Diabetes Flashcards
List 6 commonest complications of diabetes
- Ischemic heart disease
- Diabetic foot ulcers
- Diabetic retinopathy
- Diabetic nephropathy
- Stroke
- Peripheral artery disease
- Erectile dsyfunction
List 5 commonest symptoms of diabetes.
- Polyuria and nocturia
- Polydipsia
- Fatigue
- Susceptibility to infections mainly UTI, Resp infections and skin infections
- Periodic change in vision with fluctuation blood glucose
Outline how diabetes is diagnosed if it is symptomatic.
Random blood glucose >=11.1 mmol/L
Or
Fasting glucose>=7 mmol/L
Or
2-hour plasma glucose in a 75 g oral glucose tolerance test ≥ 11.1 mmol/l
HbA1c is not diagnostic of diabetes
What is considered fasting when fasting blood glucose has to be determined?
Fasting is defined as no caloric intake for ≥ 8 hours.
State how asymptomatic diabetes is diagnosed.
» Random blood glucose ≥ 11.1 mmol/L.
OR
» Fasting blood glucose ≥ 7.0 mmol/L.
OR
» 2-hour plasma glucose in a 75 g oral glucose tolerance test ≥ 11.1 mmol/l
2 positive tests done on separate days are
required for diagnosis
What should be measured at every routine visit for diabetes?(3)
- Finger prick random glucose
- Weight
- Blood pressure
List 8 baselines investigations that need to be established at the diagnosis of diabetes.
» Serum creatinine concentration (and calculate eGFR).
» Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min.
» Urine protein by dipstix.
» BMI for cardiovascular risk assessment if appropriate
» Blood lipids (fasting total cholesterol, triglycerides, HDL and LDL cholesterol).
» Foot examination.
» Eye examination to look for retinopathy.
» Abdominal circumference.
At diagnosis of diabetes, if urine dipstix is negative what should you do?
Urine albumin: creatinine ratio unless already on an ACE inhibitor
What should be checked at an annual diabetes visit?
» Serum creatinine concentration (and calculate eGFR).
» Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min.
» Urine protein by dipstix
» HbA1c, in patients who meet treatment goals (3–6 monthly in patients whose therapy has changed, until stable).
» Eye examination to look for retinopathy.
» Foot examination.
What is the target HbA1c for a young low risk individual, new diagnosed diabetic individuals and individuals with no cardiovascular disease?
<6.5%
What is the target HbA1c for the majority of patients?
<7.0%
What is the target HbA1c for the elderly, high risk individual , individuals with hypoglycemic unawareness and patients with poor short term prognosis?
<7.5%
What is the target fasting blood glucose for all diabetics?
4-7 mmol/l
What is the target post prandial glucose for the following
1. New diagnosed diabetic
2. Majority of patients
3. Elderly
- 4.4-7.8 mmol/L
- 5-10 mmol/L
- <12 mmol/L
This is the same category used in previous questions
What is the BMI and blood pressure target in diabetes?
BMI <=25
BP 120/70-139/89 (some say <130/75 or <130/80
State 7 urgent indications for referral in diabetes.
» Acidotic breathing.
» Dehydration and hypotension.
» Nausea, vomiting and abdominal pain.
» Ketonuria (more than 1+).
» Hyperglycaemia >25 mmol/L.
» Gangrene.
» Sudden deterioration of vision.
» Serious infections
Consider IV infusion with sodium chloride 0.9%, before transferring very ill patients.
Non urgent indications for referral in diabetes (7)
» Pregnancy.
» Failure of step 3 to control diabetes.
» eGFR< 30 mL/minute.
» Ischaemic heart disease.
» Cerebrovascular disease.
» Refractory hypertension.
» Progressive loss of vision
State the
State the immediate management of a patient with a random glucose level of > 11 with and without symptoms
With symptoms: NaCl 0.9 % 20 ml/kg IV over the first hour then 10 ml/kg/hour thereafter and give short acting insulin 0.1 unit/kg IM
Without symptoms:
1. Ketones in urine: NaCl 0.9 % 20 ml/kg IV over the first hour then 10 ml/kg/hour thereafter and give short acting insulin 0.1 unit/kg IM
2. No ketone in urine: give diabetes routine care
What is the immediate management of diabetes patients with a glucose level of <4 mmol/L?
Conscious and can drink: Glucose 5 ml/kg orally
Conscious but unable to drink: Dextrose 10% 5 ml/kg via nasogastric tube
Decreased level of consciousness: Dextrose 10% 5 ml/kg IV
Add thiamine if the patient is a known alcohol user
What are the constituents of the glucose solution given to patients with hypoglycemia?
Three teaspoons of sugar(15 g) in 1 cup(200 ml) of water
What do you do if you do not have dextrose 10% in your facility but the patient has hypoglycemia?
Mix 1 part of dextrose 50% to 4 parts water to make a dextrose 10 % solution
Who must get an influenza vaccine routine?
- Age >65 years
- History of lung or heart disease
- HIV positive
4 indications of simvastatin if there is no history of cardiovascular diseases for diabetes patients.
- CVD risk >20%
- eGFR<60
- Diabetes for at least 10 years
- Age>40 years old
Is enalapril only added in diabetes management if the patient has hypertension?
Nope, it is also added if.albuminuria or proteinuria has been detected in the absence of hypertension
ACE inhibitor alternative is losartan
When should the patient with diabetes seen again after they are stsble
At 6 months
What is the alternative of simvastatin if a patient is using a protease inhibitor?
