DIABETES Flashcards
What is the target fasting blood glucose level
4-7mmol/L
What are the 3 rules for making insulin dose adjustments
Make 1 adjustment at a time
make small adjustments
review blood glucose levels 2-3 days after adjustment
What does it mean if the blood glucose level is rising over night several nights a week?
Basal dose is too low and needs to be increased
What does it mean if the blood glucose level falls over night
basal dose is too high
How should you adjust the insulin dose if the patient is on 10 units or less
increase/decrease by 0.5 units
How should you adjust the insulin dose if the patient is on 10-20 units
increase/decrease by 1-1.5 units
How should you adjust the insulin dose if the patient is on 20-30 units
increase/decrease by 2-2.5 units
How should you adjust the insulin dose if the patient is on more than 30 units
increase/decrease by 3-4
What issues should be checked before adjusting the insulin dose?
is the carb counting accurate? Are injection sites lumpy? are injections given 10-20 minutes before meals? was any exercise done? any injections missed?
What should the blood glucose level be after eating?
3-10mmol
What is the Once daily insulin regimen and who is it suitable for?
Suitable for type 2 and for people that require assistance in taking injections. Involves either long acting peakless insulin or an intermediate
What is the twice daily insulin regimen and who is it suitable for?
Type 1/type 2. Must stick to consistent daily routine with 3 meals on this regimen. Biphasic due to 2 phases of activity: mix of short and intermediate.
What is the basal/bolus insulin regimen and who is it suitable for?
4/more injections daily. Basal = once or twice. Bolus at each main meal. Involves long acting or intermediate acting dose with short or rapid insulin at each meal. Common in type 1: offers flexibility over when meals are taken and allows dose variation in response to different carb quantities in meals
What is the continuous s/c insulin infusion/pump regime and who is it suitable for?
Insulin pump connected to body constantly. At mealtimes increase bolus of insulin delivered to control blood glucose levels
What is the fixed dose insulin regimen and who is it suitable for?
Fixed dose at each meal, can be on this and another regimen, no flexibility with carbs
Discuss rapid acting insulins (when taken, onset, peak and duration of action, examples)
Novorapid, humalog taken just before, with or after food onset of action = 10-20 mins peak of action= 1-3 hours duration of action 2-5 hours
Discuss short acting insulins (when taken, onset, peak and duration of action)
Actrapid, humulin s, insuman rapid taken 15-30 minutes before food onset of action: 30-60 mins peak of action: 1-5 hours duration of action: 5-9 hours
Discuss intermediate acting insulins (when taken, onset, peak and duration of action)
Insulatard, humulin 1, insuman basal taken about 30 mins before food or bed time onset of action= 60-90 mins peak of action 2-12 hours duration of action = 12-24 hours
Discuss intermediate acting insulins (when taken, onset, peak and duration of action)
Insulatard, humulin 1, insuman basal taken about 30 mins before food or bed time onset of action= 60-90 mins peak of action 2-12 hours duration of action = 12-24 hours
Discuss long acting insulins (when taken, onset, peak and duration of action)
levemir, lantus, tresiba
Taken once or twice a day
onset of action 2-4 hours, 6-14 hour or no peak, action between 16 and 42 hours
Discuss mixed acting insulins (when taken, onset, peak and duration of action)
Novomix, humalog, humulin, insuman.
Taken before or just after food, fast acting, with peaks after 1-4 hours but up to 24 hour coverage
When must meals be eaten around ultra rapid acting insulin?
Meals must be spaced out to prevent stacking of insulin
In hospital, what must be remembered with rapid acting insulins?
Wait 4 hours before redosing
What is the honeymoon phase?
A period where no insulin or reduced insulin is required, can last up to a year and requires careful counselling
How do you calculate total daily dose of insulin?
0.3-0.5 units per kg, split as 50% basal and 50% bolus, bolus split across 3 meals
how do you calculate how much one unit of insulin will drop blood sugar?
1800(TDDx18)
How should insulin be adjusted if a patient is experiencing morning hypos
Give more in morning and less at night - 2/3 basal in morning and 1/3 at night
How should insulin dose be adjusted if the patient is experiencing erratic levels and hypos
Give a flatter profile insulin, with a 10-18% increase/ decrease in strength
How can diabetes be managed?
Healthy diet, lose weight, stop smoking, attend diabetes checks, regular foot care, regular blood tests every 3 months then every 6 months when stable
What hba1c is classed as pre diabetic
42mmol/L
What are the symptoms of hypoglycaemia?
Sweating, palpitations, tremor, hunger, confusion, drowsiness
What are risk factors for hypos
history of hypos, decreased awareness, impaired renal funtion, dementia, alcohol misuse, starvation and high exercise, food malabsorption, glucose level less than 3mmol/L
What counselling should be given around injection technique?
Wash hands, roll bottle, draw up correct dose, clean and pinch injection site, safely discard.
