Diabetes Flashcards
Male presents with painful itchy penis with thick white discharge/exudate on retracted foreskin. Diagnosis, cause and investigations?
Candidal balanitis
Differentials:
* STD
* Poor hygiene
* Balanitis circinata- skin conditon associated with reactive arthritis= ring shaped dermatitis on glans of penis
Risk factors:
* Diabetes
* Oral antibiotics
* Poor hygiene
* Immunosuprresion
Investigations:
* Urine dip
* Swab
* Blood sugar
Diagnostic criteria for diabetes?
In symptomatic patients:
* Fasting glucose test greater than or equal to 7
* Random glucose test greater than or equal to 11.1
If patient is asymptomatic then the above needs to be met on 2 seperate occasions
HbA1C- equal or greater than 48= T2D diabetes
* If asymptomatic a second one should be done
Modifiable/non modifiable risk factors for T2D?
Non-modifiable:
* Older age
* Ethnicity
* Fam history
Modifiable:
* Obesity
* Sedentary lifestyle
* High carb diet
Presentation of diabetes?
- Tiredness
- Polyuria and polydipsia
- Unintentional weightloss
- Oral thrush
- Slow wound healing
- Glucose in urine
- Acanthosis nigircans- thickening and darkening of skin- associated with insulin resistance
HbA1c reading for pre diabetes?
HbA1c- 42-47 mmol/mol
HbA1c reading that indicates T2D?
Above 48 mmol/mol
HbA1c treatment targets for new type 2 diabetics?
48 mmol/mol
Measured every 3-6 months until under control and stable
HbA1c treatment target for patients requiring more than 1 antidiabetic medication?
53 mmol/mol
Medical management of Type 2 diabetes?
1st line:
* Metformin
* Then add an SGLT-2 inhibito e.g. dapagliflozin if the patient has existing cardio disease or HF
2nd line- add sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT2 inhibitor
3rd line:
* Triple therapy with metformin and 2 of the 2nd line drugs
* Insulin therapy
Significant potential side effect= ketoacidosis
Action of metformin and side effects?
Increases insulin sensitivity and decreases glucose production by the liver
Does not cause weight gain but may cause weight loss
Side effects:
* Gasto symptoms- pain, nausea, diarrhoea- can try modified release to help these
* Lactic acidosis- secondary to acute kidney injury
SGLT-2 inhibitors action and side effects?
SGLT-2 inhibitors end with the suffix- gliflozin
SGLT is found in proximal tubules of the kidneys- acts to reabsorb glucose from the urine back into the blood- SGLT-2 inhibitors stop this causing more glucose to be excreted in the urine
= lower HbA1c, lower BP, weight loss and improves heart failure
Side effects:
* Hypoglycaemia
* Glycosuria
* Increased urine output and frequency
* UTI and thrush- key
* Weight loss
* Diabetic ketoacidosis- key
Action of pioglitazone and side effects?
Thiazolidinedione- increases insulin sensitivity and decreases liver production of glucose
Side effects:
* Weight gain
* Heart failure
* Increased risk of bone fractures
* A small increase risk of bladder cancer
Action of Gliclazide and side effects?
Sulfonylureas stimulate insulin release from the pancreas
Side effects:
* Weight gain
* Hypoglycaemia
Types of insulin (5)
Rapid acting insulins e.g. Novorapid-start working after 10 mins and last 4 hours
Short-acting insulins e.g. Actrapid start working around 30 mins and last about 8 hours
Intermediate acting insulins e.g. Humulin 1 start working around 1 hour and last about 16 hours
Long acting insulins e.g. Levemir/Lantus- start working in around 1 hour and last 24 hours or longer
Humalogs- contain rapid and intermediate
1st line treatment to manage hypertension in patients with type 2 diabetes?
ACE inhibitors
What is type 1 diabetes?
Autoimmune disorder where the insulin producing beta cells of the islets of langerhanns in the pancreas are destroyed by the immune system= reduction in insulin production
What is type 2 diabetes?
Reduced sensitivity to insulin due to increased adipose tissue
What is maturity onset diabetes of the young? MODY
A group of inherited genetic disorders affecting the productino of insulin
Management of T1D? Side effects?
