Diabetes Flashcards
Name 6 clinical presentations of dm
- Hunger
- polyuria
- ketoacidosis (type 1 )
- thirst especially at night
- unexplained weight loss (type 1 )
- tiredness
Type 2: periodic changes in vision due to fluctuations in blood glucose concentration
Susceptibility to infections, especially of urinary tracts, respiratory tract and skin
How is diabetes mellitus diagnosed? (3)
Classic symptoms of polyuria and polydypsia associated with hyperglycaemia:
• random blood glucose ≥ 11,1 mmol / l
Or
• fasting (no caloric intake ≥ 8 hours) ≥ 7,0
For type 2: if screening and not symptomatic, 2 positive tests on separate days
Target for hbA1c, FBG, PPG for young, low risk, Newly diagnosed diabetics with no CVS disease?
hbA1c <6.5%
FBG 4-7
PPG 4.4 -7,8
Target for hbA1c, FBG, PPG for majority diabetics?
hbA1c < 7,0%
FBG 4-7
PPG 5-10
Target for hbA1c, FBG, PPG for 1 diabetics That are elderly, high risk, hypoglycemic unawareness, poor short term prognosis?
hbA1c <7.5% ‘
FBG 4-7
PPG <12,0
Target bp and BMI for diabetics?
Bp <140/90 (for type 2 keep ≥ 120/70 )
BMI ≤ 25
Name the 3 types of insulin and doses
- Short acting subcutaneous injections (Sc) 3x daily 30 min before meals
- intermediate acting sc once or twice daily usually at night at bedtime, approx 8 hours before breakfast
- biphasic sc once or twice daily
What is the makeup, onset of action, peak action and duration of action of short acting insulin?
- Regular human insulin
- onset 30 min
- peak 2-5 hours
- duration 5-8 hours
What is the, onset of action, peak action and duration of action of Intermediate acting insulin?
- Onset 1-3 hours
- peak 6-12 h
- duration 16-24 h
What is the Makeup, onset of action, peak action and duration of action of biphasic insulin?
- Mixtures of regular human insulin and intermediate in different proportions
- onset 30 min
- peak 2-12 h
- duration 16-24 h
Name and describe the 2 insulin regimens for dm 1
Basal bolus regimen: combined intermediate acting (basal) and short acting (bolus). Pre-meal short acting and bedtime intermediate acting not later than 22h00. Preferred in dm 1
Pre-mixed insulin: twice daily mixture of intermediate or short acting insulin and used with at least daily glucose monitoring - practical solution for those that can’t monitor blood glucose frequently
Dose Of basal bolus insulin regimen?
Initial total daily insulin dose: 0,6 units/kg/ body weight
Total dose divided into
• 40-50% basal insulin
• rest as bolus insulin, split equally before each meal
Adjust according to individual needs
How should patients draw up insulin from vials? (4)
• Clean top of insulin bottle with antiseptic swab
• draw air into syringe to number of marks of insulin required and inject this into the bottle, then draw the required dose of insulin into the syringe
. Before withdrawing needle from insulin bottle, expel air bubble if one has formed
Name 4 criteria for screening for diabetes 2 in children
• BMI > 85th percentile for age and sex • family history dm 2 • hyperlipidemic, ht or PCOS And Physical signs of puberty or age >10 years age
What baseline monitoring should be done for dm 2? (8)
- Serum creatinine concentration and calculate
- serum potassium concentration of on ace I or eGFR <30 ml /min
- Urine protein Dipstix - if negative send to lab for albumin: creatinine ratio unless already on ace-i. If positive, diabetic nephropathy
- BMI for cv risk assessment if appropriate
- blood lipids: fasting total cholesterol, triglycerides, HDL, LDL
- foot exam
- eye exam for retinopathy
- abdominal circumference
What annual monitoring should be done for dm 2 patients? (6)
- Serum creatinine conc and calculate egfr
- serum potassium if on ace-i or egfr <30
- urine protein by dipstix. If negative, send to lab for albumin: creatinine unless already on ace i
- hbA1c in patients who meet treatment goals (3-6 monthly in patients whose therapy has changed until stable)
- eye exam for retinopathy
- foot exam
First line treatment dm 2?
• Lifestyle modification, diet, weight loss
• Metformin 500mg oral daily with meals
Titrate dose slowly depending on hbA1c and or fasting glucose to max dose 850mg 8 hourly.
Name 4 contraindications to metformin
- Uncontrolled congestive cardiac failure
- severe liver disease
- patients with significant respiratory compromise
- severe renal impairment eGFR < 30
How should dose of metformin be altered with renal impairment?
EGFR > 30-60: use 50% of dose, max 500 Mg 12 hourly.. Monitor renal function 3-6 monthly.
