16 - Diabetes Flashcards
What are some of the presenting symptoms of type 1 diabetes?
Children: sudden onset, polyuria, polydipsia, excessive tiredness, weight loss as fat broken down for energy
Adults: rapid weight loss, family history of autoimmune disease, ketosis (urine dip), age of onsrt <50, BMI<25
Onset of symptoms in a few days/weeks, needs immediate treatment with insulin
What are some of the complications of type 1 diabetes?
- Microvascular: retinopathy, nephropathy, and neuropathy.
- Macrovascular: MI, stroke, and peripheral arterial disease.
- Metabolic: DKA and hypoglycaemia (glucose <3.5 mmol/L).
- Psychological: anxiety, depression, and eating disorders.
- Increased risk of other autoimmune conditions: thyroid disease, coeliac, Addisons, and pernicious anaemia. All often screened for on diagnosis
- Reduced quality of life and life expectancy
What is the diagnostic criteria for type 1 diabetes?
- Symptoms + test
OR
- Asymptomatic + two positive tests on different days
- Random >11.1
- Fasting >7
- OGTT >11.1
When diagnosing diabetes in children you should assume it is type 1 unless the child has risk factors for type 2. What are these risk factors?
- Strong family history of type 2 DM
- Obesity
- Black or Asian family origin.
- No insulin requirement, or insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase.
- Evidence of insulin resistance (for example acanthosis nigricans).
When should you suspect DKA?
- Finger prick BM >11 mmol/L
- Increased thirst and urinary frequency.
- Weight loss.
- Inability to tolerate fluids.
- Persistent vomiting and/or diarrhoea.
- Abdominal pain.
- Visual disturbance.
- Lethargy and/or confusion.
- Fruity smell of acetone on the breath (pear drops)
- Acidotic breathing — deep sighing (Kussmaul) respiration
What investigations should you do if you suspect a DKA?
- Assess for precipitating factors e.g infection, physiological stress, non-adherance to insulin treatment, drug treatment e.g steroids
- Test for ketones: in adults test urine and blood ketones even if blood glucose is ok. in children test blood ketones. Ketones high if 2+ in urine or >3mmol/L
When should you suspect hypoglycaemia in type 1 diabetes? (levels below 3.5 mmol/L)
What are normal BM ranges for people without diabetes and for people with diabetes?
How is type 1 diabetes managed on initial presentation?
Immediate same day referral to the hospital to confirm diagnosis and start insulin
How is type 1 diabetes managed for adults in primary care?
- Ensure individual care plan is in place. Review in a few weeks and then annually from then on
- Offer a structured education program like DAFNE within 6-12 months so pt takes responsibility
- Provide info on how to communicate with diabetes team
- Provide info on disability allowance
- Manage lifestyle issues like diet, exercise and alcohol intake
- Provide info on diabetes support groups like Diabetes UK and Living With Diabetes
What things are included in an individual care plan for type 1 diabetes?
- A medical, environmental and cultural assessment are all undertaken with a general exam to form a care plan tailored to the patient
What is the DAFNE programme?
Dos Adjustment For Normal Eating
Structured education programme for type 1 diabetics allowing them to lead as normal a life as possible. Helps them learn how to correct their sugars, carbohydrate counting etc
How should blood glucose be monitored in type 1 diabetics?
HbA1c:
- Every 3-6 months aiming for below 6.5%
Self-Monitoring:
- Test at least 4 times a day: before breakfast, 2 hours after meals, during periods of illness, before driving, and if they feel hypoglycaemic
- May be offered Libre if more than 1 hypo a year, severe fwar of hypos, persistent hyperglycaemia despire 10xday testing
- Aim for 5-7 on waking, 4-7 before meals and 5-9 at least 90 minutes after eating
What lifestyle advice should you give to adults with type 1 diabetes?
Diet
- Carbohydrate-counting training (matching carbs to insulin dose)
- To prevent CVD diet low in fat, sugar, and salt, and contain at least 5 portions of fruit and vegetables a day
- Avoid sugary drinks
Alcohol
- Avoid drinking on empty stomach as will be absorbed faster
- May prolong hypoglycaemic effect of insulin/nocturnal hypoglycaemia and may be more difficult to spot hypo signs
- Wear medicalert bracelet or carry ID card when drinking as hypos can be confused with alcohol intoxication
Exercise
- Encourage it because it lowers risk of CVD
- Warn them it can lower blood sugars and you need to alter insulin doses for the next 24 hours
<u><strong>Smoking Cessation</strong></u>
What are sick day rules for adults with type 1 diabetes?
