5. Diabetes Presentation and Management Flashcards
What are the main presenting complaints in someone with T2 DM
(hint glucose is an osmotic diuretic)
fatigue Polydipsia and polyuria (thirsty and urinating a lot) unintentional weight loss opportunistic infections slow healing glucose in urine
for pre-diabetes what does impaired fasting glucose mean
their body struggles to get their blood glucose levels in to normal range, even after a prolonged period without eating carbs
for pre-diabetes what does impaired glucose tolerance mean
their body struggles to cope with processing a carb meal
diabetes can be diagnosed if a patient fits what criteria for;
HbA1c
random glucose
fasting glucose
OGTT2 hour result (fast and then have 75g glucose drink)
HbA1c: greater than 48 mmol/mol
random glucose greater than 11 mmol/l
fasting glucose greater than 7 mmol/l
OGTT 2 hour result greater than 11 mmol/l
in men what is a common opportunistic infection of the penis
Candida balantis
although rare, what its diabetes insipidus and what are the common PC
disorder of the posterior pituitary gland which causes inadequate ADH secretion therefore imbalance of fluids (ADH causes more aqua porin channels init the DCT
symptoms are, polyuria, dilute urine and polydipsia
A differential for DM could be hypercalcaaemia, what are the common symptoms of this
loss of appetite nausea and vomitting constipation and abdo pain tiredness/ weakness and muscle pain !!!!! confusion/headaches
weight loss even though you are eating more
is this a common T1 or T2 DM presentation
T1
tingling, pain, or numbness in the hands/feet
is this a common T1 or T2 DM presentation
T2
what is the main hyperglycaemic emergency in type ! DM and then type 2DM
T1 is diabetic ketoacidosis DKA
T2 is hyperosmolar hyperglycaemic state
What are the main treatment goals in management of diabetes
minimise treatment side effects (hypoglycaemia and weight gain)
as near normal glucose as possible (to minimise complications)
cardiovascular risk management (optimise risk factors)
In management of diet what things would you advise
eat vegetables and only fish
low glycemic, high fibre diet
low carb diet (not mainstream yet)
What risk factors do you want to optimise and how would you advise this
exercise and weight loss
stop smoking
optimise treatment for other illnesses, eg hypertension, hyperlipidaemia and CVD
what lifestyle changes cause the following;
improving islet function
reduces insulin resistance
improves insulin sensitivity
reduced calories improving islet function
weight loss reduces insulin resistance
Exercise improves insulin sensitivity with or without weight loss
What is the first line treatment for T2 diabetes after lifestyle management and how does it work
metformin 500mg once daily
“biguanide” which increases insulin sensitivity and decreased liver production of glucose
what are the main side effects of metformin
diarrhoea and abdo pain (lowering dose resolves symptoms)
Lactic acidosis
note that it does NOT typically cause hypoglycaemia
What is the second line treatment for T2 DM
lifestyle changes +metformin + one of the following;
Sulfonylureas, pioglitazone, DPP-4 inhibitor, SGLT-2 inhibitor
based on individual factors and drug tolerance
what is the third line treatment for T2 DM
triple therapy with metformin and two of the second line drugs combined or
metformin plus insulin
SIGN guidelines suggest the use of which second line drugs in particular for pt with CVD
SGLT-2 inhibitors and GLP-1 inhibitors
How does pioglitazone work
it is a thiazolidinedione which increases insulin sensitivity and decreases liver production of glucose
How does Sulfonylureas work
it is a gliclazide. Stimulates insulin release from the pancreas
How do incretins work
incretins are hormones produces by the GI tract in response to meals and act to reduce blood sugar by
- increasing insulin secretions
- inhibiting glucagon production
- slow absorption by the GI tract
the main incretin is GLP-1 and they are inhibited by an enzyme called DPP4
how do DPP4 inhibitors work such as sitagliptin
inhibits the DPP-4 enzyme and therefore increases GLP-1 activity
how do SGLT-2 inhibitor work (have the suffix -glifloziini)
SGLT-2 protein responsible for reabsorbing glucose from the urine ini to the blood in PCT
SGLT-2 inhibitors block the action of this protein and cause glucose to be excreted in the urine
which kind of T2DM treatments have side effect of weight gain
Sulphonylurea
Thiazolidinediones
insulin
which kind of T2DM treatments have side effect of hypoglycaemia
any that increase beta cell activity
insulin
which kind of T2DM treatments have side effect of GI symptoms
Incretins (GLP-1)
sometimes metformin
which kind of T2DM treatments have side effect of weight loss
metformin
incretins/ GLP-1 agonist
SGLT-2 inhibitors
which T2 DM drug can cause osteoporosis and which can causes UTIs
osteoporosis is pioglitazone
UTI is SGLT-2 inhibitors
what should be the ideal treatment target of HbA1c levels
48 mmol/mol for new T2 diabetics
53 mmol/mol for diabetics that have moved beyond metformin alone
Describe rapid acting insulins and give some examples
start to work after 10 mins and last around 4 hours
novorapid, Humalog, apidra
describe short-acting insulins and give some examples
start to work in around 30 mins and last around 8 hours
act rapid, humbling S and inhuman rapid
describe intermediate acting insulins and give some examples
start to work in around 1 hour and last around 16 hours
insulatard, humulin I, insuman basal
describe long actin insulins and give some examples
start to work in an hour and last around 24 hours
Lantus, Levemir, Degludec (lasts over 40 hours)
describe combinations insulins
contain a rapid acting and intermediate acting insulin Humalog 25 (25:75) Humalog 50 (50:50) novomix 30 (30:70)
why is venous gases acceptable as routine use
less painful for patient
similar Ph and bicarb to arterial values
gives potassium and glucose levels too
in what instances would an arterial blood gas be favoured over a venous one
if you are concerned about the patients respiration (or ventilation) as O2 and CO2 in venous samples are not useful clinically to guide treatment
What would be a classic presentation to A&E which would suggest type 1 diabetic
high blood glucose ketones young age ethnicity (white) low weight
what is the name of the structured education programme for type 1 diabetics that should be started 6-12 months after initial diagnosis
DAFNE - diabetes adjustment for normal eating
What is the DVLA guidance regarding type 1 diabetics
they must take their blood sugars before driving
before falling pregnant what is advised in pt with diabetes
low HbA1c levels and start taking folate supplements
If anti-GAD are positive what is the diagnosis more likely to be
this would indicate type 1 diabetes
