diabetes Flashcards
what causes diabetes
body is resistant to insulin or doesnt produce enough
what is diabetes insipidus- what are the different types
decrease in the amount of adh
means you cant hold water in your body resulting in excessive thirst and urination
2 types
cranial- problem with production of adh in the pituitary gland
nephrogenic- kidneys are resistant to ADH
What is the treatments for cranial diabetes insipidus
desmopressin or vasopressin- to replace the adh that isnt being produced
what are the treatments for nephtogenic diabetes insipidus
carbamazepine or thiazide like diuretic- paradoxcical effect
or oxytocin in nephrogenic/ partial pituitary diabetes
what is an extreme side effect that can happen with with vasopressin
extreeme dilutions of water leads to hyponatreamic convulsions
when do you have to notify the DVLA when you have diabetes
all drivers using insulin must report to DVLA
Iincluding if you have a hypoglycaemia epidoses or complications
drugs with greatest risk- sulphonyureas, meglitinides, insulins
what is the DVLA advice surrounding driving if pt is diabetic
aboid hypoglycaemia
carry glucose meter and test strips
carry sugar snack
check glucose 2 hours before and every 2 hours whilst driving
should always be over 5mmol when driving
take snack if below 5mmol and wait 45 mins
what advice should be given to diabetic patients about alcohol consumption
dont have to stop drinking
have with food and in moderation
alcohol can mask the symptoms of hypoglycaemia- confuison, tachy, hunger
what is the oral glucose tolerance test (OGTT) and what is it used for
diagnose impaired glucose intolerance
establish gestational diabetes
involves measuring blood glucose conc after fasting for 8 hrs then 2 hrs after drinking standard anhydrous glucose drink e.g polycal, OGTT oral
what is HbA1c used to diagnose
How often should it be measured for type 1 or type 2 pts
glycated haemoglobin
used to diagnose type 2 diabetes mellitus
also used to see if you might have macro complications
to see how well you have been managing ypur blood sugar in the last three months
performed at anytime of the day and with no preparation
expressed as mmol/mol
lower values are associated with vascular complications
individualised targets
monitor type 1 every 3-6 months or more frequently if rapidly changing
monitor type 2 pts every 3-6 months until stable then every 6 months
when should we not use hba1c
if pt is pregnant women within 2 months of women giving birth type 1 diabetes children symptoms of diabetes within 2 months actuely ill pancreatic damage, CKD, HIV Hyperglycaemia
what are the four different types of diabetes blood test and when they are used
tyoe 1 diabetes- random blood glucose test
type 2 diabetes- hba1c and fasting blood glucose test
oral glucose tolerance test- gestational diabetes
what is type 1 diabetes
insulin deficiency or no insulin secretion due to the destruction of insulin producing beta cells in the pancreatic islet of langerhans
autoimmune- any stage but mostly childhood
if hyperglycaemia poorly managed it leads to complications e.g retinopathy, nephropathy, neuropathy, premature CVD, PAD
What are the signs and symptoms of diabetes type 1
increased thirst frequent urination esp at night Hyperglycaemia - random glucose over 11 extreme hunger weight loss Irritability and other mood changes fatigue and weakness blurred vision
how many time should adults monitor their blood glucose in a day?
