Diabetes Flashcards
1
Q
Which type of diabetes involves a complete absence of insulin production?
A
Type 1, none produced by pancreas, normally younger people. May lead to diabetic ketoacidosis (DKA) -> coma -> death
2
Q
What is DKA?
A
Cannot use sugar as energy due to lack of insulin.
Body breaks down fat as an alternative fuel source.
3
Q
What are the symptoms of DKA? (P.P.N.A.T.S)
A
Polyuria (Pee) Polydipsia (thirst) Nausea Abdominal pain Tiredness SoB
4
Q
Why can smelling someone’s breath diagnose DKA?
A
Excess ketones in the body may be detected via fruit-smelling breath. (Only occurs for 20% of patients tho)
5
Q
Which type of diabetes, if untreated, can lead to DKA?
A
Type 1.
6
Q
How rapidly can DKA develop?
A
Over 1 day.
7
Q
Why does DKA occur?
A
Insulin suppresses lipolysis, so an absence means that fat is broken down and converted to ketones in the liver which are acidic.
8
Q
When does DKA commonly occur?
A
Not using insulin.
Illness/Infection.
Surgery.
Often the first sign someone has of being diabetic.
9
Q
What is the first step to treating DKA?
A
Fluid replacement.
Then insulin and possibly glucose administration.
10
Q
Why is fluid replacement necessary for DKA treatment?
A
Aims to correct hypotension by restoration of circulatory volume, clear the ketones and correct electrolyte imbalances.
11
Q
What is the recommended replacement fluid for DKA and why?
A
0.9% sodium chloride, it needs to be crystalloid (balanced salt solutions that freely cross capillary walls) rather than colloid.
12
Q
What is the recommended volume of fluid replacement and over what period?
A
6-8L, very patient dependent, over 24 hours.
13
Q
What monitoring needs to take place of a patient receiving fluids for DKA?
A
BP, electrolytes.
Specifically Na and Ca.
Also: U&Es, HCO3, anion gap, Blood plasma glucose, venous pH, fluid balance, urine ketones, FBC, ECG, Chest X-ray.
14
Q
How often does blood plasma glucose monitoring of a DKA patient need to occur?
A
Hourly
15
Q
Why does an ECG investigation of DKA patients need to be performed?
A
Exclude MI
16
Q
Why does a chest X-ray of DKA patients need to occur?
A
Exclude Pneumonia
17
Q
For DKA, an intravenous insulin infusion given at what rate is recommended?
A
0.1 units/kg/hour OR 6 units per hour.
18
Q
Why is a 6 units/hour regime of insulin infusion for DKA not recommended?
A
It doesn’t work well in the overweight or underweight.
19
Q
The dose of insulin infusion would be increased in DKA treatment when blood ketones have not fallen by at least ______
A
Reduction of the blood ketone concentration by at least 0.5mmol/L/hr
20
Q
The dose of insulin infusion would be increased in DKA treatment when glucose has not fallen by at least ______
A
if <5mmol/L/Hr reduction in glucose.
21
Q
The dose of insulin infusion would be increased in DKA treatment when CAPILLARY glucose has not fallen by at least ______
A
<3mmol/L/hr
22
Q
The dose of insulin infusion would be increased in DKA treatment when venous bicarbonate levels have not risen by at least_____
A
3mmol/L/hr
23
Q
How is an insulin infusion for DKA treatment formulated?
A
Concentration of 1 unit/ml, mix 50 units of short acting insulin with 50ml normal saline. Put into pump and adjust rate to 6ml/hour or adjust based on weight.
24
Q
If 6U/hour is not enough for DKA treatment, what can this be increased to?
A
8U/hr then 12U/hr then seek specialist.
25
If a patient has DKA, and we are administering large amounts of insulin, which electrolyte will be impacted the most?
K+.
| Need to monitor it and maybe add more.
26
In what circumstances would the dose of insulin infusion be increased in DKA treatment? [4]
1. if <5mmol/L/Hr reduction in glucose.
2. <3mmol/L/hr rise in venous bicarbonate.
3. <3mmol/L/hr drop in cap blood glucose
4. If blood ketones have not reduced by at least 0.5mmol/L/hr
27
Insulin for DKA is given at a concentration of _____, which is done by mixing ____ of ______ insulin with _____ normal saline. That is then put into a pump and adjusted to _____ and then this might get adjusted depending on the patient.
