Diabetes Flashcards
1
Q
what is OGTT?
A
oral glucose tolerance test
2
Q
what is normal fasting glucose levels?
A
4-6mmol/L
3
Q
what is normal post -prandial adult blood glucose?
A
<7.8mmol/L
4
Q
what is normal HbA1c in adults?
A
<53mmol/L
5
Q
what do you do if someone has borderline levels?
A
clinical judgement to decide what is most appropriate for patient
6
Q
what glucose levels would be deemed as impaired?
A
5.6-6.9mmol/L
not failed but are failing
7
Q
what is the majority of the pancreas’ function?
A
digestive makes up 95%
8
Q
where is the pancreas in respect to the stomach?
A
retroperitoneal and lies deep to greater curvature of the stomach
9
Q
what do the duct cells secrete?
A
aqueous NaHCo3 solution
10
Q
what do acinar cells secrete?
A
digestive enzymes
11
Q
what two ducts form the main bile duct?
A
common bile duct and common hepatic duct
12
Q
why is having 2 hormones important for control of blood glucose?
A
allow for tighter regulation - insulin and glucagon
13
Q
how do negative feedback systems work?
A
if one increases it will work to decrease back to normal?
14
Q
how does positive feedback mechanisms work?
A
responses increases deviation
15
Q
do the Islets of Langherhans equate to a large % of pancreatic mass?
A
no about 2%
16
Q
how mnay Islets of Langherhans are there within pancreas?
A
1.5 million and spread out throughout
17
Q
what do alpha cells secrete?
A
glucagon
18
Q
what cells secrete insulin?
A
beta cells of pancreas
19
Q
what secretes somatostatin cells?
A
delta cells of pancreas
20
Q
what is the role of somatostatin cells?
A
inhibit insulin and glucagon
21
Q
what do epsilon cells do?
A
increase appetite
22
Q
what do pancreatic polypeptides do?
A
promotes GI fluid secretion and feeling full
23
Q
what is satiety?
A
feeling of fullness
24
Q
what is glycogenesis?
A
glycogen to glucose
25
what is gluconeogenesis?
using amino acids/ glycerol to make glucose
26
can you store amino acids well in the body?
not very well
27
what occurs duirng periods of hyperglycaemia (following meals)?
beta cells are stimulated and they release insulin into blood
insulin triggers glucose absorption into cells
then will be converted into glycogen
28
what is HbA1c?
test to measure glycation of RBC over past 2-3months
29
why is HbA1c measuring past 2-3mths?
RBC lifespan is 120 days
30
what is T1DM aetiology?
genetic, auto-immune mechanisms, can be environmental linked
31
what is the pathophysiology of T1DM?
pancreas function suddenly declines - no insulin produced
results in hyperglycaemia - hence symptoms
32
when is common onset of T1DM?
early
10-14yrs for diagnosis
more common in europeans
33
what are symptoms of T1DM?
weight loss
polydipsia, polyuria, glycosuria
first presentation may be a DKA
34
what are symptoms of DKA?
dehydration and acidosis
nausea, abdo pain, tachypnoea, tachycardia, acetone breath
35
what is T2DM aetiology?
higher genetic deposition than T1
lifestyle and exercise
obesity
36
what is T2DM pathophysiology?
due to prolonged hyperglycaemia, peripheral tissues stop responding to insulin
pancreas works harder to produce more insulin
vicious circle
results in desentisation
less insulin secreted, less receptors
37
what is HHS or HONK?
hyperosmolar hyperglycaemia state
very high glucose result sin dehydration - water follows glucose that needs to be excreted by urine as no other way
there are no ketones as there is some insulin
38
what is diabetes insipidus?
not diabetes
lack of ADH - causing polyuria hence got similar name
39
what tissues get priority for glucose during fasting periods?
glucose -requiring - CNS has a huge glucose need
degradation of liver glycogen first to get glucose
40
which hormones promote glycogen degradation?
adrenaline and glucagon
41
which receptor is responsible for bringing in glucose?
GLUT-4 - when insulin binds the transporter is moved to membrane to allow for glucose to be brought in
42
what is the role of incretins?
released following a meal - stimulates insulin release
makes you feel full, promotes gastric emptying
reduce glucose synthesis
43
in diabetics what is the lowest BM result you want?
