DIABETES Flashcards
What is the difference between type 1 and type 2 diabetes?
Type 1: insulin deficiency due to immune mediate destruction of insulin producing pancreatic beta cells
Type 2: relative insulin deficiency caused by progressive loss of pancreatic beta cell insulin secretion on background of insulin resistance
What is the BSL range for “pre-diabetes”?
fasting: 6.1 - 6.9 mmol/L
random/OGTT: 7.8 - 11 mmol/L
What is the diagnostic HbA1c and BSL for diabetes?
Fasting BSL > 7
Random BSL >11
HbA1c > 6.5%
When should HbA1c be checked post partum?
Not within the first 3 months post partum as it will be falsely low due to lower BSL concentrations due to pregnancy (haemodilution).
Describe the procedure of an OGTT`
- Fast overnight for 8-12 hours, avoid smoking or caffiene
- take fasting blood sample before 75g glucose drink
- drink must be consumed within 5 min
- pt must remain seated and not eat or drink for the 2 hour duration of test
- if non pregnant take blood test at 2 hours after consuming the drink, if pregnant take blood at 1 hour and 2 hours
Screening for T2DM
- AUSDRISK: should be used every 3 years in > 40s or > 18 if ATSI
- considers: age, sex, ethnicity, fhx, elevated BP, elevated BSL, smoking, diet, physical activity and obesity
- if at high risk screening should be annual
What AUSDRISK score = high, intermediate or low risk
Low = 5 and under Intermediate = 6-11 High = > 12
What are the 5 goals of diabetes management?
- optimise quality of life
- manage hyperglycaemia
- avoid acute complications (DKA, HONK)
- avoid hypoglycaemia
- avoid chronic complications
What should be included in a diabetes management plan?
- short and long term goals and treatment targets
- dietary plan
- physical activity and exercise plan
- medication management plan
- sick day management plan
- schedule for screening and monitoring of complications
- ways to reduce cardiovascular disease
- plan for self management
What classifies as severe hyperglycaemia?
BSL > 20
Indications for referral to hospital in adults with hyperglycaemia
- signs of ketosis
- signs of dehydration
- severe hyperglycaemia and vomiting
- symptoms and signs of underlying infection
- altered LOC, confusion or delirium
What are the 3 insulin regimens for Type 1 diabetes?
- multiple daily injections (basal + bolus), usually 4 injections daily
- continuous s/c insulin infusion via pump
- mixed insulin, usually 2 injections daily
What BSL and HbA1c targets should Type 1 diabetics have?
BSL 4-8
HbA1c < 7%
Examples of total daily insulin doses at different phases and ages.
- during remission phase for all ages—less than 0.5 units/kg daily
- beyond remission phase for pre-adolescent children—0.7 to 1 unit/kg daily
- beyond remission phase during puberty—1.2 to 1.5 units/kg daily.
What is the aim of basal insulin in T1DM?
- aim to lower rates of nocturnal hypoglycaemia
- aim to achieve fasting BSL 4-8
How often should children with T1DM check their BSL?
At least four times a day, before meals and at bedtime
What is LADA?
Latent autoimmune diabetes
- T1DM subtype
- associated with type 1 autoantibodies (GAD and IA-2 _ ZnT8)
What BSL targets should be given to adult patients with T1DM?
Fasting BSL 4-8
Post prandial BSL 6-10
What percentage of total daily insulin should basal insulin be?
~40-50% of total daily insulin
Name 3 long acting insulins and their onset/peak and duration
Detemir 100 units/ml: onset 90min, duration 16-24hrs
> levemir
Glargin 100 units/ml: onset 1-2 hours, duration up to 24H
> lantus
Glargin 300 units/ml: onset 1-6 hrs, duration 24-36hrs
> toujeo
Name 4 rapid acting insulins
- Aspart 100units/ml (Novorapid)
> onset 10-15min, peak 60-90min, duration 3-5 hrs - Glulisine 100 units/ml (Apidra)
> onset 10-15 min, peak 60-90 min, duration 3-5 hrs - Lispro 100 units/ml (Humalog)
> onset 10-15min, peak 1-2 hours, duration 3-5 hrs - Lispro 200unit/ml (Humalog U200)
> onset 10-15min, peak 1-2 hours, duration 3-5 hrs
What is the general onset, peak and duration of rapid acting insulins?
Novorapid, apidra, humalog
Onset - 10-15min
Peak - 1-2 hrs
Duration - 3-5 hrs
Name 1 short acting insulin.
Neutral 100 unit/ml (Actrapid, Humulin)
> onset 30min, peak 2-3 hours, duration 6-7 hrs
What is the total daily insulin requirement for a healthy adult?
0.5-0.8 units/kg
What is the typical initial total daily insulin dose for a type 1 diabetics?
