Diabetes Flashcards
Diabetes type 2 diagnosis
Suspect a diagnosis of type 2 diabetes if an adult presents with persistent hyperglycaemia that may be accompanied by clinical features:
Symptoms such as polydipsia, polyuria, blurred vision, unexplained weight loss, recurrent infections, and tiredness.
Signs such as acanthosis nigricans (a skin condition causing dark pigmentation of skin folds, typically the axillae, groin, and neck), which suggests insulin resistance.
The presence of risk factors.
Persistent hyperglycaemia is defined as:
HbA1c of 48 mmol/mol (6.5%) or more.
Fasting plasma glucose level of 7.0 mmol/L or more.
Random plasma glucose of 11.1 mmol/L or more in the presence of symptoms or signs of diabetes.
If symptomatic, a single abnormal HbA1c or fasting plasma glucose level can be used.
If asymptomatic, do not diagnose on the basis of a single abnormal test. Arrange repeat testing.
If the repeat test result is normal, monitor for development of diabetes (frequency on clinical judgement).
Management what should they know
Offer referral to an education programme. Annual reinforcement and review. DESMOND.
Provide advice on lifestyle measures, such as diet, exercise, and weight loss.
Assess for associated anxiety and depression, and manage.
Advise about sexual health, contraception, and the importance of pre-pregnancy counselling.
Offer immunization against influenza and pneumococcal infection.
Advise the person to always wear or carry some form of diabetes identification.
Advise that HbA1c should be measured at 3–6 monthly intervals initially until stable on unchanging antidiabetic treatment, and then every 6 months to ensure adequate blood glucose control.
Advise that screening for complications will be arranged at diagnosis and then annually thereafter.
Management pharmacological
If an adult with type 2 diabetes is hyperglycaemic with symptoms, consider the need for immediate insulin therapy or sulfonylurea depending on specialist advice.
Review treatment when blood glucose control has been achieved.
Offer standard-release metformin as first-line treatment
Then assess cardiovascular status - if they have - chronic heart failure, atherosclerotic CVD, or high risk of developing CVD - Offer an SGLT-2 inhibitor.
If metformin is contraindicated:
Offer an SGLT-2 inhibitor to people with CVD.
For other people, consider one of the following as first-line:
A DPP-4 inhibitor/ SGLT-2 inhibitor
Pioglitazone.
A sulfonylurea.
If monotherapy is ineffective, consider adding one of the following with metformin:
A DPP-4 inhibitor.
Pioglitazone.
A sulfonylurea.
An SGLT-2 inhibitor — may be considered if a sulfonylurea is contraindicated or the person is at significant risk of hypoglycaemia.
If dual therapy is ineffective:
For people who can take metformin, consider:
Triple therapy by adding a DPP-4 inhibitor, pioglitazone, a sulfonylurea, or an SGLT-2 inhibitor.
Starting insulin-based treatment.
If triple therapy is ineffective:
Consider switching one drug for a GLP-1 receptor agonist for people with:
BMI of 35 kg/m2 or higher or
BMI lower than 35 kg/m2, and insulin therapy would have significant occupational implications, or weight loss would benefit other comorbidities.
Management lifestyle
Diet
Offer nutritional advice from a healthcare professional.
Importance of a healthy, balanced diet:
Encourage high fibre, low-glycaemic-index sources of carbohydrate (such as fruit, vegetables, wholegrains, and pulses), low-fat dairy products, and oily fish.
Control the intake of saturated and trans-fatty acids, high-sugar drinks, and foods high in salt.
Individualize recommendations for carbohydrate and alcohol intake, and regular meal patterns, to reduce risk of hypoglycaemia, especially in people being treated with insulin or a sulfonylurea.
If the person is overweight or obese, set an initial body weight loss target of 5–10%.
Exercise and physical activity
Regular exercise. Minimize time spent being sedentary.
Diabetes UK -information on the type and duration of recommended exercise.
Advise that regular exercise may lower blood glucose levels, improve cardiovascular risk, and reduce excess weight (when combined with a healthy diet).
