Case 5 - Diabetes Flashcards by Rosemarie Stringfellow

What are the typical symptoms of hyperglycaemia?

Polyuria
Thirst
Weight loss
Tiredness

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What is the minimum random blood glucose level that is sufficient to make a diagnosis of diabetes mellitus?

> 13mmol/l

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What are the normal levels for HbA1c and what is it to diagnose diabetes?

Normal < 42mmol/mol
Pre diabetes 42-47mmol/mol
Diabetes >48mmol/mol

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What is the minimum glucose level after a fasting glucose test to diagnose diabetes mellitus?

> 7.0mmol/L

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What are the 9 main tests at an annual diabetes check?

Weight 
Blood pressure
Smoking status 
HbA1c - aim for less than 6.5%
Urinary albumin 
Serum creatinine 
Cholesterol
Eye exam
Foot exam

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What level of glucose indicates hypoglycaemia?

<3mmol/L (or 4mmol/L ‘four is the floor)

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What are the common symptoms of hypoglycaemia?

Sweating
Anxiety 
Hunger
Tremor
Palpitations 
Dizziness
Confusion 
Drowsiness
Visual disturbance 
Seizures

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What is the drug therapy guidelines for type II diabetes?

1st line - metformin
2nd line (HbA1c >58mmol/mol) - metformin + 2nd drug 
3rd line (HbA1c >58mmol/mol) - metformin + 2nd drug + 3rd drug

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What is the main side effects of metformin?

Gastrointestinal upset

Lactic acidosis

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How does treatment of diabetes differ in pregnant women?

Women can be treated with metformin alone, or in combination with insulin

Both gliclazide and liraglutide are contraindicated in pregnancy

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How can C-peptide be used to differentiate between type I and type II diabetes?

C-peptide will be low in type I diabetes (as the pancreas is not making enough insulin precursor which breaks down to form insulin and C-peptide)

C-peptide is normal or high in type II diabetes

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How often should a person with type I diabetes monitor their blood glucose each day?

At least 4 times a day, including before each meal and before bed

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What are the type I diabetes daily blood glucose targets?

5-7mmol/l on waking

4-7 mmol/l before meals at other times of the day

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Name the most common sulfonylurea drug

What is the most common side effect?

Glicazide

Hypoglycaemia

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Name the most common TZD (thiazolidinediones) drug used in diabetes?

Pioglitazone

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Name the most common DDP-4 inhibitor used in diabetes?

Sitagliptin

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What are the major side effects of glitazones?

Worsening of heart failure due to fluid retention
Increased risk of fractures
Liver dysfunction
Weight gain

What is the difference between nephrogenic diabetes insipidus and cranial diabetes insipidus?

How do the treatments differ?

Cranial diabetes insipidus is where the pituitary gland is unable to produce sufficient amounts of vasopression (ADH) - Treat with desmopressin

Nephrogenic diabetes is caused by the kidneys inability to respond to vasopressin - treat with thiazide diuretic (chlorothiazide)

What drugs can cause nephrogenic diabetes insipidus?

Demeclocycline (tetracycline antibiotic)

Lithium

What should the target blood pressure be for patients with diabetes with and without end organ damage

With end organ damage: 130/80

No end organ damage: 140/80

What are the major side effects of sulfonylureas?

Hypoglycaemic episodes
Increased appetite and weight gain
Syndrome of inappropriate ADH secretion
Liver dysfunction (cholestatic)

At what threshold of HbA1C should you consider adding a 2nd drug to metformin for type II diabetes?

58mmol/mol

What is the first line treatment for hypertension in patients with diabetes?

Ramipril (regardless of age)

What is the immediate treatment for a patient with diabetic ketoacdosis

Intravenous insulin

Intravenous fluids enriched with potassium

Why do you use VBGs instead of ABGs to monitor acutely unwell patients

Less painful If you don't need to know about O2 and CO2 levels Information about pH and bicarbonate are very similar VBGs provide information about potassium and glucose

What are the 'sick-day rules' for a patient with diabetes mellitus?

Increase frequency of BM monitoring to 4 hourly Aim to drink 3L of fluid in 24 hours If not eating, drink sugary drinks to maintain carbohydrate intake

Which hormones oppose the action of insulin?

Glucagon Cortisol Noradrenaline

How would you differentiate if a patient had type I or type II diabetes?

Age Family History Urine Test - ketones could be raised in type I diabetes Anti GAD antibodies - present in type I diabetes

What is the differential diagnosis for polyuria?

UTI Diabetes mellitus Diabetes insipidus Hypercalcemia

What is balantis?

A fungal infection of the penis Hyperglycaemia is a risk factor

What are the complications of uncontrolled diabetes?

Diabetic retinopathy Diabetic neuropathy Vascular disease - peripheral vascular disease Diabetic nephropathy

What is diabetic ketoacidosis (DKA)?

Where a patient has hyperglycaemia + ketosis + metabolic acidosis Characterised by severe insulin deficiency, and also stresses that act to secrete glucagon, catecholamines and cortisol which act to increase blood glucose

What are the different insulin regimes for type I diabetics?

BD biphasic regimen - twice daily premixed insulins by pen, useful for patients with regular lifestyles QDS regimen - before meals ultra fast insulin + bedtime long acting analogue. Useful for patients for flexible lifestyle (e.g adjust dose for meal sizes or exercise)

What is the DAFNE principles for diabetes?

Dose adjustment for normal eating This is to help diabetics live the most normal life possible. They can adjust their insulin dosages before meals.

What is non diabetic hyperglycaemia?

Where there is a higher level of glucose but not at diabetic levels There is some impaired glucose tolerance Higher risk of progression to T2DM (5-10% progress each year) This increases the risk of macrovascular disease It can occur in pregnancy - gestational diabetes

What are the main risk factors for diabetes?

``` Weight - visceral obesity having a bigger effect Physical activity Diet Smoking Poor blood pressure Black and South Asian more at risk ```

What is hyperosmolar hyperglycaemic state (HHS)?

A complication of type II diabetes where high glucose levels results in high osmolarity without significant ketoacidosis Symptoms include: dehydration, weakness, leg cramps, uriantion, thirst, nausea, dry skin

What are the different insulin types?

``` Quick acting (Subcutaneous injection, IV infusion) Slow acting (subcutaneous injection only) Biphasic - mix of both in a ratio 25/75 or 30/70 ```

How is severe hypoglycaemia treated?

If patient can cooperate - encourage lucozade or equivalent Unable to cooperate but conscious - glucose gel (glucogel) If patient is in coma stage/fitting - IV/IM glucagon

What are the adverse effects of SGLT2 inhibitors?

Genital infections | Diabetic ketoacidosis

Which diabetic drug class are associated with an increase risk of bladder cancer?

Thiazolidinediones | In particular pioglitazone

What are the adverse effects of GLP-1 mimetics?

Nausea Vomiting Pancreatitis