4 including before each meal and before bed time
what is the target HbA1c for type 1 diabetics
48mmol or below
6.5%
what is the target fasting glucose level on waking
wake up at 5 to 7
5-7mmol
what is the target plasma glucose level before meals and other times in the day
Be4 meals
4-7
whta is the target plama gluocse level after meals
dine at nine
5-9
what is the target plama glucose concentration when driving
five to drive
5 and over
what is the target random plasma glucose
less than 11
when is metformin appropriate to give to type 1 diabetics
pts with bmi over 25 or 23 if south asian who wish to improve glucose control and reduce insulin use
what is basal insulin
what is bolus insulin
slow and steady insulin released as background insulin that controls glucose continuoudly released from the liver
bolus secreted in repsonse to glucose absorbed by food or drink
what are the thre types of insulin
human insulin
human insulin analogue
animal insulin (bovine/porcine)
why is insulin given by injection rather than orally
where should it be injected
insulin is inactivated by the G.I enzymes
subcut fat area- abdomen (faster absorption rate), outer thigh or buttock
why should pts not inject the same area when admin insulin
lipohypertrophy
you should rotate the sites to minimise the risk
can cause erratic absorption of insulin and contribute to poor glycaemic control
name the short acting insulins
duration of action
and time to onset
When is it injected
injected immediately before meals 15 mins to onset- so inject 15 mins before meal lasts for 2-5 hrs examples: LAG Lispro- humalog Aspart- novorapid, fiasp Gluisine- apidra
name the short acting insulins- soluble
duration of action
and time to onset
when are they used over short acting rapid insulin
soluble I.V for diabetic emergencies S.C admin e.g ketoacidosis, peri-operatively 30-60 mins onset 9 hrs duration examples actrarapid humulin S Insuman
name the intermediate acting insulins
duration of action
and time to onset
when is it injected
before meals, biphasic, minic bassal basal insulin isophane= insulin and protamine time to onset is 1-2 hrs duration is 11-24 hrs \examples Isophan/NPH I humulin I Novomix Humalogmix, Humulin M3
name the long acting insulins
duration of action
and time to onset
which brands are used in type 2 diabetics
minic basal insulin time to onset 2-4 hrs duration of action 36 hrs determir and lantus used in type 2 dm Examples determir -Levemir OD-BD as add on to liraglutide Glargine - lantus, toujeo OD Degludec- tresiba OD
What is the basal bolus regimen
when are the injections taken
what are the benefits/ diadvantages
when is it first line
long acting/ intermediate and short acting
basal injected at meal times
bolus taken twice or once a day at bedtime
advantage- closer to normal secreion profile, dose can be adjusted to carbohydrate in meal
Disadvantage for children at school
first line for newly diagnosed type 1 diabetics. ideal for busy pts because it is flexible
can be used in type 2 diabetics
what is the once daily regimen
who is for
what are the insulins in it
once daily of insulin
for type 1 diabetics alongide tablets
Insulins long acting or intermediate Isophane NPH
long acting is Ideal for pts who have hyperglycaemia in the day andn night
inttermediate is ideal for patients who experience hyperglycsemia at night and in the morning- in this case taken at night
what is the mixed / biphasic regimen
taken once, twice or three times a day
asssuming you have 3 meals a day- have to stick to regimen
has soluble/rapid and intermediate
can be used by both type 1 and type 2
type 1; ideal for pts who are consitent with day to day routine which includs 3 meals at similar times each day e.g school kids- no need for lunch injections
type 2 pts: who experience hyperglycaemia after meals\
not for actutely ill pts or newly diagnosed type 1 diabetics
Recommend in type 2 diabetics
what is the continous subcut insulin infusion (insulin pump)
rapid or soluble insulin
delived by pump via cannula or subcut needle
only for adults who suffer from disabling hypoglycaemia or hugh HBA1C over 69 mmol
initiated by specialists
what factors can reduce insulin requirements or cause a hypo
impaired food intake,
vomiting
imapired renal function
endocrine disorders e.g addisons, physical activity
what can increase insulin requirements- risk of hyperglycaemia
infection
stress
accidental or surgical trauma
Pregnancy - 2nd/3td trimester
what advice should you give a diabetic pt on sick days
SICK
s- sugar: nmonitor blood glucose more because they can rise when unwell some meds such as sulphonyureas and insulin may need to be increased
I-Insulin: never stop taking insulin or oral diabetic medication apart from-metformin, and SGLT2 inhibitors
C- Carbohydrate : ensure adequate carb and fluid intake. if cant keep food down then use sugary fluids ro replace meals wether blood glucose high or low. if blood glucose high then encourage fluid intake
K- Ketones: type 1 diabetics check ketones every 2- 4 hrs. if present then give extra rapid acting doses . maintain hydration to flush out ketones
Which meds need to be stopped if pt is SICK because it can lead to AKI if dehydrated
SADMAN
when can the pt restart taking meds
SGLT2 inhibitors ACEI diurectics metfromin ARBS NSAIDS can start taking again once pt can eat for 24-48hrs
what is teh important safety info associated with insulin
dont pull out insulin from insulin pen or cartridge because can result in wrong dose/ overdose= insulin pens or syringes should be used
units or international units must be written - not abbreviated
insulin deposits of amyloid protwin under skin- cutaneous amyloid. this interfers with absorption of insulin- ask pt to feel lump under injection site skin.
