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ENDOCRINE TOPIC PRE-REG > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is meant by diabetes

A

Persistent hyperglycaemia

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2
Q

What are the causes of diabetes

A

Deficient insulin secretion (type 1)
Resistance to the action of insulin (type 2)
Pregnancy (gestational)
Medication (secondary) steroids

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3
Q

What is the criteria for driving with diabetes

A

All drivers treated with insulin must notify the DVLA
- drivers should be assessed awareness of hypoglycaemia
The capability of bringing their vehicles to a safe controlled stop

Group 1 drivers
-adequate awareness of hypos
No more than 1 episode of severe hypoglycaemia while awake in the preceding 12 months

Group 2 drivers
- Group 2 must report ass episodes of severe (requires assistance) hypoglycaemia episodes including in sleep
- fully aware of hypoglycaemia
-no episodes of severe hypoglycaemia in the preceding 12 months
- must use a blood glucose meter with sufficient memory to store 3 months of reading
-visual complication- must notify the DVLA and not drive

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4
Q

What advice does the DVLA give those who are diabetic

A

Drivers treated with insulin should ALWAYS carry a glucose meter and blood glucose strips

Check blood glucose concentration and no more than 2 hours before driving and every 2 hours while driving

Blood glucose should always be above Mmol/l while driving

If blood falls below <5mmol/l take a snack

Ensure a supply of fast acting carbohydrate is available in the vehicle

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5
Q

What do you do if you get hypoglycaemia whilst driving

A

Hypoglycaemia is considered when the blood glucose level is lower than <4mmol/l

Driver should:
- safely stop vehicle
- switch off the engine, remove the keys from the ignition and move from the drivers seat
- eat or drink a suitable source of sugar
- wait until 45 mins after blood glucose has returned to normal before continuing journey

  • DRIVERS MUST NOT DRIVE if hypoglycaemia awareness has been lost and the DVLa must be notified
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6
Q

What is meant by type 1 diabetes mellitus

A

Insulin deficiency - destroyed beta cells in the islet of langerhans

Most commonly before adult hood

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7
Q

What are the typical features of type 1 diabetes

A

Hyperglycaemia (>11mmol/l)
Ketosis
Rapid weight loss
BMI <25kg/m2
Age <50
Family history of autoimmune disease

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8
Q

What are the requirement of blood glucose monitoring with type 1 diabetes

A

Monitored at least 4 times a day (including before each meal and before bed)

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9
Q

What are the blood glucose monitoring requirements for type 1 diabetes

A

5-7 mmol/l on walking (fasting)
4-7 mmol/l fasting blood glucose before meals at other times of the day
5-9mmol/l 90 mins after eating
>5mmol/l when driving

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10
Q

What are the insulin regimens for patients with T1D

A

All t1d patients should receive insulin therapy

First line: multiple daily injections basal-bolus insulin regimen
-basal (long/intermediate acting insulin) once or twice daily AND
Bolus (short/rapid acting) before meals
First line basal detemir TWICE a Day second line= glargine ONCE daily

Biphasic mixtures
- short acting ,iced with intermediate insulin 1-3 times a day

  • continuous subcutaneous insulin infusion (insulin pump)
    Adults who suffer disabling hypos/ uncontrolled hyperglycaemia
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11
Q

What factors would you increase your insulin dose?

A

Infection
Stress
Trauma

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12
Q

What factors would you decrease your insulin dose

A

Physical activity
Incurrent illness
Reduced food intake
Impaired renal function
Certain endocrine disorders (thyroid disorders, coeliac disease, addisons disease)

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13
Q

How do you administer insulin

A

Inactivated by GI enzymes- given subcutaneously

Injected into a body area with plenty of subcutaneous fat
- abdomen is the fastest absorption rate
- outer thighs/buttocks (slower absorption)

Rotate the injection site
-lipohypertrophy can occur due to repeated injecting into the same area
-leads to erratic absorption of insulin.Rotate injection site

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14
Q

What are the different types of short acting insulin

A

Soluble insulin
-human + bovine/ porcine
- inject 15-30 mins before a meal
Onset: 30-60 mins, peak action 1-4 hours
Duration : up to 9 hours

