16 - Diabetes Flashcards

1
Q

What are some of the presenting symptoms of type 1 diabetes?

A

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

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2
Q

What are some of the complications of type 1 diabetes?

A

- 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

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3
Q

What is the diagnostic criteria for type 1 diabetes?

A
  • Symptoms + test

OR

  • Asymptomatic + two positive tests on different days

- Random >11.1

- Fasting >7

- OGTT >11.1

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4
Q

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?

A
  • 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).
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5
Q

When should you suspect DKA?

A
  • 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
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6
Q

What investigations should you do if you suspect a DKA?

A

- 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

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7
Q

When should you suspect hypoglycaemia in type 1 diabetes? (levels below 3.5 mmol/L)

A
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8
Q

What are normal BM ranges for people without diabetes and for people with diabetes?

A
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9
Q

How is type 1 diabetes managed on initial presentation?

A

Immediate same day referral to the hospital to confirm diagnosis and start insulin

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10
Q

How is type 1 diabetes managed for adults in primary care?

A

- 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

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11
Q

What things are included in an individual care plan for type 1 diabetes?

A
  • A medical, environmental and cultural assessment are all undertaken with a general exam to form a care plan tailored to the patient
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12
Q

What is the DAFNE programme?

A

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

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13
Q

How should blood glucose be monitored in type 1 diabetics?

A

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
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14
Q

What lifestyle advice should you give to adults with type 1 diabetes?

A

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>

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15
Q

What are sick day rules for adults with type 1 diabetes?

A
  • 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
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16
Q

How should cardiovascular risk factors be managed in type 1 diabetes?

A

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)
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17
Q

How should you monitor a type 1 diabetic for complications?

A

- 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

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18
Q

How are the following complications assesed in type 1 diabetics:

  • Retinopathy
  • Neuropathy
  • Nephropathy
A
  • 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

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19
Q

What are some signs of autonomic neuropathy in diabetics?

A

- 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)

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20
Q

What is the diagnostic criteria for gestational diabetes?

A
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21
Q

What are the different insulin regimes for type 1 diabetics?

A

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

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22
Q

What advice should be given to patients on insulin injection sites?

A

- 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
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23
Q

What advice should be given on injection technique for type 1 diabetics?

A
  • 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
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24
Q

How should hypoglycaemia be managed?

A

- 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
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25
Q

What are some adverse effects of insulin?

A

- 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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26
Q

What are some drugs that can enhance/antagonise the hypoglycaemic effect of insulin?

A

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)
27
Q

What are some of the presenting symptoms of type 2 diabetes?

A

- 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

28
Q

What is the definition of diabetes, particularly type 2?

A

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

29
Q

What is the diagnostic criteria for type 2 diabetes?

A

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

30
Q

When should HbA1c be used with caution to diagnose type 2 diabetes?

A

Sickle cell trait

31
Q

What initial care and support should be offered to a newly diagnosed adult with type 2 diabetes?

A

- 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
32
Q

What are the treatment targets for adults with type 2 diabetes?

A

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

33
Q

When should type 2 diabetics do self monitoring of their blood glucose?

A

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
34
Q

What treatment is offered to type 2 diabetics first line?

A

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.

35
Q

If a patients HbA1c is not controlled by first line treatment, what should be done next?

A

SEE PASS MEDICINE!!!

36
Q

What immediate treatment is recommended for adults with type 2 diabetes who have symptomatic hyperglycaemia?

A

Insulin or sulfonylurea

37
Q

What advice on diet, weight and exercise can you give to a type 2 diabetic

A
  • 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
38
Q

What equipment do diabetics need for ‘sick days’?

A
39
Q

How should screening for diabetic complications be managed in primary care?

A

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

40
Q

What statin should be given to diabetics? (use image)

A

Primary prevention: if QRISK >10% give 20mg atorvastatin

Secondary prevention: 80mg atorvastatin

41
Q

Which drugs do diabetics need to be careful taking when they have autonomic neuropathy?

A

TCA antidepressants and antihypertensives as they increase the risk of postural hypertension

42
Q

What is the following for Metformin (biguanide):

  • MOA
  • Benefits
  • Side effects
  • Contraindications
  • Drug interactions
A

- 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

43
Q

What is the following for gliptins:

  • MOA
  • Benefits
  • Side effects
  • Contraindications
  • Drug interactions
A

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

44
Q

What are some adverse reactions specific to the following drugs:

  • Sitagliptin
  • Saxagliptin
  • Linagliptin
A

Black triangle drugs so intensely monitored and patients encouraged to report adverse reactions

45
Q

What is the following for Pioglitazone (thiazolidinediones):

  • MOA
  • Benefits
  • Side effects
  • Monitoring
  • Contraindications
  • Drug interactions
A

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

46
Q

What is the following for Gliclazide/Tolbutamide/Glibenclamide (Sulfonylurea):

  • MOA
  • Benefits
  • Side effects
  • Monitoring
  • Contraindications
  • Drug interactions
A

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

47
Q

What is the following for GLP1 analogues:

  • MOA
  • Benefits
  • Side effects
  • Monitoring
  • Contraindications
  • Drug interactions
A

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.

48
Q

What is the following for SGLT2 inhibitors:

  • MOA
  • Benefits
  • Side effects
  • Monitoring
  • Contraindications
  • Drug interactions
A

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

49
Q

What are the other classes of drugs you may consider giving to diabetics to manage their vascular risk factors?

A
  • Statins
  • Antihypertensives with ACEi first line
  • Stop smoking
50
Q

What is the aetiology behind micro and macrovascular complications in diabetes?

A

- Nephropathy and neuropathy due to small vessel damage by atherosclerosis

- Neuropathy due to ischaemia from small vessel damage and direct damage due to hyperglycaemia

51
Q

What is LADA?

A

Latent Autoimmune Diabetes of Adulthood

Type 1 diabetes that develops in adulthood

52
Q

When are people with diabetes prescribed aspirin or antiplatelet therapies?

A
  • Do not give to diabetics who have no cardiovascular disease for primary prevention. Bleeding risk outweighs benefits
  • ?beneficial to give to hypertensive diabetics
53
Q

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?

A
  • 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
54
Q

What are some factors that can affect the accuracy of HbA1c results?

A
55
Q

What are some of the signs of hypoglycaemia?

A
56
Q

What are some signs a diabetic has autonomic neuropathy?

A
  • If have hypo unawareness do not use drug with risk of hypos
57
Q

What is reactive hypoglycaemia?

A
  • 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
58
Q

What should you offer to someone if their HbA1c levels are between 6.1 and 6.4?

A

National diabetes prevention programme

59
Q

What are some factors that affect the accuracy of HbA1c?

A
  • Haemoglobinopathies e.g Sickle Cell
  • Type 1 Diabetes
  • Pregnancy
  • Children
  • HIV
  • Splenectomy
60
Q

What are some of the macrovascular complications of Diabetes?

A
  • Cerebrovascular disease
  • Peripheral Vascular disease
  • Coronary Heart disease
61
Q

If a type 2 diabetic needs to be started on insulin as they are not hitting their targets, what insulin should be prescribed?

A
  • Metformin should be continued
  • Start with human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need
62
Q

Fill in this table for the following:

  • DPP4 inhibitors
  • Metformin
  • Pioglitazone
  • SGLT2 Inhibitors
  • Sulfonylurea
A
63
Q

What criteria needs to be met when on Liraglutide or a GLP1 analogue to continue NHS funding?

A

> 11 mmol/mol (1%) reduction in HbA1c and 3% weight loss after 6 months

Major adverse effects: N+V, Pancreatitis