advise pt to rotate injection site
what is the patient and carer advose giebn to pts on insulin
hypoglycaemia- pts aware how to avoid hypo
insulin passports- PILS
driving skilled tasks- avoid hypo
if converting to human insulin what do you need to do to the insulin dose
bovine (cow) to human insulin = reduce dose by 10% toavoid hypo
porcine to human= no dose change
how long is the lifestyle approach trialled for befor starting anti-diabetic meds as a type 2 diabetic
3 months
name the biguanide drug
How it should be started
which pts it is appropriate for
risk of hypos/weight
metformin
1st line for all pts
no hypos- doesn’t stimulate insulin secretion
increase dose slowly to prevent G.I effects (OD-BD-TDS)
Offer MR if standard not tolerated
no effect on weight
side effects of metformin
taken with food or after food due to G.I effects
can cause lactic acidosis but rare- discontinue if seen
what are the contraindications associated with metformin
Acute metabolic acidosis including lactic acisosis and DKA
Ketoacidosis, renal failure- avoid in egfr under 30ml/min, general anaethesia
reanl failure increases risk of lactic acidosis
can metformin be used in pregnancy
can be used for pre existing and gestational diabetes - discontinue after birth for gestational
can use in breast feeding
Monitoring reqirements for metformin
renal function before starting and annually
pt and carer advise associated with metformin
warning signs of lactic acidosis which are - muscle cramos dyspnoa- difficult breathing abdo pain Hypothermia asthenia (lack of energy)
examples of sulphonyureas risk pf hypos/weight gain when it is used when to use long acting/short can it be used in pregnancy/ breast feeding weight
glicazide, glipizide, glipermaide, tolbutamide
causes hypo and gain weight
hypo more likley with long acting sulphyonyureas e.g glimepiride
for pts where metformin is contraindicated
avoid before surgery- change to insulin
avoid long acting in eldery- give short acting glicazide or tolbutamide
avoid in pregnancy and breastfeeding
side efefcts of sulfonyureas
G.I- N/V/D/C
Heptaic impairment- jaundice, hepatitis, hepatic failure
Allergic skin reactions in the first 6-8 weeks
what are the caustions and contraindications assocaiated with sulfonyureas
Acute polyuria, ketoacidosis
cautioned in elderly and G6PD deficiency
avoid or reduce dose in renal and hepatric himpairment
example of alpha glucosidase inhibitors
risk of hypos/ weight
acarbose
poorer anti hyperglycaemic effect than othe rantidiabetic meds
Interfers with sucrose absorption
give glucose not sucrose if hypo
Example of thazolidinediones
mhra warning
risk of which cancer
weight
pioglitazones
associaetd with heart failure increased risk with insulin
risk of bladder cancer
continue treatment only if hba1c decreased by at least 0.5% within 6months of starting treatment
weight gain
what are the side efects associated with pioglitazone
pee pioglitazone
bone fractures , weight gain, visual impairment, increased risk of infections and numbness
bladder cancer
what are the monitoring requirements for pioglitazones
liver function and advise pts to report signs of liver toxicity
examples of gliptins = DPP-4 inhibitors
weight
alogliptin, linagliptin, sitagliptin, saxagliptin, vidagliptin
no effect on weight
Contraindications and side effects of gliptins= DPP4 inhibitors
s/e= G.I, skin reactions
CI= diabetic ketoacidosis
Discontinue if symptoms of acute pancreatitis e.g persistent severe abdo pain
SGLT2 Inhibitors glifozins examples
mhra warnings
weight
canaglifozin, empaglifozin, dapaglifozin
canaglifozin- increased risk of lower limb amptuation
dapaglifozin avoid if egf under 15
insulin and sulfonyureas- may need to reduce the dose
weight loss
examples of glucagon like peptide 1 receptor agonists (GLP-1)
When to discontinue
women of child bearing age
when is it used over other antidiabetic meds
weight
exenatide, dulaglutide, liraglutide, lixisenatide and albiglutide
discontinue if acute pancreatitis
women of child bearing age wear effective contraception
used as combo therapy when other treatments have failed
weight loss
moa of alpha glucosidase inhibitors
acorbos inhibits intestinal glucosidases.
