Diabetes

Question 1

What are the key parts of care in the treatment for diabetes?

Answer 1

Glycaemic control
Aspirin
BP control
Lipid control
Eye care
Dorsum care

Question 2

What is the normal range for fasting glucose?
What is the normal range for after a meal or 2 hour post OGTT?
What is a normal HbA1c

Answer 2

<7 mmol/l
<11.1
48 mmol/l (6.5%)

Question 3

What are the methods for testing blood glucose?

Answer 3

Capillary glucose daily
Urine - not reliable
HbA1c
Fructosamine

Question 4

What are some symptoms to look for in diabetes?

Answer 4

Blurred vision and weight loss

Question 5

What type of drug is glicazide? What is a side effect?

Answer 5

Sulphonylurea and hypoglycaemia

Question 6

What is the treatment regimen for T2 diabetes?

Answer 6

1. If above 48 mmol/l (6.5%) offer metformin (MY) and supportive management
2. If above 58 mmol/l (7.5%) on monotherapy offer sulphonylurea (SISTER), pioglitazone (PLAYS) or DDP4.( DURING)
3. If still above 58 mmol/l offer triple therapy (THE)
4. If triple therapy fails offer GLP-1 mimetics (GAME)
5. If metformin not tolerated move to the others

Question 7

For T1 diabetes, what are the types of insulin?

Answer 7

Short acting (novarapid, humalog)
Intermediate
NPH
Long acting (lantus, glargine, detamir)

Question 8

What does hyperglycaemic hyperosmolar syndrome mean?

Answer 8

Osmotic diuresis

Question 9

What causes DKA or HHS?

Answer 9

1. Failure to produce or secrete insulin
2. Increase in the counterregulatory hormones such as adrenaline, cortisol (Cushing’s), growth hormone (acromegaly) and glucagon

Question 10

What is the effect of counteregulatory hormones?

Answer 10

Raised gluconeogenesis

Raised lipolysis

Question 11

What are the markers of DKA?

Answer 11

1. Glucose (‘Diabetic’)
    Blood glucose > 11 mmol/L or known diabetes
    Lab glucose
2. Ketones (‘Keto’)
    Capillary blood: Ketonaemia ≥ 3 mmol/l
    Urinary: significant ketonuria (> 2+ on standard dipstick urinalysis)
3. pH (‘Acidosis’)
    Venous pH <7.3
    Bicarbonate (HCO3-) <15 mmol/l

Question 12

What are the symptoms of DKA?

Answer 12

Drunk - dehydration
Hippies - hypotension
Always - acidosis
Have - hypothermia
Beer - blurred vision
and
Gin - gastraparesis

Question 13

How is DKA treated?

Answer 13

Fluid replacement
 Restoration of circulatory volume
 Clearance of ketones
 Correction of electrolyte imbalance
 Crystalloid: 0.9% normal saline
 Insulin
 Suppression of ketogenesis
 Reduction of blood glucose
 Correction of electrolyte imbalance
 Fixed rate IVII (0.1 units/kg/h)
 Continue usual long acting insulin
Avoid hypoglycaemia
 Once the blood glucose falls to 
<14 mmol/L, give10% glucose 
infusion
 Potassium
 Not with initial fluid resuscitation
 Target: 4.0 - 5.0 mmol/L
 No replacement if >5.5mmol/L
 Give replacement if 
<5.5mmol/L. i.e. 0.9% NaCl 
solution with potassium 40 
mmol/L (ready-mixed)

FIMAP - fluid, insulin, monitor, avoid hypo, potassium

Question 14

What did HHS used to be called?

Answer 14

HONK
Hyperosmolar - non ketotic coma

 Serum osmolality > 320
 ‘Hyperosmolar’
 = 2[Na] + glucose + urea
 Glucose usually > 30 mmol/L
 ‘Hyperglycaemic’
 Marked hyperglycaemia!
 HCO3 > 15 mmol/L, pH > 7.3
 Not acidotic
 Blood ketones < 3.0 mmol/L
 Not ketotic

Question 15

How is HHS treated?

Answer 15

 Fluid replacement
 0.9% normal saline, average fluid deficit 9-10L
 Gradual decline in osmolality – check regularly and adjust rate
accordingly
 Lowering osm shift of water into intracellular space 
increase in serum sodium (watch for hypernatraemia)
 Will lower blood glucose alone without insulin
 Insulin – only if BGL is not dropping by 5mmol/L/h
 If needed, give fixed rate IVII at 0.05 units/kg/h
 Potassium replacement – same as in DKA
 Thromboprophylaxis – LMWH
 Foot protection (risk of pressure ulcers) – examine daily, heel
protectors

Question 16

What is Whipple’s triad for hypoglycaemia?

Answer 16

 Whipple’s triad:

1. low plasma glucose
2. symptoms consistent with hypo
3. resolution of symptoms with hypo correction

Question 17

What is the threshold for hypoglycaemia?

Answer 17

Biochemical: glucose value <4.0 mmol/l in
hospital/diabetes patients should be treated
 “make four the floor”

Question 18

What are the two types of symptoms for hypoglycaemia?

Answer 18

Autonomic and neuroglycopneic

Question 19

What are neuroglycopenic symptoms?

Answer 19

 Neuroglycopenic
 Confusion
 Odd behaviour
 Drowsiness
 Incoordination
 Slurring 
 Diplopia
 Dizziness
 Headache

Question 20

What are autonomic symptoms?

Answer 20

 Sweating
 Pallor
 Tachycardia
 Tremor
 Tingling 
 Hunger

Question 21

What is the treatment for conscious (swallow) hypoglycaemia?

Answer 21

1. Give 15–20 g rapid acting 
carbohydrate (or 1.5-2 tubes of 
GlucoGel if uncooperative)
2. Recheck BGL after 10-15 min. If 
still <4, repeat step (max 3 
times)
3. Consider 1mg IM glucagon
4. If still <4, IV glucose (i.e. 200ml 
of 10% over 15 minutes)
5. Once recovered and BGL >4, 
give 20g LA carbohydrate

Question 22

What is the treatment for unconscious hypoglycaemia?

Answer 22

1. ABCDE
2. Give IV glucose: 100 ml of
   20% over 15 minutes
3. 1mg IM Glucagon
4. Recheck BGL after 10min. If
   still <4, repeat IV glucose
   (max 3 times)
5. Once recovered and BGL >4,
   give 20g LA carbohydrate

Question 23

What happens to the body as glucose falls?

Answer 23

Glucose levels mmol/l
 4.5 own insulin suppressed
 3.8 counterregulatoryhormones
 3.2 symptoms
 2.8 cognitive dysfunction
 2.0 EEG changes
 1.5 reduced conscious level, seizures, possible death