Diabetes Flashcards
Diagnostic Features of Diabetes
Type 1
Type 2
Type 2 Risk Factors x6
HbA1c
Finger Prick Test
1.) Type 1 - random plasma BG >11mM w/ one of sx :
- ketosis, rapid weight loss, <50, BMI <25, FH of autoimmune disease
- refer to diabetes specialist team for confirmation (if unsure, antibody profile: anti-GAD, anti-insulin)
- C-peptide is low in T1 (helps differentiate from T2)
2.) Type 2 -
- symptomatic (polyuria, polydipsia, weight loss, fatigue/lethargy): require a fasting BG >7mM OR random BG >11.1mM OR HbA1c >48mM (6.5%)
- asymptomatic: the above criteria apply but must be demonstrated on 2 separate occasions
3.) Type 2 Risk Factors - obesity (80-85% risk)
- FH, ethnicity, diet, low birth weight
- drugs: thiazides, glucocorticoids, beta blocker
4.) HbA1c (mm/%) - measures glycation of Hb over last 3 months, may be inaccurate due to altered RBC lifespan due to:
- ↓lifespan: haemoglobinopathies (inc sickle-cell), GP6D deficiency, hereditary spherocytosis, haemodialysis
- ↑lifespan: iron deficiency anaemia, chronic alcoholism, vitB12/folate deficiency, splenectomy
- fructosamine can be used as an alternative to HbA1c
5.) Finger Prick Test - measures plasma BG
- can be done instantly but not completely diagnostic
- fasting >7mM, random >11mM suggests diabetes
Insulin Therapy
Site of Administration
Long Acting Insulin
Rapid Acting Insulin
Intermediate Acting Insulin
Contraindications/Side Effects x3
Cautions x2
1.) Site of Administration - SC injections in the:
- upper arms, thighs, buttocks, and abdomen
- must rotate site to prevent lipodystrophy
- IV for emergency treatment
2.) Long-Acting (Basal) Insulin - dose is taken once a day at the same time every day
- insulin glargine (Lantus/Toujeo), insulin detemir (levemir)
- target BG upon waking is 5-7mM
3.) Rapid-Acting (Bolus) Insulin - dose is taken 15-30 mins before meals, can be used PRN
- insulin aspart (Novorapid)
- 1unit of Novorapid decreases BG by 3-4mM
- target BG before meals is 4-7mM
4.) Intermediate-Acting Insulin - 2 doses a day
- isophane insulin (Humulin I)
- cheaper, lasts about 12 hours
5.) Mixed-Acting Insulin - dose is taken x2 a day
- contains mixture of long and rapid acting insulin e.g Humalog Mix
- dose has to be adjusted to diet so patient should maintain a stable diet all the time
5.) Contraindications/Side Effects
- hypoglycaemia, renal impairment (risk of hypos)
- lipodystrophy (lipohypertrophy or lipodystrophy)
6.) Cautions
- ↑dose with steroids, other hypoglycaemic agents
- beware of gastroparesis which can lead to erratic BG control, bloating, and vomiting
- there are 100 units in 1mL of insulin, must never use a normal syringe
NICE guidelines for the management of type 2 diabetes w/ metformin
Standard Treatment
First Intensification
Second Intensification
Additional Information
1.) Standard Treatment - if HbA1c >48mM (6.5%)
- lifestyle modification for 3 months, if ineffective:
- PO metformin 500mg OD -> BD -> TDS (modified-release if standard not tolerated)
- target: <48mM
2.) First Intensification - HbA1c >58mM (7.5%)
- metformin + DPP-4i/pioglitazone/SU/SGLT-2i
- target: 53mM (7.0%)
3.) Second Intensification - HbA1c still >58mM, options:
- metformin + SU + DPP-4i/pioglitazone/SGLT-2i
- metformin + SGLT-2i + pioglitazone
- metformin + SU + GLP-1 agonist (last resort, if BMI >35)
- if triple therapy doesn’t work, consider insulin treatment
4.) Additional Information
- metformin is contraindicated in eGFR <30: SU/DPP-4i/pioglitazone becomes first line unless the patient has established/high risk of CVD
- SGLT-2i are preferred in any patient w/ established/high risk of CVD
- avoid gliclazide if patients at increased risk of hypos