The effect of exercise on blood glucose levels when insulin levels are adequate (risk of hypoglycaemia).
The effect of exercise on blood glucose levels when the person is hyperglycaemic (risk of worsening blood glucose control and ketones in the blood).
The appropriate adjustments of insulin dosage or nutritional intake for exercise and post-exercise.
Alcohol intake
Advise on the recommended alcohol limits.
Advise the person to ideally eat a snack that contains carbohydrate before and after drinking alcohol.
Educate that alcohol may exacerbate or prolong the hypoglycaemic effect of antidiabetic drugs.
The signs of hypoglycaemia may become less obvious, and delayed hypoglycaemia may occur up to several hours afterwards.
Advise to always wear diabetes identification.
Smoking and drug misuse
Complications, such as cardiovascular disease.
Advise on smoking cessation.
Reinforce this advice annually for people who currently do not plan to stop smoking, and at all review appointments if there is a prospect of the person stopping.
Advise young adult non-smokers never to start smoking.
Provide information on the risks of drug misuse and the possible effects on blood glucose control.
Periodontitis
Advise adults with type 2 diabetes at their annual review:
That they are at higher risk of periodontitis.
That if they get periodontitis, managing it can improve their blood glucose control and can reduce their risk of hyperglycaemia.
To have regular oral health reviews.
Treatment targets
Lifestyle including diet management — 48 mmol/mol (6.5%).
Lifestyle including diet combined with a single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%).
Drug treatment associated with hypoglycaemia (such as a sulfonylurea): 53 mmol/mol (7.0%).
Measure HbA1c levels at 3–6 monthly intervals until the HbA1c is stable on unchanging treatment, then at 6-monthly intervals.
If HbA1c levels rise to 58 mmol/mol (7.5%) or higher:
Reinforce advice on lifestyle including diet.
Assess the person’s adherence to antidiabetic drug treatment.
Intensify antidiabetic drug treatment, if appropriate.
HbA1c targets may be reduced if:
Tight blood glucose control and possible hypoglycaemia may be inappropriate for people at risk of falls, those with impaired awareness of hypoglycaemia, and people who drive or operate machinery.
If the person achieves an HbA1c level that is lower than their target and there is no hypoglycaemia - maintain it, Be aware of alternative reasons such as deteriorating renal function or sudden weight loss.
Do not routinely recommend self-monitoring of blood glucose levels.
Advise the person on the need to self-monitor if they:
Are using insulin therapy.
Have evidence of hypoglycaemic episodes.
Are taking a drug that may increase the risk of hypoglycaemia while driving (such as a sulfonylurea).
Are pregnant or planning a pregnancy.
If routine self-monitoring of blood glucose is indicated, review annually to check:
Self-monitoring skills, the quality and frequency of testing, and the equipment.
The person knows how to interpret blood glucose results, and what action to take.
The impact of self-monitoring on the person’s quality of life.
Complications foot
Advice, risk factors, what to look for in exam, risk and when to refer, reassessment, emergencies
Foot problems
Foot check in primary care at diagnosis and then annually.
Give basic foot care advice including the need to check daily the entire surface of both feet, including areas between the toes.
Footwear advice, including to avoid shoes that are too tight, have rough edges, to avoid tight-fitting socks; and change socks daily.
Nail-cutting advice.
Risk factors for developing foot complications:
Previous foot ulcer or lower limb amputation, peripheral arterial disease, and end-stage renal disease (ESRD).
Symptoms of peripheral neuropathy.
Symptoms of peripheral arterial disease (claudication or rest pain).
Smoking history.
Examine both feet for following risk factors:
Neuropathy — use a 10 g monofilament for foot sensory examination.
Limb ischaemia — use ankle brachial pressure index (ABPI).
Ulceration
Callus.
Infection (redness, warmth and tenderness) or purulent discharge.
Deformity (such as claw or hammer toes), large bony prominences, limited joint mobility.
Gangrene.
Charcot arthropathy — acute inflammatory condition- leads to bone destruction, subluxation, dislocation, and deformity.
