Diabetes Flashcards
Diagnosis of diabetes
OGTT
Symptoms Random plasma glucose Fasting plasma glucose > 7mmol HbA1c > 48 mmol/mol No symptoms - oral glucose tolerance test fasting
Presenting features of diabetes
Thirst - osmotic activation of hypothalamus
Polyuria - osmotic diuresis
Weight loss and fatigue - dehydration, lipid and muscle loss
Pruritus vulvae and balanitis - vaginal candidiasis
Hunger
Blurred vision - altered acuity due to uptake of glucose/water into lens
Clinical features of newly diagnosed type 1
Short history of severe symptoms e.g weeks
Moderate or large urinary ketones present
Weight loss
Any 2/3 features indicate type 1 diabetes and are an indication of immediate insulin Tx at any age
Commonest age at diagnosis of Type 1 diabetes
Prevalence
What kind of disease
Treatment
5-15 years but can occur at any age
Rare - 250000
Insulin deficiency disease
Autoimmune destruction of beta cell
Restoring appropriate insulin concentrations
Aims of treatment of type 1 diabetes
Relieve symptoms and prevent ketoacidosis
Prevent microvascular and microvascular disease
Avoid hypoglycaemia
Microvascular complications
e.g kidney
30% in UK
Diabetic nephropathy - much smaller, higher urine protein, decreased fx
CV mortality x30
Proliferative retinopathy and severe neuropathy
What can happen in retina
Blood vessels burst due to excess glucose
Tx of type 1 diabetes - restore physiology of beta cell
Insulin tx
- twice daily mixture of short and medium acting insulin
- basal bolus injection - 1/2x daily medium acting insulin plus pre meal quick acting insulin
Ability to judge carbohydrate intake
Awareness of blood glucose lowering effect of exercise
Symptoms of insulin XS
Risk of?
Dizzy Warm Nauseous Tachycardia Increased breathing
Insulin shock
Benefits and risk of tight glucose control
Good glucose control - very low chances of retinopathy and v.v
Tight glucose control - higher risk of hypoglycaemia and v.v
Dilemma for type 1
Solution
Setting higher glucose targets will decrease risk of hypoglycaemia but increase risk of diabetic complications
Setting lower glucose targets will decrease risk of complications but increase risk of hypoglycaemia
Engage students for their own management
Type 2 diabetes
Greatest non-infective threat to global health
1/20 in UK
Meds cost £1000 million
Disease of western industrialised lifestyle - obesity and lack of exercise
Pathogenesis of type 2 diabetes
Major cardiovascular risk
Insulin resistance Hypertension Hyperglycaemia Abnormal lipids Early hyperinsulinaemia Increased thrombogenesis
Insulin resistance
Common in?
Probably inherited and demands increased production of insulin to maintain normal glucose levels before development of diabetes
Beta cells lose ability to produce sufficient insulin for amount of glucose intake
Progressive failure of insulin secretion
Complications in type 2 diabetes and examples
Macrovascular affect the majority and often advance at diagnosis - MI, stroke, Peripheral vascular disease
Microvascular affect 20-25% at diagnosis and modified by underlying vascular disease
Life expectancy is shortened at diagnosis by 5-10 years
Treatment in type 2 diabetes
Ideally consists of weight loss and exercise (improve insulin resistance) which if substantial will reverse hyperglycaemia
- but most of those with Type 2 diabetes have been making the ‘wrong’ lifestyle choices all their lives
At present, management usually consists of medication to control BP, blood glucose and lipids
Tight control of BP and lipids has a greater effect in reducing the risk of macrovascular disease (and reduces microvascular complications) and is usually easier to achieve than blood glucose control
Typical treatment pathways in type 2
Eat less and reduce refined CHO
Metformin
Sulphonylurea
INSULIN
Metformin is a
What does it do
Side effects
Biguanide
Reduces blood glucose by impoving glucose uptake without increasing body weight and also reduces CV disease in the longterm
Abdo pain
Diarrhoea limit dose
Sulphonylureas - mechanism
Stimulating release of insulin from pancreatic beta cells so can cause weight gain and hypoglycaemia e.g gliclazide and glibenclamide
Insulin - secretion in type 2 what happens to it over time
Declines progressively
Type 2 - conclusions
The ‘best’ treatment, weight loss and increased exercise is rarely achieved
Needs multiple medications, many of which are probably not taken
The challenge is to engage the patient in the management of their own condition
This is not ‘mild’ diabetes - high risk of premature vascular death and other vascular complications
Diabetic ketoacidosis
Definition
Symptoms
Causes
Mortality
Condition of severe insulin deficiency where fats are broken down to ketones which results in acid excess and lowered blood pH. Blood glucose also rising = osmotic diuresis and dehydration
Thirst, polyuria, SOB, confusion and coma
Hyperglycaemia
Venous bicarbonate less than 15mmol
Ketones
Infections
Omitting insulin
New diagnosis of Type 1
Mortality
1-5%
Elderly - associated co morbidity and late diagnosis
Young - severe DKA recognised late
- rare and poorly understood condition of cerebral oedema in children
Hyperosmolar Hyperglycaemic State (HHS) or
Hyperosmolar Non-Ketotic Coma (HONK)
Definition
Hyperglycaemia (blood glucose usually over 50 mmol/l)
Hyperosmolality (osmolality usually over 350 mosmoles/l)
Accompanied by dehydration
Those at risk
Poorly controlled Type 2 diabetes
Newly diagnosed Type 2 diabetes patients, often elderly
Symptoms and signs of hypoglycaemia
Autonomic
Neuroglycopenic
Sweating
Tremor
Palpitations
Loss of concentration
Drowsiness
Anger sadness confusion