Insulin
Side effects:
Hypoglycaemia
Weight gain
Lipodystrophy
Features of diabetic ketoacidosis?
- Abdo pain
- Polyuria, polydipsia and dehydration
- Kussmaul respiration (deep hyperventilation)
- Acetone smelling breath (pear drops smell)
= signs in a new diagnosis of T1D
Investigations for T1D?
- Urine dip- glucose and ketones
- Fasting glucose and random glucose
- HbA1c- NOT recomended
- Low C-peptide levels (by product of insulin production)
*
The antibodies present in T1D?
anti-GAD, ICA and IAA
Typical presentation of T1D?
- Ketosis
- Rapid weight loss
- Age of onset below 50 years old
- BMI below 25kg
- Family history of autoimmune disease
Sick day rules for patients with T1D?
Do not stop insulin but check blood glucose more frequently
Drink enough fluid
Sick day rules for T2D?
- stop some oral hypoglycaemics during acute illness
- Do not stop insulin
- Monitor blood glucose more frequently
Blood results in DKA?
- Glucose- >11 mmol/l
- PH- <7.3
- Bicarbonate <15 mmol/l
- Ketones >3mmol/l or urine ketones ++ on dip
Management of DKA?
- Fluid replacement- isotonic saline
- Insulin- IV 0.1 unit/kg/hour and then one blood glucose is <14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in additon to saline
- Electrolyte disturbance correction
- Long acting insulin should be continued and short acting insulin stopped
Blood results for when DKA is resolved?
- PH >7.3
- Blood ketones- <0.6 mmol/L
- Bicarbonate >15 mmol/L
Should be resolved within 24 hours
An important complication in the brain of fluid ressusitation in DKA?
Cerebral oedema
How does diabetic neuropathy present?
Sensory loss- glove and stocking distribution- with the lower legs affected first due to the lenght of the sensory neurones in this area
Management of diabetic neuropathy?
- 1st line- amitriptyline, duloxetine, gabapentin or pregabalin
- Tramadol may be used as rescue therapy for pain
- Pain management clinics
Patient has erratic blood glucose control, bloating and vomiting- Diagnosis? Management?
Think gastroparesis- due to gastrointestinal autonomic neuropathy
Management- metoclopramide, domperidone or erythromycin
Also causes chronic diarrhoea usually at night
Screening and management of diabetic nephropathy?
Screening:
* Annually using ACR- early morn specimen
Management:
* Diet
* Good glycemic control
* ACE inhibitor or ARB- all diabetic patients with a urinary ACR of 3 or more should be started on one of these
Non-proliferative diabetic retinopathy?- management?
Mild- 1 microaneurysm
Moderate:
* Microaneurysms
* Blot haemorrhages
* Hard exudates
* Cotton wool spots- represent areas of retinal infarction
Severe:
* Everything in 4 quadrants
Management:
* Regular observation
* Optimise glucose control, BP and hyperlipidemia
Proliferative diabetic retinopathy?- features and management
Features:
* Retinal neovascularisation
* Fibrous tissue forming
* More common in T1D- 50% blind in 5 years
Management:
* Optimise glycaemic control, BP and hyperlipdidemia
* Panretinal laser photocoagulation- can cause up to 50% reduction in visual fields and decrease in night vision
* Intravitreal VEGF inhibitors
BP target for patient with diabetes?
140/80
Which electrolyte is essnetial to monitor during DKA therapy?
Potassium- ensure its not too low as giving insulin will drop potassium leevls
When should a patient with DKA be excelated to crit care?
PH <7.1
GCS <12
Pregant
Sats- <92% on air
Potassium <3.5 on admission
Hallmark symptoms of T1D?
Polyuria
Polydipsia
Fatigue
How many times should a diabetic check their glucose levels?
At least 4 times a day
Check before each meal and before you go to bed
Blood glucose targets for diabetics are?
5-7 mmol/L on waking
4-7 mmol/L before meals and at other time in the day
A condition that is a complication in T2D?
Hyperosmolar hyperglycaemic state
Patients have glucose levels over 40mmol/l and profound dehydration
Mortality- 10-20%
