Diabetes Flashcards
What is a HbA1c measurement?
It reflects average plasma glucose over the previous 2-3 months; measures glycated haemoglobin which forms when red blood cells are exposed to glucose.
HbA1c tests can be used to diagnose Type 2 diabetes, but not type 1 diabetes. Which other patient categories should it not be used to diagnose diabetes in?
Children
Women that are up to 2 months post-partum
HIV infected patients
End-stage CKD
Acutely ill patients
Had diabetes symptoms less than 2 months
For type 1 and type 2 diabetics, how often should HbA1c be measured?
Type 1: Every 3-6 months, or more if needed
Type 2: Every 3-6 months, when stable can be reduced to every 6 months
What are the units used for blood-glucose concentration in the UK?
mmol/litre
What are the risks associated with diabetic women becoming pregnant?
-Pre-eclampsia
-Rapidly worsening retinopathy
-Miscarriage
-Stillbirth
-Congenital malformations
What should diabetic women who are planning to get pregnant aim to keep their HbA1c below?
48 mmol/mol (6.5%)
Folic acid should be offered to all diabetic women that are planning to get pregnant. True or False?
True
Which oral antidiabetic drugs should be discontinued before pregnancy, and swapped to insulin?
All except metformin
Metformin is unsafe during breast-feeding. True or False?
False- it is the only safe oral antidiabetic drug
Which insulin is the first-choice for long-acting insulin during pregnancy?
Isophane insulin (can keep women on their current long-acting insulin analogues such as insulin detemir and insulin glargine if their control is good)
At what point during pregnancy is the risk of hypoglycaemia highest?
First trimester- advise to always carry a fast-acting form of glucose
During pregnancy, which antihypertensive medication should be stopped?
ACE inhibitors and ARBs- swap to more suitable alternative
Gestational Diabetes
-Women with gestational diabetes who have a fasting plasma glucose below 7 mmol/litre at diagnosis, should first attempt a change in diet and exercise alone in order to reduce blood-glucose. If blood-glucose targets are not met within 1 to 2 weeks, metformin hydrochloride may be prescribed. Insulin may be prescribed if metformin is contraindicated or not acceptable, and may also be added to treatment if metformin is not effective alone.
-Women who have a fasting plasma glucose above 7 mmol/litre at diagnosis should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise.
-Women who have a fasting plasma glucose between 6 and 6.9 mmol/litre alongside complications such as macrosomia or hydramnios should be considered for immediate insulin treatment, with or without metformin hydrochloride.
-Women with gestational diabetes should discontinue hypoglycaemic treatment immediately after giving birth.
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What are some potential complications of diabetes?
Diabetic nephropathy
Neuropathy
Retinopathy
Stroke
Cardiovascular disease
How can the CVD risk in diabetics be reduced, besides being well-controlled?
ACE inhibitors, or ARBs. Also statins
For all diabetic patients with confirmed nephropathy and an ACR of 3mg/mmol, how should they be treated?
An ACE inhibitor or ARB, even if BP is normal
What drugs can be used to treat painful diabetic peripheral neuropathy?
Amitriptyline
Pregabalin
Gabapentin
Opioid analgesic can be used alongside gabapentin if pain is not adequately controlled with monotherapy
How can autonomic neuropathy be managed?
Tetracycline
Codeine
What is a diabetic foot infection?
Diabetic foot infection is defined as any type of skin, soft tissue or bone infection below the ankle in patients with diabetes. It includes cellulitis, paronychia, abscesses, myositis, tendonitis, necrotising fasciitis, osteomyelitis, and septic arthritis. It is defined clinically by the presence of at least 2 of the following: local swelling or induration, erythema, local tenderness or pain, local warmth, or purulent discharge.
What is the oral first-line antibiotic for a mild diabetic foot infection?
Flucloxacillin (then clarithromycin, doxycyline or erythromycin-pregnancy if unsuitable)
For moderate or severe diabetic foot infections, what is the first-line antibiotic treatment?
`Flucloxacillin with OR without IV gentamicin and/or metronidazole
OR
co-amoxiclav with OR without IV gentamicin OR IV ceftiaxone with metronidazole
If pt has a penicillin allergy then co-trimoxazole with or without IV gentamicin and/or metronidazole would be used.
