Case 5- Diabetes Mellitus Flashcards
Causes of DM
Steroids
Pancreatitis
Pancreatic surgery
Acromegaly
Pregnancy
Metformin
Increased insulin sensitivity
Decreases hepatic gluconeogenesis
GI disturbance (if intolerable, the MR version can be trialled)
Lactic acidosis
Contraindicated in reduced eGFR (below 30)
Stop in MI (due to lactic acidosis)
Pioglitazone (Thiazolidineione)
Activate PPARgamma receptors in adipocytes to promote adipogenesis and fatty acid uptake and reduce peripheral insulin resistance
Weight gain
Fluid retention (contraindicated HF)
Bladder cancer
Liver impairment
Increase fracture risk
NB- rarely Used second line
Sulfonylurea (glicazide/glimperide)
Stimulate pancreatic beta cells to secrete insulin
Weight gain (apetite)
Hypoglycaemia
Hyponatraemia (due to SIADH)
Hepatotoxicity (cholestasis)
Increased risk of CVD when used as a mono therapy
Avoid in breast feeding and pregnancy
Overdose- hyperinsulinaemia and increased C peptide levels
DPP4 Inhibitor (sitagliptin)
Increases incretins (inhibits breakdown) which inhibit glucagon secretion
GI disturbance
Pancreatitis
GLP 1 Mimetics (liraglutide/ exenatide)
Incretin mimetic which inhibits glucagon secretion
GI disturbance
Weight loss
Pancreatitis
SGLT 2 Inhibitors (empaglifozin)
Inhibits glucose resorption in kidney (proximal convoluted tubule SGLT2 transporter), increases urinary glucose
Glucose excreted in urine- UTI
Reduced risk of CVD
Weight loss
DKA
Necrotising fasciitis if the genitalia or perineum eg. Fourniers gangrene
Increased risk of lower limb amputation
Meglitinides SE
Hypoglycaemia
Weight gain
DM blood glucose ranges
Random >11.1
OGTT >11.1
Fasting >7
HbA1c >48
NB- OGTT: don’t eat for 8-12 hours prior
HbA1C Targets
48 if on one medication
53 if one 2 or more/ hypo risk drug monotherapy/ elderly at risk of fall
If above 58- step up management
If above 80- need insulin
Symptoms of hypoglycaemia
Autonomic- tremor, pallor, anxiety, tachycardia, palpitations, hunger, nausea and vomiting
Neuroglycopenic- agitation, confusion, behavioural changes, seizures, somnolence
Hyperglycaemia symptoms
Polyuria, polydipsia, n & v, volume depletion signs, altered mental status, lethargy, coma, blurred vision, weakness
Diabetes Mellitus type 1 Sx
Typical hyperglycaemia Sx eg. Polyuria
Diabetes type 2 investigations and management
Finger prick BM
Urine- ketones and glucosuria
Bloods- HBA1c, OGTT, plasma ketones, fasting blood glucose, UE (diabetic nephropathy)
Tests for complications- fundoscopy and diabetic foot exam
DKA and HHS Investigations
Urinalysis- ketones
Bloods- FBC, ketones, UE (K will be normal but it is extra cellular so need to replace to make it intra cellular), ABG (metabolic acidosis, resp compensation), blood cultures, BM
ECG and CXR
Needs acidaemia, ketonaemia, hyperglycaemia
Replace potassium!
