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Diabetes Flashcards

1
Q

What produces insulin? How does it decrease blood sugar?

A
  • Beta cells in the Islets of Langerhans in the pancreas
  • Firstly, it causes cells in the body to absorb glucose from the blood and use it as fuel
  • Secondly, it causes muscle and liver cells to absorb glucose from the blood and store it as glycogen (glycogenesis)
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2
Q

What produces glucagon? How does it increase blood sugar?

A
  • Alpha cells in the Islets of Langerhans in the pancreas
  • It tells the liver to break down stored glycogen and release it into the blood as glucose (glycogenolysis)
  • It also tells the liver to convert proteins and fats into glucose (gluconeogenesis)
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3
Q

What is the normal range for blood glucose concentration?

A

4.4 - 6.1 mmol/l

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4
Q

What HbA1c result indicates diabetes?

A

> 48 mmol/mol

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5
Q

What random plasma glucose result indicates diabetes?

A

> 11 mmol/l

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6
Q

What fasting plasma glucose result indicates diabetes?

A

> 7 mmol/l

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7
Q

What is the diagnostic criteria for T2DM in a symptomatic vs asymptomatic person?

A

Symptomatic
- Fasting glucose ≥7 mmol/l
- Random glucose ≥11.1 mmol/l (or after 75g oral glucose tolerance test)

OR if using HbA1c for dx:
- HbA1c ≥48 mmol/mol

Asymptomatic:
- Same as above but on 2 separate occasions

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8
Q

When can HbA1c not be used to diagnose T2DM?

A
  • Conditions resulting in increased red cell turnover (these can cause a raised HbA1c)
  • Children
  • Expected gestational diabetes
  • HIV
  • People taking meds that increase glucose e.g. corticosteroids
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9
Q

What’s first, second and third line management of T2DM?

A
  1. Metformin
  2. HbA1c >58 - metformin plus sulfonylurea/DPP-4 inhibotor/SGLT-2 inhibitor/thiazolidinediones
  3. HbA1c >58 - metformin plus 2 second line drugs OR metformin plus insulin
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10
Q

When should SGLT-2 inhibitors be added to metformin as a first line treatment?

A
  • If the patient has established CVD
  • If the patient has chronic HF
  • If patient has QRISK >10%
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11
Q

What is the HbA1c target for someone on metformin?

A

48 mmol/mol

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12
Q

What is the HbA1c target for someone on any drug that may cause hypo (e.g. sulfonylurea) or already on one drug with a HbA1c >58?

A

53 mmol/mol

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13
Q

What type of drug is metformin?

A

Biguanide

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14
Q

What is the MOA of metformin?

A
  • Increases insulin sensitivity
  • Decreases hepatic gluconeogenesis
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15
Q

Give the main side effects of metformin

A
  • GI upset
  • Lactic acidosis
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16
Q

What eGFR is a contraindication to metformin?

A

<30ml/min

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17
Q

What is the MOA of sulfonylureas?

A
  • Stimulate beta cells to produce insulin
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18
Q

What is an example of a sulfonylurea?

A
  • Gliclazide
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19
Q

What are the main side effects of sulfonylureas?

A
  • Hypoglycaemia
  • Wt gain
  • Hyponatraemia
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20
Q

What drugs are DPP-4 inhibitors?

A

-gliptins

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21
Q

What is the role of DPP-4 inhibitors in the management of DM?

A
  • DPP-4 is an enzyme that inhibits hormones called incretins
  • Incretins are good and are secreted in response to large meals to lower blood glucose
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22
Q

What are the main side effects of DPP-4 inhibitors?

A
  • Increased risk of pancreatitis
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23
Q

What is an example of a Thiazolidinedione?

A
  • Pioglitazone
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24
Q

What drugs are SGLT-2 inhibitors?

A

-gliflozins

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25
Q

What are the main side effects of SGLT-2 inhibitors?

A
  • UTI
  • Weight loss
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26
Q

What drugs are GLP-1 agonists? When are they indicated?

A

-tides

  • May be used when triple therapy has failed to control diabetes/insulin contra-indicated
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27
Q

Which diabetic meds are given SC instead of oral?

A
  • Insulin
  • GLP-1 agonists (-tides)
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28
Q

What are the main side effects of GLP-1 agonists?

A
  • N+V
  • Pancreatitis
  • Weight loss
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29
Q

What viruses can trigger T1DM?

A
  • Coxsackie B virus
  • Enterovirus
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30
Q

What should you always screen new T1DM patients for? Why?

