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General Medicine > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What are the symptoms of diabetes?

A
  • polyuria
  • polydipsia
  • lethargy
  • boils
  • pruritus vulvae
  • blurred vision
  • CVD and PVD
  • nephropathy
  • neuropathies
  • diabetic foot ulcers
  • frequent infections
  • DKA/hyperosmolar hyperglycaemic state
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2
Q

What are the screening criteria for diabetes?

A
  • FHx
  • CVD and PVD and risk factors
  • SE Asian
  • BMI>30
  • age
  • prior gestational diabetes
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3
Q

What are the functions of insulin?

A

Stimulate:

  • glucose uptake in liver, muscle, and adipose
  • clearance of free fatty acids
  • active transport of amino acids into cells

Inhibit:

  • liver glycogenolysis
  • liver gluconeogenesis
  • protein catabolism
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4
Q

How is diabetes diagnosed?

A

Symptoms + 1 abnormal result

OR 2 abnormal results at 2 different times

  • fasting glucose >7mmol/l
  • random plasma glucose >11.1mmol/l
  • glucose tolerance test > 11.1mmol/l
  • HbA1c > 6.5%
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5
Q

Outline the features of type 1 deficiency.

A

Short Hx of polyuria, polydipsia, lethargy, and weight loss

Usually present in teens-early adulthood, but can get presentations later in life (latent autoimmune Type 1 diabetes)

Autoimmune destruction of beta-cells leading to absolute insulin deficiency (associated with other immune disorders)

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6
Q

What level of ketones indicates immediate insulin therapy?

A

Urine ketones >3-4mmol/l

Capillary blood ketones >1mmol/l

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7
Q

Outline the features of type 2 diabetes.

A

Potential reversible metabolic disorder precipitated by chronic intra-organ fat deposition

Risk factors:

  • central obesity
  • SE Asian/Black
  • Hx of gestational diabetes
  • drugs
  • PCOS
  • FHx
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8
Q

What metabolic changes occur post-bariatric surgery?

A

7 days: fasting blood glucose normalises and Type 2 diabetes disappears

–> reduced liver fat content and return of normal insulin sensitivity

–> reduced pancreatic fat content over 8wks normalises beta-cell function so that the first phase insulin release and maximal rates of insulin release returns to normal

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9
Q

Outline the features of gestational diabetes.

A

Usually develops at ~28wks

Any form of glucose intolerance with onset during pregnancy

Up to 4% of pregnancies

Check HbA1c 3 months post-pregnancy

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10
Q

What are some causes of secondary diabetes?

A

Pancreatic disease: cystic fibrosis, chronic pancreatitis, pancreatectomy, pancreatic carcinoma

Endocrine: Cushing’s, acromegaly, thyrotoxicosis, phaeochromocytoma, glucagonoma

Drug-induced: thiazide diuretics, corticosteroids, atypical antipsychotics, antiretroviral protease inhibitors

Congenital lipodystrophy

Acanthosis nigricans

Genetic: Wolfram’s syndrome (diabetes insipidus, diabetes mellitus, optic atrophy, deafness), Friedreich’s ataxia, dystrophi myotonica, haemochromatosis, glycogen storage disorders

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11
Q

What is the management of type 1 diabetes?

A

HbA1c target = 7%-9% to avoid hypoglycaemia

Insulin = intermediate-acting, rapid-acting (e.g. Humalog), long-acting (e.g. glargine), mixed action (e.g. Novomix-30), insulin analogues

Patient education = home blood glucose monitoring, DAFNE course

Regular HbA1c testing

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12
Q

What is the management of type 2 diabetes?

A

Diet, exercise

Anti-obesity drugs

Oral hypoglycaemic agents: metformin, sulfonylureas, gliptins

Insulin

Injectable GLP-1 agonists

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13
Q

What are the features of metformin?

A

500mg-2.5g

1st choice in overweight/obese unless contraindicated

Contraindications = eGFR<30, heart failure

Mechanism = lowers HbA1c by ~1%, reduces hepatic glucose production

Benefits = limited weight gain, fewer CV events, low risk of hypoglycaemia

ADRs = GI symptoms, lactic acidosis

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14
Q

How much glucose is used per day?

A

~250g/day

~180g from diet, ~70g from glycogenolysis/gluconeogenesis

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15
Q

What are the features of sulfonylureas?

A

e.g. gliclazide, glimepride

2nd or 3rd lime

Mechanism of action = increased insulin release from beta-cells

Benefits = reduced microvascular risk

ADRs = higher risk of hypoglycaemia, promotes weight gain

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16
Q

What are the feature of pioglitazone?

