4. Diabetes Mellitus and hypoglycaemia Flashcards
Diabetes mellitus
A metabolic disorder characterised by persistently high blood glucose levels
Type 1 and Type 2 Diabetes mellitus
Type 1: Autoimmune destruction of beta islet cells
Type 2: Cells do not respond to insulin
Diabetes Mellitus symptoms
- Polyuria - body’s attempt to get rid of excessve glucose from the blood
- Polydipsia
- Polyphagia - peripheral tissues cannot take up glucose from the blood to use an energy
- Poor wound healing
- Fatigue
- Weight Loss - body breaks down fat and muscle to use an alternative form of energy
- Blurred vision
- Glucosuria - predispose to cystitis vaginal thrush. (REFER DIABETES PATIENTS = POOR GLYCAEMIC CONTROL)
Macrovascular complications of diabetes mellitus
- Stroke
- Heart attack/atherosclerosis
Microvascular complications of diabetes mellitus
- Diabetic retinopathy
- Diabetic nephropathy
- Peripheral neuropathy —> diabetic foot, wound healing is slow in diabetes
Refer diabetics immediately, if they present with foot issues, do not treat with anything OTC
Treatment of macrovascular complications
Cardiovascular disease:
Primary -
Low dose statin
(If patient is over 40, has had type 1 diabetes for over 10 years, has had type 2 diabetes for over 20 years, has target organ damage)
Secondary-
Low-dose aspirin
Treatment of microvascular complications
High blood pressure and high glucose levels damage blood vessels supply the kidneys and eyes. Must reduce BP to treat retinopathy and nephropathy
Diabetic retinopathy
Treat hypertension
Diabetic nephropathy
Treat hypertension
The vessels in the kidneys, leak albumin into the urine = proteinuria. This is treated with a low-dose ACE inhibitor, which has renal protective properties.
ACE inhibitors cause hyperkalaemia. In kidney disease, you have reduced ability to excrete potassium into the urine. Therefore cannot combine this with another drug that also causes hyperkalaemia
Diabetic neuropathy
Neuropathic pain is treated with analgesics, tricyclic antidepressants, anti-epileptic drugs.
Nerves suppling penis is damaged, therefore can cause erectile dysfunction. This is treated with a phosphodiesterase type 5 inhibitor (sildenafil).
Diabetic ketoacidosis symptoms
- fruity breath
- dehydration & extreme thirst
- polyuria
- High conc of ketones in blood and urine
- Blood glucose conc >11 mmol/L
- Abdominal pain
- N + V
Diabetic ketoacidosis treatment
- IV infusion to replace eletcrolytes and insulin
- Short acting insulin
- Do not administer potassium if patient is anuric, as kidneys will be unable to filter it out from blood
What is diabetic ketoacidosis
More common with type1 diabetics, where the body breaks down fat to use as an alternative source of energy. This process causes a build-up of ketones in the blood and urine. Ketones lower blood PH and make blood acidic.
Risk factors for diabetic ketoacidosis
- surgery
- interucurrent illness
- dehydration
- restricted food intake
What are the 3 types of insulin
- Human- soluble insulin (developed from recombinant technology)
- Human analogues - rapid and long-acting (modified human insulin, developed from recombinant technology)
- Beef/Pork - soluble animal
Diabetes Mellitus
Type 1 treatment
- Parenteral insulin (mostly subcutaneous), adjusted according to patient’s needs.
More insulin is needed, during:
- infection/illness, as cortisol increases which causes glucose to increase
- surgery, trauma
- Puberty, pregnancy (2nd/3rd timester)
Less insulin needed, during:
- Reduced food intake, physical activity
- Renal impairement
- Endocrine disorders, e.g Addison’s disease
Side effect of insulin
Weight gain
HypOglycaemia
Insulin counselling
- Adminster subcutaenously into abdomen, thighs, buttocks, upper arm
- Rotate injection sites to prevent lipodystrophy which reduces insulin abroption, thus glycaemic control
- Check site for signs of swelling, bruising
- Avoid missing meals and strenous exercise
- Residual insulin SHOULD NOT be extracted from pen devices
- Patients should not inject themselves intravenously, route only reserved for medical personnel
- Unopened insulin should be stored 2-8 degrees and once opened, should be stored at room temperature. Can be used by <28 days. FROZEN INSULIN must be thrown away
Prescribing insulin considerations
- NEVER give IV syringes for SC injections. IV syringes are in mm and SC syringes are in units
- Doses should be prescribed in UNITS of INTERNATIONAL UNITS, IU/U not acceptable
Types of insulin preparations
BOLUS/Large single dose. Usally faster onset,
- Rapid-acting
- Short-acting
BASAL/Background insulin. Usually has a slow onset.
- Intermediate-acting
- Long-acting
Short-acting insulin (soluble insulin)
- HUMAN OR BEEF/PORK
Route:
SC and IM
IV: surgery or emergency
Time:
15-30 min before meals. Must eat within less than 30 minutes of administering to prevent hypos
Rapid-acting insulin (analogue)
- Aspart (Novorapid)
- Glulisine (Apidra)
- Lispro (Humalog)
Route: SC, IV if emergency
Time:
Just before meals, lower risk of hypo before meals as it prevents insulin levels from spiking, during meals.
Rapid-acting insulins mimic the insulin secretion profile more closely - more preferred
Intermediate acting insulin
- Isophane (NPH). This is mixed with short-acting insulin and protamine, which is a protein used to extend duration of action. However, protamine associated with allergic reactions.
Route:
NOT IV - linked to thrombosis
Administration:
Take BD
Long-acting insulin
- Degludec (Tresiba)
- Detemir (Levemir)
- Glargine (Lantus)
- Protamine zinc
- Zinc Insulin
Time:
Taken OD at the same time