Footwear
Foot hygiene — ingrown nails, unwashed feet, superficial fungal infection.
Assess the person’s current risk of developing a diabetic foot problem or needing an amputation:
Low risk - No risk factors present except callus alone.
Moderate risk - Deformity, or Neuropathy, or Peripheral arterial disease.
High risk: Previous ulceration, or Previous amputation, or On renal replacement therapy, or Neuropathy and peripheral arterial disease together, or Neuropathy in combination with callus and/or deformity, or
Peripheral arterial disease in combination with callus and/or deformity.
Manage the person’s risk of developing a diabetic foot problem:
For people at low risk - Continue to carry out annual foot assessments.
Moderate risk — referral to foot protection service to be seen within 6–8 weeks. Reassessment Every 3–6 months
High risk — referral to foot protection service to be seen within 2–4 weeks. Reassessment every 1-2 months
Every 1–2 weeks— high risk, immediate concern.
For people with a limb-threatening refer immediately to acute services:
Ulceration with fever or any signs of sepsis.
Ulceration with limb ischaemia.
Deep-seated soft tissue or bone infection (with or without ulceration).
Gangrene (with or without ulceration).
Complications Microvascular
Retinopathy
Diabetic eye screening will be offered at diagnosis and:
Every 2 years for people at low risk of sight loss (no identified diabetic retinopathy on two successive screening tests).
At least annually for all other people with diabetes.
Arrange emergency assessment by ophthalmology if there is:
Sudden loss of vision.
Rubeosis iridis (formation of abnormal blood vessels on the anterior iris).
Pre-retinal or vitreous haemorrhage.
Suspected retinal detachment.
Arrange an urgent referral if unexplained reduction in visual acuity.
Peripheral and autonomic neuropathy
Peripheral Symptoms - numbness, burning or shooting pain, tingling and/or paraesthesia of the hands and/or feet, typically in a stocking and glove distribution, often at night, which may be relieved by activity.
Motor neuropathy - muscle weakness, wasting, cramps and/or twitching, which may cause eventual deformity.
If there is hand involvement, it may affect fine motor skills over time.
If there is foot involvement, consider referral to podiatry for footwear advice and possible specialist footwear.
Symptoms or signs suggesting autonomic neuropathy (affect multiple systems and has a gradual, progressive onset):
Postural hypotension (drop in systolic blood pressure of more than 30 mmHg when changing from a lying to a standing position, without any increase in heart rate).
TCA or antihypertensive may contribute to symptoms.
‘Diabetic gastroparesis’ suggested by delayed gastric emptying, bloating, nausea, and post-prandial vomiting.
Advise a small-particle-size diet (mashed or pureed food).
Lower gastrointestinal involvement may cause lower abdominal pain, unexplained diarrhoea (may be nocturnal), and faecal incontinence.
Unexplained urinary symptoms such as hesitancy, reduced frequency, inadequate bladder emptying, and urinary retention, if other possible causes have been excluded.
Sexual dysfunction, erectile dysfunction, and/or retrograde ejaculation.
Sweating abnormalities, such as reduced sweating in a stocking and glove distribution.
Impaired awareness of hypoglycaemia.
Diabetic kidney disease
Annual screening for diabetic kidney disease.
Complications macro
Cause - atherosclerosis
Cardiovascular risk factors - assessed at least annually, including:
Smoking status
Blood glucose control
Blood pressure
Albuminuria
Full lipid profile
Family history of CVD.
Measure waist circumference, and calculate BMI.
Offer management for people who are overweight or obese.
Ensure people with CVD risks factors are managed appropriately.
Antihypertensive treatment
If the person is already on antihypertensive drug treatment - lifestyle advice. Review BP control and drug treatments used.
Urine albumin:creatinine ratio (ACR) less than 70 mg/mmol - systolic less than 140 mmHg and diastolic less than 90 mmHg.
ACR of 70 mg/mmol or more, aim for systolic less than 130 mmHg diastolic less than 80 mmHg.