Lifestyle Advice for Type 2 Diabetes
Diet
Exercise
Alcohol
Diabetes Structured Education Programmes
1.) Diet - low-glycaemic-index sources of carbohydrates:
- fruit, vegetables, wholegrain, and pulses
- fibre, low-fat dairy products, and oily fish
- reduce saturated and trans fatty acids
- can refer to dietician if obese
2.) Exercise - can lower blood glucose levels
- active daily, reduce time being sedentary
- 150 mins of moderate intensity OR 75mins of vigorous intensity across the week
- risk of hypoglycaemia when insulin levels are low
3.) Alcohol
- less than 14 units a week spread across 3 days
- avoid drinking on an empty stomach
- can prolong hypoglycaemic effect of antidiabetics
4.) Diabetes Structured Education Programmes
- DESMOND: Diabetes Education for Self-Management for Ongoing and Newly Diagnosed (for type 2)
- DAFNE: dose adjustment for normal eating, for type 1 diabetics, teaches patients amount of rapid acting insulin they need to take depending on amount of carbs they are about to eat
Hypoglycaemic Episodes (‘Hypos’)
Causes
Clinical Features
Immediate Management
Implications on Driving Licence
1.) Causes
- insulin: incorrect injection techniques +/- the timing
- other drugs: e.g. gliclazide, ß-blockers, haloperidol
- CKD, Addison’s disease, hypothyroidism
- ↓↓food intake, vigorous exercise, drinking alcohol
- impaired awareness of hypo episodes: due to increased frequency of hypos, beta-blockers (inhibits SNS which reduces warning signs e.g. tremors)
2.) Clinical Features - BG < 4mM
- mild: hunger, anxiety, irritability, palpitations
- moderate: confusion, lethargy, impaired vision,
- severe: seizures, ↓consciousness, coma
3.) Immediate Management
- fast-acting carbs (15-20g) or 200ml of orange juice - up to x3 every 15 mins e.g. dissolved sugar, glucogel, pure fruit juice,
- IM glucagon 1mg
- severe hypoglycaemia: 100ml of 20% Dextrose over 15 minutes
- long-acting carbs after BG >4mM to prevent relapse
4.) Implications on Driving Licence
- must inform DVLA of episodes of hypos
- test >5mM before driving, test again after 2hrs, must wait >45mins after treating hypos
- cannot drive for 6 months of severe hypos, must stop driving immediately and inform the DVLA if you’ve had two hypos requiring help within the last 12 months
Management of Hyperglycaemia
Patient Clinically Unwell
Patient Clinically Well
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Diabetic Ketoacidosis (DKA)
Clinical Triad
Clinical Features
Precipitating Factors
Management
1.) Clinical Triad - ketosis, acidosis,hyperglycaemia
- ketosis due to body using fat instead of glucose for energy due to increase in glucagon(or less insulin) and stress hormones
- ketonaemia (>3mM) or ketonuria
- can be euglycaemic (SGLT2 side effect)
- presents in type 1 diabetics, very rare in type 2
2.) Clinical Features
- polyuria, polydipsia, can’t tolerate fluids, weight loss,
- persistent vomiting or diarrhoea, abdominal pain, succussion splash on auscultation of the abdomen
- visual disturbance, lethargy, confusion
- fruity acetone smell on the breath, acidotic breathing
- dehydration, shock signs (from severe dehydration)
3.) Precipitating Factors - must assess for
- poor insulin adherence, stress (e.g. trauma)
- infection: CXR, blood cultures, MSU for microscopy and culture
- other conditions e.g. hypothyroidism, pancreatitis
- ADR e.g. corticosteroids, diuretics, sympathomimetics e.g salbutamol
4.) Management - if suspected, admit to A/E for:
- IV fluids: severe dehydration due to osmotic hyperglycaemia (1L bolus, 1L over 1hr, then 1L over 2-4hrs, then 1L over 4-6hrs)
- IV insulin: VRIII (SC Novorapid in meantime) until ketones <0.3mM
