Diabetes Flashcards
Diabetes Mellitus- types
T2DM,GESTATIONAL,TYPE 1
Description: persistent hyperglycaemia
Can be caused by:
What three things?
- Deficient insulin secretion (type 1)
- Resistance to the action of insulin (type 2)
- Pregnancy(gestational)
- Medications(secondary) etc steroids
Assessing fitness to drive:
Who do drivers need to inform of their condition? Drivers awareness should be assessed on the ability to do what exactly??
- All drivers being treated with insulin must notify the DVLA
- Drivers should be assessed on awareness of hypoglycaemia - the capability of bringing their vehicle to a safe controlled stop
Group 1 drivers:
Have what kind of awareness?? How many episodes of severe hypoglycaemia have they had whilst awake in the preceding 12 months ?
- Adequate awareness of hypoglycaemia
- No more than 1 episode of severe hypoglycaemia while awake in the preceding 12 months
Group 2 drivers:
10 pts
- Group 2 drivers must report all episodes of severe(requires assistance) hypoglycaemia episodes including in sleep
- Full awareness of hypoglycaemia
- No episode of severe hypoglycaemia in the preceding 12 months
- Must use a blood glucose meter with sufficient memory to store 3 months readings
- Visual complications - must notify DVLA nd not drive
- Drivers treated with insulin should always carry a glucose meter and blood - glucose strips
- Check blood glucose concentration- no more than 2 hours before driving and every 2 hours whilst driving
And every 2 hours whilst driving - Blood glucose should always be above 5 mol/litre while driving
- If blood - glucose falls less than 5 mol/l take a snack
- Ensure a supply of fast acting carbohydrate is available in the vehicle
Hypoglycaemia whilst driving-
- Considered a blood glucose less than 4 mol/l
Drivers should: be able to safely do what? Eat what and wait for how long?
- Safety 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 a blood - glucose has returned to normal, before continuing journey
Drivers must not drive, if
hypoglycaemia awareness has been lost and DVLA must be notified
Type 1 diabetes Mellitus:
Insulin deficiency- destroyed beta cells in islets of langerhans
- Most commonly before adulthood
Typical features of t1dm
- Hyperglycaemia less than 11mmol/litre
- Ketosis
- Rapid weight loss
- BMI less than 25kg/m2
- Age less than 50 years
- Family history of autoimmune disease
Blood glucose monitoring =
Monitored at least 4 times a day (including before each meal and before bed)
Targets:
-waking
-fasting
-90 mins
- driving
- 5-7 mmol/l on waking fasting
- 4-7 mmol/L fasting BG before meals at other times of the day
- 5-9 mmol/l 90 mins after eating
- Greater than 5 mmol/l when driving
Insulin regimens:
All type 1 patients should receive insulin therapy:
(Detimir (FL), Glargine(SL))
- Multiple daily injections basal bonus insulin regimens (first line)
- Basal (long/intermediate acting insulin) once or twice daily AND bolus(short/rapid acting) before meals
- First basal = determine BD,Second line = glargine OD
Biphasic mixtures:
- Short acting mixed with intermediate insulin injected 1-3 times a day
Continuous subcutaneous insulin infusion(insulin pump)
- Adults who suffer disabling hypoglycaemia/uncontrolled hyperglycaemia
Insulin requirements:
A few factors may affect how much insulin that is needed:
Increase insulin when… there is:
- An infection
- Stress
- Trauma
- Puberty
- 2nd/3rd trimester
Decrease insulin when:
- Physical activity
- Inter current illness
- Reduced food intake
- Impaired renal function
- Certain endocrine disorders, coeliac disease,Addison disease
Insulin administration is a activated by GI enzymes so..
FASTEST AND SLOWEST =
- Inactivated by GI enzymes - given subcutaneously
- Injected into a body area with plenty of subcutaneous fat - abdomen (fastest absorption rate)
- Outer thigh/buttocks(slower absorption)
Rotate injection site-
- Lipohypertropy can occur due to repeatedly injecting into the same small area- leads to erratic absorption of insulin
The types of insulin:
Short acting -
Human- (15-30, 30-60,peak 1-4) =9
Rapid= bm,15,2-5)
Soluble insulin:
- Human and bovine/porcine
- Inject:15 to 30 mins before meals
- Onset : 30 to 60 mins,peak action 1-4 hours
- Duration:up to 9 hours
Rapid acting insulin:
- Lispro,aspart,glulisine (no laging)
- Inject: immediately before meal
- Onset less than 15 mins
- Duration 2-5 hours
Now, intermediate acting insulin- what is intermediate insulin a combined mixture of?
(1-2,3-12)(11-24)
-biphasic isoprene,biphasic aspart/lispro(isophane insulin mixed with short acting insulin)
Onset: 1-2 hours,peak affect of 3-12 hours
Duration: 11-24 hours
Long acting insulin:
(2-4),(36)
-detemir,degludec,glargine
-inject: once daily (detemir=bd)
-onset: 2-4 days to reach steady state
Duration 36 hours
Type 2 diabetes Mellitus
HB1Ac of(42-47) is….
(48) is…..
Characterised by insulin resistance
- Typically develops later in life
- Patients with pre diabetes:
HbA1c of 42-47 mmol/mol
Can try and prevent diabetes with lifestyle advice
Diabetic considered Hb1A1c of 48mmol/mol
Treatment of diabetes (low CVD RISK)
1) Assess Hb1Ac, kidney function and cardiovascular risk-
— treat with metformin
- Aim for the individually agreed threshold
2)if Hb1Ac above the individually agreed threshold-
- Add in DPPi-4i (Gliptins),pioglitazone, su (sulfonylurea) or SGLT-2i(Flozins)
- Aim for the individually agreed threshold
3) If Hb1Ac above the individually agreed threshold:
- Triple therapy by adding or swapping class of anti diabetic
- Aim for the individually agreed threshold
Treatment of diabetes (High CVD risk)
1) what d owe need to access patients for 1st?
1) what do we treat them with?
2) what can we add once it’s tolerated?
3) if not tolerated what do we give alone?
4) if still above the agreed threshold what do we do?
1) Assess Hb1Ac,kidney function and cardiovascular risk:
- High risk: established atherosclerotic CVD /HF or a QRISK more than 10%
- Treat with metformin
- Once metformin is tolerated - add SGLT-2i
- If metformin is not tolerated: alone SGLT-2i
- Aim for the individually agreed threshold
2) If HbA1c above te individually agreed threshold
- Follow the guidance for dual and triple therapy as previous slide
- If patient at any point develops high risk - consider an SGLT-2i