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Endocrine > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Diabetes Mellitus- types

A

T2DM,GESTATIONAL,TYPE 1

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2
Q

Description: persistent hyperglycaemia
Can be caused by:
What three things?

A
  • Deficient insulin secretion (type 1)
    • Resistance to the action of insulin (type 2)
    • Pregnancy(gestational)
    • Medications(secondary) etc steroids
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3
Q

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??

A
  • 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
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4
Q

Group 1 drivers:
Have what kind of awareness?? How many episodes of severe hypoglycaemia have they had whilst awake in the preceding 12 months ?

A
  • Adequate awareness of hypoglycaemia
    • No more than 1 episode of severe hypoglycaemia while awake in the preceding 12 months
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5
Q

Group 2 drivers:
10 pts

A
  • 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
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6
Q

Hypoglycaemia whilst driving-

A
  • Considered a blood glucose less than 4 mol/l
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7
Q

Drivers should: be able to safely do what? Eat what and wait for how long?

A
  • 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
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8
Q

Drivers must not drive, if

A

hypoglycaemia awareness has been lost and DVLA must be notified

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9
Q

Type 1 diabetes Mellitus:

A

Insulin deficiency- destroyed beta cells in islets of langerhans
- Most commonly before adulthood

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10
Q

Typical features of t1dm

A
  • Hyperglycaemia less than 11mmol/litre
    • Ketosis
    • Rapid weight loss
    • BMI less than 25kg/m2
    • Age less than 50 years
    • Family history of autoimmune disease
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11
Q

Blood glucose monitoring =

A

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

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12
Q

Targets:
-waking
-fasting
-90 mins
- driving

A
  • 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
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13
Q

Insulin regimens:
All type 1 patients should receive insulin therapy:
(Detimir (FL), Glargine(SL))

A
  • 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
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14
Q

Biphasic mixtures:

A
  • Short acting mixed with intermediate insulin injected 1-3 times a day
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15
Q

Continuous subcutaneous insulin infusion(insulin pump)

A
  • Adults who suffer disabling hypoglycaemia/uncontrolled hyperglycaemia
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16
Q

Insulin requirements:

A

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

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17
Q

Insulin administration is a activated by GI enzymes so..
FASTEST AND SLOWEST =

A
  • 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)
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18
Q

Rotate injection site-

A
  • Lipohypertropy can occur due to repeatedly injecting into the same small area- leads to erratic absorption of insulin
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19
Q

The types of insulin:
Short acting -
Human- (15-30, 30-60,peak 1-4) =9
Rapid= bm,15,2-5)

A

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

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20
Q

Now, intermediate acting insulin- what is intermediate insulin a combined mixture of?
(1-2,3-12)(11-24)

A

-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

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21
Q

Long acting insulin:
(2-4),(36)

A

-detemir,degludec,glargine
-inject: once daily (detemir=bd)
-onset: 2-4 days to reach steady state
Duration 36 hours

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22
Q

Type 2 diabetes Mellitus
HB1Ac of(42-47) is….
(48) is…..

A

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

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23
Q

Treatment of diabetes (low CVD RISK)

A

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

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24
Q

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?

A

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

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25
Q

Treatment of diabetes - metformin resistant:
STEP 1- What do we assess??
2) treatment?? High risk CVD we give what??
3) aim to agree on what with the patient?
2) if its above the agreed threshold??
- if its still not controlled??

A

If patients can’t tolerate metformin due to side effects, use MR preparation

1)Assess Hb1Ac,Kidney function and cardiovascular risk -
- Treat with DPP-4i,pioglitazone,SU or SGLT-2i
- High risk of cardiovascular disease - SGLT-2i
- Aim for the individually agreed threshold
2) If HbA1c above the individually agreed threshold
- Treat with DPP-4i or DPP-4i +SU or pioglitazone +su
- Aim for the individually agreed threshold
If Hb1Ac still not controlled,insulin therapy to aim for individually agreed threshold.

26
Q

Metformin(Biguanide)

A

Decreases glucogenesis and increases peripheral utilisation of glucose

27
Q

Side effect of metformin in 30!!!!!!!!!!!!!!!!!!!!!!!egfr +solutions

A

Lactic acidosis - avoid if eGFR is less than 30 ml/min/1.73m2
GI side effects - increase dose slowly or give MR prep
Can reduce vitamin b12

28
Q

Stop medication if (..injury)

A

patient experiences acute Kidney injury

29
Q

Sulphonylureas: Augment….. Short acting …
Long acting

A

augments insulin secretion
Short acting:
- Gliclazide
- Tolbutamide
Long acting:
Glibenclamide
Glimepiride
Associated with prolonged and sometimes fatal cases of hypoglycaemia - avoid in elderly

30
Q

Side effect - Sulf

A
  • High risk of hypoglycaemia which needs to be treated in hospital - hence why target is 7.0% instead of 6.5%
    when used
    • Avoid prescribing in acute porphyria
    • Should be avoided in hepatic and renal failure
      Caution G6PD!!!!
31
Q