What is diabetic ketoacidosis (DKA) and Hyperosmolar hyperglycaemic state (HHS)?
Diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycamic state ((HHS), previously referred to as hyperosmolar non-ketotic (HONK) coma) are medical emergencies with significant morbidity and mortality. HHS has a higher mortality than DKA.
What are the main precipitating factors for both DKA and HHS?
- Infection (main one)
-Discontinuation or inadequate insulin therapy
-Acute illness such as MI
-New onset of diabetes
-Stress
DKA mainly affects type 1 diabetics, where HHS is more likely to occur in T2 diabetics. True or false?
True
DKA
-Develops rapidly within hours
-Mainly occurs in T1 diabetics
-Characterised by hyperglycaemia, ketonaemia (elevated ketone levels) and acidosis (low venous pH).
-Common signs include dehydration, weight loss, fatigue, nausea, vomiting, abdominal pain, acetone breath and reduced consciousness.
Treatment involves IV fluid replacement and IV insulin, as well as potential electrolyte replacement. The aim is to restore cirulatory volume and to correct electrolyte imbalance and high BG, clear ketones.
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HHS
-Can take days to develop
-Features tend to be hypovolaemia, marked hyperglycaemia (above 30mmol/L) and hyperosmolality.
Commons signs include dehydration, weakness, weight loss, tachycardia, hypotension, acute cognitive impairment.
Main aim of treatment is to correct fluid and electrolyte losses, hyperosmolality and hyperglycaemia and to prevent complications. IV fluid replacement and IV insulin is the main treatment.
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What is lipohypertrophy?
Can occur due to repeatedly injecting insulin into the same area- can cause erratic insulin absorption
What are short-acting insulins used for?
To replicate the insulin usually produced around meals, so they are used at meal times.
What are the two types of short-acting insulins?
Soluble insulins (very rarely used0
Rapid-acting insulin
Rapid-Acting Insulin
-Insulin aspart, insulin glulisine and insulin lispro
-Onset within 15 minutes, should be injected immediately before meals
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Intermediate-Acting Insulin
-Isophane insulin- can be given as a one or more daily injection alongside separate meal-time short-acting uslin injections
-Biphasic insulins: pre-mixed insulin preparations that contain short-acting and intermediate-acting insulin.
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Long-Acting Insulin
- Mimic endogenous basal insulin secretion, can last up to 36 hours.
-Insulin glargine and insulin degludec are given once a day, insulin detemir is once or twice daily.
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What is the first choice antihypertensive treatment for a diabetic?
Ramipril
How many grams of carbohydrate should be used to treat a hypo?
15-20g
Management of Ketoacidosis
-IV fluid replacement
-IV insulin- patients who take long acting insulin should continue taking this insulin throughout treatment.
Same management for HHS
Management of Diabetic Nephropathy
-If no contraindications, patients with an ACR of 3mg/mmol or more should be started on an ACEi (ARB if CI), even if BP is normal.
-For T2 patients with CKD that are already on an ACEi or ARB, an SGLT2 inhibitor should be offered if the ACR is over 30mg/mmol (consider if between 3-30mg/mmol).
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How should diabetic nephropathy initially be managed?
Starting an ACEi or ARB
What is the requirement if if someone has a hypo whilst driving?
Stop, eat, wait 45 minutes after BG normalised before continuing to drive
What is the HbA1c target for a type 2 diabetic controlled by lifestyle alone, or lifestyle+metformin?
48 mmol/mol (6.5%)
What is the HbA1c target for a type 2 diabetic controlled by lifestyle + an antidiabetic drug that can cause hypoglycaemia?
53 mmol/mol (7.0%)
What are some potential microvascular complications of diabetes?
Retinopathy
Neuropathy
Nephropathy
Foot problems
Metabolic- dyslipidaemia, Ketoacidosis, Hyperosmolar, HHS
What are some potential macrovascular complications of diabetes?
Coronary heart disease
Cardiomyopathy
Arrhythmias
Cerebrovascular disease
Peripheral artery disease
