Diabetes Flashcards
What is diabetes?
Raised blood glucose level due to problem with insulin
What is insulin?
A hormone secreted into the blood by the beta cells of the pancreatic islets
What does insulin stimulate?
Uptake of glucose into cells, particularly liver, muscle and adipose tissue
Is type 1 diabetes insulin-dependent or non-insulin dependent?
Insulin-dependent
What causes type 1 diabetes?
The autoimmune destruction of beta cells
When does type 1 diabetes occur?
Juvenile onset (from childhood)
Is type 2 diabetes insulin-dependent or non-insulin dependent?
Non-insulin-dependent
Is type 1 or type 2 diabetes more commonly seen?
Type 2
What is the main onset of type 2 diabetes?
Maturity onset (usually middle age)
Which type of children/teenagers can develop early onset of type 2 diabetes?
Overweight
What causes type 2 diabetes?
Combination of insulin resistance and relative insulin lack
What is gestational diabetes?
Diabetes in pregnant women
What are the symptoms presented in type 1 diabetes?
Polyuria
Polydipsia
Weight loss
Blurred vision
What are the symptoms presented in type 2 diabetes?
May be asymptomatic
Similar to type 1 but less rapid and dramatic
Long term complications
What are predisposing infections of type 2 diabetes?
Candida in urine and mouth
What is the prevalence of diabetes in percentage in the population of the UK?
6%
Which racial groups are particularly predisposed to diabetes?
South Asians (Indian, Sri Lankan)
Native Americans (Pima, Arizona)
What is the peak onset age of type 1 diabetes?
10 to 14
What is the test used to diagnose type 2 diabetes?
75-gram oral glucose tolerance test
How does the 75-gram oral glucose tolerance test work?
Fast patient overnight
Measure blood glucose in a fasted state in the morning (<6.0 is normal; 6.0-7.0 is impaired fasting glucose; >7.0 is diabetes)
Give 75 grams of oral glucose in a liquid form
Measure blood glucose level again after 2 hours (<7.8 is normal; 7.9-11.0 impaired glucose tolerance; >11.0 diabetes)
What is the abbreviation of glycated haemoglobin?
HbA1c
How long is the life span of haemoglobin in red cells?
120 days
What is the normal glycated haemoglobin level?
<42 mmol/mol
What is the pre-diabetes glycated haemoglobin level?
42 to 47 mmol/mol
What is the diabetes glycated haemoglobin level?
> 48 mmol/mol
What are the aims of diabetes treatment?
Control symptoms
Prevent complications
Lead a normal life (no need to rely on measuring blood glucose or injecting insulin on a daily basis)
What is type 1 diabetes glucose control?
Always needs insulin
What is type 2 diabetes glucose control?
Diet to lose weight/less carbs or sugar
Diet plus tablets/injected drugs
Diet plus insulin
What will happen to type 1 diabetic patients if they stop their insulin replacements?
Die rapidly
Will type 2 diabetic patients die rapidly if insulin replacement is stopped? Why?
No, they are not insulin-dependent
What raises blood glucose?
Food
Glucagon
Adrenaline
Cortisol
Growth hormone
Illness/stress (makes you eat more)
What lowers blood glucose?
Starvation
Insulin
Anti-diabetic drugs
Exercise
Illness/stress (makes you eat less/starve)
What do oral hypoglycaemic drugs do?
Lower blood glucose levels
What are the classes of oral hypoglycaemic drugs (and examples) that increase insulin secretion/act as insulin secretagogues?
Sulphonylureas eg gliclazide
DPP4 inhibitors eg sitagliptin, vildagliptin
GLP-1 binders eg exenatide, liraglutide (injected)
What are the classes of oral hypoglycaemic drugs (and examples) that increase the action of insulin/act as insulin sensitisers?
Biguanides (metformin)
Thiazolidinediones (glitazones eg pioglitazone)
What class of oral hypoglycaemic drugs (and examples) have a mechanism of increasing glycosuria?
SGLT-2 inhibitors eg empagliflozin, campagliflozin
How is insulin administered?
Injected subcutaneously
What are some basic equipment that can be found on someone with insulin-dependent diabetes?
Vial of insulin + syringe
Insulin pen injector
Finger prick blood test kit
Glucose monitor
What type of glucose monitor only gives readings when interrogated?