C peptide levels
Indicate amount of endogenous insulin being produced- very low levels indicative of type 1
NB- GAD autoantibodies serve as a marker for autoimmune diabetes in adults
HHS vs DKA
No ketones or acidaemia in HHS, and history is usually longer (glucose often more than 35 in DKA)
Diabetic foot exam
Compare one foot to another (inspection and all other steps)
Statins
QRISK greater than 10% (and no known heart disease) for type 2 diabetics or T1DM or CKD if eGFR less than 60, offer 20mg OD atorvastatin
Diabetes type 2 management
Lifestyle modifications- diet, exercise, weight loss, smoking cessation, statin and ACE-I (ARB if Afro Caribbean)
Monitoring for complications
Drug therapy- as per the 2 diagrams on passmedicine
Normal blood glucose ranges
Random <7.8
OGTT <7.8
Fasting 4-6.0
HBA1c <42
Hall marks of DKA
Acidaemia
Ketonaemia
Hyperglycaemia
Hallmarks of HHS
Hyperglycaemia
Hyper osmolarity
Volume depletion
NO KETOSIS
Diagnose DKA
pH <7.3 (or bicarbonate <15)
Ketones >3 or more than 2+ on dipstick
BM >11 or known diabetic
Diagnose HHS
Glucose >11
Osmolarity >320
Absence of significant ketosis
Management of HHS
IV fluids
IV Insulin (sometimes not even needed)
Stop metformin for 2 days
Prophylactic LMWH
NB- continue long acting insulin but stop other forms
Management of DKA
IV fluids (0.9% saline/isotonic)
IV insulin (0.1unit/kg/hour)- 5% dextrose when glucose starts dropping below 15
Potassium replacement (after first saline bag)- if potassium is within 3.5-5.5
Treat cause
NB- continue long acting insulin but stop other forms
Impaired glucose tolerance (pre diabetes) ranges
Random 7.8-11.1
OGTT 7.8-11.1
Fasting 6.1-7.0
HBA1c 42-47
Investigations for type 1 DM
Finger prick BM
Urine- ketones and glucosuria
Bloods- OGTT, plasma ketones, fasting blood glucose, UE (diabetic nephropathy), c peptide (low), diabetes specific autoantibodies
Tests for complications- fundosdopy and diabetic foot exam
NB- HbA1c isn’t helpful in T1DM
Diagnosing between T1DM and T2DM
See gallery
For those in whom there is a doubt, C-peptide levels (low in T1DM) and diabetes-specific autoantibodies are the investigations of choice (positive in T1DM)
Diagnosing type 1 diabetes
Fasting greater than 7 or Radom glucose/ OGTT greater than 11.1
If patient is asymptomatic, above criteria must be demonstrated on 2 separate occasions
Diagnosing type 2 diabetes
Fasting greater than 7, Radom glucose/ OGTT greater than 11.1, HBA1c measurement of 48 or greater
If patient is asymptomatic, above criteria must be demonstrated on 2 separate occasions (even HBA1c)
What is type 1 DM
Autoimmune disorder where insulin producing beta cells of islet of langerhans in pancreas are destroyed by immune system
What is type 2 DM
Relative deficiency of insulin due to an excess of adipose tissue
Maturity onset diabetes of the young (MODY)
A group of inherited genetic disorders affecting the production of insulin
Young patients with symptoms similar to T2DM eg. Asymptomatic hyperglycaemia
Autosomal dominant condition
Latent autoimmune diabetes of adults (LADA)
A small group of patients who develop autoimmune diabetes later in life (check c peptide and diabetes as often misdiagnosed as T2DM)
Side effects of insulin therapy
Hypoglycaemia (tell patients about symptoms, 10-20g of short acting carb, glucagon kit at home)
Weight gain
Lipodystrophy (rotate injection site, causes erratic insulin absorption)
Management of T1DM
Monitor HBA1c every 3-6 months
Self monitor blood glucose 4 times a day (before each meal and before bed- more if unwell, during and after sport, should be 5-7 on waking and 4-7 at other times of day)
Insulin
Hypertension and type 2 diabetes
Blood pressure targets are the same as those without diabetes
ACE-I is preferred except in Afro-Caribbean patients where ARB is first line
Ramadan and diabetes
Eat a long acting carbohydrate meal prior to sunrise
Patients should have access to BM monitoring
Some changes with metformin and glicazide (sulfonylureas)
Diabetes Mellitus sick day rules
Increase frequency of blood glucose monitoring (should be able to access urinary ketone monitoring too)
Increase fluid intake (3 litres in 24 hours)
Drink sugary drinks if can’t eat
Continue taking oral hypoglycaemics (don’t take metformin in dehydration)
Don’t stop insulin
NB- low threshold of admitting these patients eg. Persistent vomiting, no one at home in case they are unconscious, persistently high BM’s
Features of DKA
Abdominal pain
Polyuria, polydipsia, dehydration
Deep hyperventilation (Kussmaul breathing)
Acetone breath (pear drops)
Resolution of DKA
Ketonaemia and acidosis should resolve within 24 hours
If labs suggest it has resolved and patient is eating and drinking normally, revert to insulin regime
Complications of DKA
VTE
