Diabetes 3 Flashcards
What should be taken into account when prescribing insulin?
Patient usual regimen and dose, BGM, ketone monitoring, sepsis/acute illness, steroid therapy, age/lifestyle. For new initiation- age, lifestyle, current health status, unit/kg
When is IV insulin used?
In DKA, role in hyperosmolar hyperglycaemic state (HHS), acute illness, fasting patients unable to tolerate oral intake
What monitoring is required for IV insulin management?
Hourly BGM, aim for BG 5-12, free of hypo, check ketones if BG >12, check U&E’s at least daily. Eventually safe transition from IV to SC insulin
What are some symptoms of hypoglycaemia?
Shaking, sweating, anxious, dizziness, hunger, fast heartbeat, impaired vision, weakness, fatigue, headache, irritable
What is severe hypoglycaemia?
Hypoglycaemia that leads to seizures, unconsciousness, or the need for external assistance
What is the immediate treatment of hypoglycaemia?
Eat 15-20g glucose/simple sugar. Recheck BG after 15mins, if continuing repeat. Once normal, eat small snack if next meal is more than 1/2hrs away
What are examples of 15g of simple carbs commonly used in hypo treatment?
Glucose tabs, gel tube, 2 tbsp raisins, 4 ounces juice or coke, 1 tbsp sugar, honey or corn syrup, 8 ounces nonfat/1% milk, hard sweets, jellybeans, or gumdrops
What is the treatment of severe hypo?
Glucagon 1mg injection-buttock, arm or thigh. When consciousness occurs (usually 5-15/60), nausea/vomiting may occur
At what BG level does hypoglycaemia occur?
Less than 4 mmol/l
What is DKA?
A disordered metabolic state that usually occurs in the context of an absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones ie. glucagon, adrenaline, cortisol and growth hormone
How is DKA diagnosed biochemically?
Ketonaemia >3mmol/l, or significant ketonuria (>2+ on dipstick). BG >11.0mmol/l, or known DM. Bicarb less than 15mmol or venous pH less than 7.3
What are some common contributors to DKA?
Infection, illicit drugs and alcohol, non-adherence with treatment, newly diagnosed diabetes
What are some typical symptons and signs of DKA?
Osmotic related-thirst and polyuria, dehydration
What effect does fat ingestion have on glycaemic control?
Little effect on BG, delays gastric emptying and peak glycaemic response
What effect does protein ingestion have on glycaemic control?
Little effect on BG, stimulates insulin secretion which increases glucose clearance from blood
How would you roughly work out a basal bolus regimen for a T1DM patient?
0.3 units/kg- Half pre bed (2200hrs), other half split across pre meals
What are some prandial insulin analogues?
Insulin aspart (Novorapid), lispro (Humalog)
What are some prandial soluble insulins?
Actrapid, Humulin S
What is the onset of action, peak action and duration of insulin analogues?
10-15mins, 60-90mins, 4-5hrs
What is the onset of action, peak action and duration of soluble insulins?
30-60mins, 2-4hrs, 5-8hrs
What are some basal isophane insulins?
Insulatard, humulin
What are some basal analogue insulins?
Lantus (glargine), levemir (determir)
What is the ratio of insulin:CHO in insulin dose calculations?
1 unit of insulin per 10g CHO
What are some macrovascular complications of diabetes?
IHD, Stroke
What are some chronic complications of diabetes, other than macro/microvascular ones?
ED, Psychiatric
How does neuropathy occur?
Blood vessels providing oxygen and nutrients to nerves are damaged when blood flows through them with high levels of glucose. Therefore there is no longer a sufficient supply of nutrients to nerves, which in turn damages them and causes nerve death, leading to neuropathy
What is peripheral neuropathy?
Pain/loss of feeling in feet/hands
What is autonomic neuropathy?
Changes in bowel, bladder function, sexual response, sweating, heart rate, blood pressure, hypoglycaemic unawareness
What is proximal neuropathy?
Pain in thighs, hips or buttocks leading to weakness in legs (amyotrophy)
What is focal neuropathy?
