diabetes in women who are pregnant. This is because glucose tolerance is altered during pregnancy and a separate glucose-based diagnostic algorithm is used. At present, oral glucose tolerance testing is used for diagnosis of gestational diabetes in women with an abnormal initial polycose test.
| 5. Which of the following conditions reduce the accuracy of an HbA1c test? | Your peers | Answer |
| Alcoholism | 90% | |
| Donating blood | 38% | |
| Regular exercise or weight training | 2% | |
| Folate deficiency | 91% | |
| COPD and other lung disorders | 5% | |
There are a range of conditions that are known to reduce the accuracy of an HbA1c test. HbA1c results may be falsely high in people with alcoholism, due to reduced liver function, and in people with a folate deficiency, due to anaemia.
Some respondents incorrectly stated that donating blood would reduce the accuracy of HbA1c. Donating blood will not alter HbA1c results significantly, however, having a blood transfusion within three months of testing, may result in a falsely low HbA1c level.
Neither exercise nor the presence of a respiratory disorder affects HbA1c results.
| 6. Which of the following statements about initiating insulin are true? | Your peers | Answer |
| Insulin should be considered when a patient’s HbA1c level consistently does not meet an agreed target | 98% | |
| Oral hypoglycaemic medicines should be trialled for at least five years prior to initiating insulin | <1% | |
| All oral hypoglycaemic medicines should be ceased once insulin has been initiated | 1% | |
| Self-monitoring of blood glucose should be performed for one week to help determine which insulin regimen the patient would benefit the most from | 87% | |
| Once insulin has been initiated, it can never be stopped | 2% | |
Most respondents provided correct answers for this question. Patients should be considered for insulin treatment if they consistently fail to meet agreed HbA1c targets or where they have symptoms of hyperglycaemia despite appropriate focus on lifestyle factors and compliance with oral medicines. The decision to initiate insulin should not be based on the length of time a person has had diabetes for or how long they have used oral hypoglycaemics. In some cases, patients may be commenced on insulin shortly after diagnosis.
Self-monitoring of blood glucose is an important part of the insulin initiation process. Patients should monitor their blood glucose levels for one week to determine their pattern of hyper- and hypoglycaemia, in order to chose an appropriate insulin regimen.
While many people with type 2 diabetes will require insulin for the rest of their lifetime, it may be possible for some people to cease insulin if they reduce their weight and have had diabetes for only a short time.
| 7. Which of the following statements about isophane are true? | Your peers | Answer |
| Isophane is the recommended first-line insulin treatment for type 2 diabetes in New Zealand | 96% | |
| Patients should be started on twice daily doses of isophane | 1% | |
| When initiating once daily isophane cease sulphonylurea medicine | 5% | |
| If pre-breakfast blood glucose is > 8 and never < 4 increase once-daily isophane by two to four units | 15% | |
| If pre-evening meal blood glucose is > 8 and never < 4 increase once-daily isophane by four to six units | 85% | |
Isophane is the recommended first-line treatment for type 2 diabetes in New Zealand. It is an intermediate-acting form of insulin and is usually administered once daily, particularly when insulin is first being initiated. Twice daily isophane would only be prescribed if the patient had high blood glucose levels day and night, or was significantly hyperglycaemic.
Metformin and sulphonylurea should be continued when initiating isophane, though when moving to a twice daily regimen sulphonylurea should be stopped. This is to prevent hypoglycaemia.
The isophane “once daily at night” regimen is used for people with high pre-breakfast glucose levels. The starting dose is eight to ten units. If pre-breakfast blood glucose is > 8 and never < 4, the dose may be increased by four to six units (not two to four).
The isophane “once daily before breakfast” regimen is used for people with acceptable pre-breakfast glucose levels that rise during the day. The starting dose is eight to ten units. If pre-evening blood glucose is > 8 and never < 4, the dose may be increased by four to six units.
| 8. Which of the following statements about hypoglycaemia are true? | Your peers | Answer |
| Sulphonylurea medicine should be ceased with twice-daily dosing of isophane as this increases the risk of hypoglycaemia | 93% | |
| Symptomatic hypoglycaemia can occur when blood glucose levels fall below 5.5 mmol/L | 6% | |
| A lack of food is one of the most common reasons for hypoglycaemia in a person with type 2 diabetes on insulin | 94% | |
| Consuming alcohol without food can lead to hypoglycaemia in a person with type 2 diabetes on insulin | 94% | |
| People who experience slurred speech as a symptom of hypoglycaemia have a higher level of hypoglycaemic awareness than those who experience sweating and shaking | 2% | |
Hypoglycaemia can occur when a person’s blood glucose levels fall below 4.0 mmol/L. All people taking diabetes medicine need to be aware of the symptoms of hypoglycaemia, particularly those being treated with insulin. Symptoms of hypoglycaemia vary from patient to patient. Sweating and shaking can alert people to consume some glucose to alleviate symptoms. People who experience slurred speech, dizziness and fainting are likely to be less aware of the onset of hypoglycaemia.
The most common cause of hypoglycaemia is lack of food. In addition, consuming alcohol without food puts people with diabetes at risk of hypoglycaemia. Sulphonylurea medicine should be stopped prior to twice daily dosing of isophane to avoid hypoglycaemia.