Arrhythmia
Gastric stasis
ARDS
AKI
Cerebral oedema (children)- headache, irritability, visual disturbance, focal neurology (usually 4-12 hours post treatment)
Management of diabetic neuropathy
Optimise glycaemic control
Amitriptyline, duloxetine, gabapentin, or pregabalin (if one doesn’t work, try another one)
Tramadol for exacerbations
Topical capsaicin
Pain management clinics if persistent
Gastrointestinal autonomic neuropathy
Gastroporesis- Erratic blood glucose control, bloating, vomiting
Chronic diarrhoea
GORD
DVLA and diabetes
Diet controlled- no need to inform
If on tablets- no need to inform
If on sulfonylurea (glicazide) or hypo causing tablet, mustn’t have had more than 1 episode of hypoglycaemia requiring the assistance of another on the preceding 12 months
If on insulin- tell DVLA, need hypoglycaemic awareness, no visual impairment, mustn’t have had more than 1 episode of hypoglycaemia requiring the assistance of another on the preceding 12 months
Drivers on insulin can have type 2 (HGV) license but need to follow standards above and do regular glucose monitoring (machine with a memory function), no complications of disease, there has not been any severe hypoglycaemic event in the previous 12 months
Causes of a reduced HBA1c (reduced RBC life span)
Sickle cell anaemia
GP6D deficiency
Hereditary spherocytosis
NB- haemolysis/increased turnover
Causes of an increased HBA1c
Iron deficiency anaemia
Vitamin B12 or folate deficiency
Splenectomy
NB- reduced turnover ie. less Fe/B12 to create new cells
Insulinoma
Tumour derived from pancreatic islets of langerhans cells (endocrine tumour)
Weight gain, high insulin, hypoglycaemia, high c peptide
Symptoms and signs of hypoglycemia
Plasma glucose < 2.5 mmol/L
Reversibility of symptoms on the administration of glucose
Diagnose- prolonged fasting (72 hours), CT pancreas
Management- surgery or diazoxide/somatostatin
NB- C-peptide production does NOT fall on exogenous insulin injection in patients with an insulinoma (it does with self-administration of insulin)
Kallman’s syndrome
Delayed puberty secondary to hypogonadotropic hypogonadism (x Linked recessive)
Usually anosmia in a boy with delayed puberty
Other features- cryptorchidism, hypogonadism, low sex hormone levels, LH and FSH levels are low/normal, normal or above average height
May also have cleft lip/palate and visual/hearing defects
Management of hypoglycaemia
Unconscious- 150ml 10% glucose IV or glucagon 1mg IM
Conscious can’t swallow- 2 tubes glucose gel around teeth
Conscious can swallow- 15-30g fast acting carbs eg. 5-7 glucose tabs or 150ml fruit juice, and long acting carbs eg, biscuit, toast
Estimate serum osmolarity
2 x Na+ + glucose + urea
In newly diagnosed adults with type 1 diabetes, what is the first-line insulin regime
basal–bolus using twice‑daily insulin detemir
Causes of hypoglycaemia
Diabetics;
Insulin or sulfonylurea treatment with an increase in activity or a missed meal or non-accidental overdose.
Non-diabetics (EXPLAIN);
Exogenous drugs such alcohol, aspirin poisoning, pentamidine, quinine sulfate, ACE-inhibitor
Pituitary insufficiency
Liver failure
Addison’s disease
Islet cell tumours eg insulinoma
Non-pancreatic neoplasms
Causes of hypoglycaemia
Diabetics;
Insulin or sulfonylurea treatment with an increase in activity or a missed meal or non-accidental overdose.
Non-diabetics (EXPLAIN);
Exogenous drugs such alcohol, aspirin poisoning, pentamidine, quinine sulfate, ACE-inhibitor
Pituitary insufficiency
Liver failure
Addison’s disease
Islet cell tumours eg insulinoma
Non-pancreatic neoplasms
Impaired fasting glucose and impaired glucose tolerance
NB- 2 different things
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)
Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
Thiazides and glucose tolerance
Thiazides worsen glucose tolerance (and predispose to digoxin toxicity)
Diabetic medications and elective surgery
Omit agents that can precipitate hypoglycaemia ie. glicazide (but continue others ie. metformin)
Diabetic medications and elective surgery
Omit agents that can precipitate hypoglycaemia ie. glicazide (but continue others ie. metformin)
Conditions where HBA1c cannot be used for diagnosing diabetes
haemoglobinopathies
haemolytic anaemia
untreated iron deficiency anaemia
suspected gestational diabetes
children
HIV
chronic kidney disease
people taking medication that may cause hyperglycaemia (for example corticosteroids)
T1DM and BMI 25+
NICE recommend considering adding metformin if the BMI >= 25 kg/m²
Metformin and surgery
OD or BD: take as normal
TDS: miss lunchtime dose
assumes only one meal will be missed during surgery, eGFR > 60 and no contrast during procedure
Adding and sglt2 inhibitor
add even if diabetes is well controlled ie. hba1c is <48