Sudden weakness in one nerve or a group of nerves causing muscle weakness or pain e.g. carpal tunnel, bells palsy etc
What are some neuropathy diagnostic tools?
NCS/electromyography, HR variability, US, gastric emptying studies
What levels of microalbumin indicate microalbuminaria?
30-300mg/ml
What levels of microalbumin indicate macroalbuminaria?
> 300mg/ml
What can cause a false positive in an UACR test?
Menstruation, vaginal discharge, UTI, pregnancy, other illness, non-diabetic renal disease
What number of results must you have to diagnose microalbuminuria?
Repeat test, at least 2/3 positive
What are some eye pathologies diabetes can get?
Retinopathy, cataracts, glaucoma, visual blurring (in acute hyperglycaemia)
Why does diabetes increase the risk of various vascular diseases?
Dyslipidaemia-increased Triglycerides/LDL, endothelial dysfunction, platelet aggregation, thrombogenesis, inflammation/increased oxidative stress
What are some signs of the metabolic syndrome?
Central obesity (apple), high BP, high triglycerides, low HDL, insulin resistance
What psychiatric complications can occur in diabetes?
Depression, eating disorders, bi-polar, schizophrenia
What obstetric problems are associated with diabetes?
Cardiac and skeletal development, such as caudal regression syndrome. Stillbirth, mechanical problems in birth canal due to fetal macrosomia, hydramnios and pre-eclampsia. Genital and GI abnormalities- ureteric duplication
What neonatal problems may occur in diabetes?
Fetal macrosomia. Infant of diabetic mother more susceptible to hyaline membrane disease, neonatal hypoglycaemia may occur.
Why does neonatal hypoglycaemia occur?
Maternal glucose crosses placenta, but insulin does not, fetal islets hypersecrete to combat maternal hyperglycaemia, and a rebound to hypoglycaemic levels occurs when the umbilical cord is severed. This is due to hyperglycaemia in the third trimester
What is the management of a DM patient who is pregant?
Good sugar control prior to conception, folic acid 5mg, consider change to insulin if not on, regular eye checks, avoid ACEI/statin, for BP use labetalol, nifedipine, methyl dopa
What is gestational diabetes?
Glucose intolerance that develops or is first recognised during pregnancy, typically asymptomatic and remits following delivery
When is a GTT performed to ensure resolution of GDM?
6 weeks post delivery
What problems associated with GDM?
All obstetric and neonatal problems as with pregnant diabetic, but no increased risk of congenital abnormality
What does pregnancy cause of the thyroid?
Increased demand-increase in size and increased T4 production to maintain normal concentrations
What are normal thyroid function tests in pregnancy?
Low TSH in 9% pregnancies, fT4 increased in 14%
How should pre-existing hypothyroidism in pregnancy be managed?
Increase thyroxine by 25mg soon as pregnancy suspected. Regular TFTS.
What are the risks of untreated hypothyroidism in pregnancy?
Increased abortion, pre-eclampsia, abruption, post partum haemorrhage, preterm labour. Risk to foetal neuropsychological developlement
What may the high level of HCG in pregancy cause?
Suppressed TSH with slightly elevated fT4/T3 which may be associated with hyperemesis gravidarum
What can hyperthyroidism cause regarding fertility and pregnancy?
Infertility, spontaneous miscarriage, stillbirth, thyroid crisis in labour, transient neonatal thyrotoxicosis (due to TRAbs)
How is hyperthyroid managed in pregnancy?
B-blockers if needed. Low dose anti-thyroid drugs - propylthiouracil 1st trimester, carbimazole 2/3rd. Check TRAbs during pregnancy
What are the side effects of carbimazole in pregnancy?
Can cause embryopathy in 1st trimester, scalp abnormalities, GI abnormalities, choanal and oesophageal atresia, others
What are the side effects of propyl thiouracil in pregnancy?
Risk of liver toxicity, best avoided except in 1st trimester
What kind of goitre can postpartum thyroiditis cause?
Small diffuse
What is the expected cause of postpartum thyroiditis?
Results from modifications to the immune system necessary in pregnancy
What can postpartum thyroiditis cause?
Hypo/hyperthyroidism or both sequentially
