1 Diabetes L1 Flashcards
What causes T1 diabetes?
Autoimmune destruction of pancreatic B-cells.
Idiopathic - theories about viruses/animal products
Aetiology of T1
Could be either. Reduced insulin secretion or hyperinsulinemia and insulin resistance or reduction in insulin recptors
Stages of T2
1 hyperinsulineaemia - body compensates for insulin resistance by increasing insulin secretion
2 hyperglycemia - as resistance increases and b-cells fail to compensate glucose levels rise
3 T2 escalating b-cell failure and loss of hypoglycemic control
90% of diabetes is T1/T2?
T2
Ethnicities more affected by T1?
T2?
T1 - European
T2 - Asian and afriacan-caribean
Difference between DKA and HHS?
Diabetic ketoascidosis (T1) Hyperosmolar hyperglycaemic state (T2) is like DKA withour the ketones
Diagnostic:
HbA1c for diagnosis
Fasting
2hr post glucose load
>/= 48mmol/mol >/= 7mmol/L >/= 11mmol/L
What are the units for
HbA1c?
Blood gluc
mmol/mol
mmol/L
Problems with treating diabetes?
Diabetes and complications are often silent - treatment may cause more symptom than disease.
How often is diabetes reviewed?
What is screened? (4)
Annually Retinal Nephropathy Hypertension Clinical examination for vascular disease
Problem with repeated hypos?
Your body stops warning you so eventually there is only a few minutes from being fine to being unconcious
Aim of insulin therapy
to replicate what happens in people without diabetes
Recommended targets Fasting 2 hour post meal HbA1c Urine
Fasting 4-7mmol/L
2 hour post meal <8.5mmol/L
HbA1c 48-58mmol/mol
Urine: negative
Indications for insulin use:
Type 1
Poor controlled type 2
Intercurrent illness (pre/post op, infection, MI, steroid therapy)
Pregnancy (if uncontrolled)
Once daily basal insulin - advantage of modern basal insulins (lantus and levimir)?
less risk of hypo in the night as levels are stable - 24h cover
Insulin degludec advantage/disadvantage
Expensive
vs
od ultra long acting and flat profile (reduced risk of nocturnal hypo)
How does insulin degludec work?
Forms soluble hexamers at injection site - monomers gradually separate and absorb
Isophane insulin is ……. acting
Intermediate acing
Basal bolus involves how many injections daily?
4
1 long acting, 3 rapid
Isophane insuline disadvantage compared to long acting insulins?
risk of nocturnal hypos
BASAL BOLUS:
When is the rapid insulin administered?
After eating - allow flexibility with that we eat
What regime is good if you don’t like injections
Premixed insulin, once, twice or three times daily
PREMIXED INSULIN REGIME
Each injection contains
Basal component
Short-acting component
PREMIXED INSULIN REGIME
possible regimes? (3)
- Once daily with largest meal
- Twice daily with breakfast and dinner
- Three times daily with each meal
DO NOT GIVE AT BED TIME
PREMIXED INSULIN REGIME
Advantage for raised BMI?
You can have three doses with meals (encouraged not to have afternoon snack)
Insulins in order of action
Shortest Fast acting analogues Soluble Isophane Detemir Glargine
Most common regiemes:
basal bolus
and
biphasic analogue mix
REGIMES
Once daily insulin regime is ……..
must be administered….
and can be given with….
Long acting insulin (insulatard, glargine, levemir)
administer at same time each day
can be given in combo with OHA
REGIMES
Twice daily regime is …
Disadvantage:
Short acting component controlling rise after eating breakfast and dinner
Snacks are needed to prevent hypos
REGIMES
Twice daily regime is divide into
2/3 in the morning
1/3 eveing
What regime do we want most patients to be on?
Basal bolus
REGIMES
Basal bolus is
Long acting at the same time each day (usually bed)
Short acting just before meals (adjusted to exercise, carb count, BG)
Carb counting ratio
1unit for 10g carbs
but you initially need to adjust to patterns to obtain a baseline
Factors of influence in insulin (3)
- length of needle
- absorption from injection site
- time of injection (crucial in hospital)
What size needle should be used?
4mm
How does weight affect insulin requirements?
drops as you lose weight
How does illness affect insulin levels?
BG usually rises during illness
How does climate affect insulin?
More rapidly absorbed in hot weather
Needle advice (2)
don’t reuse
don’t go through clothes
What happens in a night hypo?
Cortisole raises sugar when you wake so it looks like you need to increase your insulin dose