Insulin for DKA is given at a concentration of 1 unit/ml, which is done by mixing 50 units of short acting insulin with 50ml normal saline. That is then put into a pump and adjusted to 6ml/hour and then this might get adjusted depending on the patient.
28
Why does insulin impact K+ levels?
Drives K+ back into cells, a short-term effect. Lowers potassium levels.
29
At what stage do we give a DKA patient glucose IV and what concentration recommended?
When blood glucose below 13mmol/L. 10% glucose until normal eating and drinking habits have returned.
30
Why would a VTE assessment of a DKA patient be undertaken?
Dehydration is a risk factor for VTE.
31
If a DKA patient takes long-acting insulin, can this be continued while receiving treatment?
Yes, not short-acting though.
If the patient is on basal-bolus schedule, the basal insulin is continued, but the DKA treatment is replacing the bolus part - we want the baseline insulin.
32
Blood glucose is monitored either _________, depending on how ill the patient is, and the insulin is adjusted according to that.
Blood glucose is monitored either every 20 minutes, 30 minutes or hourly, depending on how ill the patient is, and the insulin is adjusted according to that.
33
To prepare an insulin intravenous sliding scale, ________________ should be diluted up to ____________, so that a concentration of ______is achieved. The infusion rate is set depending on the last blood glucose value recorded.
To prepare an insulin intravenous sliding scale, Human Actrapid Insulin (short-acting insulin) 50 units should be diluted up to 50mls 0.9% sodium chloride solution, so that a concentration of 1unit/ml is achieved. The infusion rate is set depending on the last blood glucose value recorded.
34
What effect does infection have on glucose production?
Increases it, so insulin requirements go up.
35
What is hypoglycaemia defined as?
<4mmol/L glucose. Low glucose impairs brain function.
36
What are the typical causes of hypoglycaemia?
Too much insulin or not enough food.
Too much exercise or alcohol.
Long-acting insulin can cause morning hypoglycaemia.
Liver or kidney disease.
37
What are the signs of hypoglycaemia?
Feeling shaky, sweating, tingling in the lips, going pale, heart pounding, confusion and irritability.
38
How is hypoglycemia treated?
Oral sugar 10-20grams glucose (10g in 100ml of coke).
Glucagon IM
Glucogel
Follow-up with more carbohydrate rich meal.
39
What is a basal bolus insulin regimen?
Involves multiple daily injections: a long- or intermediate acting insulin is injected once or twice a day, PLUS a bolus injection of a short-acting insulin is injected before each meal.
40
Who would normally use a basal bolus insulin regimen?
T1DM.
41
What are the purpose of the different injections in a basal bolus insulin regimen?
The bolus injections of short-acting insulin control postprandial peaks.
The daily injections regulate basal hepatic glucose output.
42
What is a biphasic insulin regimen?
An alternative to the basal bolus regimen. Mixture or short- and long- acting insulin in fixed dose preps.
Injections twice a day.
43
What are the main types of insulin?
```
Rapid-acting insulin.
Short-acting insulin.
Intermediate acting insulin.
Long-acting insulin.
Biphasic insulin.
```
44
What is biphasic insulin.
Mixture of short or rapid acting and intermediate acting insulin. Useful for patients who do not want too many injections per day.
45
What is the difference between rapid-acting and short-acting insulin?
Rapid: reduced risk of severe hypoglycaemia, can be injected just before a meal.
More expensive than short-acting.
46
When does NICE advise to use rapid-acting insulin analogues?
Where nocturnal or late inter-prandial hypoglycaemia is a problem. Or if the patient needs or desires adequate blood glucose control without the use of snacks between meals.
47
Biphasic rapid-acting insulin analogues can be a suitable option for ______
Biphasic rapid-acting insulin analogues can be a suitable option for those prone to experiencing nocturnal hypoglycaemia
48
A mixture of short or rapid acting and intermediate acting insulin is known as____
Biphasic insulin. Useful for patients who do not want too many injections per day.
49
How long before a meal must short-acting insulin be injected?
30 mins.
50
Why can it be difficult to achieve optimal glucose control with intermediate-acting insulins?
Patients can be concerned about nocturnal hypoglycaemia - a dose administered at bedtime will cause a peak in insulin activity overnight, increasing the risk of nocturnal hypoglycaemia.
51
Which type of insulin requires mixing?