4mmol/L
4 is the floor
44
at 3mmol/L what symptoms are likely?
mild neurological and cognitive impairment slightly
45
what lifestyle advice is given to T1DM?
- Health balanced diet – low fat/ sugar. Lots of fibre/ fruit and veg
- Specialist diabetes dietician referral
- Smoking cessation
- Reduce alcohol intake
- Physical exercise – 30mins 5xweek
- Manage weight to healthy BMI
- Regular diabetes check ups: most GP surgeries have a special diabetes clinic – can detect and treat complications. They check HbA1c, cholesterol, BP. Diet/ lifestyle. Eye, urine, foot, sensory and blood tests
46
how long is the onset on rapid acting insulin?
10-20mins
47
how long does rapid acting last?
2-3hrs
48
give examples of rapid acting insulin?
vovorapid
aspira
49
how long does short acting insulin take to work?
<20mins
50
what examples of short acting insulin?
actrapid
Humulin S
51
which insulins are clear suspension?
short acting - no zinc crystals
52
name some examples of intermediate acting inuslin?
HUmulin I
Insulatard
Insuman basal
53
how long does intermediate insulin last?
4-12hrs
54
give some examples of long acting insulin?
Lantas
levemir
abagalar
55
how long does ultra long analogue insulin last?
steady state after 2-3 days
56
how can long acting insulin prevent hypos?
basal control in biphasic therapy
prolonged plateau that is fairly stable
57
how do you prepare cloudy mixtures?
invert 10x to resuspend
58
what analogue insulin?
more like human
59
what is soluble insulin?
modified insulin - better absoption
60
why is basal bolus regime the gold standard?
short acting/ rapid acting at meal times
long acting is during other periods of the day to provide basal control
61
how does carb counting work?
- Determining dose of insulin from amountof carbs that you eat – more freedom and can not having to restrict as much
62
in carb counting what is the ration between carbs and insulin?
1:10 insulin to carb
eg for 70g of carbs, you would need 7 units of insulin
63
what can DAFNE do?
dose adjustment for normal eating
- support group in T1DM
64
what is the initial dose of starting insulin?
0.2-0.4 units/kg/ day
65
how many units of insulin is needed for a small meal?
4 units
66
how many units of insulin are needed for a large meal?
8 units
67
name some examples of devices used to administer inuslin?
- Vial and injection – hospital care
- Pre-filled pen – patient own
- Cartridges and re-usable pen – patient own
- Continuous subcutaneous insulin infusion pump
68
when might a continuous subcutaneous insulin pump be used?
recommended in those 12+ that will require multiple injections a day or have disabling hypos or if their BM remains high despite continuous injections. Children may be eligible if they require many injections through the day or injections are inappropriate
69
what are the advantages of using insulin pumps?
better control of BM (less high and lows)
- Less injections
- More flexibility in what you eat
- Better accuracy when bringing BM down
70
what disadvantages are using insulin pumps?
pump is attached all the time except for small breaks eg swimming/ showering
- Infusion can sometimes get blocked – might need to change at short notice
- Lots of education required about pump
- Small risk of infection – cannula inserted at all times
- Always need to know which insulin – still need to finger prick
71
how do you store insulin?
in the fridge
can be in room air for 30 days
72
where on the body do you inject insulin?
– in stomach in subcutaneous fat layer (thigh, buttock can be used).
never through clothes
73
where on the body do you never want to inject insulin?
avoid back of arm - risk of getting into muscle - unpredictable absorption - hypo risk
74
what needle sized should be used for injecting insulin?
4-5mm needle to ensure it goes into subcutaneous fat
75
what are lipotrophies caused by?
caused by poor administering technique
76
what are lipotrophies?
fatty lumps die to repeated insulin injections - unsightly, painful and unpredictable absorption
77
how do you reduce lipotrophies?
rotate between sites and within sites - new needle for each injection and avoid injecting into lumps
78
why does a reused needle have less accurate penetration?
microscopic changes - less sharp
79
why is there no need for 24hr basal insulin in T2DM?
managed by insulin secretion in the B cells
80
which antidiabetic medication with insulin has a risk of hypos?
sulfonylureas
81
insulin and glitazonees have a risk of what condition?
heart failure
82
how often should a diabetic check their insulin?
