Diabetes Flashcards
What are the symptoms of diabetes?
T1DM vs T2DM
polyuria - due to osmotic diuresis
polydipsia - stimulated by fluid and electrolyte losses
weight loss - caused by fluid depletion and muscle/fat breakdown (lipolysis) due to insulin deficiency
hyperglycaemia
glycosuria
ketoacidosis - due to fats being used for energy instead of glucose
weight gain
blurred vision
fatigue
thrush/genital
slow wound healing
T1DM - thirst, polyuria, weight loss, lethargy and ketoacidosis
T2DM - same symptoms but less marked and extending over several months
How is diabetes investigated?
fasting blood glucose levels > 7mmol/L
random blood glucose levels > 11.1mmol/L
oral glucose tolerance test
Hb1Ac > 48mmol/L, > 6.5%
What are the risk factors and complications associated with diabetes?
cardiovascular disease
- other risk factors are smoking, hyperlipidaemia, hypertension and obesity
= can be treated with NRT, statins and ACEi (non-black) or ARB (black)
What are the
types of insulin + brand name
duration of action
benefits
short acting
= for uncontrolled DM, emergencies and low risk of hypoglycaemia/nighttime hypos
= given with meals and basal-bolus regimen
- soluble insulin = Actrapid
- insulin aspart = Novorapid, Fiasp
- insulin lispro = Humalog
intermediate acting
= for controlled DM with fixed meals/schedule and has an increased risk of hypoglycaemia
= given once or twice daily
- insulin isophane = Humulin, Insulatard
- suspension of insulin with protamine
long acting insulin
= for uncontrolled DM, emergencies and have a low risk of hypoglycaemia/nighttime hypos
= given as basal-bolus regimen
- insulin determir = Levemir
- insulin glargine = Lantus, Toujeo
- insulin degludec = Tresiba
How should blood glucose be monitored in DM?
fasting blood glucose
blood glucose before meals
blood glucose 90 mins after meals
blood glucose before driving
fasting blood glucose - 5-7mmol/L
blood glucose before meals - 4-7mmol/L
blood glucose 90 mins after meals - 5-9mmol/L
blood glucose before driving - at least 5mmol/L
What is an insulin passport?
should be offered to all patients receiving insulin
- provides a record of the patient’s insulin preparations and emergency information
- provides advice on safe use of insulin
What is the first line treatment for T2DM?
lifestyles changes before any pharmacological treatments
- smoking cessation
- reduce caloric intake = lose weight
- a mediterranean diet
- moderate to vigorous physical activity of >150 min
What are
insulin sensitiser
insulin providers
incretin based therapies
gastrointestinal glucose absorption inhibitor
renal glucose reuptake inhibitor
insulin sensitiser - metformin, pioglitazone
insulin providers - insulin, sulfonylureas, meglitinides
incretin based therapies - GLP-1 receptor agonists, DPP-4 inhibitors
gastrointestinal glucose absorption inhibitor - acarbose
renal glucose reuptake inhibitor - SGLT2 inhibitors
How does metformin work?
What are the advantages and disadvantages?
What are the cautions?
Increases insulin sensitivity and uptake by skeletal muscle
Suppresses hepatic gluconeogenesis
- activates AMPK
advantages - weight loss, does NOT cause hypos
disadvantages - GI side effects, lactic acidosis
caution - do not use in hepatic or renal impairment (eGFR < 30ml/min/1.73)
How do sulfonylureas work?
What are the advantages and disadvantages?
What are the cautions?
Stimulates pancreatic insulin secretion by blocking K+ channels in pancreatic beta cells
advantages - reduces Hb1Ac
disadvantages - weight gain, GI side effects, hypersensitivity reaction
caution - risk of hypoglycaemia, increased risk of hepatic and renal impairment, contraindicated in ketoacidosis
How does pioglitazone work?
What are the advantages and disadvantages?
What are the cautions?
enhances insulin release
- increased peripheral glucose uptake + reduces gluconeogenesis
= via PPAR-TZD complex affecting transcription of genes needed for glucose and fatty acid metabolism
advantages - increased insulin sensitivity
disadvantages - weight gain, peripheral oedema
caution - CI in heart failure, hepatic impairment, bladder cancer and increases risk of bone fracture
How do DPP-4 inhibitors work?
What are the advantages and disadvantages?
What are the cautions?
sitagliptin, saxagliptin
delays inactivation of GLP-1 by blocking DPP-4 which metabolises it
- GLP-1 is an incretin that increases insulin release
advantages - well tolerated, reduces appetite, weight loss
disadvantages - GI side effects, headache, sore throat, hypersensitivity reactions
cautions - increased risk of pancreatitis, urticaria and angioedema, requires dose titration in chronic kidney disease
What is the advantage of Linagliptin?
What is the risk associated with Canagliflozin?
DPP-4 inhibitor
can be used in renal impairment
SGLT2 inhibitor
- increased risk of amputation
How do SGLT2 inhibitors work?
What are the advantages and disadvantages?
What are the cautions?
Inhibits renal absorption of glucose
advantages - weight loss, can reduce blood pressure
disadvantages - increased risk of UTI’s and thrush, euglycaemic diabetic ketoacidosis
caution - avoid in CKD (works on the kidney so has no effect if it is dysfunctional), avoid use with diuretics (excessive fluid loss), risk of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
What are the side effects of alpha glucosidase inhibitors?
GI side effects
- flatulence, bloating and diarrhoea
How do GLP-1 receptor agonists work? How are they taken?
What are the advantages and disadvantages?
What are the cautions?
are incretin mimetic so act in the same way
- increases insulin secretion from beta cells after meals
- suppresses glucagon release,
- reduces gastric emptying, increases satiety
are given via subcutaneous injections
advantages - weight loss
disadvantages - GI side effects
caution - increased risk of pancreatitis
What are the blood pressure target levels in diabetes? How often should it be monitored? What are the treatment options? What treatment should not be used?
T1DM
- T1DM = 135/85 mHg or less
- T1DM with metabolic syndrome symptoms = 140/90 mmHg
T2DM
- T2DM and less than 80 yrs = 140/90 mmHg
- T2DM and older than 80yrs = 150/90 mmHg
monitor every 1-2 months
non-black ethnicity - ACE inhibitor
black ethnicity - ARB
women with the possibility of becoming pregnant - CCB (ACEi and ARB are teratogenic) = labetolol or nifedipine
beta blockers can mask the symptoms of hyperglycaemia - masks anxiety/palpitations
What tests can be done to monitor and diagnose diabetes?
urine testing for glucose
- for elderly patients where tight control is unnecessary
urine ketones
- ketouria indicates diabetic ketoacidosis
microalbuminurea
- marker of diabetic nephropathy
albumin creatinine ratio (ACR)
<30mg/g is normal, 30-300mg/g is raised, >300mg/g is severely raised
= marker of early reversible diabetic nephropathy
Hb1Ac (glycosylated haemoglobin)
- <48mmol/L is normal, <53mmol/L for T2DM on more than 2 medications or single drug associated with hypos (S)
Glycosylated plasma proteins (fructosamine)
- useful in haemoglobinopathies = sickle cell disease