0.3-0.4 units/kg
What is the most common insulin regimen for type 1 diabetes?
Basal = 40% daily or BD, long acting insulin Bolus = 60% in divided doses 15 min prior to meals, rapid or short acting insulin
Describe how to adjust basal insulin.
Dose of basal insulin should be adjusted by 10-20% every 3-7 days until fasting BSL targets (4-8) are achieved. Should always stabilise basal insulin first before adjusting bolus doses.
Describe how to adjust bolus insulin.
Provided patient is having fixed carbohydrate intake bolus insulin doses can be adjusted by 10-20% every 3-7 days to achieve:
> 2 hour post prandial bsl
- most patients will have an insulin:carbohydrate
i. e. 1:10, if eating 60g of carbs will need 6 units of insulin
- most patients will have an insulin:carbohydrate
Correction/supplemental insulin doses
- This is calculated by drop in BSL concentration from a 1 unit bolus
- If patient is on a stable insulin dose you can calculate from total daily insulin
> sensitivity factor = 100/total daily insulin dose
Example = total daily insulin dose 50U, needing to drop BSL from 14 to 6 (8mmol/L drop).
> sensitivity factor = 100/50 = 2, therefore 1 unit of insulin will drop BSL by 2
> hence correction dose needed will be 4 units
Given in combination to usual dose of bolus to cover carbohydrate content of meal
How to avoid hypoglycaemia with exercise in T1DM.
- eat 15-30g of carb for every 30 min of moderate exercise
- reduce insulin dose in relation to anticipated intensity and duration
- if aerobic exercise expected to last more than 30 min a decreased insulin dose is preferred to increased carb intake
When should ketones be tested for in T1DM?
- during acute illness or stress
- when BSLs are consistently > 15
- with symptoms of DKA, nausea/vomiting/abdo pain
What classified as mild ketosis?
ketones 0.6-1.5mmol/L
> 1.5 indicates potential for developing DKA
How often should HbA1c be reviewed in T1DM?
Every 3-4 months
How often should retinopathy be screened for in T1DM?
- start screening 2-5 years after diagnosis (after 11)
- assess every 12 months if ATSI, known retinopathy, high HbA1c levels
Otherwise assess every 2 years if previous eye examination was normal
How often should a foot examination/peripheral neuropathy be screened for in T1DM?
If high risks screening every 3-4 months
Otherwise at least annually
Other autoimmune screening in T1DM.
Thyroid: every 2 years
Coeliac: screen at 2 and 5 years after diagnosis
How often should lipids be screened for in T1DM?
- every 5 years if normal results
Describe effects of alcohol and hypoglycaemia.
ETOH inhibits glucose production by the liver and increases risk of hypoglycaemia in T1DM
T1DM and driving
- bsl should always be checked prior to driving to ensure it is > 5
- bsl should be checked Q2H while driving
- patients should always have glucose containing foods available while driving
Metformin role in pre-diabetes.
- metformin has greatest benefits in reducing progression to diabetes in adults < 60 with BMI > 35
- should consider if lifestyle modifications are unsuccessful
What are the glycaemic targets in T2DM?
- < 7% generally
- however can be more aggressive in newly diagnosed patients
- <6% if lifestyle modifictaion +/- metformin
- <6.5% if 2 antihyperglycaemics
Physical activity recommendations in T2DM
- 150 -300min per week of moderate intensity exercise
- interrupt sitting every 30 minutes
Indications for bariatric surgery
- T2DM + BMI > 40 or with BMI 35-40 in context of suboptimal glycaemic control despite optimal lifestyle modifications and medical treatment
Dietary advice for T2DM
- aim for 5-10% weight loss
- suggest low GI food: wholegrain bread, pasta, fruits and dairy provides
- reduce sugar!
Factors influencing choice of antihyperglycaemic agent in T2DM
Patient factors
- degree of hyperglycaemia
- risk of hypoglycaemia
- weight
- comorbidities
Drug factors
- efficacy
- potential nonglycaemic effects (i.e. CVD benefit)
- risk of hypoglycaemia
- effect on patient weight
- contraindications
Anti-hyperglycaemic class: Biguanide
Advantages and Disadvantages
Metformin
- MOA: suppresses glucose production by liver and increases insulin sensitivity
Advantages: unlikely to cause hypoglycaemia, assist with weight loss, improved cardiovasc outcomes, low cost
Disadvantages: GIT side effects, B12 deficiency, lactic acidosis (rare)
Renal: adjust dose in renal impairment
Anti-hyperglycaemic class: Sulfonylureas
Advantages and Disadvantages
Gliclazide, glipizide, glibenclamide
MOA: act at the pancreas to stimulate insulin secretion
Advantages: low cost
Disadvantage: can cause weight gain and hypoglycaemia, especially in older patients
Renal: avoid in patients with renal impairment!