A

Mechanism = reduces insulin resistance

ADRs = bladder cancer, osteoporosis, dilutional anaemias

17
Q

What are the features of GLP-1 agonists?

A

e.g. exenatide

Indicated for Type 2 diabetics with poor glucose control/not able to lose weight

Benefits = low risk of hypoglycaemia

ADRs = nausea, ?pancreatitis/pancreatic cancer

18
Q

What are the features of gliptins/DPP-4 inhibitors?

A

e.g. sitagliptin, saxagliptin

Mechanism = inhibits DPP-4 activity to increase postprandial active GLP-1 concentrations, modest HbA1c reduction

Benefits = weight neutral, low risk of hypoglycaemia

19
Q

What are the features of glifozins?

A

e.g. dapaglifozin

Mechanism = selective inhibiton of SGLT2 to reduce amount of glucose reabsorbed

Benefits = lose weight, low risk of hypoglycaemia

ADRs = LUTS (UTIs, thrush, polydipsia)

20
Q

What are the effects of GLP-1?

A
  • reduced glucagon secretion
  • increased insulin secretion, release, and biosynthesis
  • reduced ghrelin
  • reduced liver gluconeogenesis
  • reduced appetite, increased satiety, reduced gastric emptying
  • increased glucose uptake into muscles
  • reduced BP
  • reduced inflammation
  • reduced non-alcohol fatty liver disease
21
Q

What are the features of diabetic retinopathy?

A

BACKGROUND:
Hyperglycaemia causes basement membrane thickening and weakness –> outpouchings (microaneurysms and blot haemorrhages) and leaking protein causes nard, shiny exudates in macula

PRE-PROLIFERATIVE:
Capillary closure –> retinal infarcts (soft fluffy exudates) and release of vasoactive growth factors from dying retina

PROLIFERATIVE:
Proliferation of vessels in attempt to re-vascularise –> can grow anteriorly from retina where unsupported by collagen (friable) –> vitreous haemorrhage

COMPLEX:

  • fibrosis
  • retinal detachment
  • blindness
22
Q

What are the features of diabetic nephropathy?

A

Capillary closure –> glomerulosclerosis –> Kimmelstiel-Wilson nodules (periodic acid Schiff positive) –> reduced eGFR

23
Q

What are the consequences of diabetic peripheral neuropathy?

A

Ulcers typically located on plantar aspect of foot, esp. underneath metatarsal heads

Reduced light touch and vibration sense

Neuropathic (Charcot) foot = grossly disorganised foot joint +/- fractures –> collapse of foot due to demineralisation of bones, trauma, and stretching of ligaments

Cellulitis –> osteomyelitis

Toe ischaemia –> Buerger’s sign (lift foot up –> white, put foot down –> purple –> takes time to return to previous colour)

24
Q

What are the indications for IV insulin?

A
  • DKA/hyperosmolar hyperglycaemic syndrome
  • surgical patients who are NBM or miss more than one meal
  • vomiting
  • major vascular event e.g. MI, CVA
  • TPN pts
  • steroid use
  • metabolically unwell: not eating and drinking
25
Q

What are the advantages and disadvantages of IV insulin?

A

ADV

  • target driven glucose control for specific indication for use
  • avoid metabolic decompensation

DISADV

  • frequent blood glucose monitoring (hrly in first 12hrs)
  • IV infusion intrusive
  • difficult to manage if pt is eating
26
Q

What are the risks of IV insulin?

A
  • hypo/hyperglycaemia (inadequate monitoring/rate of infusion)
  • rebound hyperglycaemia/DKA if IV access lost/stopped
  • fluid overload
  • hypokalaemia + hypernatraemia
  • infection
27
Q

Describe the method of administering IV insulin.

A

Types of insulin rate: reduced rate (sensitive pts), standard rate, increased rate (resistant)

Take blood glucose readings for first 12hrs and rate adjusted if no response

Ensure:

  • infusion equipment is working
  • substrate infusion running at correct rate
  • patient cannula

If blood glucose < 4mmol/l:

  • stop insulin infusion
  • give 75ml of 20% IV glucose over 15min (and repeat if still <4mmol/l)
  • restart IV insulin once >4mmol/l
  • do not let blood glucose >6mmol/l in pts with acute coronary syndrome/CVD
  • hrly monitoring of blood glucose, daily U&Es, review need for infusion

Do not discontinue infusion until 30min after usual diabetes treatment has been restarted and pt is able to eat and drink; check blood glucose 1hr after discontinuation and at least 4 times for first 24hrs

General Medicine (12 decks)

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