In adults aged 80 or more - systolic less than 150 mmHg and diastolic less than 90 mmHg.
If the person has newly diagnosed hypertension:
Lifestyle advice.
Confirm with blood pressure of 140/90 mmHg or higher and ABPM daytime average or HBPM average of 135/85 mmHg or higher.
Measure standing as well as seated blood pressure.
Classify the person’s stage of hypertension.
If antihypertensive drug treatment is indicated:
Explain the risks and benefits.
Offer ACE inhibitor or angiotensin-II receptor antagonist (AIIRA) to all adults.
For adults of black African or African-Caribbean origin, consider an AIIRA.
Offer a CCB or thiazide-like diuretic in addition to an ACE inhibitor or AIIRA, if hypertension is not controlled by monotherapy.
Offer a combination of an ACE inhibitor or AIIRA, a CCB and a thiazide-like diuretic if hypertension remains uncontrolled.
If hypertension is not controlled with optimal tolerated doses of an ACE inhibitor or an AIIRA, plus a CCB and a thiazide-like diuretic - Consider adding a fourth antihypertensive drug, or seek specialist advice.
Lipid modification
Offer atorvastatin 20 mg once daily for primary prevention of CVD if:
Less than 84 and estimated 10-year risk of developing CVD is 10% or more.
The person is 85 + older, taking into account co-morbidities.
The person has a diagnosis of chronic kidney disease (CKD).
Offer atorvastatin 80 mg once daily for secondary prevention of CVD.
Aim for a greater than 40% reduction in non-HDL cholesterol.
Consider up-titration of the atorvastatin dose to achieve this target, if appropriate.
Antiplatelet treatment
Do not routinely offer antiplatelet treatment (aspirin or clopidogrel) for the primary prevention of cardiovascular disease (CVD) in adults with type 2 diabetes.
Type 1 diagnosis adults
Diagnose type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia (random plasma glucose more than 11 mmol/L), bearing in mind that adults with type 1 diabetes typically (but do not always) have one or more of the following:
Ketosis.
Rapid weight loss.
Age of onset younger than 50 years.
Body mass index (BMI) below 25 kg/m2.
Personal and/or family history of autoimmune disease.
Refer immediately to a diabetes specialist team.
Do not routinely measure C-peptide and/or diabetes-specific autoantibody to confirm the diagnosis.
May be measured (usually in secondary care) if:
Suspected but the clinical presentation includes some atypical features (for example age 50 years or older, BMI of 25 kg/m2 or above), or
Type 1 diabetes treatment started but there is a clinical suspicion that the person may have a monogenic form of diabetes or
Classification of diabetes is uncertain.
Type 1 diagnosis children
Suspect type 1 diabetes when presenting with hyperglycaemia (random plasma glucose more than 11 mmol/L) and the characteristic features of:
Polyuria.
Polydipsia.
Weight loss.
Excessive tiredness.
Refer immediately
When diagnosing diabetes in young person, assume type unless there are strong indications of other types.
Features of type 2:
A strong family history of type 2 diabetes.
Obesity.
Black or Asian family origin.
No insulin requirement, or have an insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase.
Evidence of insulin resistance (for example acanthosis nigricans).
Features of other types of diabetes (such as monogenic or mitochondrial diabetes) or other insulin resistance syndromes include:
Diabetes in the first year of life.
Rarely or never develop ketone bodies in the blood during hyperglycaemia.
Associated features, such as optic atrophy, retinitis pigmentosa, deafness, or features of another systemic illness/syndrome.
Suspect DKA
Suspect diabetic ketoacidosis (DKA) in a person with known diabetes or significant hyperglycaemia (finger-prick blood glucose level greater than 11 mmol/L) and the following clinical features:
Increased thirst and urinary frequency.
Weight loss.
Inability to tolerate fluids.
Persistent vomiting and/or diarrhoea.
Abdominal pain.
Visual disturbance.
Lethargy and/or confusion.
Fruity smell of acetone on the breath.
Acidotic breathing — deep sighing (Kussmaul) respiration.