4x a daily - before each meal and bed
83
what is continuous flash glucose monitoring?
the circle on people arms
all T1DM have should have access or T2DM who require lots of injections daily
84
what is defined as hypoglycaemia?
<4mmol/L
85
what can cause hypos?
- Causes: too much diabetes medication, delaying/ missing meal/ snack. Not eating enough carbs, taking part in too much unplanned/ strenuous activity. too much alcohol or drinking alcohol without food
86
what BM is seen in a DKA?
>11mmol/L
87
what capillary ketones is seen in DKA?
≥ 3mmol/L
88
what pH is seen in DKA?
≤7.3
89
what are symptoms of DKA?
acetone breath, tachycardia, hypotension, acidosis, hyperglycaemia, hyperkalaemia, polyuria
90
how do you manage DKA?
: fluids, replace K+, fixed rate insulin (0.1 units insulin/ kg/hr), hourly monitoring and senior input, needs glucose potentially
91
why do you replace fluids first in DKA management?
as the fluid dehydration will kill first
92
what is VRIII?
variable rate insulin?
93
when would be VRIII be indicated?
hyperglycaemia, vomiting (no DKA), NBM, severe illness to achieve good glycaemic control
94
what do you do with a patients normal insulin during hypo/ HHS/ DKA?
keep going with normal insulin regimes
95
would you give glucose if someone has DKA?
yes later in management - to stop ketones being created by burning fat
96
what are SICK day rules?
management in HHS/ DKA/ hypo
S: sugar – check Bm every 2-3hrs – even more if children/ pregnant
I: Insulin – continue to take meds even when unwell to prevent DKA
C: carbs: make sure you take enough carbs in and rink enough fluids – not all sugary
K: ketones – check blood or urine ketones every 4hrs, take rapid insulin if ketones are present. Drink lots of fluids to flush out ketones in system
97
when should you inform the DVLA?
- Inform DVLA if taking insulin/ have had 2+ hypos in last year/ if hypos are disabling or unable to recognise start
98
what is recommended for diabetics to do with driving?
- Check BM before driving and every 2hrs on long journeys.
- Eat some carbs before driving
- Have hypo treatment in car
- Have snacks incase of delays
99
what is T2DM characterised by?
insulin resistance - impaired secretion, receptor resistance
100
how much of the cases does T2DM account for?
90-95%
101
what HbA1c do you aim for in T2DM?
48mmol/L
102
if 48mmol/L is not achievable what HbA1c should be aimed for?
53mmol/L
103
what should BM be before meals?
4-7mmol/L
104
what should BM be 2hrs after eating?
<8.5mmol/L
105
how often should HbA1c be measured?
checked every 3-6mths until it is stable than 6mths following
106
what is the DESMOND programme?
- Diabetes, Education, Self Management for Ongoing and Newly Diagnosed
supportive and patient education
107
what BP should be aimed for in T2DM?
<140/90
108
what BP should be aimed for in T2DM in those with albuminuria or other features of metabolic disease?
<135/85
109
what does hyperglycaemia do to the body?
- Neurotransmitter dysfunction
- Increased lipolysis and reduced glucose uptake
- Increased glucose reabsorption in kidneys
- Decreased incretin effect- released after eating and signal for insulin to be released
- Increased hepatic glucagon secretion in liver
- Impaired insulin secretion in pancreas
110
what medication is the gold standard in T2DM?
metformin
111
what is the action of metformin?
reducing hepatic glucose production, intestinal absorption of glucose, increasing glucose utilisation by enhancing the action of insulin at peripheral receptors
- Needs to be taken with meals
112
when does metformin need to be taken?
with meals
113
what are the advantages of metformin?
