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
-
What are some drugs that can enhance/antagonise the hypoglycaemic effect of insulin?
Enhance
- Alcohol
- Anabolic steroids
- ACEi
- Beta blockers (also can mask signs of hypoglycaemia)
- Fibrates
- MAOi
Antagonise (more insulin needed)
- Corticosteroids
- Diuretics (loop and thiazides).
- Glucagon
- Growth hormone
- Levothyroxine
- Oral contraceptives.
- Sympathomimetic drugs (such as adrenaline, salbutamol, and terbutaline)
What are some of the presenting symptoms of type 2 diabetes?
- Persistent hyperglycaemia
- Risk factors for type 2 DM (e.g FHx, obesity, black or asian origin, PCOS, drug treatments like diuretics/steroids, low birth weight)
- Evidence of insulin resistance (e.g acanthosis nigricans)
- Characteristics like thirst, recurrent infections, tiredness, blurred vision, weight loss are likely to be less severe than type 1 or absent
What is the definition of diabetes, particularly type 2?
Group of metabolic disorders characterized by persistent hyperglycaemia (HbA1c more than 48 mmol/mol [6.5%] or random plasma glucose more than 11 mmol/L).
Type 2 is a mixture of insulin resistance and insulin deficiency
What is the diagnostic criteria for type 2 diabetes?
Asymptomatic: 2 abnormal HbA1c results >6.5% or if CKD fasting plasma glucose >7
Symptomatic: single abnormal HbA1c or fasting plasma glucose level
No additional features of type 1 diabetes (such as rapid onset, often in childhood, insulin dependence, or ketoacidosis).
If child and suspect type 2 should still do immediate referral
When should HbA1c be used with caution to diagnose type 2 diabetes?
Sickle cell trait
What initial care and support should be offered to a newly diagnosed adult with type 2 diabetes?
- Individual care plan inc things like polypharmacy
- Structured education programme e.g DESMOND/Empower
- Ensure the person/family knows how to contact the diabetes team
- Provide info on government disability benefits
- Manage lifetstyle issues
- Screen for diabetic complications
- Signpost to Diabetes UK or Leicester Diabetes Centre
- Review in 3/12 to see if lifestyle changes have worked
What are the treatment targets for adults with type 2 diabetes?
Should measure at 3 month intervals until HbA1c stable, then can be measured every 6 months
- Below 6.5%: if managed by lifestyle/diet or if managed by lifestyle and one drug not associated with hypoglycaemia
- Below 7.0%: if managed by one drug associated with hypoglycaemia e.g sulfonylurea or if on multiple drugs
- Individual target: may be relaxed for elderly or frail who are unlikely to see long term benefits of lower blood sugars
When should type 2 diabetics do self monitoring of their blood glucose?
Not routinely advised (as does not help improve sugars at 6 months) unless:
- On insulin therapy
- Evidence of hypoglycaemic episodes
- Taking a drug that may increase risk of hypoglycaemia while driving or operating machinery (such as a sulfonylurea)
- Pregnant or trying to concieve
- Short term if starting corticosteroids
What treatment is offered to type 2 diabetics first line?
High risk of cardiovascular disease
- QRISK2 more than 10% in adults aged 40 and over or
- an elevated lifetime risk of cardiovascular disease (defined as the presence of 1 or more cardiovascular risk factors in someone under 40)
Cardiovascular disease risk factors: hypertension, dyslipidaemia, smoking, obesity, and family history (in a first-degree relative) of premature cardiovascular disease.
If a patients HbA1c is not controlled by first line treatment, what should be done next?
SEE PASS MEDICINE!!!
What immediate treatment is recommended for adults with type 2 diabetes who have symptomatic hyperglycaemia?
Insulin or sulfonylurea
What advice on diet, weight and exercise can you give to a type 2 diabetic
- High fibre, low-glycaemic-index sources of carbohydrate (such as fruit, vegetables, wholegrain, and pulses), low-fat dairy products, and oily fish.
- Control the intake of foods containing saturated and trans fatty acids
- If overweight set target of 5-10% body weight loss and consider referral to dietician
- Encourage 150 minutes of moderate exercise a week in bouts of at least 10 mins
What equipment do diabetics need for ‘sick days’?
How should screening for diabetic complications be managed in primary care?