Intermediate acting, Insulatard, Humulin I.
| This is because they are a white crystalline precipitate of isophane insulin.
52
How are inter-mediate acting insulins such as Insulatard and Humulin I used?
Require mixing.
Usually used with a rapid/short-acting insulin as part of a basal-bolus regimen. Given once or twice a day without needing to be coordinated with meals.
53
Insulin aspart, Insulin lispro, Insulin glulisine are examples of:
Rapid-acting insulins.
54
Insulin glargine (Lantus, Insulin determir (Levemir) and Insulin degludec are examples of:
Long-acting insulin.
55
When does NICE recommend long-acting insulins should be used?
Nocturnal hypoglycaemia is an issue.
56
How is blood glucose detected?
Finger prick, testing capillary blood glucose.
57
How is glucose in the urine detected?
Dipstick.
58
Why is urine monitoring not recommended?
No glucose in urine unless glucose levels are very high >10mmol/L.
Does Not give an indication of blood glucose levels at the time tested because the urine that is being tested may have been produced several hours before.
59
How is long-term diabetes control monitored?
Plasma glucose monitoring.
| HbA1c.
60
What are the optimal targets for capillary blood glucose levels pre-prandial?
4-7mmol/L
61
What are the optimal targets for capillary blood glucose levels post-prandial?
<9mmol/L
62
What is the HbAc1 test?
Test which shows levels of glucose control over previous 3 months.
63
Patients should keep their HbA1c below what?
59mmol/mol (7.5%)
64
Patients with an increased risk of arterial disease should aim to keep their HbA1c below what?
48mmol/mol (6.5%)
65
How often does NICE recommend patients receiving diabetes treatment should have their HbA1c checked?
Every 2-6 months.
66
<9mmol/L is the capillary blood glucose target ______
Post-prandial
67
John Adamson, a slim 13 year-old boy, has been receiving about 30 units of soluble insulin daily and needs to be converted to a more suitable formulation ready for discharge. What regime is likely to be suitable for John?
Basal-bolus or biphasic.
Basal-bolus preferred as more flexible.
Biphasic is easier but less control.
68
4-7mmol/L is the target capillary blood glucose target ______
Pre-prandial
69
What are the 4 T's for diabetes in children?
Thirst, Toilet, Tiredness, Thinner.
70
What needle length is applicable for insulin injections in overweight people?
Everyone should use 4/5mm regardless of weight.
71
Why would a patient be prescribed glucogel?
For hypoglycaemic episodes, provide all newly diagnosed diabetics with it?
72
When starting a biphasic insulin regimen, what type of split is used?
30/70 split is standard.
73
In terms of insulin adsorption, what is the fastest to slowest sites of injection?
Abdomen > Arm > Thigh > Buttock
74
For a basal-bolus regimen, where would it be recommended to inject?
Basal - thigh or buttocks as want slow adsorption.
| Bolus - As this is the one we want to be quick, arm or abdomen.
75
For a patient on a biphasic regimen, where would we expect them to inject insulin in the evening and why?
Thigh as slower action over night.
76
For a patient on a biphasic regimen, where would we expect them to inject insulin in the morning and why?
Abdomen as quicker action.
77
What is lipodystrophy?
Fatty deposits under the skin resulting from patients constantly injecting into the same site. Can result in lack of insulin adsorption.
78
If a patient with lipodystrophy starts injecting in a different location what can occur?
Hypoglycaemia due to higher amounts of insulin being absorbed. May need to reduce dose.
79
What are sick day rules?
Do not stop insulin completely, adjust dose, monitor blood glucose more closely and up to 10 times per day.
80
Regarding illness in diabetic patients, when should they seek medical assistance? (4)
1. BG is >17mmol/L persistently.
2. Ketones in urine.
3. Vom/Diarrhoea for 6 hours.
4. Not able to eat/drink
81
What % of patients develop diabetic complications within 10 years of diagnosis?
30%.
82
The incidence of type 2 diabetes has risen by how much in the last 10 years?
70%
83
Diabetes reduces average life expectancy by______
>20 years for T1.
| Up to 10 years for T2.
84
What are the top 5 countries with diabetes?
```
China,
US,
Brazil,
India,
Russia,
```
85
What is the aetiology of T1 diabetes?
No known confirmed cause.
Autoimmune destruction of pancreatic B-cells.