Pioglitazone - reduces peripheral insulin resistance so we avoid in patients with a history of what? Patients that have an increased risk of what? How often do we review efficacy and safety?? Stop treatment if what is inadequate? What do we report? There is a risk of what (bone and organ)

A
  • Avoid in patients with history of heart failure
    • Increased risk of bladder cancer: review safety and efficacy after 3-6 months,stop treatment if patient responds in adequately
    • Report: haematuria,dysuria or urinary urgency
    • Increased risk of bone fractures
    • Increased risk of liver toxicity - report nausea,vomiting, abdominal pain,fatigue and dark urine develops
32
Q

DPP-4i - increases the secretion of …and lowers ALSSV

A

Increase insulin secretion and lower glucagon secretion

Can cause pancreatitis
- Discontinue if symptoms of acute pancreatitis occur
- Persistent,severe abdominal pain

Low
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Vildagliptin
High hepatoxicity

33
Q

SGLT-2i are sodium….

A

sodium glucose co transporter 2 inhibitor
Inhibits SGLT2 in renal proximal convoluted tubule

34
Q

MHRA WARNING:
SGLT2

A
  • Lie threatening and fatal cases of diabetic ketoacidosisDKA
    • Monitor ketones - if treatment interrupted for surgical procedure or illness
    • Fournier gangrene (necrotising fascilis if the genitalia or perineum)
    • Canagliflozin only - risk of lower limb amputation mainly toes
    • Volume depletion - correct hypovolaemia before starting treatment
    • Monitor renal function - canagliflozin,dapagliflozin,empagliflozin
35
Q

GLP-1 Agonist AND EXAMPLES DEEEEELLLLLL - what is their mechanism of action? What is the mhra risk when concomitant use of what was reduced??? What else can it cause? What causes dehydration (what precaution advise to take?)

A

Increase insulin secretion,suppresses glucagon secretion and slows gastric emptying
-MHRA - risk of diabetic ketoacidosis when concomitant insulin was rapidly reduced
-acute pancreatitis - patient warned or persistent,severe abdominal pain
- Dehydration - risk of dehydration due to gastro-intestinal side-effects and advised to take precaution to avoid fluid depletion
- Dulaglutide
- Exenatide
- Liraglutide
- Lixisenatide

36
Q

Other anti diabetics-
(Tummy aches)

A
  • Acarbose
    • Delays the digestion and absorption of starch and sucrose
    • High risk of gastrointestinal side effects may need to reduce dose
37
Q

Meglitides(Nateglinide or repaglinide)
STIMULATE THE…. SECRETION BUT WHEN THERE IS STRESS

A
  • Stimulates insulin secretion
    • Stress exposure - treatment interruption and replacement with insulin to maintain glycemic control
38
Q

Anti diabetic effects on weight:

A

Weight gain = pioglitazone + sulphonylureas
Neutral weight:DPP-4i
Weightloss- GLP-1,SGLT-2i

39
Q

Diabetic complications -what can be offered to patients with strong CVD risk? Think - QRISK10, Who is it offered to? What can ace reduce??

A
  • Strong risk factor for cardiovascular disease
    • Low-dose atrovastatin - considered in all type 1 patients
      • offered to 40+,diabetic for 10+ years,nephropathy or other CVD factors
    • ACE inhibitor reduces cardiovascular disease risk
40
Q

Diabetic nephropathy causes and can be treated using the drug can to what to hypoglycaemic effect???

A
  • Patients with nephropathy causing proteinuria - treat with ACE -I/ARB
    • ACE - I can potentate hypoglycaemic effect of anti diabetic drugs/ insulin
41
Q

Diabetic complications:
Diabetic neuropathy:
How would we treat the following-
- painful peripheral neuropathy
- diabetic foot?
Autonomic neuropathy?
- neuropathic postural hypotension?
- gustatory sweating?
Erectile dysfunction?

A
  • Painful peripheral neuropathy: antidepressants,gabapentin/pregablin
    • Diabetic foot :treat pain and manage infection
    • Autonomic neuropathy: treat diarrhoea with codeine or tetracyclines
    • Neuropathic postural hypotension:increases salt intake or fludrocortisone
    • Gustatory sweating - antimuscarinic (prpantheline bromide)
    • Erectile dysfunction - slide fail
42
Q

Visual impairment -

A

Have yearly eye tests

43
Q

Diabetic ketoacidosis DKA is caused by hyperrrrr

A

SEVERE HYPERGLYCAEMIA

44
Q

Symptoms OF DKA

A

-polyurea
- Thirsty
- Pear drop breath - ketones
- Deep or fasting breathing
- Lethargy/unconsciousness
- Confusion

45
Q

Check blood sugar level if displaying symptoms of DKA
If the blood sugar is above…… then …..
(3 more) (0.6-1.5)(1.6-2.9) (3mmol+)

A

If blood sugar is above 11mmol/l check ketone levels urine/blood
- 0.6-1.5mmol=slight risk(retest in 2 hours)
- 1.6-2.9mmol=increased risk (contact GP)
- 3mmol+= medical emergency

46
Q

DKA Treatment:
(BP L- 90 - 500ml Nacl, nacl+ insulin, ketone conc before 0.5 , blood conc at 3mmol, when bG less than 14 = IV…) , continue till ketone is /l and ph more than ??? back to eating Give them Fast acting insulin and Stop 1…..after….