Anti-hyperglycaemic class: DPP4I
Advantages and Disadvantages
“Gliptins” - sitagliptin, linagliptin, saxagliptin
MOA: inhibits breaks down of GLP1 leading to increase insulin secretion and reduce glucagon
Advantages: hypoglycaemia unlikely, no weight gain, improves post prandial glucose control, safe in patients with CVD (except saxagliptin)
Disadvantage: avoid in heart failure, avoid in pts with hx of pancreatitis, can cause MSK pain
Renal: reduce dose with renal impairment
Anti-hyperglycaemic class: GLP1 RA
Advantages and Disadvantages
“Tides” - guaglutide, exenatide, liraglutide
MOA: increases insulin secretion and reduced glucagon secretion by inhibiting action of DPP4 by binding GPL1
Advantages: hypoglycaemia unlikely, weight loss, improves post prandial bsl, reduces CVD events, slows progression of CKD
Disadvantages: avoid in patients with hx of pancreatitis or family hx of thyroid ca or MEN, GIT side effects
Renal: avoid in severe renal impairment
Anti-hyperglycaemic class: SGLT2 I
Advantages and Disadvantages
“Flozins”
MOA: increases glucose excretion in urine
Advantages: hypoglycaemia unlikely, weight loss, reduces CVD risk, reduces BP, slows progression of CKD
Disadvantages: avoid in fasting pts due to risk of euglycaemic DKA, can cause urinary infections, reversible increase in creatinine
Renal: reduced glycaemic efficacy with renal impairment
What medication is suggested for T2DM patients with HbA1c < 8.5% at diagnosis?
Metformin immediately OR after 2-3 months if targets not achieved with lifestyle modification
Second drug: sulfonulurea, DPP4 or SGLT2 inhibitor
If CVD risk factors: consider SGLT2 inhibitor of GLP 1
If target not achieved in 3 months add or substitute a third drug: sulfonylurea, DPP4, SGLT2I or GLP1 RA
What medication is suggested for T2DM patients with HbA1c > 8.5% at diagnosis?
Start metformin and a second drug immediately
Suggested management if on triple antihyperglycaemic rx in T2DM and still not achieving glycaemic control.
- if using triple therapy change one or more drugs to GLP1 receptor agonist OR insulin
- if using a regimen with a GLP1R agonist change this to a basal insulin OR add a basal or mixed insulin regimen
- if using a basal insulin consider adding SGLT2I or GLP1 RA
- or may need to consider basal + multipole daily injections (basal- bolus) or BD mixed insulin regimen
Initial insulin dosing in T2DM with suboptimal control
Long acting insulin 0.2 units/kg (up to 30units) S/C daily
What is the pathophys behind hyperglycaemia in acute illness in diabetics?
Counter-regulatory hormones such as glucagon, cortisol and adrenaline
Sick day plan for T1DM
- check BSL + ketones every 1-4 hours
- ketones > 0.6 + high BSL suggests need for supplemental insulin and increased fluids
- in acute illness basal insulin requirement generally increases and supplemental/correction rapid acting insulin should be given every 2-4 hours in addition to usual meal time boluses to reduce hyperglycaemia and stop ketosis
Sick day plan for T2DM
- if unwell and BSL > 12 mmol/l without episodes of hypoglycaemia can increase basal insulin by 10-20% (110-120% of usual insulin dose)
- may need to include short term rapid acting boluses doses with meals to manage acute hyperglycaemia
- metformin may need to be withheld if dehydrated or reduced renal function
- SGLT2 inhibitors should be withheld!
- GLP1 RA can be temporarily withheld if nausea, vomiting or anorexia
- DPP4I can be continued
- sulfonylureas can be continued as tolerated
With what renal function is metformin contraindicated?
Creat clearance < 40ml/min
CKD stage III or more
Which antihyperglycaemic agent is associated with increased risk of UTI and DKA?
SGLT2 inhibitors
What antihyperglycaemic agent is contraindicated in heart failure?
DPP4 inhibitor “gliptin”
What is the cut off for HbA1c for major elective procedures?
<9%
Suggested subcut insulin management day of procedure in T1DM.