- Never stop insulin, follow the rules from the specialist team about sick days and adjusting doses
- Check BM more frequently, every 1-2 hours, and through the night
- Check blood or urine ketones more frequently, and through the night
- Maintain normal eating pattern even if loss of appetite, could replace meals with milkshakes and drinks
- Aim to drink at least 3l of fluids to prevent dehydration
- Seek medical help if drowsy, violently sick or unable to keep fluids down
How should cardiovascular risk factors be managed in type 1 diabetes?
Monitor the following:
- Lifestyle
- Waist circumference
- Albuminuria
- Full lipid profile
- Blood glucose control
- BP (target <135/85 with first line ACEi)
- Statins (don’t use Qrisk, offer 20mg atorvastatin for primary prevention, 80mg atorvastatin for secondary prevention)
How should you monitor a type 1 diabetic for complications?
- Every appt: measure HbA1c, height, weight, waist circumference, check for depression, eating disorders like diabulimia, check smoking status
- Yearly: check injection sites, assess cardiovascular risk factors (lipid profile, bp, FHx, smoking status, blood glucose control), ensure screening for thyroid disease, ensure screening feet/eyes/kidneys
How are the following complications assesed in type 1 diabetics:
- Retinopathy
- Neuropathy
- Nephropathy
- Retinopathy: annual review by local eye clinic. also if in GP and abnormal blood vessels on retina, referred to opthamologist
- Neuropathy: ask about ED and offer a PDE-5 inhibitor if so, ask about autonomic neuropathy, do diabetic foot checks with monofilament/looking for calluses/pulses
- Nephropathy: screen anually by bringing in first-morning urine and looking at creatinine:albumin ratio and eGFR (if below 60 diagnose CKD)
advise low protein diet and offer ACEi if nephropathy
What are some signs of autonomic neuropathy in diabetics?
- Bladder emptying problems
- Unexplained diarrhoea particularly at night
- Gastroparesis (advise small particle diet if vomiting, referral to gastro for metoclopramide or continuous subcut insulin)
- Postural hypotension
- Excessive sweating
- Acute painful neuropathy of rapid improvement of blood glucose control (advise analgesics until resolved)
What is the diagnostic criteria for gestational diabetes?
What are the different insulin regimes for type 1 diabetics?
Offer multiple daily injection basal-bolus insulin regimens as 1st line
Offer twice-daily insulin detemir as the long-acting basal insulin and then a rapid-acting insulin analogue injected before meals
What advice should be given to patients on insulin injection sites?
- Pinch the skin to avoid injecting muscle. Don’t need to pinch if small needle or using buttocks
- Check injection sites regularly for lumps (lipohypertrophy) and rotate injection sites to prevent this and lipodystrophy
- Swtich from left to right side of body weekly
What advice should be given on injection technique for type 1 diabetics?
- Leave insulin at room temp 30 mins before administering to prevent pain of the cold
- Check expiry date
- Ensure injection site is clean
- Inject needle quickly at 90 degrees, leaving in for 5-10 seconds to prevent leakage
- Do not rub the site after injection as will increase insulin absorption
- Keep insulin in fridge if not being used in next 28 days, keep away from radiators
How should hypoglycaemia be managed?
- Promptly consume 10–20 g of a fast-acting form of carbohydrate, preferably in liquid form. (3-6 glucose tablets, 100ml of Lucozade energy, 2-4 teaspoons of sugar in water)
- Recheck blood glucose after 10-15 minutes and if no improvement repeat the oral intake
- At next meal increase the amount of carbohydrate
- If patient unconscious give IM 1g glucagon immediately or call 999
What are some adverse effects of insulin?
- Painful injections: numb site with ice, use shorter needles
- Bruising/Bleeding: apply pressure and shorter needle
- Lipohypertrophy: rotate injection sites
- Insulin leakage: keep needle in for 5-10 secs
- Altered vision: on initiation, assure only temporary
- Acute painful neuropathy on rapid improvement of glucose control: NSAIDs and reassure
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