Before exam Flashcards
What are the normal ranges for Haemoglobin A1c( HbA1c)
Normal range <42 mmol/mol
Good control varies from individual to individual (depending on age, co-morbidities etc.)
Generally HbA1c < 53 mmol/mol indicates well controlled diabetes
if HbA1c is greater than 48 mol/mol for two times then you have diabetes
For an individual who has no diabetes symptoms how many tests do you have to do
two diagnostic tests are required (eg 2x FPG, or HbA1c, but only one abnormal OGTT is required)
list the numbers needed for diagnosis of diabetes for each test
- Fasting plasma glucose
- 2 hour plasma glucose
- random plasma glucose
- HbA1c
- Fasting plasma glucose = greater than 7 mmol/L
- 2 hour plasma glucose = greater than 11.1mmol/L
- random plasma glucose = greater than 11.1mmol/L
- HbA1c = greater than 48mmol/mol(6.5%)
what do you use to measure impaired glucose tolerance and what does it mean
can only be diagnosed using an oral glucose tolerance test
- so the 2 hour plasma glucose
- this is between 7.8-11 mol/L - the is not a diagnosis of diabetes but it is abnormal
What is used to measure impaired fasting glucose and what does it mean
- Slightly higher than normal which is less than 6 but it is not quite in the diabetes range yet
- measured by using fasting plasma glucose
- between 6.1-6.9 mol/L
what autoimmune antibodies are present in type 1 diabetes
GAD and ICA antibodies
what drug causes NODAT
Tacrolimus (used in transplantation – may cause “New Onset Diabetes after Transplantation” [NODAT])
At what glucose level do the two symptoms for hypoglayemia occur at
- autonomic symptoms - 3.6 mmol/L
- neuroglycopenic symptoms - 2.7 mmol/L
Name neuroglycopenic symptoms of hypoglycaemia
- Confusion
- soured speech
- visual disturbances
- drowsiness
- aggression
Name the autonomic symptoms of hypoglycaemia
- Sweating
- Shaking or tremor
- anxiety
- palpitations
- hunger
- nausea
How do you treat mild hypoglycaemia
Mild - conscious, lucid and able to self treat
Sugary drink, e.g. lucozade, ordinary coke, orange juice
5-7 glucose tablets, or 3-4 heaped teaspoons of sugar in water
How do you treat moderate hypoglycaemia
Moderate - conscious, but cannot self administer and needs help
Glucogel® – 1-2 tubes buccally (into the cheek), or jam, honey, treacle massaged into the cheek.
Intramuscular glucagon
How do you treat severe hypoglycaemia
Severe - unconscious
- Do not put anything in the mouth
- Place the person in the recovery position
- Administer 0.5-1mg glucagon IM
- If carer is unable to administer glucagon, call 999
What happens in hospital when you present with severe hypoglycaemia
Ideally 75mls of 20% glucose or 150mls 10% glucose over 15 mins
50mls 50% glucose can be given, but take care with veins – extravasation can cause chemical burns
What should you take after the hypoglycaemic episode
Post hypo once glucose above 4.0 mmol/L, must have some longer acting carbs, eg:
Two biscuits
One slice of bread/toast
200-300ml glass of milk (not soya)
Normal meal if it is due (but must contain carbohydrate)
What is the definition of diabetic ketoacidosis
A state of absolute or relative insulin deficiency resulting in hyperglycemia and an accumulation of ketoacids in the blood with subsequent metabolic acidosis
What are the clinical features of DKA
Often a short history
Abdominal pain and vomiting is common – can present as an acute
abdomen - can be very severe
Kussmaul’s respiration – deep sighing respirations due to acidosis
Ketones on breath (remember ~40% people cannot smell these)
Drowsiness, confusion
Dehydration and Tachycardia
- polyuria and polydipsia
- vomiting
What fluid therapy should you give in DKA
Sodium chloride 0.9%
- 1 Litre stat
- 1 Litre in 1 hour
- 1 Litre over 2 hours (+20 mmol potassium chloride)
- 1 Litre over 4 hours (+potassium chloride)