A

Coeliac disease, the conditions are often linked

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31
Q

What are the key investigations for T1DM?

A
  • Urine dip for glucose and ketones
  • Fasting glucose
  • Random glucose
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32
Q

What is the diagnostic criteria for T1DM in a symptomatic vs asymptomatic person?

A

Symptomatic:
- Fasting glucose ≥7 mmol/l
- Random glucose ≥11.1 mmol/l (or after 75g oral glucose tolerance test)

Asymptomatic:
- Same as above but on 2 separate occasions

33
Q

When is further investigation required for diagnosing T1DM? What does this involve?

A
  • If the clinical presentation includes atypical features e.g. age >50, BMI>25, slow evolution of hyperglycaemia
  • C-peptide (low in T1DM)
  • Diabetes-specific autoantibodies
34
Q

How often should type 1 diabetics monitor their blood glucose?

A
  • At least 4 times daily
  • Before each meal and before bed
35
Q

What are the blood glucose targets for type 1 diabetics
a) on waking
b) before meals?

A

a) 5-7 mmol/l
b) 4-7 mmol/l

36
Q

What 4 categories of insulin is there?

A
  • Rapid-acting insulin
  • Short-acting insulin
  • Intermediate-acting insulin
  • Long-acting insulin
37
Q

What is an adverse effect of insulin injecting? What do pts do to manage this?

A
  • Lipodystrophy
  • SC fat hardens and prevents normal absorption of insulin
  • Cycle injection sites
38
Q

What insulin regime are patients typically started on? Briefly outline this

A
  • Basal bolus regime
  • Long acting insulin injecting in the evening (basal) e.g. Lantus
  • Short acting insulin 3 times a day before meals e.g. Actrapid
39
Q

When should you consider adding in metformin for a type 1 diabetic?

A

If BMI >25

40
Q

What is the effect of chronic exposure to hyperglycaemia on blood vessel?

A
  • Causes damage to endothelial cells of blood vessels leading to leaky malfunctioning vessels that are unable to regenerate
41
Q

What are long term macro-vascular complications of diabetes?

A
  • Stroke
  • CAD (major cause of death)
  • Hypertension
  • Peripheral ischaemia (diabetic foot)
42
Q

What are long term microvascular complications of diabetes?

A
  • Peripheral neuropathy
  • Retinopathy
  • Kidney disease (particularly glomerulosclerosis)
43
Q

What is the management of chronic kidney disease in patients with T2DM?

A
  • ACE-In when albumin-to-creatinine ratio is above 3mg/mmol (in non-diabetics you start an ACE-In when ACR is above 30)
  • Add an SGLT-2 inhibitor when the ACR is above 30mg/mmol
44
Q

What 3 features suggest gestational diabetes

A
  • Large fetus
  • Polyhydramnois
  • Glucose on urine dip
45
Q

What is the screening test for gestational diabetes? When is it offered?

A
  • Oral glucose tolerance test
  • 24-28 weeks
46
Q

What are the diagnostic thresholds for diagnosing gestational diabetes?

A

Either one of…
- Fasting glucose ≥5.6 mmol/l
- 2 hour glucose ≥7.8 mmol/l

REMEMBER cut off for gestational diabetes is 5-6-7-8

47
Q

What is the management of someone with a fasting glucose <7 mmol/l?

A
  1. Diet + exercise for 1/2 wks
  2. Metformin
  3. Short acting insulin
48
Q

What is the management of someone with a fasting glucose >7 mmol/l?

A

Short acting insulin +/- metformin

49
Q

What is the management of someone with a fasting glucose >6 mmol/l PLUS macrosomia?

A

Short acting insulin +/- metformin

50
Q

What are the target blood glucose levels for women with gestational diabetes/pre-exsisting diabetes:
1) Fasting
2) 2 hours after meals

A

1) 5.3 mmol/l
2) 6.4 mmol/l

51
Q

What are some complications of gestational diabetes?

A
  • Neonatal hypoglycaemia
  • Macrosomia
  • Polyhydramnios
  • Polycythaemia
  • Preterm birth
  • Pre-eclampsia
  • Stillbirth
52
Q

When would you repeat an OGTT postpartum in women with gestational diabetes?

A

6 weeks postpartum to ensure returned to normal

53
Q

What is the management of pre-existing diabetes in pregnancy?

A
  • Wt loss if BMI>27
  • Stop oral hypoglycaemic agents (apart from metformin) and start insulin
  • Folic acid 5mg until 12 wks
  • Tight glycemic control
54
Q

How may someone present with DKA?