Islet cell antibodies present in 85%-90% of people with T1.
86
What is the epidemiology of T1 diabetes?
10-15% of people with diabetes have T1.
Common in younger people.
Increase incidence of latent autoimmune diabetes in adults (LADA)
87
What is the aetiology of T2 diabetes?
Abnormality in insulin secretion or effect.
| Reduction in insulin receptors?
88
How do T1 and T2 diabetes differ in terms of genetics?
T1: weak genetic link.
T2: strong genetic link.
89
Which type of diabetes is more common?
T2, 85-90% of people.
90
How do T1 and T2 differ in term of onset?
T1: acute onset - not always though.
T2: chronic progressive onset.
91
What is HHS?
Hyperosmolar Hyperglycaemic State in T2 diabetes.
92
A diagnosis of diabetes can be made with a HbA1c value of:
>48mmol/mol
93
What are the main complications from diabetes?
1. Cardiovascular death
2. Strokes.
3. Blindness
4. Foot amputation
5. Kidney failure
94
The recommended target for 2-hour post-meal blood glucose is _______
<8.5mmol/L
95
The recommended target for fasting blood glucose is______
4-7mmol/L
96
What is the aimed for target Hb1Ac in diabetics?
53mmol/mol
97
What are the three sources of insulin?
Bovine: prepared from a process of recrystalisation - differs by 3 amino acids.
Porcine: differs by 1 amino acid. Not linked to amino acid formation.
Human: Produced by enzymatic modification of porcine insulin. Via E.coli/yeast etc.
98
Which source of insulin differs from human insulin by only one amino acid and is not linked to antibody formation?
Porcine,
| Bovine: 3 amino acids.
99
Who with diabetes would use insulin?
Anyone with type 1, those with type 2 who are not well controlled on other medication alone. If illness occurs, if pregnancy occurs.
100
What is the difference between administration of U100 and U200/U300?
U100 insulin can be administered in any format.
| U200/U300 can only be administered using a disposable pen ONLY.
101
What is the greatest benefit of using long acting insulin analogues?
There is no peak.
102
Prolonged duration of zinc insulin can result in______
Hypoglycaemi
103
Why do patients on twice daily regimens of insulin often need snacks?
Snacks are needed in between meals to prevent hypoglycaemia.
104
In the management of DKA, how should fluid replacement take place?
At what stage should glucose be initiated? At what strength?
0.9% NaCl,
6-8L over 24 hours.
Monitor BP.
Once the CBP falls below 14mmol/L, start 10% glucose alongside the 0.9% NaCl.
105
In the management of DKA, how should insulin be used?
What if the patient is on long acting/basal insulin already prior to admission?
Dilute 50 units of soluble insulin in 50ml of 0.9% NaCl.
Start at a fixed rate of 0.1U/kg/h.
Continue the long acting/basal insulin the patient is already on.
MEASURE the blood ketones and CBG hourly.
106
In the management of DKA, how should potassium replacement be undertaken?
If the Serum K+ is >5,5 then no replacement is needed.
If the level is 3.5-5.4 then we need to add 40mmol/L
If the serum is less than 3.5 then need urgent specialist review.
107
Other than: fluid replacement, glucose and insulin addition and potassium replacement, how else should a DKA patient be managed?
VTE risk assessment - dehydration is a risk factor - and identify cause of DKA.
108
Which has the slower rate of absorption of insulin, thigh/buttocks or arm/abdomen?
IF a patient is injecting the basal dose we recommend they should use the thigh or buttock as this will have slower absorption.
If the patient is injecting the bolus dose then they should inject into the arm or the abdomen as this is where it will be quickly absorbed.
109
How should someone on a biphasic regimen be advised to inject their insulin? (location)?
Thigh in morning: slower absorption.
| Abdomen in evening.
110
Why are ACEi first line antihypertensives in diabetes?
Renal protective. Apart from short term where can reduce eGFR due to less pressure = worsen impairment.
111
Why might a diabetic be taking Duloxetine?
Neuropathic pain - diabetic neuropathy.
| Need to review if it is working and if not use amitriptyline.
112
What is the problem with beta blockers and diabetes?
They can mask symptoms of hypos and can precipitate DKA.
Can reduce circulation to extremities and hence worsen peripheral vascular disease.
113
Why can K+ levels decrease during insulin supplementation?
Temporary drive K+ back into cells.
