257. Diabetes Flashcards
What is diabetes?
Metabolic derangement derived from lack or reduced effectiveness of insulin.
Long term this leads to serious micro or macrovascular impacts
What is type 1 DM?
Insulin deficiency from autoimmune destruction of insulin secreting pancreatic b cells.
Prone to ketacidosis and weight loss
Associated with HLA DR3 and DR4
WHAT IS TYPE 2 diabetes mellitus?
Caused due to decreased insulin secretion and enhanced insulin resistance. Associated with a lack of exercise, calorie and increased alcohol intake.
How is an impaired glucose tolerance test carried out?
Fasting plasma glucose <7mmol
Given them glucose then assess after 2 hours, >7.8mmol but <11mmol
How is an impaired fasting glucose test carried out?
just get them to fast, should be between 6.1 and 7mmol
What are some other causes of diabetes?
Iatrogenic: steroids, Anti HIV drugs, newer antipsychotics
What is metabolic syndrome X?
Central obesity BP>130/85 Triglycerides>1.7mmol HDL<1.2 Fasting glucose >5.6
According to WHO how do you diagnose diabetes?
Symptoms of hyperglyceamia (polyuria, fatigue, polydypsia, weight loss)
Raised venous glucose on two separate occasions (fasting>7mmol, random> 11mmol)
HbA1c>48mmol (cant use in type 1, pregnant, children)
What are the various types of insulin?
Ultra fast acting: humalog, novorapid- for meals
Isophane insulin: variable metabolised after 4-12 hours
Pre mixed insulins: e.g. novomix, mix of long and short acting
Long acting recombinant insulin analogues: used at bedtime in Types 1 and 2, good if nocturnal hypos are an issue
What are meant by sick days in diabetes?
What advice is given surrounding insulin?
Patients tend to eat less on days when they are acutely unwell e.g. with flu
Despite this they often need more insulin. They should check their blood glucose more often when they are unwell and if concerned phone GP or specialist nurse
If ketotic, dehydrated or vomiting, admit.
What is the treatment ladder for type 2 diabetes?
- Lifestyle chamges
- Metformin
- +DPP4/pioglitazone/sulphynurea/SGLT-2i
- 1 agents above that not already on
- Insulin/GLP
Discuss metformin:
- mechanism of action
- side effects
- contraindications
Biguanide.
Increases insulin sensitivity and improves weight
Nausea, diarrhoea, abdo pain
Avoid if EFGR 36ml/min
Discuss DPP4 inhibtors:
- mechanism of action
- side effects
- contraindications
E.g. sitagliptin
Stops action of DPP4 an enzyme which destroys the hormone incretin
Discuss Glitazone:
- mechanism of action
- side effects
- contraindications
Increases insulin sensitivity
Hypo, fractures, fluid retention, abnormal LFT’s
CCF, osteoperosis, stop if oedema
Discuss Sulfonylurea:
- mechanism of action
- side effects
- contraindications
e.g. gliclazide
Increased insulin secretion
hypo, increases weight
Discuss Selective sodium glucose co transporter 2 inhibitors (SGLTI):
- indications
- mechanism of action
- side effects
- contraindications
e.g. empagliflozin
blocks re-absorbtion of glucose in the kidneys and promotes excretion of excess glucose in urine
Discuss Glucagon like peptide analogues:
- indications
- mechanism of action
- side effects
- contraindications
mimics incretin (augments insulin release)
Patients are either BMI>35 and psychological or other medical problems or BMI<35 where insulin would have complications with work
When do you treat BP in diabetes?
When it is over 135/80mmhg
Treat with ACE-I
What non diabetic medications are good to consider to treat complications?
Statins
Aspirin
Nephropathy is an early complication of diabetes. How is it recognised early?
What is the best way to treat nephropathy in diabetes
Microalbuminuria is recognised when urine dipstick is -ve for protein but urine albumincreatinine ratio is >3mg/mmol
Treat is UA:CR>3 ACE-I, ARB, spironolactone may help
What are the different levels of eye disease that occur with diabetes?
Background retinopathy
Pre-proliferative retinopathy
Proliferative retinopathy
Maculopathy
Describe the pathogenesis of diabetic eye disease?
Capillary endothelial change Vascular leak Microaneurysms Capillary occlusion local hypoxia and ischeamia new vessel formation Ischaemic areas bleed fibrose and can detach from retina
What are the signs of diabetic neuropathy?
Absent ankle jerks,
loss of sensation
deformity (pes cavus, charcots)
Swelling, instability or deformity
What are the signs of ischaemic changes in a diabetic foot
Loss of pulses
Reduced doppler score
Foot ulceration
How do you manage diabetic foot problems
Regular chiropody
Bed rest and therapautic shoes
bed rest and crutches for charcot’s
Bisphosphonates may help
What antibiotics are typically started for diabetic foot infections?
Benzylpenicllin
Flucloxacillin
Metranidazole
What other neuropthies may diabetics get?
Systemic sensory polyneuropathy (glove and stocking)
Mononeuritis multiplex
Amyotrophy- painful wasting of quads
Autonomic neuropathy- affects BP, Gastric motility, erectile dysfucntion, arryhtmias
