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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
What are the short acting sulphonylureas
Gliclazide Tolbutamide
26
What are the ling acting sulphonylureas
Glibenclamide Glimepride Associated with prolonged and sometimes fatal cases of hypoglycaemia (avoid in the elderly)
27
What are the side effects of sulphonylureas
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
What is pioglitazone moa
Reduces peripheral insulin resistance
29
When should pioglitazone be avoided
Avoid in patients with a history of heart failure - contraindicated
30
What are the side effects of pioglitazone
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
What is DPP-4i and what is the moa
Drugs include: Alogliptin Linagliptin Saxagliptin Sitagliptin Vildagliptin (hepatotoxicity) Moa: inhibits dipeptidylpeptidase- 4 to increase insulin secretion and lower glucagon secretions
32
What are the side effects of DPP-4i
Can cause pancreatitis -discontinue if symptoms of acute of pancreatitis occur -persistent, severe abdominal pain
33
What is SGLT-2i and what is their moa
Inhibits SGLT2 in the renal proximal convoluted tubule Drugs includes Canagliflozins Dapagliflozins Empagaflozins Makes you urinate frequently and so get low blood levels
34
What are the MHRA warnings about SGLT-2i
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
What monitoring is required for SGLT-2is
Volume depletion: correct hypovolaemia before starting treatment Monitor renal function
36
What is a GLP-1 agonist and what is the moa
Increases insulin secretion, suppresses glucagon secretion and slows down gastric emptying Dulaglutide Exenatide Liraglutide Lixsenatide
37
What are the MRHA warning about GLP-1 agonists
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
What are the other anti-diabetic drugs
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
What are the anti diabetic effect on weight
Weight gain : pioglitazone + sulphonylureas Neutral weight: DPP-4i and metformin Weight loss: , GLP-1 + SGLT-2i
40
What are the diabetic complications associates with cardiovascular disease
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
What are the diabetic complications associated with diabetic nephropathy
Patients with nephropathy causing proteinuria - treat with ace-i/arb -ACE-i can potentiate hypoglycaemic effects of anti-diabetic drugs/ insulin
42
What are the diabetic complications associated with diabetic neuropathy
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
What are the diabetic complications associated with the eyes
Visual impairment -have yearly eye test
44
What is meant by DKA
Severe hyperglycaemia
45
What are the symptoms of DKA
Polyurea Thirsty Pear drop breath smell (ketones) Deep or fast breathing Lethargy/ unconsciousness Confusion
46
What do you do if you suspect DKA
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
What is the treatment of DKA
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
What are the guidelines for having insulin during surgery
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
What are the insulin regimen guidelines post surgery
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
What are the sick day rules (mostly T1D)
Sugar levels- blood should be checked regularly Insulin: carry on taking insulin Carbohydrates: keep eating and stay hydrated Ketones: check ketones regularly
51
What are the guidelines for diabetic patients who are pregnant or breastfeeding
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
What is meant by gestational diabetes
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
What is meant by hypoglycaemia
When the BG level is <4mmol/l
54
What are the symptoms of hypoglycaemia
Sweating Lethargic Dizziness Hunger Tremor Tingling lips Palpitations Extreme moods Pale
55
How do you treat a hypoglycaemic patient who is conscious and able to swallow
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
How do you treat a patient who is hypoglycaemic where oral administration doesn’t work or the patient is unconscious
I’m Glucagon - and then if unresponsive after 10 mins: IV glucose
57
What is meant when a patient is blunted hypoglycaemia
Some patients awareness is blunted, preventing early recognition This can happen through increased number of hypo episodes or even taking beta blockers
58
Which antidepressant is used for diabetic neuropathy
Duloxetine
59
What does metformin do to vitamin level
Reduced vitamin b 12 levels

ENDOCRINE TOPIC PRE-REG (6 decks)

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