A
  • Abdo pain
  • Vomiting
  • Reduced consciousness
  • Kussmaul respiration (deep hyperventilation)
  • Acetone-smelling breath
55
Q

What is the diagnostic criteria for DKA?

A
  • Hyperglycaemia (>11mmol/l)
  • Ketosis (blood ketones >3mmol/l)
  • Acidosis (<7.3)
56
Q

What are the 3 most dangerous aspects of DKA?

A
  • Potassium imbalance
  • Ketoacidosis
  • Dehydration
57
Q

What blood pH would indicate mild DKA?

A

<7.3

58
Q

What blood pH would indicate moderate DKA?

A

<7.2

59
Q

What blood pH would indicate severe DKA?

A

<7.1

60
Q

What are the levels of …. in DKA?
1. Bicarbonate
2. Creatinine
3. Sodium

A
  1. Low (HCO3 is used up trying to buffer ketones)
  2. Raised (sign of dehydration)
  3. Normal/raised (due to dehydration)
61
Q

What affect does insulin have on potassium?

A

Drives K into cells

62
Q

What causes potassium imbalance in DKA?

A
  • Without insulin potassium is not driven into cells
  • The serum potassium may be high/normal as the kidneys continue to balance the amount of K in the blood and urine
  • Total body K is low as no K is stored in cells
63
Q

What can happen to potassium when insulin treatment of DKA starts? What is a complication of this?

A
  • Severe hypokalaemia as K is driven into cells
  • Fatal arrhythmias
64
Q

When does ketogenesis occur?

A

When there is insufficient supply of glucose and glycogens stores are exhausted e.g. in prolonged fasting

65
Q

What causes ketoacidosis in DKA?

A
  • As people with T1DM have low glucose stores, fatty acids are converted into ketones as a source of energy (ketogenesis)
  • Initially the kidneys produce bicarb to counteract rising levels of ketone acids
  • Overtime ketone acids use up bicarb and blood becomes more acidic
66
Q

What causes dehydration in DKA?

A
  • Glucose in the urine draws water out with it in a process called osmotic diuresis
  • This results in polyuria and severe dehydration
67
Q

How do you treat DKA? What is the acronym?

A

FIG PICK:
F – Fluids – IV fluid resuscitation with normal saline (e.g. 1 litre stat, then 4 litres with added potassium over the next 12 hours)
I – Insulin – Add an insulin infusion
G – Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l)
P – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required
I – Infection – Treat underlying triggers such as infection
C – Chart fluid balance
K – Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable)

68
Q

What is the purpose of given a fixed rate insulin infusion in DKA?

A

Allows cells to start using glucose again, in turn switching off the production of ketones

69
Q

What is hyperosmolar hyperglycaemic state?

A
  • Complication of T2DM
  • Characterised by hyperosmolality (concentrated blood), hyperglycaemia and the absence of ketones
70
Q

What are typical symptoms of hypoglycaemia?

A

Tremor, sweating, irritability, dizziness and pallor

71
Q

What is the management of severe hypoglycaemia?

A

IV dextrose and IM glucagon

72
Q

What are sick day rules for patients on insulin?

A
  • Do not stop insulin due to risk of DKA
  • Monitor BM more regularly
73
Q

What are sick day rules for patients taking oral hypoglycaemic?

A
  • Temporarily stop some oral hypoglycaemics during an acute illness
  • Medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours
74
Q

What is diabetes insipidus characterised by?

A

1) Decreased secretion of ADH from the pituitary (cranial DI)

OR…

2) An insensitivity to ADH (nephrogenic DI)

75
Q

What are causes of nephrogenic diabetes insipidus?

A
  • Idiopathic
  • Lithium
  • Genetic mutations in the ADH receptor gene
  • Kidney disease
  • Electrolyte disturbances (high calcium or low potassium)
76
Q

How does diabetes insipidus present?

A
  • Polydipsia
  • Polyuria
  • Dehydration
  • Postural hypotension
77
Q

How do you investigate diabetes insipidus? What is the diagnostic test

A
  • High plasma osmolality, low urine osmolality
  • Water deprivation test (urine osmolality is measured after water deprivation, demopressin aka synthetic ADH is given and urine osmolality is re-measured)
78
Q

What is the management of diabetes insipidus?
1) Nephrogenic
2) Cranial/central

A

1) Manage underlying cause, ensure drink plenty of water, thiazide diuretics
2) Demopressin

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