- IV Dextrose (10%): prevent hypoglycaemia (keep BG at 10-15mM), started at a rate of 125ml/hr once the BG falls below 14mM
- potassium: prevent hypokalaemia (insulin drives K+ into cells)
- correct hypomagnesaemia (complication of DKA)
- regular BG, ketones, pH monitoring , takes roughly 4/5hrs to improve
- patient can go back on SC insulin when DKA is biochemically resolved (ketonaemia <0.6, pH >7.3, bicarb >15)
- review by a senior endocrinologist if DKA hasn’t resolved in 24 hours
Hyperosmolar Hyperglycaemic State (HHS)
Diagnosis
Clinical Features
Immediate Management
Complications
1.) Diagnostic Features
- CBG > 30mM, serum osmolality >320 mM
- 2xNa + urea + BG to work out osmolality
- no evidence of ketosis
2.) Clinical Features - insidious onset (few days)
- disorientation, confusion+/- drowsiness
- severe dehydration, polyuria, polydipsia, nausea
- hypernatraemia and hyperuraemic
- same precipitating factors as DKA: carry out investigations looking for cause
3.) Immediate Management
- IV fluids: severe dehydration, slowly correct osmolality over a few days, can use hypertonic saline
- IV insulin: until glucose comes back down to range
- IV potassium
- prophylactic LMWH
4.) Complications
- ↑blood clotting: stroke, PE, DVT, DIC, mesenteric artery occlusion
- rhabdomyolysis, LOC, coma
Peri-Op Management of Diabetes
Susceptible Diabetics
Basal Insulin
Variable Rate IV Insulin Infusion (VRIII)
Dextrose and Potassium
Stopping the VRIII
1.) Susceptible Diabetics
- type 1 diabetics: should be 1st on morning list
- diet controlled diabetes dont need any interventions
2.) Basal Insulin - 80% of usual dose
- should be done the day before the surgery and continued throughout the intra-operative period
3.) VRIII (‘sliding scale’) - insulin infusion at infusion rate determined by bedside CBG measurement
- for patients with poorly controlled diabetes or will have long starvation period (>1 missed meals)
- target range is 6-10mM (6-12 acceptable)
- BG should be measured hourly for first 12 hours
4.) Dextrose and Potassium - given alongside VRIII
- IV infusion of 5% dextrose along with potassium
- K+ needed to prevent hypokalemia (insulin)
- dextrose need to also prevent hypos
5.) Stopping the VRIII - needs overlapping to prevent DKA since halflife of IV insulin is only 5 mins
- VRIII is continued until the patient can eat and drink
- give SC rapid acting insulin 20 mins before a meal and stop the VRIII 30-60mins after they have eaten
Complications of Diabetes
Macrovascular
Neuropathy
Retinooathy
Nephropathy
Screening
1.) Macrovascular - hyperglycaemia and insulin resistance ultimately leads to atherosclerosis causing:
- CVD (e.g. MI), cerebrovascular disease (stroke, TIA)
- peripheral arterial disease (intermittent claudication)
- assess for cardiovascular risk factors every year
2.) Neuropathy - damaged nerves
- ↓sensation and pain can lead to a silent MI
- autonomic neuropathy can cause sweating, postural hypotension, gastroparesis, diarrhoea, ED
- gastroparesis: stomach doesn’t empty normally –> bloating, vomiting, early satiety, tx w/ pro-kinetics
- neuropathic foot ulcers, foot checks every year
- infected ulcers treated w/ oral flucloxacillin (S.aureus) or IV Tazocin (P.aeruginosa) or clindamycin (abnormal pathogen)
3.) Retinopathy - damaged retina
- eye tests required every year
4.) Nephropathy - damaged kidneys
- diabetic nephropathy is different to AKI or CKD
- ACR and eGFR checked every year
- ACR threshold is 2.5 in men and 3.5 in women
- if raised ACR, give ACEi to protect the kidneys
5.) Screening
- each review: measure BMI, assess for depression and anxiety, smoking cessation, assess neuropathic sx
- every 6 months: measure HbA1c levels
