Diabetes Flashcards
What is type 1 diabetes mellitus?
Autoimmune
Attacks beta cells so can’t produce insulin
Glucose can’t enter cells
What are some symptoms of T1DM?
Symptoms develop over few days or weeks:
peeing more than usual
feeling very thirsty
feeling very tired
losing weight quickly without trying to
blurred vision
breath that smells sweet or fruity (like nail
polish remover or pear drop sweets)
cuts and wounds taking longer to heal
getting frequent infections, such as thrush
How is gestational diabetes diagnosed?
Diagnosed if woman has either:
fasting plasma glucose level of 5.6mmol/l or above or
a 2-hour plasma glucose level of 7.8mmol/l or above
Whats the criteria for a diabetes diagnosis with symptoms?
Diabetes symptoms (e.g. polyuria, polydipsia and unexplained weight loss for Type 1) 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)
Whats the criteria for diagnosing diabetes with no symptoms?
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
When is HbA1c not appropriate for diagnosis of diabetes?
ALL children and young people
patients of any age suspected of having Type 1 diabetes
patients with symptoms of diabetes for less than 2 months
patients at high risk who are acutely ill (e.g. those requiring hospital admission)
patients with acute pancreatic damage, including pancreatic surgery
in pregnancy
presence of genetic, haematologic and illness-related factors that influence HbA1c and its measurement (see annex 1 of the WHO report for a list of factors which influence HbA1c and its measurement)
What HbA1c level is the recommended cut off for diagnosing diabetes?
48mmol/mol (6.5%)
value of less than 48mmol/mol (6.5%) does not exclude diabetes diagnosed using glucose tests
What other investigations should be done for a new diagnosis of T1DM?
FBC
TFTs and TPO
Anti-TTG
Insulin antibodies, anti-GAD antibodies and islet cell antibodies - to test for antibodies associated with destruction of the pancreas and the development of type 1 diabetes
What are some short term complications of T1DM?
-Hypoglycaemia: hunger, tremor, sweating, irritability, dizziness and pallor, reduced consciousness, coma and death
-hyperglycaemia, may need to increase insulin dose, if enter DKA they need hospital admission
What are some long term complications of T1DM?
Chronic exposure to hyperglycaemia causes damage to the endothelial cells of blood vessels
suppression of the immune system
What are some Macrovascular Complications of T1DM?
Coronary artery disease
Peripheral ischaemia causes poor healing, ulcers and “diabetic foot”
Stroke
Hypertension
What are some Microvascular Complications of T1DM?
Peripheral neuropathy
Retinopathy
Kidney disease, particularly glomerulosclerosis
What are some infection related complications of T1DM?
Urinary tract infections
Pneumonia
Skin and soft tissue infections, particularly in the feet
Fungal infections, particularly oral and vaginal candidiasis
How is T1DM managed?
Basal-bolus insulin regime
The basal part refers to an injection of a long acting insulin, such as “Lantus”
The bolus part refers to an injection of a short acting insulin, such as “Actrapid” - usually before meals
Use carb counting
Insulin pumps
How is blood sugar monitored?
HbA1c - counting glycated haemoglobin, average blood glucose level over the last 3 months. Measure ever 3-6mths
Capillary Blood Glucose
Flash Glucose Monitoring (e.g. FreeStyle Libre)- sensor on the skin that measures the glucose level of the interstitial fluid in the subcutaneous tissue. Has 5 min lag
What diabetes screenings are available and how often should they be done?
Once a year:
Eye problems (diabetic retinopathy) through retinopathy screening
Nerve damage and circulation through foot examinations
Cholesterol screening - blood test
Blood pressure screening
Kidney disease screening (diabetic nephropathy) - urine tested for proteins
What is T2DM?
combination of insulin resistance and reduced insulin production cause persistently high blood sugar levels
Repeated exposure to glucose and insulin makes the cells in the body resistant
What causes the T2DM complications?
A high carbohydrate diet combined with insulin resistance and reduced pancreatic function leads to chronic high blood glucose levels (hyperglycaemia). Chronic hyperglycaemia leads to microvascular, macrovascular and infectious complications
What are some risk factors for T2DM?
Non-modifiable risk factors:
-Older age
-Ethnicity (Black African or Caribbean and South Asian)
-Family history
Modifiable risk factors:
-Obesity
-Sedentary lifestyle
-High carbohydrate (particularly sugar) diet
What’s the presentation of T2DM?
Tiredness
Polyuria and polydipsia (frequent urination and excessive thirst)
Unintentional weight loss
Opportunistic infections (e.g., oral thrush)
Slow wound healing
Glucose in urine (on a dipstick)
What skin appearance is associated with insulin resistance?
Acanthosis nigricans
thickening and darkening of the skin, often at the neck, axilla and groin
What are the treatment targets for T2DM?
HbA1c measured every 3-6 months:
48 mmol/mol for new type 2 diabetics
53 mmol/mol for patients requiring more than one antidiabetic medication
What’s the recommended management for T2DM?
A structured education program
Low-glycaemic-index, high-fibre diet
Exercise
Weight loss (if overweight)
Antidiabetic drugs
Monitoring and managing complications
What is a complication unique to T2DM?