Rapid acting insulin
Lispro, Aspart and Glulisine (no LAGing)
- inject: immediately before meals
Onset: <15mins
Duration: 2-5 hours

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15
Q

What are the intermediate acting insulin

A

Biphasic isophane, biphasic aspart/ lispro (isophane insulin mixed with Short acting insulin)
- onset: 1-2 hours, peak affect of 3-12 hours
Duration: 11-24 hours

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16
Q

What are the long acting insulin

A

Detemir, degludec, glargine
Inject: once daily (detemir = BD)
Onset: 2-4 days to reach steady state
Duration: 36 hours

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17
Q

What is meant by type 2 diabetes

A

Characterised by insulin resistance
Typically develops later in life

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18
Q

What are the characteristics of patients with prediabetes in T2D

A

HbA1c level of 42-47mmol/l
Can try and prevent diabetes with lifestyle advice
Diabetic is considered HbA1c level of 48mmol/l and above

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19
Q

What is the treatment of T2D with patients who have low CVD risk

A

Assess the HbA1c, kidney function and cardiovascular risk
- first line: treat with metformin
- agree for individual agreed threshold

If HbA1c is above the individuals agreed threshold
- add in DPP-4i (-gliptins), pioglitazone, SU (sulfonylurea) or SGLT-2i (-flozins)

If HbA1c above the agreed individual threshold
- triple therapy by adding or swapping class of anti-diabetic drugs
-aim to get individual agreed threshold

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20
Q

What is the treatment plan for patients with high risk of CVD?

A

Assess the HbA1c, kidney function and cardiovascular risk
- high risk: established atherosclerotic CVD/ HF or a QRISK2 > 10%
- treat with metformin
- once metformin is tolerated: then try add a SGLT-2i
- if metformin is not well tolerated: alone SGLT-2i
- aim for individual agreed threshold

If HbA1c above the individual agreed threshold
- follow the guidelines for dual and triple therapy (check slide before )

If the patient at any point develops high risk- consider an SGLT-2i

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21
Q

What do you use instead when you have metformin resistance

A

If patient cannot tolerate metformin due to side effects to use MR preparation of metformin

Assess the HbA1c, kidney function and cardiovascular risk
- treat with DPP-4i, pioglitazone, SU, or SGLT-2i
- high risk of cardiovascular disease: use SGLT-2i
-Aim for individual agreed threshold

If HbA1c is above than the individual agreed threshold
- treat with DPP-4i AND pioglitazone OR
DPP-4i AND SU OR
Pioglitazone AND SU
- aim for the individual agreed threshold

IF HbA1c level is still not controlled, INSULIN THERAPY to aim for individual agreed threshold

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22
Q

What are the side effects of metformin

A

GI disturbances - give MR prep
Diahhoroea
Nausea
Vitamin B deficiency
Lactic acidosis: avoid if eGFR <30ml/min/1.73m2

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23
Q

What is metformin and how does it work

A

Metformin is a biguanide
Moa: decreases gluconeogenesis and increases peripheral utilisation of glucose

STOP MEDICATION IF THE PATIENT IS EXPERIENCING ACUTE KIDNEY INJURY

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24
Q

What is the moa of suphonylureas

A

Augments insulin secretion

25
Q

What are the short acting sulphonylureas

A

Gliclazide
Tolbutamide

26
Q

What are the ling acting sulphonylureas

A

Glibenclamide
Glimepride
Associated with prolonged and sometimes fatal cases of hypoglycaemia (avoid in the elderly)

27
Q

What are the side effects of sulphonylureas

A

High risk of hypoglycaemia which needs to be treated in hospital (hence why target is 7% instead of 6.5% when used)

Avoid prescribing in acute porphyria

Should be avoided in hepatic and renal failure

28
Q

What is pioglitazone moa

A

Reduces peripheral insulin resistance

29
Q

When should pioglitazone be avoided

A

Avoid in patients with a history of heart failure - contraindicated

30
Q

What are the side effects of pioglitazone

A

There is an increased risk of bladder cancer (blood in urine need to stop the treatment and seek medical attention)
Review safety and efficacy after 3-6 months
Stop treatment if patients responds inadequately
Report: haematuria, dysuria, or uriinary urgency

