Diabetes Flashcards
what 3/4 features support a diagnosis of hyperosmolar hyperglycaemia syndrome?
- hypovolemia
- hyperglycaemia
- no ketones or acidosis
- osmolality usually >320 mosmol/Kg
what type of diabetes (I or II) is HHS more common in?
type II diabetes
what can precipitate a patient getting HHS?
- cardiac event
- infection/sepsis
- fall
- stroke
(can take days to develop)
what is the immediate management of HHS?
- IV fluids (crystalloids - given over 2/3 days)
- normalise blood glucose by giving IV insulin
- anticoagulation
- monitor potassium and renal function
what are the main complications of HHS?
- central pontine myelinolysis
- CCF from fluid overload if previous CVD
- cerebral oedema
- thrombosis
what is diabetic ketoacidosis?
a condition that occurs most commonly in T1DM patients where they dont have enough insulin and ketones start to build up due to enhanced lipolysis
what are teh main features that support a diagnosis of ketoacidosis?
- acidosis
- hyperglycaemia
- ketonaemia
what is the immediate management of DKA?
- fluids FAST @ fixed rate
- insulin to reduce ketones
- potassium - as falls when insulin given
- correction of electrolyte imbalances using fluids
when is a patient moved from IV insulin to subcutaneous after DKA?
when their ketone level is <0.6mmol/L and they are ready to eat
what investigations need to be doen when a patient comes in suspected of having DKA?
- blood ketones
- capillary blood glucose
- venous plasma glucose
- U+E’s
- venous blood gases
- FBC
- blood cultures
- ECG
- CXR
- urinalysis and culture
- continous cardiac monitoring
what are the clinical features of a diabetic foot?
- painless ulcer
- cellulitis possibly
- redness
- changes to skin, nails
- foul smell
- discharge
- swelling
what are the investigations needed when assessing a diabetic foot?
- clinically
- doppler
- angiography
- xray (if bone deformity/osteomyelitis)
- FBC, swab and blood cultures (if infection)
what is the management fo a diabetic foot ulcer?
- remove callus/tissue debridement and washout
- regular chiropody
- bed rest
- therapeutic shoes
- if cellulitis then ABx
what are teh most common types of organisms cuasing diabetic foot ulcers? and what ABx therefore needed to treat?
- staphs and streps
- benzylpenicillin and flucloxacillin +/- metronidazole
name some chronic complications of diabetes?
- diabetic foot ulcer
- nephropathies
- neuropathies
- retinopathy
what are teh clinical features of a charcots foot?
pes cavus, claw toes, loss of transverse arch, rocker-bottom sole
what is the main investigation for diabetic nephropathy?
albumin:creatinine ratio (≳3mg/mmol in microalbuminuria but urine dipstick -ve for proteins)
what is the management of diabetic nephropathy?
- ACEi
- lifetsyles managament
- BP control
- glycaemic control
- low protein diet
what investigations are done to test for diabetic neuropathies?
clinical diagnosis
fasting blood glucose
HbA1c
serum thyroid-stimulating hormone
what is the clinical plasma glucose level for hypoglycameia?
<3mmol/L
what are teh clinical features of hyoglycaamia?
- sweating
- palpitations
- shaking
- hunger
- confusion
- drowsiness
- speech difficulty
- incoordination
- headache
- nausea
- seizures
- coma
what are teh causes of hypoglycaemia? in diabetics and non diabetics?
↑activity, missed meal, accidental or non-accidental overdose, insulinoma
non diabetics: alcohol, starvation, lvier fialure, addisons, pituitary insufficeincy, certain medication e.g. aspirin, ACEi,,
what is the whipples triad for hypoglycaemia?
it confirms a diagnosis of hypoglycaemia:
symptoms or signs of hypoglycemia + ↓plasma glucose + resolution of symptoms or signs post glucose rise
what investigations are done when a patient presents with hypoglycaemia?
- whipples triad
- DHx to exlude liver failure
- document BM during attack
what is the treatment for hypoglycaemia?
If conscious, and able to swallow, give 15–20g of quick-acting carbohydrate snack and recheck blood glucose after 10/15mins (repeat snack up to 3 times).
If conscious but uncooperative, squirt glucose gel between teeth and gums.
In unconscious patients, start glucose iv or give glucagon
Once blood glucose >4.0mmol/L and patient has recovered, give long-acting carbohydrate
what are the main acute complications of diabetes?
- DKA
- HHS
- hypoglycaemia
what are the clinical features of a fundoscopy for diabetic retinopathy?
- Microaneurysms (dots), haemorrhages (blots), and hard exudates (lipid deposits)
2, Cotton-wool spots (eg infarcts), haemorrhages, venous beading - New vessels form
what are the features for a diagnosis of diabetes mellitus?
- Symptoms of hyperglycaemia (eg polyuria, polydipsia, unexplained weight loss, visual blurring, genital thrush, lethargy) and raised venous glucose detected once—fasting ≥7mmol/L or random ≥11.1mmol/L OR
- Raised venous glucose on two separate occasions—fasting ≥7mmol/L, random ≥11.1mmol/L or oral glucose tolerance test (ogtt)—2h value ≥11.1mmol/L OR
- Hba1c ≥48mmol/mol
management of TIDM?
insulin
what are the four mian types of subcut insulin?
1 Ultra-fast acting (Humalog; Novorapid); inject at start of meal, or just after
2 Isophane insulin (variable peak at 4–12h): CHEAP
3 Pre-mixed insulins (NovoMix 30 = 30% short-acting and 70% long-acting).
4 Long-acting recombinant human insulin analogues (insulin glargine) are used at bedtime in type 1 or 2 dm. There is no awkward peak, so good if nocturnal hypoglycaemia is an issue. Caution if considering pregnancy. Insulin detemir is similar and has a role in intensive insulin regimens for overweight type 2 dm.
what are the three different types of insulin regimes?
- ‘bd biphasic regimen’: twice daily premixed insulins by pen (NovoMix 30®)—useful in type 2 dm or type 1 with regular lifestyle.
- ‘qds regimen’: before meals ultra-fast insulin + bedtime long-acting analogue: useful in type 1 dm for achieving a flexible lifestyle
- Once-daily before-bed long-acting insulin: a good initial insulin regimen when switching from tablets in type 2 dm. Consider retaining metformin (±pioglitazone)
WHat is DAFNE?
dose adjustment for normal eating:
a course that aims to help adults with type 1 diabetes lead as normal a life as possible, whilst also maintaining blood glucose levels within healthy targets, to reduce the risk of long-term diabetes complications
how should insulin dosing chnage in a T1DM patient with an acute illness
advise patietns to stop insulin during an episode of acute illness, need to :
Check blood glucose ≥ 4 times a day and look for ketonuria. Increase insulin doses if glucose rising. Advise to get help from a specialist diabetes nurse or gp if concerned
when are insulin pumps needed?
Consider when attempts to reach Hba1c with multiple daily injections have resulted in disabling hypoglycaemia or person has been unable to achieve target Hba1c despite careful management
what HbA1c is aimed for in diabetes?
<48mmol/mol or 53 if two or more agents
name the 6 different types of oral hypoglycaemics (briefly mention their action)
- biguanide - metformin (increase insulin sensitivity)
- glitazones - pioglitazone (increase insulin sensitivity)
- DPP-4 inhibitors - sitagliptin (increase incretin - hormone that triggers insulin release)
- sulfonylurea - glicazide (increase insulin secretion)
- SGLT2 inhibitors - dapagliflozin (increased glucose excretion)
- GLP-1 receptor agonists - exenatide (incretin mimetic)