delay digestion and absorption of starch and sucrose. has small effect on lowering glucose
what is the moa of metformin
decreases gluconeogensis and increases peripheral utilisartion of glucose. acts in the presence of insulin- need functioning pancreas cells
moa of DPP-4 inhibitors
inhibit the DPP-4 enzyme to increase insulin secretion and lower glucagon secretion
moa of sulphonyureas
augment insulin secretion- effective only if pancreatic beta celle activity is present
moa of thiazodiazones
reduces peripheral insulin resistance leading to reduction of blood glucose
SGL2 inhibiotrs moa
reversibly inhibits SGLT2 in renal proximal convuluted tubule to reduce glucose reabsorption and increase urinary glucose excretion
moa of GLP-1
augment glucose dependent insulin secretiion and slows gastric emptying
meglitides MOA
Stimulate insulin secretion
What does the HBA1C reading have to be to start antidiabetic meds
first intensifacation
second intensification
48mol/mol aim to go below 48
58mmol/mol metformin plus … either sulphonyureas, pioglitazone, SGLT-2, DPP-4
if no improvement add third drug metformin plus another plus another: same as above or insulin treatment
what are the signd of hypoglycaemia
confusion shaking/ trembling sweating pins and needles paliptatioins conculsions headache double vision dlurring speech, unconscious , change in behaviour
how is hypoglycaemia managed if blood glucose is over 4mmol/l with hypo symptoms
small carb snack e.g bread/normal meal
how is hypoglycaemia managed when blood glucose is under 4mmol/ with or without symptoms of hypoglycaemia and is conscious and can swallow
Fast acting carbohydrate by mouth e.g lift glucose liquid, glucose tablets, glucose 40% gels e.g glucogel, dextrogel or rapilose
Wait 15 mins then give again to see if it goes up- can repeat 3 times/ if doesn’t raise after 45 mins then give IM glucagon or IM glucose and thiamine if alcohol pt
how is hypoglycaemia managed when blood glucose is under 4mmol/l and they are conscious but cant swallow
IM glucagon or IV glucose 10%
and thiamine in alcohol pts
when blood glucose is under 4mmol/l and pt is unconscious how is hypoglycaemia managed
IM glucagon or glucose IV 10%/20%
which foods should be avoided when trying to raise blood sugar in a pt experiencing hypoglycaemia
orange juice- high in potassium so avoid in pts with low potassium diet due to CKD
Chocolate and biscuits because they have a high fat content therefore can slow gastric emptying
dissovled sugar sucrose e.g pure fruit or sugar (not suitable for pts taking acarbose
how is blood glucose maintained straight after hypo episode where pt treated with a small snack
maintain with a snack such as a long acting carbohydrate e.g 2 biscuits, one slice of bread, 200-300ml of milk (not soya, almond etc
dont omit insulin but possibly change dose
what effect does glucagon have on glycogen and therefore when should it be avoided when treating hypoglycaemia
it mobilises glycogen in the liver and therefore should be avoided in pts whose liver glycogen is depleted e.g
alcohol induced hypoglycaemia , chronic hypoglycaemia , prolonged fasting, adrenal insufficiency , pts taking sulponyureas- give IV glucose instead
which drug classes are used for CVD complications associated with diabetes
ACEI
Low dose aspirin
lipid modifying drug
how is diabetic neuropathy prevented in diabetes
BP should be reduced to the lowest level to prevent decline of flomerular filtration rate and reduce proteinuria
test for urinary protein and serum creatinine
if negative test for microalbuminuria (earliest sign of neuropathy)
all diabetic pts with neuropathy should be given ACEI or ARB even if BP normal