: no weight gain, has CVD protective effects -reduce risk of MI and stroke, do not cause hypoglycaemia, cost effective and long term evidence
114
what are the disadvantages of metformin?
starting dose is 500mg daily and needs to be titrated upwards over period of weeks, often limited bu GI side effects. Care is eGFR <45
115
does elective surgery effect metformin?
stop 48hrs prior to surgery
continue 48hrs following
116
name some sulfonylurea examples?
glictazide - short acting
glimepride - long acting
117
what is the action of sulfonylureas?
stimulates insulin secretion by acting directly on pancreatic beta cells
- Increase tissue sensitivity to insulin
- Requires residual beta cell function
118
what can sulfonylureas cause?
hypos in T2DM
119
name DDP-4 inhibitors
gliptins
120
what are the actions of DDP-4 inhibitors?
inhibiting DDp-4 which acts on GLP1 pathway to increase insulin secretion and lower glucagon secretion
121
name some GLP-1 agonists
exenatide, semaglutinade
122
which is the action of GLP-1 agonist?
: binds to and activates the GLP-1 receptor: increase insulin secretion, decrease glucagon secretion, slow gastric emptying
123
what are thiazolididiones?
glitazones
124
what is the action of thiazolidiones?
: agonist of receptor called PPAR-gamma which enhances the action of insulin on liver, fat and skeletal muscle by increasing glucose uptake into muscle cells, reducing insulin resistance, decreasing hepatic glucose production
125
name some SGLT-2 inhibitors?
dapaglifloxin
126
what is the action of SGLT-2 inhibs
reversibly inhibits sodium – glucose co transporter (SGLT-2). Reduces glucose re-absorbtion and increases urinary glucose excretion. It is an osmotic diuretic
127
what is the difference between DKA and HHS?
DKA - T1DM and ketones present
HHS - T2DM and no ketones
128
what can be triggers for hypos?
- Infection, over exercise, undereating, missed eating, delayed meals, gastroparesis (delayed gastric emptying), hypo unawareness, too much insulin (self harm, admin error), lipohypertrophy, renal failure, medications (sulfonylureas – stimulates insulin release from B cells – T2DM have some insulin secretion anyway)
129
which type of symptoms appear first in a hypo?
autonomic - general - sweating, confusion, pale
130
when would neuro symptoms appear in a hypo and what symptoms?
persistent - difficulty in speaking, loss in conc, drowiness, dizziness, hemiplegia, fits, coma, death
131
what are macrovascular complications of diabetes?
: affects larger blood vessels
- Hypertension
- Arterial stiffness
- CKD
- Stroke
- MI
132
what are microvascular complications of diabetes?
as smaller vessels experience atherosclerosis – causing ischaemia
- Retinopathy
- Nephropathy
- Neuropathy
133
how many diabetic patients experience microvascular complications?
>80%
134
how many newly diagnosed diabetics have microvascular complications?
20-50%
135
what is retinopathy?
- Damage to blood vessels in retina due to hyperglycaemia
136
what are the stages of retinopathy?
background diabetic retinopathy
pre proliferative retinopathy
proliferative retinopathy
advanced diabetic retinopathy
137
what is seen in background diabetic retinopathy?
dots (micro-aneurysms) and blots ( small haemorrhages). Hard exudates – lipid that collect in circle around leaking blood vessel – yellowing deposits with sharp margins
138
what is seen in pre proliferative diabetic retinopathy?
: cotton wool spots – fluffy opaque areas that result from retinal ischaemia. Venous changes – bleeding in segmental dilators
139
what is seen in proliferative retinopathy?
: cotton wool spots – fluffy opaque areas that result from retinal ischaemia. Venous changes – bleeding in segmental dilators
140
what is seen in advanced diabetic retinopathy?
– areas of neo-vascularisation lead to recurrent vitreous haemorrhage. The neo-vascularisation is usually on surface of iris and retina becomes ischaemic. The ischaemic retina releases VEGF – stimulating angiogenesis – new blood vessels grow in abnormal areas eg iris. It eventually becomes fibrotic, closing the normal angle of the eye and prevents fluid from leaving which increases intraocular pressure – neovascular glaucoma
141
why is lens swelling common in newly diagnosed diabetics?
- The hyperglycaemia causes the movement of water into the wrong places which results in lens swelling
142
apart from retinopathy, what other eye complications can occur in diabetics?
