Diabetes

Question 1

Describe the different types of insulin?

Answer 1

Short acting insulin: last for approximately 6-8 hours with peak affect at 2-5 hours. Given just before meals.

Intermediate and long acting insulin: length of action varies between brands but general rule is approximately 24hrs.

Question 2

Describe the different insulin dosing regimens?

Answer 2

Once daily long acting insulin: used in type 2 diabetics

Twice daily mix: 2 daily injections before breakfast and before the evening meal. A mixed insulin containing short- and longer-acting insulins. 2/3 of the insulin is given as the morning dose. This is the most common regimen.

Basal Bolus (multiple dosing): A single dose of intermediate acting insulin is given before bed and bolus doses of short acting insulin are given before each meal. 
Allows for more flexibility and potentially tighter control as the insulin dosing can be adjusted more easily.

Administration:
In hospital can be IV.
In community it is administered subcutaneously.
Expert patients may have insulin pumps which allow continuous administration of subcutaneous insulin.

Question 3

Describe the circumstances when a patients insulin requirements will increase/decrease?

Answer 3

Increased insulin requirements:
Infection
Trauma
Stress
Pregnancy

Decreased insulin requirements:
Coeilac disese
Addison's disease
Hepatic impairment
Renal impairement

Question 4

What are the major risks of insulin treatment and how do you treat them?

Answer 4

Hypoglycaemia

Treat with oral glucose drink (lucozade)
Buccal glucose

Unconscious
IV dextrose
If dextrose doesnt work glucagon

Question 5

Describe the management of T2DM?

Answer 5

Lifestyle advice:
Lose weight
Exercise
Reduce simple carbs, sugars and fats (risk of CVD)

Pharmaceutical:
1st line: Overweight?
Yes = Metformin
No = Sulphonylureas (gliclazides) if renally impaired 1st line

2nd line : Take 2 metformin and a sulphonylurea (or a glitazone if others are not tolerated)

3rd line: Insulin +/- metformin

Control complications and RF:

BP > 140/80mmHg or any renal impairement: give ACEI as it reduces BP and is protective against nephropathy.

Question 6

Describe the mechanism of action of sulphonylureas and the important side effects?

Answer 6

Inhibit ATP-sensitive potassium channels. This causes the cell to depolarise causing there to be an influx of calcium and insulin to be secreted.

AKA increases insulin secretion.

S/e:
Cause weight gain (+increase insulin resistance), often avoided in obesity.
Associated with hypo’s particularly in:
The elderly
People who skip meals
Long acting sulphonylurea agents (glibencamide)

Question 7

Describe the mechanism of action of thiazolindiediones (‘glitazones’)?

Answer 7

Activates PPAR-gamma which alters gene expression resulting in a insulin sensitising effect aka increase gluocse uptake.

Effects include:

• reduced hepatic glucose output
• increased glucose transporters (GLUT) in skeletal muscle with increased peripheral glucose utilization
• increased fatty acid uptake into adipose cells

Question 8

Describe how diabetic ketoacidosis is diagnosed and managed?

Answer 8

Must have all 3 of the following:

Raised blood glucose> 11mmol/l
Ketonuria >3mmol/l
Acidosis pH