Diabetes Flashcards
WHO definition of diabetes
“Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves”
A group of conditions where the body cannot produce enough or any insulin, cannot properly use the insulin that is produced, or cannot do a combination of either.
What are the 7 main types of diabetes?
Type 1 - life changing and lifelong
Type 2 - can be put into remission, more aggressive in children and high complication risk at diagnosis
MODY – rare form of diabetes, runs in families, caused by a single gene mutation with 50% inheritance. Not necessarily needing insulin and can be treated with sulphonylureas
Neonatal - rare form diagnosed in under 6 mths of age. Transient or permanent, but if transient usually recurs later on in life. Treated with Glibenclamide, sulphonylurea
Wolfram (DIDMOAD – DI, DM, optic atrophy and deafness, rare autosomal recessive)
Alstrom – rare genetic disorder, progressive loss of hearing and vision, obesity, short stature, T2
Gestational Diabetes – high blood sugar (glucose) that develops during pregnancy and usually disappears after giving birth. Risk factors high BMI, previous GDM, S Asian, Black, Afro-Carribean, Middle Eastern origin, FH diabetes. It can happen at any stage of pregnancy, but is more common in the second or third trimester.
LADA – latent autoimmune diabetes in adults (type 1 ½), seems to straddle elements of T1 and T2
Others – include secondary causes such as CF related diabetes, thalassaemia
What is the incidence of T1 diabetes in children
UK has the highest number of children aged 0-14 years with T1DM in Europe
Incidence of Type 1 diabetes increased significantly in 2020/21 amongst those aged 0-15, from 25.6 new cases per 100,000 in 2019/20 to 30.9 in 2020/21 – an increase of 20.7% (p<0.001).
The estimated prevalence rate of Type 1 diabetes in England and Wales was 204.5 per 100,000 of the general population.
2 peaks of incidence – 4-5 year olds, and 10-11 year olds
Risk factors – family history, genetics, geography and age
Autoimmune destruction of the insulin producing pancreatic beta cells, assoc with HLA types DR3 and DR4
Environmental and viral triggers on a genetically susceptible background
Presenting features – polyuria, polydipsia, weight loss and tiredness
4 Ts of T1 diabetes
Toilet
Thirst
Tired
Thinner
T1 generally an acute presentation via GP or ED
Symptoms described may be non-specific
Must be same day referral to hospital
May present compensating, or in DKA
Diagnosis should never be made based on waiting for OGTT or HbA1c
T2 diabetes in children
Incidence is rising
Very aggressive disease and worse prognosis than T1
At presentation, 44% already have hypertension, and 25% have kidney disease
In 2000, no recorded children in UK with T2DM
In 2015 0.72 / 100 000
In 2019/20 NPDA report, 866 cases in CYP
In 2020/21 NPDA report, 973 cases
The numbers diagnosed between the two years had shown a 14% increase, in the same timeframe as a 20% increase in overweight and obesity
Risk factors – obesity, girls, non-white ethnicity and deprivation
The response to insulin is diminished, producing insulin resistance, initially countered by an increase in insulin production to try and maintain glucose homeostasis.
Diagnosis often made on OGTT
More insidious presentation, usually asymptomatic, may have outward signs of insulin resistance such as acanthosis nigricans, and therefore screened
Prevalence of diabetes types
Type 1 – 97%
Type 2 – 1.5%
Other – 1.5% - MODY, secondary diabetes
What is needed for a diabetes diagnosis?
Diabetes symptoms plus:
a random venous plasma glucose concentration ≥ 11.1 mmol/l or
a fasting plasma glucose concentration ≥ 7.0 mmol/l (whole blood ≥ 6.1 mmol/l) or
two hour plasma glucose concentration ≥11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).
How do we give a diagnosis if there is no symptoms?
With no symptoms diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test result on another day with a value in the diabetic range is essential, either fasting, from a random sample or from the two hour post glucose load
What HbA1c is needed for diabetes?
A venous HbA1c of 48mmol/mol (6.5%) is the cut off point for diagnosing diabetes. A value of less than 48mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose tests.
Pre-diabetes for T2 – HbA1c 42-48mmol/mol
What is the initial management for T1 not in DKA?
Insulin treatment
Commence on 0.5-0.8 Units/kg/day
Approx 50% given as long acting insulin
And 50% as rapid acting for meals (10% breakfast, 20% lunch, 20% tea)
Pen therapy is usual initial treatment, converting to pump therapy if indicated /appropriate
Fixed doses to start with and then carb counted meals with a set insulin:carbohydrate ratio (ICR)
Insulin sensitivity factor for correction doses (ISF), based on total daily dose of insulin and 100 rule
Blood glucose testing at least 5 times a day, pre-meals, pre bedtime, exercise, feeling unwell and post-prandial
CGMS / FGMS
Advantages of DKA
accuracy, no time lag
Advantages of continuous glucose monitoring system
Glucose trends, alarms for highs and lows, ‘follow’ facility for carers and teachers, can communicate with pump delivery systems, less trauma to fingers
What are the signs of DKA?
Nausea and vomiting
Abdominal pain
Hyperventilation
Dehydration
Reduced level of consciousness
DKA severity values
MILD – pH < 7.3 or plasma bicarbonate <15 mmol/l
MODERATE – pH <7.2 or plasma bicarbonate < 10 mmol/l
SEVERE – pH < 7.1 or plasma bicarbonate < 5 mmol/l
One to one nursing or HDU if under 2 years or severe DKA
What are the blood gases for DKA?
pH 7.06
pCO2 2.8
BE – 15
HC03 13