Hyperosmolar Hyperglycemic State
hyperosmolality (water loss leads to very concentrated blood), high sugar levels (hyperglycaemia) and the absence of ketones
presents with polyuria, polydipsia, weight loss, dehydration, tachycardia, hypotension and confusion.
Treated with IV fluids
Whats the medical management options for T2DM?
-First-line is metformin
Add SGLT-2 inhibitor if pt has CVD or HF
-Second-line is to add a sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor
-Third line is Triple therapy with metformin and two of the second-line drugs
OR Insulin therapy (initiated by the specialist diabetic nurses)
What options are available if triple therapy fails?
patient’s BMI is above 35 kg/m2, there is the option of switching one of the drugs to a GLP-1 mimetic (e.g., liraglutide).
What are the key complications of T2DM?
Infections (e.g., periodontitis, thrush and infected ulcers)
Diabetic retinopathy
Peripheral neuropathy
Autonomic neuropathy
Chronic kidney disease
Diabetic foot
Gastroparesis (slow emptying of the stomach)
Hyperosmolar hyperglycemic state
How is hypertension managed in T2DM patients?
ACE inhibitors first line
How is CKD managed in T2DM patients?
ACE inhibitors started when the albumin-to-creatinine ratio (ACR) is above 3 mg/mmol (as opposed to 30 mg/mmol in patients without diabetes)
SGLT-2 inhibitors are started when the albumin-to-creatinine ratio (ACR) is above 30 mg/mmol (in addition to the ACE inhibitor).
How can gastroparesis be managed?
Prokinetic drugs (e.g., domperidone or metoclopramide)
Used with caution due to cardiac side effects
What can be given to manage neuropathic pain?
Amitriptyline – a tricyclic antidepressant
Duloxetine – an SNRI antidepressant
Gabapentin – an anticonvulsant
Pregabalin – an anticonvulsant
What is DAFNE?
DAFNE is a skills-based education programme in which adults with type 1 diabetes learn how to adjust insulin to suit their free choice of food, rather than having to work their life around their insulin doses
What is DESMOND?
Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) is a structured group education programme for adults with type 2 diabetes. DESMOND has a theoretical and philosophical base; the programme supports people in identifying their own health risks and responding to them by setting their own specific behavioural goals
How does metformin work?
increases insulin sensitivity and decreases glucose production by the liver
What are some side effects of metformin?
Gastrointestinal symptoms, including pain, nausea and diarrhoea (depending on the dose) - can try modified release metformin
Lactic acidosis (e.g., secondary to acute kidney injury)
How do SGLT-2 inhibitors work?
sodium-glucose co-transporter 2 protein is found in the proximal tubules of the kidneys
acts to reabsorb glucose from the urine back into the blood. SGLT-2 inhibitors block the action of this protein, causing more glucose to be excreted in the urine
Lowers HbA1c, reduces BP, leads to weight loss, improves HF
What are some side effects of SGLT-2 inhibitors?
Glycosuria (glucose in the urine)
Increased urine output and frequency
Genital and urinary tract infections (e.g., thrush)
Weight loss
Diabetic ketoacidosis, notably with only moderately raised glucose
Lower-limb amputation may be more common in patients on canagliflozin (unclear if this applies to the others)
Fournier’s gangrene (rare but severe infection of the genitals or perineum)
What are some examples of SGLT-2 inhibitors and what else can they be used for?
empagliflozin - HF
canagliflozin
dapagliflozin - HF and CKD
ertugliflozin
How does pioglitazone work?
is a thiazolidinedione
increases insulin sensitivity and decreases liver production of glucose
What are some side effects of pioglitazone?
Weight gain
Heart failure
Increased risk of bone fractures
A small increase in the risk of bladder cancer
How do sulfonureas work?
Gliclazide
stimulate insulin release from the pancreas
What are some side effects of sulfonureas?
Weight gain
Hypoglycaemia
How do GLP-1 mimetics work?
GLP-1 mimetics imitate the action of GLP-1. Examples are exenatide and liraglutide.
Increasing insulin secretion
Inhibiting glucagon production
Slowing absorption by the gastrointestinal tract
These get inhibited by DPP-4
What are some side effects of GLP-1 mimetics?
Reduced appetite
Weight loss
Gastrointestinal symptoms, including discomfort, nausea and diarrhoea
How do DDP-4 inhibitors work?
inhibitors block the action of DPP-4, allowing increased incretin activity:
-Increasing insulin secretion
-Inhibiting glucagon production
-Slowing absorption by the gastrointestinal tract
Examples of DPP-4 inhibitors are sitagliptin and alogliptin
What are some side effects of DPP-4 inhibitors?
Headaches
Low risk of acute pancreatitis
Whats the onset time of rapid-acting insulins?
NovoRapid
start working after around 10 minutes and last about 4 hours
Whats the onset time of short-acting insulins?
Actrapid
start working in around 30 minutes and last about 8 hours
Whats the onset time of intermediate-acting insulins?
e.g., Humulin I
start working in around 1 hour and last about 16 hours
Whats the onset time of long-acting insulins?
e.g., Levemir and Lantus
start working in around 1 hour and last about 24 hours or longer
What are combination insulins?
a rapid-acting and intermediate-acting insulin
In brackets is the ratio of rapid-acting to intermediate-acting insulin:
Humalog 25 (25:75)
Humalog 50 (50:50)
Novomix 30 (30:70)