Rotate the injection site to prevent lipohypertrophy which can lead to insulin dumping
How do you calculate the amount of insulin an individual will need to follow sick day rules?
Calculate total daily dose (total of all meal time and background insulin) and calculate 10-20% of this
Which medications should be stopped according to sick day rules?
Metformin - can make you dehydrated sulfonylureas gliclazide, glibenclamide, gliplizide exenatide, liraglutide, semaglutide, flozins ace inhibitors ARBs
How should blood sugars and ketones be managed on sick days?
Check blood sugars and ketones
How should a patient act if they have tested their blood glucose and their ketones are less than 1.5mmol/L?
Sip sugar free fluids
Test blood glucose and ketones every 2-4 hours
Usual insulin:carb at meal time
use corrective quick acting insulin if blood glucose is raised
when unwell, may need larger bolus to reduce
if glucose levels above target, consider a 10-20% increase in basal dose
How should a patient act if their blood ketones are more than 1.5mmol/L or blood glucose is above 13mmolL
Sip sugar free fluids
test blood glucose or ketones every 2 hours
calculate total daily dose from previous day
What should a patient do if their blood ketones are 1.5-3mmol/L on blood test
Give 10% of TDD as quick acting insulin every 2 hours plus usual insulin:carb if eating. basal dose may need a 10-20% increase in basal dose.
If ketones still present, go back and result
What should patients do if their ketones are over 3mmol/L on a blood test
Give 20% total daily dose as quick acting insulin, plus usual insulin:carb. May need to increase basal by 10-20%. If ketones still present, go back and restart process
What should a patient do if ketones are still present after 4-6 hours or if they vomit
go to hospital as it is an emergency
What are the driving rules?
Check blood glucose less than 2 hours before the start of a journey and every 2 hours after driving has started. If 5.0mmol or less, eat a snack. If 4.0mmol or less don’t drive. Don’t drive until 45 mins after reading is 5mmol/l. tell DVLA if more than 1 sever hypo when driving in last 12 months.
What is diabetic ketoacidosis?
severe lack of insulin so body uses fat for energy instead of sugar, releases ketones
Ketone build up leads to blood becoming acidic
What are the symptoms DKA?
Toilet, thirsty, tired, thinner, confusion, blurred vision, stomach pain, feeling pain, sweet/fruity smelling breath.
How should you avoid DKA?
Monitor sugar levels and alter insulin in response to what you eat
What is the treatment pathway for type 2 diabetes?
Manage lifestyle issues
Offer a structured education programme DESMOND.
Target HBA1c 53mmol/L measure 3-6 monthly
1st line metformin dose gradually increased to minimise GI AEs
Monitor renal function <45mL/min.1.73m2 review dose, stop if <30mL/min.1.73m2
What should be given to type 2 diabetic patients if Metformin is contraindicated?
If metformin is not tolerated or C/I – Gliptin - sitagliptin – Pioglitazone – Sulphonylurea - gliclizide – SGLT-2i - canagliflozin
What can be done if patients have GI disturbances due to metformin?
Give m/r metformin
What should be given second line for type 2 diabetes if metformin is ineffective?
For people for whom metfomin is ineffective combine metformin with:
–Gliptin
–Pioglitazone
–Sulphonylurea
–SGLT-2i
For those who don’t tolerate metformin combine:
–Gliptin plus pioglitazone
–Gliptin plus sulphonylurea
–Pioglitazone plus sulfonylurea
–Substitute a SGLT-2i instead of a gliptin
What should be given if second line diabetes treatment fails?
If second line fails:
For people who can take metformin:
– Triple therapy with metformin, a gliptin, and a sulfonylurea, or
– Triple therapy with metformin, pioglitazone, and a sulfonylurea, or
– Triple therapy with metformin, pioglitazone or a sulfonylurea and an SGLT-2i. (The SGLT-2i dapagliflozin in a triple therapy regimen is recommended as an option for treating type 2 diabetes in adults, only in combination with metformin and a sulfonylurea NOT pioglitazone), or
– Starting insulin-based treatment.
For people in whom metformin is contraindicated or not tolerated:
– Consider starting insulin-based treatment.
What should be given in type 2 diabetes if third line treatment fails?
For people on triple therapy with metformin and two other oral antidiabetic drugs, consider combination treatment with metformin, a sulfonylurea, and a glucagon-like peptide-1(GLP-1) mimetic (exenatide) for:
– Adults who have a body mass index (BMI) of 35 kg/m2 or higher (adjust accordingly for people from Black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity, or
– Adults who have a BMI lower than 35 kg/m2 and insulin therapy would have significant occupational implications, or weight loss would benefit other significant obesity-related comorbidities.
For people on insulin-based treatment:
– Seek specialist advice (or refer the person to their diabetes team) for consideration of treatment with a GLP-1 mimetic plus insulin.