- The hyperglycaemia causes the movement of water into the wrong places which results in lens swelling
143
what management is used within diabetic retinopathy?
yearly eye screening, optimiase glycaemic control, manage BP, if later stages – laser photocoagulation can prevent angiogenesis, visual aids and DVLA regulations
144
what is the first sign of diabetic nephropathy?
microalbuminuria
145
what diagnostics can be involved in diabetic nephropathy?
- Yearly eGFR and urinary albumin excretion (first pass morning urine specimen- albumin: creatinine ration of >3mg/mol) can help diagnose if tests are raised for >3mths
146
why can you not diagnose diabetic nephropathy from one abnormal protein test?
levels may vary so need at least 3
147
what management is used within nephropathy?
- ACEi/ ARB should be started ideally before HTN to control BP
- Optimiase glycaemic control
- Reduce dietary protein to <0.7-1g/kg/day
148
what can be seen in distal symmetrical polyneuropathy?
glove and stocking neuropathy
- Numbness, pain, altered sensation, pain, neuropathic ulcers, joint abnormality
149
what is mononeuritis multiplex?
multiple individual nerves that cause issues in diabetic neuropathy
150
what can be seen in autonomic neuropathy?
: postural hypotension, neuropathic bladder, erectile dysfunction and sexual dysfunction. Gastroparesis, gustatory sweats and diarrhoea
151
what is the management within diabetic neuropathy?
- Avoid touching limbs – they have loss of sensation if broken skin they have increases infection risk. The protective film has been disrupted
- Duloxetine, amitriptyline, pregabalin – NICE says no drug is more superior
- Basic analgesia (paracetamol, opiates)
- Improve glycaemic control
152
what do you do in a diabetic foot exam?
inspect for ulcers, ischaemic, amputation, necrosis, clawing, charcots, temps
- Check sensation – monofilament
- Vibration sense
- Reflexes
- They all have different nerves for these different responses
- Pedal pulses
153
what is osteomyelitis?
infection that penetrates bone
154
in diabetic neuropathy what occurs first?
peripheral neuropathy - loss in sensation
patients unaware of foot injury - can not feel it
155
what symptoms would be seen in motor neuropathy?
: raised arch and clawed toes – pressure is mainly on pressure points and callus form – haemorrhage or necrosis can occur within callus and can ulcerate
156
what symptoms are seen in autonomic neuropathy?
reduced sweating leads to dry and cracked skin - portal for infection
157
what would peripheral vascular disease manifest as?
reduced blood supply to feet - ischaemia to peripheries
158
what is diabetic neuropathy management?
- Prevention – annual foot screening, education, wash feet daily, check feet regularly, well fitting shoes, do not walk barefoot
- Foot ulcer- relieve pressure (rest, total contact casting), treat infection, if severe – surgical debridement/ amputation
159
what accounts for 60-70% of deaths in diabetics?
cardio-vascular disease
160
how do you manage macrovascular disease within diabetics?
- Control RF: hyperlipidaemia, HTN, smoking cessation, treat obesity, healthy diet, optimise glycaemic control
161
what is included within a diabetic annual review?
Education and self management:
- How they are coping, diet, exercise
- Further info/ education – DAFNE, DESMOND
- Smoking cessaion
Complications:
- Hypo episodes – how often, signs and symptoms
- Hosp admissions – why? Frequency
- Neuro, feet, eyes, kidney, CVD
- Mood
- Other general illnesses
Review BM diary, are they planning on getting pregnant – aware of pregnancy and diabetes advice
162
what examinations would be included within diabetic annual review?
weight, height, BMI, urinalysis – ketones, protein. Inspect inject sites. CVS – BP, heart sounds, peripheral pulses and bruits. Eyes – cataracts, eye movements, inspect retina. Neuropathy – foot exam
163
what investigations would be included within a diabetic annula review?
HbA1c, BM measurement, lipid profile, kidneys – eGFR and urine albumin: creatinine ratio
164
why would ketones appear in DKA?
– when hyperglycaemic state and no insulin – body will run on stores of glycogen
- When stores run out – will turn to burn fats – the breakdown of fats produces ketones along side triglycerol
- Ketones are large acidic proteins