A

1) If BP less than 90,restore volume with 500ml IV NaCl 0.9%
2) Once Bp is more than 90,give a maintenance IV NaCl 0.9%
3) Start IV insulin mixed with NaCL and administered at a rate so that…
- Ketone concentration falls 0.5mmol/L/hr
- Blood glucose conc falls at 3mmol/L/hr
4) When blood glucose less than 14mmol->IV Glucose 10%
5) Continue insulin kill ketone less than 0.3/l and PH more than 7.3
6) When patient able to eat ->give fast acting insulin with a meal
7) Stop treatment 1 hour after food

47
Q

Insulin during surgery IF ITS AN Elective minor and if its a major surgery (kcl,variable.12,6)

A
  • Elective surgery (minor procedures with blood 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% - recast 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 (solvable human) in NaCl 0.9% given via pump
      ○ Hourly blood glucose measurements for first 12 hours
      ○ Give IV glucose if blood glucose dips under 6mmol/L
48
Q

INFUSIONS are…

A

“infusions carried on until 30-60 mins after first meal short acting INSULIN administration

49
Q

Post surgery we convert them …. When the patient can!!! Basal bolus - after…. Infusion carried out for..
Long acting carries on at at ….
And BD RESTARTS at…..

A

-convert back to subcutaneous insulin when patient can eat/drink without vomiting
- Basal- bolus regimen:restarted with the first meal - infusions carried on till 30-60 mins after first meal short acting glucose administration
- Long acting regimen - carries on at 20% reduced until patient leaves hospital
- Twice daily regimen - restart at breakfast or evening meal - infusion carried on till 30-60 after meals

50
Q

SICK DAY RULES:

A

Sugar levels - blood glucose should be checked regularly
Insulin - carry on taking insulin
Carbohydrates - keep eating and stay hydrated
Ketones - check regularly

51
Q

Diabetes and pregnancy/breast feeding:

A
  • Diabetes in pregnancy - increased risks to women and foetus
    • Risk reduced by effective blood glucose control
52
Q

Before pregnancy- we aim for Hb1Ac to be what? What can we give as a supplement?

A
  • Aim for Hb1Ac less tha 48mmol/mol
    • Take folic acid 5mg
53
Q

Medication during surgery stoppping and replace with what??

A

All oral anti diabetics except metformin should be stopped and replaced with insulin
Isophane insulin is the first choice for long acting insulin during pregnancy
If patient is taking statin/ace/arb= discontinue

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

54
Q

Gestational diabetes

A

developed during pregnancy - stop treatment after birth

55
Q

Gestational diabetes….What must fasting glucose be less than ? How can we counsel them on bringing it down?? What can we use if met for in is contraindicated or ineffective??If requirements are not met in two weeks what do we do??
Fasting glucose is more than 7 what do we do?? Fasting glucose is 6-6.9 what do we do?? WHAT CAN WE NEVER EVER EVER ADD AND WHAT GROUP IS IT TEEHEEE

A

Fasting BG Less than 7 mmol/l
- Diet
- Exercise

- If requirement not  met in two weeks thennnnnnnd
- Insulin if metformin C I not tolerated or effective

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

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

56
Q

Hypoglycaemia is defined by anything les than …. Mmol/l and symptoms include?

A

less than 4 mmol/l
- Sweating
- Lethargic
- Dizziness
- Hunger
- Tremor
- Tingling lips
- Palpitations
- Extreme moods
- Pale

57
Q

If patient is conscious and able to swallow:

A
  • Fast acting carbohydrate by mouth
    • 4-5 glucose tabs
    • 3-4heaped tea spoons of sugar
    • 150-120ml of juice
    • Repeat every 15 mins for 3 cycles
58
Q

Oral administration not work or pt not conscious

A

IM Glucagon and then if unresponsive after 10 mins = iv glucose

59
Q

Some patients awareness of hypoglycaemia

A

may become blunted,preventing early recognition. This happens through increased numbers of hypo episodes or even taking beta blockers cal

60
Q

WHEN pts are sick advised to stop And start within 24-48 hrs ….

A

Restart after 24-48 hrs of eating normally
- Metformin
- Sulfonylureas
-GLP 1 - due to be hydration
- SGLT2 inhibitors - ketoacidosis
-Ace
Arb
Diuretics
NSAIDs

Endocrine (7 decks)

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