Flash glucose monitor
What type of glucose monitor constantly transmits results to a device and gives warnings of high/low glucose?
Continuous glucose monitor
How is insulin administered?
Subcutaneous injection
What type of insulin is chemically modified, intermediate/long-acting, looks cloudy hence needs to shake the solution before drawing it up into syringe, is bound onto another molecule so it’s absorbed more slowly where its absorption activity peaks at ~4 hours and lasts for ~12 hours?
Isophane insulin
When is the peak of the absorption of the short-acting soluble insulin eg Actrapid or Humulin S?
~ 1 hour
How long does the short-acting soluble insulin last eg Actrapid or Humulin S?
~ 6 hours
What are the different types of short-acting insulin? Give example brands.
Soluble - Actrapid, Humulin S
Insulin Aspart - Novorapid
Insulin Lispro - Humalog
What are the different types of intermediate/long-acting insulin? Give example brands.
Isophane insulin - Insulatard, Humulin I
Insulin Glargine - Lantus
Insulin Detemir - Levemir
What are the different types of biphasic insulin? Give example brands and concentrations.
Biphasic Isophane Insulin - Mixtard 30 (30% soluble; 70% isophane), Humulin M3 (30% soluble; 70% isophane)
Biphasic Insulin Aspart - NovoMix 30 (30% insulin aspart; 70% aspart protamine)
Biphasic Insulin Lispro - Humalog Mix25 (25% insulin lispro; 75% lispro protamine)
When are biphasic insulins injected in a day according to the twice-daily soluble and isophane insulin regimen?
Morning before breakfast
Evening before dinner
How does the basal-bolus insulin regimen work?
Injection of long-acting insulin once a day (timing does not matter as it lasts for 24 hours; usually given at night or first thing in the morning)
Injection of short-acting soluble insulin with each meal
How is basal-bolus regimen better than twice-daily regimen?
Meal times can be more flexible
Which regimen is the insulin pump usually preset to deliver?
Basal bolus regimen
Do insulin pumps use short or long-acting insulin?
Short-acting insulin
What are some acute diabetes complications?
Ketoacidosis (type 1 diabetes)
Hyperosmolar hyperglycaemic state (type 2 diabetes)
Hypoglycaemia
What are some chronic diabetes complications?
Microvascular - retinopathy, neuropathy, nephropathy
Macrovascular - peripheral, coronary, cerebral
Foot problems (numb feet/amputations)
How to manage mild and/or benign background diabetic retinopathy (where there are microaneurysms, which are formed on the arterials, bursting to cause microhaemorrhages which are benign and do not cause problems because they are out on the periphery of the vision)?
Monitoring
How to prevent more advanced diabetic retinopathy where the blood vessels have actually burst and caused a severe haemorrhage that damages the central vision?
Laser photocoagulation
What feet problems can a diabetic patient present?
Black toe(s)
Neuropathic foot ulcer(s)
How to remove black toe?
Ray amputation
Falls off itself
How to manage diabetic patients with neuropathy of the feet where they can’t feel their feet?
Good foot care/hygiene
Podiatrists pare down thick skin using scalpels (chiropody)
Pads in shoes to prevent rubbing (protection)
Form a habit of constantly checking feet to see if there are any damages that can’t be felt
Wear well-fitting footwear
What is the condition called which is when there is a diabetic motor neuropathy affecting the hands causing wastage of hand muscles and stiffening of the fingers?
Diabetic cheiroarthropathy
How to prevent long-term complications of diabetes?
Meticulous glucose control
Control of blood pressure
Avoidance/treatment of other risk factors eg smoking, hyperlipidaemia, obesity, inactivity
Early detection and management - screening
What are the benefits of good glucose control whereby glycated haemoglobin is reduced by 11mmol/mol?
Reduce microvascular complications by 25%
Reduce amputations by 43%
Reduce heart failure by 16%
Reduce cataracts by 19%
What would glucose control that is too tight increase the risk of?
Hypoglycaemia
How to treat established diabetic retinopathy?
Laser photocoagulation
Careful monitoring
How to treat established diabetic nephropathy?
ACE inhibition
Dialysis
Transplantation
What are the treatment options for established diabetic peripheral vascular disease?