If <30, stop.
Second line treatment dm 2?
Add sulphonylurea (glimepiride) to metformin and lifestyle modifications
Consider first line treatment failed after targets not reached after max dose of metformin for 2-3 months
Name the 2 sulphonylureas and doses that may be used for treatment of dm 2
- Glimepiride 1 mg daily with breakfast , adjust in 1 mg increments at 1 to 2 week intervals. Max 4 mg
- glibenclamide 2.5mg daily 30 minutes before breakfast, max 15 mg daily. If > or 7,5 needed, divide dose into 2 daily with larger dose in morning
Which sulfonylurea is Preferred in elderly?
Glimepiride
Contraindications to sulphonylurea use? (3)
Severe hepatic impairment
Renal impairment eGFR <60
Pregnancy
Third line treatment for dm 2?
Stop sulphonylurea and start insulin.
Add on insulin therapy (intermediate to long acting) starting dose and increments for dm 2?
Starting: 10 units in evening before bedtime but not after 22h00
Increments: increase gradually to 20 units, 2-4 units increase each week.
Substitution insulin therapy (biphasic) starting dose and increments for dm 2?
Starting: twice daily. total daily dose 0,3 units /kg/day divided as 2/3 30 minutes before breakfast and 1/3 30 minutes before supper
Increment: 4 units weekly. First increment added to dose before breakfast, second added to dose before supper.
Indications for urgent same day referral in dm 2? (8)
• acidotic breathing • dehydration and hypotension • nausea, vomiting, and abdominal pain • ketonuria >1 • hyperglycaemia >25 • Gangrene • sudden deterioration vision • serious infections consider iv infusion with Nacl 0.9% before transfer very ill patients
5 s’s of diabetic foot exam?
Shoes - clean, comfortable , give support
Shape - known deformities
Skin - lost skin, ulcers, amputation, calluses, nails fungal infection, infection between toes
Sensation - pins and needles. Small, middle and big toes of both feet
Supply of blood - claudication, check pulses dorsalis pedis and post tibial
How diagnose DKA? ‘
Blood glucose ≥ 11,1 and ketones in urine at least 1+
How diagnose hyperosmolar hyperglycaemic state HHS?
Blood glucose >40
How many people in sa have diabetes?
2,5 million registered
At least 5% of pop
How diagnose hypoglycaemia?
< 4 blood glucose
Most immediate danger to life
How long does dm 2 take to get diagnosed on average?
4 years at least
Name 6 autonomic symptoms and signs of hypoglycaemia
- tremors
- Palpitations
- sweating
- hunger
- fatigue
- pallor
Metformin Drug class?
Biguanide
Name 7 neurological symptoms and signs of hypoglycaemia
- Headache
- mood changes
- low attentiveness
- speech slurred
- dizzy
- unsteady gait
- depressed loc / convulsions
What is most serious adverse reaction to metformin?
Lactic acidosis
Name signs and symptoms lactic acidosis (5)
• Muscle pain and weakness
• tachypnoea acidotic breathing
• abdominal pain diarrhea , nausea vomiting,
• extreme tired, decreased appetite , dizzy,
. Feeling cold , flushing or sudden reddening and warmth in skin
Name Common side effects metformin (5)
• Git upsets: bloating, pain, reflux , nausea vomit, diarrhoea, constipation etc • weight loss • headache • unpleasant metallic taste in mouth • erectile dysfunction possibly Taper up slowly to avoid
Name serious side effects metformin (2)
- lactic acidosis
* anemia
Glimeperide (sulfonylureas) moa
Stimulates insulin secretion
Name 5 side effects sulfonylureas
- Signs low blood sugar
- hunger and weight gain
- Skin reactions
- git complications
- dark coloured urine
Metformin moa (3)
Reduces hepatic glucose production by inhibiting gluconeogenesis and glycogenolysis
and increase insulin sensitivity, improving peripheral glucose uptake and utilisation and delays intestinal absorption.
Also stimulate intracellular glycogen synthesis by acting on glycogen synthase and increase transport capacity of all types of membrane glucose transporters
How calculate estimated average glucose from hbA1c?
1,5x
Eg hbA1c of 10 is average of 15-16
Name 4 microvascular complications diabetes
- Neuropathy: peripheral, autonomic, acute onset
- foot ulcers
- diabetic nephropathy
- retinopathy
Name 3 macrovascular complications diabetes
Aka cardiovascular risk
Hypertension
Ischaemic heart disease
Atherosclerosis which can lead to angina pectoris, mi, strokes, peripheral artery disease
Target LDL HDL and total Cholesterol for diabetics?
<1,8 LDL
HDL >1 men, 1.2 women
Total <4.5