- 1 Litre over 4 hours (+potassium chloride)
5% or 10% Glucose
- Start when the CBG is <12 mmol/L and continue at 125ml/hr
- 10 % glucose may be necessary to increase insulin infusion
- Increase infusion rate if glucose falls below 6.0 mmol/L
- given glucose so you can given insulin - insulin has a short half life so when it switches of you can become ketoacidotic again
describe the potassium regime you give in DKA
- For the first 1-2 bags fluid, give no potassium as fluid is given too rapidly
- For every subsequent bag of NaCl 0.9% or glucose 5% use a bag of fluid containing KCl as follows according to serum K+:
- less than 3.5 - may need additional potassium and delay insulin - cause potassium to plummet further and can cause arrthymia
- 3.5-5.5 - 20-40mmol/L
- greater than 5.5 - none
describe the insulin regime in DKA
- If the patient is known to be diabetic continue their normal long acting insulin on admission
- commence insulin infusion by intravenous syringe pump - contains 50 units of actrapid made up to 50mlin sodium chloride 0.9%
fixed rate IV insulin infusion
- 0.1u/kg - around 6-8 u/hour for most patients
- aiming for bicarbonate rise of 3mmol/hour and glucose fall by 3 mol/hour
- if not achieved increase the rate by 1u/hour
Describe the presentation of hyperosmolar hyperglycaemic syndrome
Hyperglycaemia often >40 mmol/L
Osmolality >340 (275-295)
Can be estimated by the formula 2x[Na+K]+Ur+Glu
Patient is often hypernatraemic
They may or may not have ketonuria – frequently “+” if not eating
No (keto) acidosis, but may have lactic acidosis
Severe dehydration
66% previously undiagnosed DM
What is the treatment of hyperosmolar hyperglycaemic syndrome
IVI as for DKA – but consider slower fluids if elderly / heart failure
NO INSULIN BOLUS - for first 12 hours
Much lower dose insulin – maybe no insulin for 1st 12 hours, then very low doses – perhaps 1 u/hr
Rapid shifts in glucose should be avoided due to risk of rapid fluid / sodium shifts, and risk of central pontine myelinolysis (CPM)
Correct BG at maximum 2 mmol/L/hr
Central venous pressure monitoring may be required
s/c Low Molecular Weight heparin may help reduce thrombosis
K+ tends to decline rapidly
Avoid 0.45% N Saline
Accept that biochemistry will be abnormal for days or risk hypernatraemia, CPM, cerebral oedema
What is the management of hyperosomolar hyperglycaemic state
Rehydrate slowly (consider age and CCF) over 48hrs with 0.9% NaCl (IVI)
- Typical deficit = 110-220ml/kg (~8-15L)
- Avoid 0.45% NaCl
No insulin bolus – Only use insulin if blood glucose is not falling by 5mmol/L/hr with rehydration or ketonuria; Slow infusion of 0.05units/kg/hr (max 1unit/hr); Avoid in first 12hrs
- Rapid shifts in glucose should be avoided due to risk of rapid fluid/Na+ shits and central pontine myelinosis (CPM)
Replace K+ when urine starts to flow
- May need CVP monitoring
- K+ ↓ rapidly
- Keep plasma glucose at 10-15mmol/L for first 24hrs to avoid cerebral oedema
- Look for cause, eg bowel infarct, drugs, etc.
Describe the NICE guidelines for glucose lowering
- Lifestyle changes
- ↓ HbA1c ≥48mmol/L
2. Metformin standard release – modified release if not tolerated - Slow titration, take after meals
- Care with dose of metformin if eGFR<45, stop if <30
- Consider sulfonylurea if not overweight, metformin CI or not tolerated↓ HbA1c ≥58mmol/L
3. Dual therapy (aim = 53mmol/L) - Metformin + Sulfonylurea (if hypoglycaemia a problem or metformin not tolerated:
DPP-4 inhibitor/Pioglitazone) - Once daily if concordance is problematic
Consider PGRs if erratic lifestyle↓ HbA1c ≥58mmol/L
- Triple therapy
- Metformin + SU + DPP-4 inhibitor/Pioglitazone/Insulin
- Consider GLP-1 analogue if: BMI>35, problems from weight gain
- Continue >6 months if HbA1c drop >1% and weight loss >5% - Intensify insulin or add Pioglitazone
- Warn re oedema