Dehydration, which can be classified as:
Mild
Moderate — dry skin and mucus membranes, and reduced skin turgor.
Severe — sunken eyes and prolonged capillary refill time.
Shock (resulting from severe dehydration) - Tachycardia, poor peripheral perfusion, and (as a late sign) hypotension.
Lethargy, drowsiness, or decreased level of consciousness (indicating decreased cerebral perfusion).
Reduced urine output (indicating decreased renal perfusion).
If DKA is suspected:
Assess for precipitating factors such as:
Infection (for example pneumonia or UTI).
Physiological stress (such as trauma or surgery).
Non-adherence to insulin treatment regimen
Other medical conditions (such as hypothyroidism or pancreatitis).
Drug treatment (such as corticosteroids, diuretics, and sympathomimetic drugs [eg salbutamol]).
Test for ketones (produced by the liver as an alternative energy source when there is insulin deficiency):
In an adult - test for urine or blood ketones even if plasma glucose levels are near normal.
In a child or young person - test for blood ketones.
Ketones are high if above 2+ in the urine or above 3 mmol/L in the blood.
Hypoglycaemia symptoms mild, moderate, severe
Hypoglycaemia presents with a wide variety of symptoms (autonomic and neuroglycopenic).
Suspect mild hypoglycaemia in a person with type 1 diabetes who presents with the following:
Hunger.
Anxiety or irritability.
Sweating.
Tingling lips.
Irritability.
Palpitations.
Tremor.
As blood glucose levels fall lower, the person may experience:
Weakness and lethargy.
Impaired vision.
Incoordination.
Reduced orientation.
Confusion.
Irrational behaviour.
Emotional lability.
Deterioration of cognitive function (when blood glucose levels fall lower than 3.0 mmol/L).
Severe hypoglycaemia may result in:
Convulsions.
Inability to swallow.
Loss of consciousness.
Coma.
Education- child or young person- type 1 diabetes
Continuing programme of education including:
Insulin therapy - aims, how it works, mode of delivery, dosage adjustment.
Blood glucose monitoring - target is Hba1c 48mmol or lower - check 4 times annually.
The effects of diet, physical activity, and intercurrent illness on blood glucose control.
Managing intercurrent illness
Detecting and managing hypoglycaemia, hyperglycaemia, and ketosis.
Be tailored to the child/young person and their family.
Diabetes support groups
Have the following immunizations:
Annual immunization against influenza (if aged over 6 months).
Immunization against pneumococcal infection.
Wear or carry something that identifies them as having type 1 diabetes.
Young person targets
Optimal targets:
Fasting plasma glucose level of 4–7 mmol/L on waking.
Plasma glucose level of 4–7 mmol/L before meals at other times of the day.
Plasma glucose level of 5–9 mmol/L after meals.
For young people of driving age, plasma glucose level of at least 5 mmol/L when driving.
Blood glucose monitoring
Encourage to attend clinic 4 times a year as regular contact is associated with optimal blood glucose control.
Self-monitoring:
Continuous glucose monitoring - measuring glucose levels continuously throughout the day and night via a tiny electrode inserted under the skin.
All should be offered real-time continuous glucose monitoring (rtCGM).
Intermittently scanned continuous glucose monitoring (isCGM) should be offered for those unable to use rtCGM or who express preference for isCGM.
If the person cannot use or does not want rtCGM or isCGM, capillary blood glucose monitoring should be offered.
Will still need to take capillary blood glucose measurements with CGM (less often, at least 5 times a day) because:
Check the accuracy of their CGM device
Back-up (eg, when levels are changing quickly or if the device stops working).
All people with type 1 diabetes will need a blood glucose monitor, lancets and testing strips to monitor capillary blood glucose.
Self-monitoring skills should be reviewed at least annually:
How to use their blood glucose monitoring meter
When to test — for example before breakfast and 2 hours after meals, during periods of illness, before driving, and if they feel hypoglycaemic.
How to assess and respond to test results - adjusting dosage and identifying cause of change in levels.
