Diabetes Flashcards
What are the target blood levels preprandial and at bedtime? (2)
Preprandial: 4-6mm/L
Bedtime: 6-8mm/L
What are the core areas for diabetes management? (3)
Education- about diabetes, managing diabetes, health care issues, complication avoidance
Targets- it is higher later in the day to prevent overnight hyperglycaemia
Reduce risks from associated diseases
ETR
When is insulin required in Type 1 diabetes?
FROM DIAGNOSIS- require insulin from the outset as the presentation features of ketoacidosis are as a result of inadequate levels of insulin
When is insulin required in Type 2 diabetes?
WITH INADEQUATE CONTROL ON ORAL MEDS- type 2 will often present with complications of diabetes or hyperglycaemia and they still have adequate insulin secretion to prevent ketoacidosis- however, sometimes the control of their blood sugar is better managed with insulin than with medication
What are the insulin regimes ? (2)
basal-bolus and split-mixer
Describe a basal bolus regime?
- More injections
- better control
- offer a single long lasting insulin which provides a background for the whole day to prevent ketoacidosis and then the patient will take intakes of short acting insulin to allow for meals and exercise to be properly regulated
Describe a split mixer regime?
- Fewer injections
- poorer control
- fewer injections needed mainly to facilitate care by external agent (nurse), patient may have only two injections of insulin throughout the day before breakfast and before evening meal
- this insulin contains both rapid acting and medium acting insulin so that the blood sugar is maintained less well but adequately over the course of the day
Compare basal bolus vs split-mixer
basal bolus has more injections but better control whereas split-mixer has less injections but poorer control
How is an insulin injection given?
sub-cutaneous
Where can insulin be injected into?
Any area of the body
Why is the injection site often rotated?
Often can lead to fat atrophy (loss of fatty tissue, pitting, scarring and bumps)
What is a new method of insulin injection?
insulin pens can be used in which they patient can dial the number of units of insulin they require and then use the needle to inject under the skin
What are 4 areas of diabetes management for the patient?
-Structured education- appropriate to the patient’s needs, evidence driven, supporting written resources
-healthy living advice- personalised diabetes management plan, dietary advice, lifestyle interventions where appropriate (for example weight loss and exercise)
- Blood glucose management- explain targets and the need to maintain them
- Consider prevention to reduce risk - anti-platelet drugs, statins, antihypertensives when appropriate
What are the 3 areas which can assist with Type 1 diabetes management?
Nutrition, Exercise, Monitoring
How can you manage the nutrition in patients with T1DM? (3)
-glycaemic index of foods compared with a standard food (GIndex of food is the equivalent of the glucose load provided by that food)
-carbohydrate counting- basal-bolus regimes
-less that 10% calories from saturated fat
How can you manage T1DM through exercise?
- Planned Activity
- lower blood glucose levels
-if this happens when unplanned it could lead patient to
developing hypoglycaemia
- lower blood glucose levels
- understand individual response
-will be necessary to maintain appropriate blood sugar levels during exercise by increasing carbohydrate intake at that time
How can you manage T1DM through monitoring?
-previous insulin dose determines plasma glucose
-initially need regular checks until the patient is familiar with their personal response to food and exercise
What sugar level are patients with T1DM aiming for?
6-10 (ideally closer to 6)
What is meant by different preparations being available ?
Time to act from injection - ultra long, long and short
-mixed forms possible to reduce injections (not too common)
What is the ideal blood glucose sugar levels?
6-10% HbA1C (ideally lower end score)
What is the relationship between HbA1C and hypoglycaemia?
the lower the HbA1C is, the higher the risk of hypoglycaemia (can be catastrophic if happens at an inopportune moment)
What can a high HbA1C increase the risk of progression of? (Hint: key change that happens as a complication of diabetes)
Retinopathy
Name two new insulin monitoring options…
Continuous glucose monitoring and closed loop glucose monitoring
How does a continuous glucose monitor work? (3)
- this device attaches to the skin and has a small needle which monitors the tissue fluid levels subcutaneously
- it will then relay this to a monitor and the patient will get an alert if their blood sugar exceeds the target range
- this will educate the patient and make then aware of anything which makes their blood sugar levels rise or fall too far
How does a closed glucose monitor work?
- the monitor is attached to an insulin pump which will change the amount of insulin delivered to the body in a continuous way in response to the subcutaneous sugar level
- these will become much more widely available and should allow for much better control of diabetes for most patients
How is T2DM generally managed ? (3)
Lifestyle
Medication
Surgery
Ways in which a patients lifestyle can affect the management of T2DM?
weight loss
diet restriction
Key diet restrictions which aid the management of T2DM? (3)
avoid refined CHO
encourage high fibre food
reduce fat, esp. saturated
What surgery can contribute to the management of T2DM ?
Gastric vertical banding
bariatric surgery
Name 4 T2DM medications
Biguanides - ‘Metformin’
DDP-4 inhibitors (gliptins)
GLP-1 (glucagon-like peptide) mimetics
Sulphonylureas
Describe the use of ‘Metformin’ (4)
- first line drug for T2DM
- enhance cell insulin sensitivity
- reduce hepatic gluconeogenesis (reduce over effects of glucagon)
- preferred in the obese
Describe ‘DDP-4 inhibitors’ (gliptins)
- they block the enzyme metabolising incretin
- incretins are released from the stomach in response to sugar absorption - and these incretins stimulate insulin release
-therefore, if the enzyme metabolising these incretins is blocked, the incretins will be maintained in the circulation for longer and improve the response of the body to glucose in producing insulin
-improves insulin response to glucose
-reduces liver gluconeogenesis and delays stomach emptying - which releases the sugar at a slower rate into duodenum
Describe the ‘GLP-1 mimetics’
- increase the levels of incretin
injection daily/weekly
same effects as DDP-4 inhibitors
they will improve insulin response and by doing so reduce effects of Type 2 diabetes
Describe Sulphonylureas
-increase pancreatic insulin secretion
can cause hypoglycaemia
When would insulin typically be used in T2DM? (3)
patients unable to maintain glycaemic control with:
- behavioural changes
- body weight reduction
- oral hypoglycaemic agents
Name the 2 key types of diabetes complications
Acute
Chronic
What is an acute complication of diabetes?