Bypass surgery
Angioplasty
Amputation
What happens in hypoglycaemia?
Plasma glucose level is too low
What are the causes of hypoglycaemia in diabetic patients?
Insulin
Oral hypoglycaemics
What are the warning symptoms of hypoglycaemia (in response to increased adrenaline in the body)?
Tremor
Anxiety
Palpitations/tachycardia
Hunger
Dry mouth/Thirst
What are the established symptoms of hypoglycaemia (neuroglycopenic; usually don’t get warning symptoms beforehand)?
Confusion/aggression
Slurred speech
Incoordination
Coma
Convulsions
Irreversible brain damage
Death
What do the established symptoms of hypoglycaemia in diabetic patients mimic?
Drunkenness
How to treat hypoglycaemia?
Establish diagnosis by measuring the blood glucose (definite hypoglycaemic range for a diabetic is <4; 4 is the floor)
If in doubt, treat anyway
Oral glucose (glucose tablets or drinks with sugar)
Buccal hypostop gel (glucose gel in a squeeze bottle)
Intramuscular glucagon 1mg (won’t work in patients with liver disease or severe starvation)
Intravenous glucose 20-30ml 50% (has to have a good large cannula that goes straight into the vein as it is a strong acid that can burn skin)
What is the resuscitation protocol (ABCDEFG) when we see anyone in a state of collapse, confusion, or unconsciousness?
Airway, breathing, circulation, don’t ever forget glucose
Why does glucagon come in dry powder form which needs to be mixed with a diluent in a vial and then drawn up into the syringe before intramuscular injection?
It has a poor shelf life in solution
Where is the most convenient place to inject glucagon?
Large muscle of the outer thighs
Which type of diabetes can diabetic ketoacidosis be presented in?
Type 1 diabetes
What causes diabetic ketoacidosis in type 1 diabetic patients?
Omitting insulin (before getting diagnosed) or
intercurrent illness
What does diabetic ketoacidosis (complete lack of insulin) cause?
Hyperglycaemia
Osmotic diuresis - leading to dehydration
Loss of Na in urine
Loss of intracellular K in urine
Accumulation of ketone bodies (soluble ketone acids that accumulate in the blood)
How long does it take for the onset of clinical features of ketoacidosis?
Over 12 to 24 hours
How to control pH of blood when acid builds up due to ketoacidosis?
Slow, deep breathing (Kussmaul respiration) to remove carbonic acid
How to prevent diabetic ketoacidosis?
Never omit insulin in type 1 diabetes
If unwell and off food, still take insulin, monitor carefully and take liquid form carbohydrate
If unable to keep any food down, immediate admission for intravenous treatment
Education of patient and doctor and dentist
What is the treatment given in the case of a medical emergency of diabetic ketoacidosis?
Intravenous insulin infusion
Intravenous rehydration and electrolyte replacement
Treat underlying causes such as infection or myocardial infarction
Secondary prevention (making sure patient understands how to prevent this from happening again)
What is the newer term for hyperosmolar non-ketotic coma?
Hyperosmolar hyperglycaemic state (HHS)
Although similar, how is the hyperosmolar hyperglycaemic state different from diabetic ketoacidosis?
Still have a bit of insulin so no build-up of ketoacids
Slower onset (over days)
Occurs in type 2 diabetes
Slower correction/rehydration
How to manage diabetic patients during dental surgery (don’t usually require fasting)?
Check control and usual treatment/ways of monitoring
Check for relevant complications
List first in the morning to minimise disruption to their routine
FIngerprick check glucose before and after procedure, be prepared to treat hypoglycaemia
Give a mid-morning snack before leaving surgery
Remember that diabetes increases the risk of infections with any surgery (does not need prophylactic antibiotics)
How to manage diabetic patients for short hospital procedures requiring fasting?
Omit morning insulin and breakfast
Get procedure done fast/first on the list
Give insulin treatment and breakfast immediately afterwards
Check if they are okay
How to manage diabetic patients for major or longer hospital procedures?
Treat in hospital
Intravenous treatment with drip and insulin
GKI - glucose, potassium, insulin infusion
Monitor glucose hourly
Adjust insulin content of bag to maintain normal glucose levels between 6 and 12