ACEI also given to pts with CKD and proteinuria to reduce progression of CKD
which medications can be used in diabetic neuropathy
paracetamol, NSAID
Duloxetine, venlafaxine, amitriptyline, impramine
pregabalin, gabapentin
Opioids alongside pregabalin such as tramadol, morphine, oxycodone
autonomic neuropathy - tetracycline , erythromycin (unlicensed) , codeine
signs and symptoms of DKA
Dehydration due to polydipsia, polyuria weight loss excessive tiredness n and v abdo pain sweet or metallic taste in mouth Different odour to sweat fruity breath reduced consciousness deep and rapid respiration
What are the signs of HSS- hyperosmolar hyperglycaemic shock
tachy weakness hypotension poor skin turgor acute cognitive imapirment shock weight loss dehydration due to polydipsia or polyuria
cause onset Mortality in comparison to HSS Characteristics aims of treatment treatment of DKA
cause: infections, stress, acute illness, inadequate insulin
onset: rapidly- hours
Mortality in comparison to HSS- lower
Characteristics - hyperglycasemia, ketonaemia, acidosis
aims of treatment- clear ketones, correct electrolyte and hyperglycaemia
treatment- IV fluid replacement, followed by IV insulin, (continue long acting) potassium and then glucose if required
cause onset Mortality in comparison to DKA Characteristics aims of treatment treatment of HSS
cause: infections, stress, acute illness, inadequate insulin
onset- slower- takes days ,
Mortality in comparison to DKA- higher
Characteristics : hypovolaemia, hyperglycaemia and hyperosmolarity
aims of treatment: correct fluid and electrolyte losses, hypermosmolarity and hyperglycaemia, underlying causing
treatment: IV fluid then IV insulin and K stoppped or replaced if required
how is DKA managed
sodium/ potassium chloride 0.9% IV infusion if systolic BP < 90 mmHg for 10-15 mins. repeat if BP remains low ans seek medical advice
mix sodium chloride 0.9% with a soluble insulin in an infusion
monitor glucose, and ketone
continue with long acting insulins- give soluble insulin
how is diabetes managed in surgery
should have emergency treatment for hypo on drug chart
give insulin during durgey
adjust based on pts
on day before of surgey, insulin should be given as normal, execept long acting once daily should be given at reduced dose by 20%
on day of suregry stop all other insulins and continue with 80% long acting until pt is drinking and eating as normal.
Throughout the surgery then give glucose and insulin infusions(variable rate insulin is soluble IV kcl and glucose aand sodium) until 30-60 mins after 1 st meal
which diabetic drugs are stopped in surgery and which are continued
STOP Acarbose, sulpohonyireas pioglitazone Meglitinides SGLT2i Gliptins
CONTINUE
Metformin
GLP-1 agonist
In which situations may insulin may have to temporarily replace oral anti diabetic meds
MI, trauma, severe infections
what dose should folic acid be given at in pregnancy?
what should the hba1c be kept at in pregnancy
can lead to pre-ecamplsia, congenital malformations, hypertension
give folic acid 5mg
keep hba1c under 48mmol/mol
whihc drugs can be used in pregannacy
metformin
insulin
which insulin can you use in pregnancy
fast acting 1st choice aspart and lispro if using long acting isophane 1st choice determir or glargine- only if pts already on before pregnancy
which medications should be prescribed for pregnant / breast feeding women with diabetes
1st trimester advice pts to carry glucose/dextrose/ glucose drink
prescribe glucagon prn fpr type 1 diabetics
discontinue ACEI/ARB replace with methyldopa or labetalol
Discontinue statin
how is getsational diabetes treated
diet execise
metformin
add insulin to metformin