Morning procedure: normal basal insulin, omit rapid acting insulin, hourly BSLs from waking
Afternoon procedure: normal basal insulin, given half usually rapid acting bolus, withhold lunch rapid insulin
Pre-procedural insulin infusion
Run with 5% glucose at 100ml/hr
Run insulin units/hr based on patients total daily insulin dose and their BSL (measured hourly)
Run between 1-4units/hour if normal BSL
Acute vs chronic (micro/macro) complications of diabetes (3 in each)
Acute: hypoglycaemia, HONK, DKA
Microvascular: kidney disease, retinopathy, neuropathy
Macrovascular: CAD, PVD, stroke
Management of severe hypoglycaemia: adult
- severe: unable to be self managed by patient
- glucagon 1mg IM/SC
- IV glucose: 10% 150-200ml (15-20g) over 15 min
OR IV glucose 20% 75-100ml (15-20g) over 15 min
Once conscious need to give long acting complex carb
Management of severe hypoglycaemia: child
- glucagon: <25kg = 0.5mg IM/SC, >25kg = 1mg IM/SC
- IV glucose 10%: 1-2 ml/kg over 20 min until BSL >4
DO not give 50% dextrose to children due to risk of hyperosmolality and death
Products containing 15g of glucose
15g tube of glucose gel 6-7 jelly beans or 4 large glucose jelly beans 3 teaspoons honey or sugar 125ml of fruit juice 150ml of soft drink
Management of non-severe hypoglycaemia
- when patient is able to self correct orally
Child: 5-10g glucose PO
Adult: 15g glucose PO
* if BLS < 3 in adults given at leat 20g glucose
Rule of 15s - 15g glucose, recheck in 15 min
Which antihyperglycamic has greatest risk of hypoglycaemia?
Sulfonylureas due to stimulation of insulin secretion
- gliclazide, glipizide, glibenclamide
Especially prominent if only insulin
Characteristics of DKA
- dehydration
- hyperglycaemia
- polyuria, polydipsia, tachypnoea
- acetone breath
- nausea/vomiting/abdo pain
Typical blood gas results in DKA
pH <7,3
bicarb <15
ketones > 1.5
BSL > 14 (but can be lower if taking SGLT2I)
Describe management of mild ketosis
Ketones 0.6 - 1.5
Can be managed as per sick day management plan withe extra insulin
What are the 4 main aims of management of DKA?
- correction of fluid loss with aggressive rehydration
- correction of hyperglycaemia and suppression of ketone production with insulin
> with addition of glucose infusion once BSL drops - correction of electrolytes - especially potassium
- investigation of precipitant/cause
Which has a higher mortality HONK or DKA?
HONK!
Definition of HONK
- high serum osmolality: often >320
- extreme hyperglycaemia > 30
- severe dehydration
How to calculate effective serum osmolality
2 x (Na + K) + BSL + urea concentration
Should be calculated hourly
Aim for reduction of 3mmol/kg/hours and can titrate fluids to these
Aims of HONK management
- slow and safe replacement of IV fluids and electrolytes
- slowly and safely normalise BSL
- treat underlying cause
- wait to avoid rapid correction of effective serum osmolality
What are the estimated fluid losses in HONK?
100-200ml/kg
Treat with 50% of estimated fluids loss within first 12 hours and then the remainder over 12-36 hours
Use of insulin in HONK
- if ketones are <1 can hold off on insulin until after some rehydration as this will reduce BSL
- once BSL stops falling from rehydration reassess fluid intake, renal function and can start IV insulin infusion
- start at 0.05units/kg/hour
- aim to reduce BSL by 4-6 mmol/L with target of 10-15mmol/L
Less commonly but if ketone > 1 then start insulin concurrently with IV rehydration
Define normal, micro and macro albuminuria
Women: 3.5, 3.5-35, > 35
Men: 2.5, 2.5-25, >25
Stages of CKD by GFR
I. >90 II 60-89 IIIa 45-59 IIIb 30 - 44 IV. 15-29 V < 15
Which antihyperglycaemic medications slow progression of diabetic kidney disease?
SGLT2I
Liraglutide
What cholesterol medication can slow progression of diabetic retinopathy?
Fenofibrate
Can slow progression irrespective of blood lipid level
Management of painful diabetic neuropathy
- amitriptyline 25mg nocte
Need to exclude other causes i..e B12 deficiency and myeloma
Charcot arthropathy
- unilateral, red, hot swollen foot
- destructive joint disorder caused by diabetes
- associated with peripheral neuropathy
- causes inflammation leading to bone fracture, dislocation, instability
- if suspected need to place patient NWB
Features of diabetic autonomic neuropathy
- hypoglycaemia unawareness
- erectile dysfunction
- orthostatic hypotension
- diabetic gastroparesis
- diarrhoea
- bladder atony and urinary retention
- cardiac autonomic neuropathy
Pharmacological management of orthostatic hypotension in diabetic autonomic neuropathy
Fludocortisone 100mcg daily, increasing according to response to max 300 mcg daily
BP target in diabetes
<130/80 with albuminuria/proteinuria
Otherwise <140/90
First line management ACEI/ARB
Likely will require CCB or thiazide in addition for combination approach
Diabetes and aspirin
Not recommended for primary prevention of CVD however advised if known atherosclerosis
When should OGTT be repeated post partum in women with GDM?
At 6-12 weeks post partum but can be delayed until 4-6 months post partum if not practical
What vaccinations are recommended for diabetics?
Influenza
Pneumococcus
DTPA