Increases the risk of bone fractures

Increased risk of liver toxicity
- report nausea, vomiting, Abdominal pain, fatigue and dark urine developing

31
Q

What is DPP-4i and what is the moa

A

Drugs include:
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Vildagliptin (hepatotoxicity)

Moa: inhibits dipeptidylpeptidase- 4 to increase insulin secretion and lower glucagon secretions

32
Q

What are the side effects of DPP-4i

A

Can cause pancreatitis
-discontinue if symptoms of acute of pancreatitis occur
-persistent, severe abdominal pain

33
Q

What is SGLT-2i and what is their moa

A

Inhibits SGLT2 in the renal proximal convoluted tubule

Drugs includes
Canagliflozins
Dapagliflozins
Empagaflozins

Makes you urinate frequently and so get low blood levels

34
Q

What are the MHRA warnings about SGLT-2i

A

Life threatening and fatal cases of diabetic ketoacidosis (DKA)
-Monitor ketones if treatment interrupted for surgical procedures or illness

Fournier gangrene (necrotising fasciitis of the genitalia or perineum

Canagliflozin only: risk of lower limb amputation (mainly toes)

Increased risk of utis

35
Q

What monitoring is required for SGLT-2is

A

Volume depletion: correct hypovolaemia before starting treatment

Monitor renal function

36
Q

What is a GLP-1 agonist and what is the moa

A

Increases insulin secretion, suppresses glucagon secretion and slows down gastric emptying

Dulaglutide
Exenatide
Liraglutide
Lixsenatide

37
Q

What are the MRHA warning about GLP-1 agonists

A

Risk of diabetic ketoacidosis when concomitant insulin was a rapidly reduced

Acute pancreatitis- patient warned of persistent, severe abdominal pain

Dehydration- risk of dehydration due to gastric intestinal side effects and advised to take precautions to avoid fluid depletion

38
Q

What are the other anti-diabetic drugs

A

Acarbose
-delays the digestion and absorption of starch and sucrose
High risk of GI side effects- may need to reduce the dose

Meglitride (nateglinide or repaglinide
- stimulates insulin secretion
- stress exposure- treatment interruption and replacement with insulin to maintain glycaemic control

39
Q

What are the anti diabetic effect on weight

A

Weight gain : pioglitazone + sulphonylureas

Neutral weight: DPP-4i and metformin

Weight loss: , GLP-1 + SGLT-2i

40
Q

What are the diabetic complications associates with cardiovascular disease

A

Strong risk factor of cardiovascular disease

Low dose atorvastatin - considered in all type 1 diabetics
-offered to age 40+, diabetic for 10 years, nephropathy or other CVD factors

ACE-i reduces the risk if cardiovascular disease risk- regardless of age/ethnicity. Antihypertensive drug would be ramipril if they are diabetic

41
Q

What are the diabetic complications associated with diabetic nephropathy

A

Patients with nephropathy causing proteinuria - treat with ace-i/arb
-ACE-i can potentiate hypoglycaemic effects of anti-diabetic drugs/ insulin

42
Q

What are the diabetic complications associated with diabetic neuropathy

A

Painful peripheral neuropathy: antidepressants, gabapentin/pregabalin
-diabetic foot: treat pain and manage infection

Autonomic neuropathy: treat diarrhoea with codeine or tetracyclines

Neuropathic postural hypotension: increase salt intake or fludrocortisone

Gustatory sweating: antimuscarinic (propantheline bromide)

Erectile dysfunction: sildenafil

43
Q

What are the diabetic complications associated with the eyes

A

Visual impairment
-have yearly eye test

44
Q

What is meant by DKA

A

Severe hyperglycaemia

45
Q

What are the symptoms of DKA

A

Polyurea
Thirsty
Pear drop breath smell (ketones)
Deep or fast breathing
Lethargy/ unconsciousness
Confusion

46
Q

What do you do if you suspect DKA

A

Check blood sugar levels if displaying symptoms of DKA

If blood sugar levels is above 11mmol/l, check ketone levels in the blood/ urine

0.6-1.5mmol = slight risk (retest after 2 hours)
1.6-2.9mmol = increased risk (contact GP)
3mmol+ =. Medical emergency

