04: Clinical Lectures 3 DIABETES Flashcards
Describe how glucose is controlled in health and disease
insulin only hormone which lowers [BG] allowing tight control
= allows uptake at tissues
meanwhile glucagon supports glycogenolysis and gluconeo
Define Diabetes Mellitus and its classification
group of metabolic diseases of multiple aetiologies characterised by hyperglycaemia together with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both
State the common presenting symptoms of diabetes mellitus
polydipsia, polyuria, blurred vision, weight loss, infections
Describe the common epidemiological features of diabetes mellitus and how this relates locally, nationally and internationally
TYPE 1, much less than TYPE 2
DM2 RF: fhx, 30+ Maori & Indian subcontinent & Pacific Island, hx of gestational DM
Compare and contrast types 1 and 2 diabetes mellitus
T1DM
+AuAb e.g. anti-GAD
younger
genetic predisp + TRIGGER (?viral)
T2DM
As the Bcells become damaged by lipotoxicity and glucotoxicity as a result of insulin resistance, they can eventually no longer compensate, resulting in hyperglycaemia. a result of underlying insulin resistance and subsequent β-cell dysfunction.
*body requires more insulin to stimulate effective Glc control/uptake
Summarise the factors which may contribute to beta cell damage and the eventual clinical presentation of type 1 diabetes mellitus
Beta cell destruction = nil insulin
• INCREASED LIPOLYSIS = Wt loss
• REDUCED Glc UPTAKE = RAISED Glc PROD = HYPERGLYCAEMIA = Vasc. ; Urine+; Dehydr.
• KETONEAEMIA = DKA = N+V, Sweet breath, tired + unconscious
+glycosuria. = infection
Importance of hyperglc
Metabolic decompensation: DKA/HHS
Long term complications:
microvascular (retinopathy, neuropathy, nephropathy),
macrovascular (stroke, MI, PVD)
DM diagnosis levels
fasting ≥7.0 mmol/l, random ≥ 11.1 mmol/l
OGTT: 2hr after 75g: ≥11.1
HbA1c ≥48mmol/mol
- ONE diagnostic lab glucose plus symptoms
- TWO diagnostic lab glucose or HbA1c levels without symptoms.
Intermediate hyperglycaemia
Impaired fasting glucose 6.1-7 mmol/l
Impaired glucose tolerance 2h glucose ≥7.8 and <11mmol/l
HbA1c 42-47mmol/mol
When HbA1c cannot be used for diagnosis
All children and young people
corticosteroids, antipsychotic drugs (2 months or less). HbA1c can be used in patients taking such medication long term (i.e. over 2 months) who are not clinically unwell.
OTHER TYPES OF DIABETES
MODY: maturity onset diabetes in the young
- AD = single gene defect
- impaired B function
*glucokinase mut=birth, stable hyperglc.
> diet tx
*TF mut. = YA onset, progressive hyperglc.
>diet, OHA, insulin
GESTATIONAL: Fhx, insulin res. in preg.
*neonatal problems
2º DIABETES: corticosteroids, pancreatic destruction, syndromes,
*endocrine disorders: cushings, acromegaly, pheochromocytoma
Outline the principles of insulin therapy.
injected to ensure activated absorption (subcut. or intravenously)
30 mins before eating in order for hexamer insulin to dissociate
- altering structure of insulin = affect rate of abs.
- amount of insulin injected for meals should balance the carbohydrate intake consumed
Describe the various methods of administrating insulin therapy; twice daily, basal bolus, insulin pump treatment
BASAL BOLUS
SHORT: rapid cover CHO at meals 1unit/10g
LONG: background (twice/once daily)
TWICE DAILY - rapid, intermediate acting
pre-breakkie+pre-eve meal
(3) +intermediate @ bedtime
(4) short acting BB, BL, BT; intermediate BBed
CONT. SUBCUTANEOUS INULIN INFUSION
controls how much insulin injected
Understanding of Home blood glucose monitoring, flash glucose monitoring and targets
HOME BLOOD GLC. MONITORING & KETONE TESTING: adjusts insulin dose prior to driving e.g.
Understanding of Blood ketone monitoring HbA1c and glycaemic control
Monitoring vital in identifying at risk of DKA (>0.6) and thus knowledge of seeking urgent medical attention
Describe the symptoms, causes and emergency treatment of hypoglycaemia.
- sweating++
- pale
- trembling,, shaking
- anxious
- tinling lips
- hunger
- palpitations
Rebound ketosis
Arrhythmias
Acute brain injury
d/t falling plasma glucose and resulting neuronal cell death via multiple pathways
conscious, oritentated, swallow+
> fast acting CHO
> rpt
> IV glc or IM Glucagon
conscious, swallow+ BUT CONFUSED
> treat as if mild if cooperative
> Glucagon & IV Glc
severe, unconscious, agressive, NBM
> stop insulin
> IV Glc +/- RPTs
> restart insulin once glc >4mmol
Aware of patient education resources
a
Describe the management of a patient with a new diagnosis of Type I Diabetes
> Levemir twice daily and a rapid acting analogue – be that Novorapid, Humalog or Apidra
Appreciate the importance of patient education and self management in a long term condition
TYPE 1 STRUCTURED EDUCATION
TECH. ENABLED DIABETES CARE
CONNECTED BG METERS
Discuss the natural progression of diabetes and the importance of patient centred care
Optimal blood glucose control (HbA1c)
to reduce microvascular disease e.g. retinopathy
to improve pregnancy outcome
Optimal blood pressure control
to reduce nephropathy
Manage cardiovascular risk factors
e.g. smoking, cholesterol
Screen for early detection of complications
feet, eyes & kidneys
Discuss the impact life events have on health and the importance of behavioural change and psychological support
a
DKA
d/t ⇧lipolysis; ⇧FFA to liver = ⇧ketogenesis
Nausea&vomiting ………………………………………................. Abdominalpain ………………………………………………….. Sweetsmelling,"ketotic" Breath ………………………………………………. Drowsiness ………………………………………………. Rapid, deep “sighing” respiration ………………………………………………. Coma
*known T1 or NEW T1; breathless pt d/t metabolic acidosis
DKA pres. mgmt
ketones less than <0.6mmol = normal
>rpt after 2 hours
0.6-1.4mmol/l = risk of DKA
1.5-2.9mmol/l
> rehydrate (sugar free), insulin, retest glc and ket
≥3.0mmol/l = DKA
>EMERGENCY
• ABC; IV access; vitals; clinical assess; full exam.
• glc, venous blood gas, urinanlysis/ketones, U+E, FBC, culture blood/urine, ECG+cardiac monitor, CXR
(hr 1) ACTRAPID 6units/hr + 0.9%saline
(hr 2) add dextrose with KCl, reduce insulin to 3U/hr
(hr 3) “”
(hr 4) restart s/c regiment when normal
Describe and explain the effects of acute deficiency of insulin, as in untreated Type I Diabetes
KETOACIDOSIS = DKA
HYPERGLC. = DEHYDR. = RENAL IMPAIRMENT
DEHYDR. = HYPEROSMOL.