21 - Diabetes Flashcards
What is the diagnostic criteria for diabetes?
Symptoms plus one abnormal result or two abnormal results at different times:
- Fasting glucose >7
- OGTT 2hrs after 75g glucose >11.1
- HbA1C >6.5%
What is the pathophysiology of type 1 diabetes? Why is Ketoacidosis more likely?
Autoimmune destruction of beta-cells so there is an absolute insulin deficiency.
Can be associated with other autoimmune conditions
Prone to ketoacidosis
What are some other causes of diabetes apart from type 1 and type 2?
- Pancreatic related: pancreatitis, pancreatic cancer
- Drugs: steroids, new antipsychotics, ARV for HIV
- Endocrine causes: cushing’s, acromegaly, hyperthyroidism
- Gestational diabetes
How can you distinguish between type 1 and type 2 diabetes?
How is type 1 and type 2 diabetes managed in general terms?
- Life style advice e.g exercise to improve insulin sensitivity, healthy eating
- Assess cardiovascular risk and consider a high intensity statin
- Control BP
- Give foot care
How is type 2 diabetes managed if diet and lifestyle changes do not improve glycaemic control?
1st Line: metformin
2nd line if HbA1c >7.5%: dual therapy
3rd line if HbA1c >7.5%: triple therapy, insulin or GLP1 analogue
How do the following oral diabetic drugs work and give some examples?
- Biguanides
- Sulfonylurea
- DPP4i
- Glitazones/Thiazolidinedones
- GLP1 analogues
- SGLT2i
- Biguanides (Metformin): decreases hepatic gluconeogenesis and increase insulin sensitivity
- Sulfonylurea (Gliclazide/Tolbutamide): increases insulin secretion by binding to ATP-K+ channels to allow the cells to depolarise
- DPP4i (Sitagliptin/Saxagliptin): inhibits DPP4i enzyme that normally breaks down incretins (GLP-1, GIP)
- Glitazones (Pioglitazone): increase insulin sensitivity by binding to PPAR-y receptor
- GLP-1 analgoues (Liraglutide/Exenatide): work like GLP1, not broken down by DPP4
- SGLT2i (Dapa/Empagliflozin): block reabsorption of glucose in PCT of kidneys so more excretion in urine. Helps BP, weight, cardiovascular disease
What are the side effects of the following diabetic drugs:
- Biguanides
- Sulfonylurea
- DPP4i
- Glitazones
- GLP1 analogues
- SGLT2i
Metformin: GI side effects (give modified release), abdominal pain, lactic acidosis if low eGFR
Sulfonylurea: weight gain, hypoglycaemia
DPP4i: GI symptoms e.g D+V+N, pancreatitis
Glitazones: hypoglycaemia, fractures, fluid retention, deranged LFTs so monitor every 8 weeks for a year, weight gain, visual impairment
GLP1 analogues: GI discomfort, pancreatitis, sweating
SGLT2i: UTIs, thrush, polyuria, stop if eGFR<45
What effect does the incretin GLP-1 have on the body?
- Increase insulin secretion
- Decrease hepatic gluconeogenesis
- Delays gastric emptying
- Decreased food intake by increased sateity
- Increased uptake of glucose in muscles
Which diabetic drugs cause weight gain, weight loss or weight neutral?
Weight gain: Sulfonylureas, Thiazolidinediones, Insulin
Weight neutral: DPP4i
Weight loss: Metformin, GLP1 analogues, SGLT2i
What diabetic drugs increase insulin secretion?
- Sulfonylureas
- GLP-1 analogues
- DPP4 inhibitors
What diabetic drugs increase insulin sensitivity?
- Metformin
- Glitazones
What are some contraindications for glitazones?
- History of bladder cancer
- History of heart failure
- Active liver disease
- Pregnant women
When starting GLP-1 analogues, what parameters have to change to continue using the drug?
If 3% weight loss or 1% Hba1c reduction does not occur within 6 months these must be stopped
What is some lifestyle advice you should give to people starting on insulin therapy?
- Carb counting
- Checking BMs
- Adjust insulin when exercising
- Avoid binge drinking
- Education on how to treat hypos
- Store insulin in fridge and remove before injecting
- Change needle every time
- Rotate injection sites
- Dial dose
- 90 degree injection
How do people self-administer insulin?
- Subcut with pen, syringe or pump (Prime pen - dial the pen!!!!)
- Into abdomen or legs
- No pinch needed if 4-6mm needle
What are the different categories of insulin and give some examples for each?
- Rapid acting (5-15 min onset): Insulin Lispro (Humulog), Insulin Aspart (Novorapid)
- Short acting (30-60 min onset): Actrapid, Humulin S
- Intermediate Acting (2-4hr onset): Isophane Inulin (NPH)
- Long acting (2-4hr onset): Insulin glargine, Insulin Detemir
- Mixed: Novomix with 30% short acting, 70% long acting
When is long acting recombinant insulin good?
No peak so good if nocturnal hypoglycaemia
What are some common insulin regimes?
- Once daily: 1 long acting at bed time
- BD Biphasic: Twice daily pre-mixed insulin (short and intermediate acting) by pen. Given morning and evening and need set routine with meals every day e.g. Novomix
- Basal Bolus/QDS: 1 long acting insulin and then rapid acting insulin injections before meals
CSII: uses libra
How do you choose which insulin regime is best for a patient?
Plan regime to suit the lifestyle of the patient!!!!