47
Q

What is the treatment of DKA

A

If blood pressure is <90, restore volume with 500ml IV NaCL 0.9%

Once BP is >90, give maintenance IV naCL 0.9%

Start IV insulin mixed with NaCL and administer at a rate so that
- ketone concentration falls at 0.5mmol/l/hr
- blood glucose concentration falls at 3mmol/l/hr

When blood glucose levels<14mmol/l give IV glucose 10%

Continue insulin until ketone levels is <0.3mmol/l and Ph >7.3

When the patient is able to eat - give fast acting insulin with a meal

Stop treatment 1 hr after food

48
Q

What are the guidelines for having insulin during surgery

A

Elective surgery (minor procedures with good glycaemic control)
- day before: reduce OD long acting dose by 20%- rest as usual

Elective surgery( major procedures or poor glycaemic control)
- day before: reduce OD long acting dose by 20%- rest as usual
On the day:
- reduce OD long acting dose by 20%- stop other insulin till patient eating
- IV infusion of KCL + glucose + NACL
- variable rate IV insulin (soluble human) in NaCL 0.9% given via a pump
-hourly blood glucose measurements for the first 12 hrs
- give IV glucose 20% if blood glucose dips under 6mmol/l

49
Q

What are the insulin regimen guidelines post surgery

A

Post surgery:
- convert back to subcutaneous insulin when patient can eat/drink without vomiting
-basal-bolus regimen: restarted with the first meal- infusion carried on until 30-60 mins after the first meal short acting glucose administration
- long acting regimens carries on at 20% reduced until the patient leaves the hospital
- twice daily regimens: restart at breakfast or evening meal- infusions carried on til 30-60 mins after the first meal

50
Q

What are the sick day rules (mostly T1D)

A

Sugar levels- blood should be checked regularly

Insulin: carry on taking insulin

Carbohydrates: keep eating and stay hydrated

Ketones: check ketones regularly

51
Q

What are the guidelines for diabetic patients who are pregnant or breastfeeding

A

Diabetes in pregnancy - increases the risk to the woman and the fetus
- risk reduced by effective blood glucose control

Before pregnancy:
Aim for HbA1c level <48mmol/l
Take folic acid 5mg- more at risk of neurotubular defects so this dose is needed

Medication:
-All oral antidiabetics except metformin should be stopped and replaced with insulin
-isophane insulin is the first choice for long acting insulin during pregnancy
- if patient taking a statin/ACE-i/ ARB : DISCONTINUE them

Women taking insulin must be aware of hypoglycaemia risk and should always carry fast acting glucose

52
Q

What is meant by gestational diabetes

A

Developed during pregnancy, stop treatment after birth

Fasting BG <7mmol/l
- diet and exercise
-metformin
- insulin if metformin is contraindicated, not tolerated or not effective

Fasting BG >7mmol/l
- diet and exercise + insulin +/- metformin

Fasting BG 6-6.9 mmol/l with complications
Insulin +/- metformin

Never give glibenclamide!!

53
Q

What is meant by hypoglycaemia

A

When the BG level is <4mmol/l

54
Q

What are the symptoms of hypoglycaemia

A

Sweating
Lethargic
Dizziness
Hunger
Tremor
Tingling lips
Palpitations
Extreme moods
Pale

55
Q

How do you treat a hypoglycaemic patient who is conscious and able to swallow

A

Fast acting carbohydrate by mouth
4-5 glucose tablets
3-4 heaped teaspoons of sugar
-150-200 ml of fruit juice

Repeat every 15 mins for 3 cycles

56
Q

How do you treat a patient who is hypoglycaemic where oral administration doesn’t work or the patient is unconscious

A

I’m Glucagon - and then if unresponsive after 10 mins:
IV glucose

57
Q

What is meant when a patient is blunted hypoglycaemia

A

Some patients awareness is blunted, preventing early recognition
This can happen through increased number of hypo episodes or even taking beta blockers

58
Q

Which antidepressant is used for diabetic neuropathy

A

Duloxetine

59
Q

What does metformin do to vitamin level

A

Reduced vitamin b 12 levels

ENDOCRINE TOPIC PRE-REG (6 decks)

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