Every appt: check BMI, smoking status, neuropathy, depression and anxiety
Every 6 months: HbA1c
Annually:
Retinopathy (starting at diagnosis)
Diabetic foot problems (starting at diagnosis with monofilament)
Nephropathy (albumin:creatinine ratio and eGFR)
Cardiovascular risk factors (albuminaemia, lipid profile, age, waist circumference, blood pressure, family history)
Autonomic neuropathy (postural hypertension)
Injection sites if on insulin
What statin should be given to diabetics? (use image)
Primary prevention: if QRISK >10% give 20mg atorvastatin
Secondary prevention: 80mg atorvastatin
Which drugs do diabetics need to be careful taking when they have autonomic neuropathy?
TCA antidepressants and antihypertensives as they increase the risk of postural hypertension
What is the following for Metformin (biguanide):
- MOA
- Benefits
- Side effects
- Contraindications
- Drug interactions
- MOA: decreases gluconeogenesis and increases peripheral utilization of glucose. Only works if residual functioning pancreatic islet cells
- Benefits: cardioprotective as lowers cholesterol and triglycerides, limits weight gain as lowers appetite, can be used in pregnancy, no hypoglycaemia
- Side effects: GI disturbance (combat by increasing dose gradually or modified release), metallic taste, lactic acidosis, Vit B12 deficiency
- Cx: eGFR<30 (check renal function annually, review if <45), people at risk of lactic acidosis (DKA), stop 48 hours before surgery
- Drug Interactions: alcohol can increase risk of lactic acidosis, beta blockers as mask hypoglycaemia, corticosteroids/COCP/thiazides/loops may all antagonise
What is the following for gliptins:
- MOA
- Benefits
- Side effects
- Contraindications
- Drug interactions
Sitagliptin, Saxagliptin, Vildagliptin, Linagliptin, and Alogliptin
MOA: DPP4 inhibitor so increase GLP1 and GIP in the blood so increased insulin secretion and decreased glucagon secretion
Benefits: no hypoglycaemia as only released on eating, weight neutral/loss as decreased appetite
Side effects: GI symptoms (constipation, vomiting), acute pancreatitis, back pain, arthralgia, bullous pemphigoid, skin reactions, headaches, hepatic dysfunction
Contraindications: hepatic or renal impairment (monitor renal annually and check both at start), pregnancy, ketoacidosis, heart failure
Drug Interactions: beta blockers as masks hypos, ACEi can increase risk of angiooedema
What are some adverse reactions specific to the following drugs:
- Sitagliptin
- Saxagliptin
- Linagliptin
Black triangle drugs so intensely monitored and patients encouraged to report adverse reactions
What is the following for Pioglitazone (thiazolidinediones):
- MOA
- Benefits
- Side effects
- Monitoring
- Contraindications
- Drug interactions
MOA: reduces peripheral insulin resistance in muscles and adipose tissue by activating PPAR-y receptors. Need insulin presence to work
Benefits: no hyperglycaemia, can lower lipids
Side effects: weight gain, bone fractures due to reduced mineralisation, risk of bladder cancer, risk of heart failure when used with insulin, decreased visual acuity, fluid retention
Monitoring: before starting check ALT, FBC for anaemia, urine for blood and record weight. Monitor liver enzymes and for fluid retention after 3-6 months initiationt then regularly
Cx: history of heart failure; previous or active bladder cancer; uninvestigated macroscopic haematuria, pregnancy
DDIs: same as other antidiabetic drugs e.g beta blockers plus liver enzyme inducing drugs as metabolised by liver
What is the following for Gliclazide/Tolbutamide/Glibenclamide (Sulfonylurea):
- MOA
- Benefits
- Side effects
- Monitoring
- Contraindications
- Drug interactions
MOA: stimulate pancreas to release insulin so only work if some residual function. Binds to ATP-K+ channels causing depolarisation
Benefits: may reduce risk of microvascular complications, very potent, may shorten length of time until injectables needed
Side effects: hypos, weight gain, abdominal pain and GI disturbance, disturbance in liver function, skin reactions
Cx: pregnancy, ketoacidosis, severe renal/hepatic impairment, acute porphyria, be careful in elderly and those with G6PD deficiency
Monitoring: self monitoring of blood glucose
DDIs: drugs that displace from protein bound site e.g NSAIDs and wafarin, fluconazole can increase amount in blood, any liver enzyme inducers/inhibitors as undergoes hepatic metabolism
What is the following for GLP1 analogues:
- MOA
- Benefits
- Side effects
- Monitoring
- Contraindications
- Drug interactions
Exenatide, Liraglutide, and Lixisenatide
MOA: activate GLP-1 receptor so insulin secretion, suppress glucagon secretion, and slow gastric emptying. Cannot be broken down by DPP4
Benefits: liraglutide has CVS benefit, weight loss by appetite decrease, low risk of hypos
Side effects: GI disturbance (N+V, diarrhoea), GORD, painful to inject sc, headaches, alopecia, renal impairment
Monitoring: after 6 months check for 3% weight loss and 1% HbA1c reduction
Cx: ketoacidosis, renal impairment <30 or <50 with exenatide, severe gastrointestinal disease, gastroparesis, IBS
DDIs: can affect absorption of drugs so take 1 hour before or 4 hours after injection e.g paracetamol, warfarin. Beta blockers.