- Once daily is good for type 2 in conjunction with oral hypogylcaemics
- Basal bolus good for type 1 who want flexibility of when to have meals
- BD good for type 1 and type 2 who have set routine
- CSII: good for type 1 with issues controlling glucose despite monitoring and multiple injections daily
What is important to note when prescribing insulin?
- Write UNITS in full
- Always prescribe by brand name and do not switch
What is Humulin R?
5x more concentrated than standard insulin for patients who are severely insulin resistant so would need large volumes of standard e.g >300 units
Injected TDS before meals
Prescribed in marks not units so do not use 1ml insulin syringe
What was the opening line on Easy Tiger (Freestyle) by Birun?
Red polo, blue polo I’m switching four lanes,
I’m tryna get my hairline back it’s causing me pains.
What education programme should type 1 diabetics be offered in conjunction with their insulin regime?
DAFNE to improve glycemic control by carb counting
How long after opening can insulin be used?
- If unopened store in fridge, if open store at room temperature
- Use within 30 days then discard
What advice should you give to patients on insulin about sick days e.g influenza illness?
- Do not stop insulin to avoid DKA
- May need to up insulin fasting acting insulin if hyperglycaemic
- Maintain calorie intake e.g milkshakes
- Check BMs every 2-4 hrs and through the night as well as checking ketonuria. Go to hospital if ketonuria
- Go to hospital if vomiting, dehydrated or ketotic
How do you read a 1ml 100U syringe?
- Every 0.1 ml is 10 units
- 1ml is 100 units
What is Tresiba?
Degludec (long acting insulin) that is available at higher concentrations
What is stress hyperglycaemia?
- Transient hyperglycaemia which normalises after discharge
- No previous diabetes diagnosis
- BM >7.8 but HbA1c<6.5%
What the issues with inpatient hyperglycaemia?
What is the pathophysiology of stress hyperglycaemia?
During stress there is an increase in cortisol secretion which leads to insulin resistance, hepatic gluconeogenesis and reduced peripheral glucose utilisation
Also can be affect by steroids and dextrose given in hospital
What is the difference between FRII and VRII?
Fixed: based on body weight, 0.1units/kg/hr, used for DKA/HHS
Variable: changes hourly based on BMs, used for NBM and will miss more than 1 meal/vomiting/ACS/tight glycaemic control needed e.g sepsis
- Glucose target 6-10 and avoid wide swings!
- Both need to continue any basal insulin
What insulin is used in an IV insulin infusion?
Soluble insulin!!!!
How do you set up insulin ready for infusion?
- 50 units in 49.5ml NaCl
- Two practioners should check
- Always set up fluids with glucose in going through the same cannula with Y connector!!!!!
What fluids should you use with VRII?
ALWAYS NEED POTASSIUM AND GLUCOSE IN THE FLUID!!!!
What monitoring should you do for a patient once they are started on VRII and when can it be stopped?
- Check glucose levels hourly and consider if need to go up or down the scale
- Aim for BM 6-10
- Check ketones in type 1 DM
- Continue until patient eating and back on their normal medication. Need to give s/c before stopping!!!
What fluids should you use with FRII?
- Add 10% glucose if BM<14
- Otherwise just 0.9% NaCl with 40% KCl
What monitoring should you do for a patient once they are on FRII and when can this be stopped?
- Blood ketones
- BMs
- If cannot get blood ketones use venous pH and bicarbonate
- Stop once patient is eating and DKA resolved. Need to give s/c insulin before stopping!!!!!
What are the aims of diabetic treatment in end of life care?
- Avoid hypos, DKA, HHS
- Avoid foot complications
- Avoid dehydration
- Reduce polypharmacy e.g stop statins, reduce doses due to steroids and weight loss, reduce complexity
What is the issue of people with diabetes taking steroids?
- Risk of hyperglycaemia that can lead to HHS
How should you manage patients with diabetes starting on steroids that have steroid induced hyperglycaemia?
How should you manage patients with steroid induced diabetes (non-diabetic before steroids)?
- If patient experiences hyperglycaemia >12 twice start on sulfonylurea or insulin/up the dose
- Stop once steroids stopped
What are some causes of hypos in diabetics that are being enterally fed?
How does gestational diabetes occur?
Release of hPL (human placental lactogen) and oestrogen from the placenta which cause a level of insulin resistance, therefore the pancreas has to increase the insulin production.
If pancreas doesn’t have ability to produce more insulin this is diabetes
Also increased hepatic gluconeogenesis
What are CBG targets in pregnancy?
What are some risk factors for developing gestational diabetes?
- >25
- Family history
- Obese
- Non-caucasian
- Previous gestational DM
How do mothers with gestational diabetes deliver?
Induced or C-section at 38 weeks!!!!!
Tend to go for C-Section due to risk of shoulder dystocia
What are the principles of management for gestational diabetes?
- Education on dietary changes
- Testing CBG
- Metformin +/- Insulin
What are some factors that can cause hypoglycaemia in a diabetic?
What are some causes of hypoglycaemia in a non-diabetic?
- Reactive hypoglycaemia (non-diabetic)
- Alcohol
- Low cortisol
- Insulinoma
- Low GH levels
- Eating less or exercising more
How do you perform a safe discharge for an inpatient with diabetes?
What features support a diagnosis of DKA?
- CBG > 11
- Known diabetic diagnosis
- Ketones +++
Cannot be pH or bicarb because this is an ABG not VBG!!!