Atovastatin
List all the treatment steps for diabetes
- Metformin
- Glimeperide
- Basal insulin(Immediate or long acting)
- Biphasic insulin
Contraindications of Metformin (4)
- Liver disease
- Alcoholism
- eGFR<30
- Uncontrolled hypertension
List three commonest side effects of Metformin.
- Diarrhoea
- Nausea
- Abdominal cramps
When should glimeperide be added on the management of diabetes?
If after 3 months on maximum dose of Metformin HbA1c>8%
When should the dose of Metformin be increased?
Monthly if fasting glucose>8 or post prandial glucose>10 and the patient is adherent
Should the Metformin dose be increased or decreased if the patient is on dolutegravir?
Decreased to 500 mg
4 contraindications of glimeperide
- Pregnancy
- Cotrimoxazole allergy
- Liver disease
- Severe kidney disease with eGFR<60
What determines the need for an additional drug in management of diabetes?
After three months on maximum dose HbA1c>8%
How frequent should you increase glimeperide in a patient with fasting glucose >8 or post prandial glucose>10?
Weekly as compared to monthly for metformin
When starting insulin which drug must be stopped?
Glimepiride
How many times a week should a person with diabetes on insulin check their fasting glucose on waking?
At least 3 X a week
Which diabetes patients should be discussed with a specialist?
If fasting glucose is still >=8 or HbA1c>8% after 3 months after Biphasic insulin fail
List 5 things that should be checked at every diabetes routine visit
- Symptoms: Screen for TOD such as IHD and PVD
- Weight
- Glucose
- Blood pressure
- Family planning
What should be checked at diagnosis of diabetes?
- Urinalysis or spot urine albumin to creatinine ratio(if Urinalysis is negative)
- Creatinine and eGFR
- Serum potassium if on enalapril/Spironolactone/eGFR<30
- Depression and if control is poor
- Alcohol use and when control is poor
- BMI and waist circumference
- Eyes
- Feet
9.Fasting lipogram
When should urine dipstix repeated after the diagnosis of diabetes?
Yearly
When should the HbA1c be checked after the routine visit of diabetes?
Yearly if HbA1c=<8%
If changed treatment or poor glucose control [HbA1c>8%]: At 3 months
When should you step up the treatment of diabetes?
If fasting glucose> 8 mmol/L or post prandial glucose>10 mmol/l
Which medication should a diabetic receive if proteins are detected in either the urine dipstick or spot urine?
Enalapril
When should the creatinine be checked again after a routine diabetes visit?
Yearly
If eGFR<60 : 3-6 monthly
If using enalapril: At 4 weeks
If someone is trying to lose weight, when should the BMI and waist circumference be repeated?
At 3.months
Goal: BMI=<25 and waist circumference of <80 cm in females and <94 cm in males
Which diabetes medications should be stopped if eGFR<30
Which diabetes medications should be stopped if eGFR<30?
Metformin and glimepiride
How to assess for alcohol and drug use
- > =4 drinks per session
- Ever used illegal drugs
- Misuse prescription or over the counter medications
Remember 1 drink is 1 tot of spirits, 1 small glass of wine(125 ml) and 1 can/bottle(330 ml) of beer
If a patient is on enalapril and the eGFR is <60, when should the creatinine be repeated?
In 2 weeks
Name two eye complications resulting from diabetes
Retinopathy and cataracts
A fundoscopy should be done at diagnosis of diabetes and when again?
Yearly or if symptoms occur
List clinical features of acute limb ischemia.
- Pallor
- Pulse less
- Numbness and parasthesia
- Severe leg pain at rest
- Weakness on the leg
Feet on a diabetic patient should be checked at diagnosis and should be repeated when?
If symptoms or yearly if no symptoms
Should someone with diabetes who gets pregnant or is planning to get pregnant be referred to a specialist?
Yes
Why? It might get worse in pregnancy remembering that pregnancy is a state of insulin suppression and more gestational diabetes happen.
What is considered good and poor glucose control
Good: HbA1c=<8%
Poor: HbA1c >8%
Should you continue enalapril is creatinine increases by more than 20% from the last visit?
Nope
Which test should be done in all patients if total cholesterol>7.5 or triglycerides>10?
TSH
Repeat if HbA1c >8 %
But if the TSH is abnormal and HbA1c=<8% refer
State why IM insulin is preferred over IV insulin?
IV insulin is associated with high likelihood of getting hypokalemia which can lead.to deadly arrhythmias.
What is preferred sugar, honey or artificial sweeteners in diabetes?
Artificial sweeteners
Which foods should diabetics avoid?
- Sugar and honey
- Avoid starch (rice, Millie’s, pap, potato,samp, sweet potato and bread
Features of hypoglycemia easily recognised by patients.
Sweating, shaking, palpitations and hunger and weakness
What should a patient do at home if they get symptoms of hypoglycemia?
Drink milk with sugar or eat sweets( Always carry sweets)
What are the common causes of hypoglycemia in diabetics?
- Missing meals
- Alcohol.abuse
- Insulin overdose
- Sulphonylurea overdose
- Exercise
- Infections
State three areas when insulin can be injected?
Thigh, abdomen and arm
Where should insulin be stored?
In the fridge or cool dark place
How many times should a diabetic check their glucose at home?
At least 3 x