What is the following for SGLT2 inhibitors:
- MOA
- Benefits
- Side effects
- Monitoring
- Contraindications
- Drug interactions
Canagliflozin, Dapagliflozin, and Empagliflozin
MOA: reversibly inhibit SGLT2 in the PCT to reduce glucose reabsorption and increase urinary glucose excretion. Can be used first line if metformin not tolerated
Benefits: Cana and Empa can be beneficial to CVS, low risk of hypos
Monitoring:
Side effects: polyuria, UTIs, thrush, Fournier’s gangrene, constipation, balanoposthitis, dyslipidaemia/raised lipids, dehydration, thirst, risk of toe amputation with canagliflozin, risk of DKA
Cx: ketoacidosis, eGFR<60, lactose intolerance, increased risk of volume depletion, foot ulcers due to risk of amputation
DDIs: thiazides/loops can volume deplete, enzyme inducers, digoxin toxicitiy
What are the other classes of drugs you may consider giving to diabetics to manage their vascular risk factors?
- Statins
- Antihypertensives with ACEi first line
- Stop smoking
What is the aetiology behind micro and macrovascular complications in diabetes?
- Nephropathy and neuropathy due to small vessel damage by atherosclerosis
- Neuropathy due to ischaemia from small vessel damage and direct damage due to hyperglycaemia
What is LADA?
Latent Autoimmune Diabetes of Adulthood
Type 1 diabetes that develops in adulthood
When are people with diabetes prescribed aspirin or antiplatelet therapies?
- Do not give to diabetics who have no cardiovascular disease for primary prevention. Bleeding risk outweighs benefits
- ?beneficial to give to hypertensive diabetics
If a patient comes in on a Fridy afternoon with polyuria and thirst, how do you decide whether or not this is diabetes and if they are safe to be left for the weekend?
- Assess clinical picture e.g risk factors
- Urine dipstick for ketones to rule out DKA
- Random glucose
- Obs: RR, temp, sats, BP
- DKA red flags: N+V, high temp, abdominal pain, pear drop breath
- If suspect type 1 then immediate referral
What are some factors that can affect the accuracy of HbA1c results?
What are some of the signs of hypoglycaemia?
What are some signs a diabetic has autonomic neuropathy?
- If have hypo unawareness do not use drug with risk of hypos
What is reactive hypoglycaemia?
- Low blood sugar that occurs after a meal — usually within four hours after eating
- Can be an early sign of diabetes as pancreas producing too much insulin
What should you offer to someone if their HbA1c levels are between 6.1 and 6.4?
National diabetes prevention programme
What are some factors that affect the accuracy of HbA1c?
- Haemoglobinopathies e.g Sickle Cell
- Type 1 Diabetes
- Pregnancy
- Children
- HIV
- Splenectomy
What are some of the macrovascular complications of Diabetes?
- Cerebrovascular disease
- Peripheral Vascular disease
- Coronary Heart disease
If a type 2 diabetic needs to be started on insulin as they are not hitting their targets, what insulin should be prescribed?
- Metformin should be continued
- Start with human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need
Fill in this table for the following:
- DPP4 inhibitors
- Metformin
- Pioglitazone
- SGLT2 Inhibitors
- Sulfonylurea
What criteria needs to be met when on Liraglutide or a GLP1 analogue to continue NHS funding?
> 11 mmol/mol (1%) reduction in HbA1c and 3% weight loss after 6 months
Major adverse effects: N+V, Pancreatitis