Hypoglycaemia
Why might an acute diabetes complication occur in a type 1 patient ?
- when there is a mismatch between the amount of insulin and the amount of sugar available
- if the patient injects insulin but then fails to have an adequate meal they will become hypoglycaemic
… need to make flash card on acute complication for T2DM
Name 3 chronic diabetes complications (3)
-cardiovascular risk
- infection risk
- neuropathy
Describe the cardiovascular risk (chronic diabetes complications)
from macro-vascular changes to blood vessels with increased atherosclerosis
What is atherosclerosis?
build up of (plaque) fats, cholesterol and other substances in and on the artery wall, the plaque can cause the arteries to narrow, blocking the flow. The plaque can also burst leading to a blood clot
What consequences are both infection risk and neuropathy ?
microvascular consequences
What does the patient develop over time with acute hypoglycaemia?
autonomic dysfunction
Why does autonomic dysfunction occur?
the microvascular changes in the nutrients supply to the autonomic nerves (and the nerves become less able to send signals)
What warnings does the patient get that they are becoming hypoglycaemic? (3) and why can this hypoglycaemic episode be aborted?
sweating
tremor
confusion
these are spaces out over a period of time giving the patient an opportunity to take some sugar
Why might a patient experience these hypo symptoms quickly instead of spaces out?
They may have been diabetic for some time and the microvascular changes bunch these changes much closer together (very little warning they are about to go hypo)
Name 5 small vessel diseases which pose as a diabetic complication
- poor wound healing
- easy wound infections
- renal disease
- eye disease
- neuropathy
Name a large vessel diabetic complication?
Atheroma
- angina & MI, claudication, anneurysm (ballooning of artery, weakness in walls)
Name 3 examples of diabetic eye disease and briefly describe these
Cateracts - will often see a very hazy image, gradually
develop change
Maculopathy - you lose high density cone section of the
retina, lose detailed vision
Proliferative retinopathy - blood vessels will grow across the
back of the retina, these may then burst leading to
haemorrhage onto the back of the retina and gradually
obliteration of the visual part of the eye
What does retinopathy produce?
Retinopathy produces changes to the small blood vessels growing out across the retina they proliferate and produce very thin poor walled vessels which will then haemorrhage onto the back of the eye
How is Diabetic Retinopathy treated?
laser therapy
- branches of vessels are targeted and obliterated so that there is no longer any blood flowing through weak walled areas - prevent damage in longer term
Describe the general sensation of diabetic neuropathy
‘Glove and Stocking’
peripheral nerves affected first - fine touch in hands and feet first
Describe Motor neuropathy..
weakness and wasting of muscles
includes autonomic tissues which can affect bowel and bladder dysfunction
Describe autonomic regulation in diabetic neuropathy
awareness of hypoglycaemia lost
postural reflexes can be reduced
bladder and bowel dysfunction
How do postural reflexes effect patients in the dental setting?
standing position from lying flat in dental chair
(Diabetes) What do patients usually receive prior to surgery ? (In a hospital setting)
to be established on a glucose drip
Why to patients need insulin and Carbohydrates in type 1 diabetes ?
need insulin to prevent ketosis
need carbohydrates to prevent hypoglycaemia
Describe metabolic changes associated with surgery ?
-Hormone changes aggravate diabetes
-more glucose production and less muscle uptake
-metabolic acidosis more likely
-patients with type 1 diabetes may need to remain in hospital until insulin regime is re-established
Which hormone changes aggravate diabetes? (3)
epinephrine
cortisol
growth hormone
Describe insulin requirements in T1DM and T2DM with surgery.
- increased insulin requirements in T1DM
- T2DM may require insulin cover peri-operatively (changes associated with surgery may make patients sugar control poorer during the time they require it the most- to help with infection resistance and wound healing)
name 5 dental aspects of diabetes to be aware of
be aware:
effect of dental treatment - food intake may be disrupted
acute emergencies
diabetic complications - IHD, dehydration, neuropathy, eyes
infection risk
poor wound healing
What are diabetes Mellitus and Insipidus abnormalities of?
Mellitus: abnormality of glucose regulation
Insipidus: abnormality of renal function
What percentage of diabetes is type 1, 2 and monogenic?
1: 10%
2: 85%
Monogenic: 5%
Simple definition of diabetes?
Elevated levels of glucose in the blood, a series of metabolic conditions sharing the major characteristic of hyperglycaemia
True of False: Diabetes is caused by hyperglycaemia
False
the disease itself is not caused by hyperglycaemia but the effects of the multi-system disease is due to other factors, usually the levels of insulin
what can be used at a measure of disease activity in diabetic patients?
Hyperglycaemia
What can exposure to chronic hyperglycaemia increase the risk of? (2)
microvascular complications
long term macro-vascular disease ß∑Ω#
