Diabetes Flashcards
Type 1 diagnosis
Random plasma glucose more than 11 mmol/L
+:
- Polyuria.
- Polydipsia.
- Excessive tiredness
- Ketosis
- Weight loss.
- Age of onset younger than 50 years.
- Body mass index (BMI) below 25 kg/m2.
- Personal and/or family history of autoimmune disease.
Mx of type 1 diabetes
Refer the child or young person immediately (on the same day) to a paediatric diabetes care team
DKA
blood glucose level greater than 11 mmol/L) and:
- Polyuria and polydipsia
- Dehydrated
- Weight loss.
- Persistent vomiting and/or diarrhoea.
- Abdominal pain.
- Visual disturbance.
- Lethargy and/or confusion.
- Fruity smell of acetone on the breath.
- Acidotic breathing — deep sighing (Kussmaul) respiration.
Precipitating DKA factors
- Infection
- Physiological stress
- Non-adherence to insulin treatment regimen
- Diabulimia
- Drug treatment e.g. corticosteroids, diuretics, and sympathomimetic drugs - salbutamol
Ix of type 1 diabetes
- Blood glucose
2. Ketones serum 3+mmol and urine 2+
Mx of type 1 diabetes
Child:
- Care package
- education
- Immunised
- T1DM identification
Education programme T1DM
DAFNE - dose adjustment for normal eating
Insulin therapy
Blood glucose monitoring,
The effects of diet, physical activity, and intercurrent illness on blood glucose control.
Managing intercurrent illness (‘sick-day rules’)
Detecting and managing hypoglycaemia, hyperglycaemia, and ketosis.
target HbA1c for children and young people with type 1 diabetes
48 mmol/mol (6.5%)
Optimal targets for glucose self-monitoring in children and young people with type 1 diabetes
Random glucose - 4–7 mmol/L
- before meals
- waking
Plasma glucose level of 5–9 mmol/L after meals.
For young people of driving age, plasma glucose level of at least 5 mmol/L when driving.
Sick-day rules
Never stop or omit insulin.
Insulin dose may need altering during illness; they should seek advice from their diabetes team
Check blood glucose and ketones more frequently
Maintain their normal meal pattern
Maintain adequate fluid intake to prevent dehydration
Type 1 follow up
Once a year, offer monitoring:
- albumin:creatinine ratio
- Hypertension
- Thyroid disease
Screening for eye disease
eye examination by an optometrist every 2 years until the age of 12 years
After 12 diabetic eye screening programme
Types of diabetes
T1DM — an absolute insulin deficiency causes persistent hyperglycaemia
T2DM— insulin resistance result in persistent hyperglycaemia.
Gestational diabetes — hyperglycaemia develops during pregnancy and usually resolves after delivery, although the woman is at increased risk for overt type 2 diabetes in the future.
Macrovasular complications of diabetes
Atherosclerotic cardiovascular disease (CVD)
- Stoke
- Peripheral arterial disease
- MI
Microvascular
Nephropathy - Diabetic kidney disease
Retinopathy - blindness
Peripheral neuropathy -
Autonomic neuropathy - postural hypotension
Diabetic foot
Due to peripheral neuropathy - can’t feel pain and ill fitted shoes
And
Peripheral arterial disease - insufficient blood supply can cause ulcers
Hyperosmolar hyperglycaemic state (HHS) presentation
Polydipsia and polyuria. Weight loss. Abdominal pain, nausea and/or vomiting. Shortness of breath. Lethargy, drowsiness, and/or confusion. A possible history of precipitating factor(s).
Clinical signs: Fruity smell of acetone on the breath. Tachypnoea, acidotic breathing (deep sighing 'Kussmaul respiration'). Tachycardia, dehydration Blood or urinary ketones
Adult - test for blood or urinary ketones, even if plasma glucose levels are near normal.
Child - test for blood ketones, even if plasma glucose levels are near normal.
T2Dm diagnosis
Symptomatic + either 1 abnormal HbA1c or fasting plasma glucose level
Asymptomatic + atleast 2 tests done on different days either HbA1c or plasma glucose
Persistent hyperglycaemia
HbA1c of 48 + mmol/mol (6.5%)
Fasting plasma glucose level of 7.0 + mmol/L
Random plasma glucose of 11.1 + mmol/L in the presence of symptoms or signs of diabetes.
When can HbA1c not be used
- Children and young people less than 18 years of age.
- Pregnant women or women who are 2 months postpartum.
- Symptoms of diabetes for less than 2 months.
- High diabetes risk who are acutely ill.
- Medication that may cause hyperglycemia (long-term corticosteroid treatment)
- Acute pancreatic damage, including pancreatic surgery.
- ESRD
- HIV infection
HHS precipitating factors
Infection
Inadequate insulin or non-adherence with insulin treatment
New onset of diabetes mellitus or other physiological stress - trauma or surgery
Medical conditions - hypothyroidism or pancreatitis
Drugs - corticosteroids, diuretics, atypical antipsychotics, and sympathomimetic drugs such as salbutamol
Hypoglycaemia
Blood glucose levels less than 3.5 mmol/L
Mx of T2DM
- DESMOND
2. Medication - metformin
HbA1c target with drug treatment associated with hypoglycaemia (such as a sulfonylurea)
53mmol 7%
Sick-day rules T2Dm
Temporarily stop some drug treatments during acute illness. Medication restarted once the person is feeling better and eating and drinking for 24–48 hours
Stop:
- Metformin - if rehydrated due to risk of lactic acidosis
- Sulfonylurea - hypoglycaemia
- SGLT2
- GLP - 1 agonist - if dehydrated due to risk of AKI
Do not stop insulin therapy
Diabetes screening
Retinopathy - every 2 years for low risk or annually for high risk
Foot review - once a year
Kidney disease - annually
- Arrange an early morning first-void urine sample for assessment of microalbuminuria
