Diabetes Flashcards
Why does blood glucose rise is patients with diabetes despite fasting
Dawn phenomena GH and cortisol are released and they raise glucose ready for the morning in those without diabetes the body responds by increasing insulin to inc glucose uptake in the cells this doesn’t happen in T1 and T 2 diabetes
What is HbA1c
Glycated haemoglobin it is measured to identify the 3 month average plasma glucose concentration Target number is 48 Normal is below 42 Prediabetes is 42-48 Diabetes 48 above
What is c peptide
It’s a connecting expertise 31 amino aci polypeptide that connect insulin A chain to its B chain
If the level is low it means you arent secreting enough insulin
If too high there is a kidney problem or an insulinoma
Diagnostic criteria WHO
Hyperglycaemia after an overnight fast randomly or overnight glucose tolerance test
If symptoms are present there is no need for a confirmation test
Symptomatic patients require a repeat of the same clinical biochemical test
If random both need to be over 11.1
Fasting over 7
OGTT 11.1 at 120mins
HbA1c >48
What colour tube is the blood test taken in
Venous sample in a fluoride tube with a grey top
HbA1c is EDTA purple top
Capillary readings are not suitable for diagnostic purposes
What are the typical symptoms
Thirst Unexplained polyuria Unexplained weight loss DKA HHS one biochem test needed to confirm No confirmatory that is only in asymptotic patients
Risk factors for type 1 diabetes
HIA DR3/DR4 association Autoimmune endocrinooathies -addisons or hasimotots thyroiditis Geography northern hemisphere 10% of diabetes patients Immune mediated destruction of beta cells It is ABSOLUTE PERMANENT DEFICIENCY OF INSULIN
Type 2 risk factors for diabetes
Obesity FHx Ethnicity Age >40 Previous GDM, PCOS metabolic syndrome INSULIN RESISTANCE RELATIVE INSULIN DEFICIENCY
How to measure risk factors to T2D
qdscore.org
Then tests can be done appropriately
Ehh so to determine the type of Diabetes depending on the signs and symptoms
Ketosis
Rapid weight loss
Age of onset under 50
BMI under 25
Personal or fhx of other autoimmune diseases
Poor response to oral hypoglycaemic drugs within 6months of diagnosis
If unsure antiGAD ab , c peptide to determine if any endogenous insulin production
DHx anti psychotics , steroids , anti retrovirals can cause metabolic syndrome including weight inc risk for diabetes development
Exocrine pancreatic failure
Look for in exam signs of obesity related autoimmune or genetic factors
- acanthosis nigricans
Cushing, acromegaly , Prader willi syndrome
What is the other type of type one diabetes
LADA
Latent onsets autoimmune diabetes in adults
Type one diabetes in adulthood
What is the other type of type two diabetes
MODY
Maturity onset diabetes of the young
Defect in HNI
Respond to sulfonylureas
What are the implications to the patient
I live 1020 years less
Complications microvascular and macrovascular
Such as Poor healing going blind ulcers leg amputations
Hypos
quarter are depressed
And insurance difficulties
DVLA year reviews
What is the immediate management
If type one diabetes need to give insulin
need to educate them on the complications how to administer the insulin and carbohydrate count
The type to diabetes depending on the severity
You can treat with diet alone , metformin, is first line then follow the algorithm for second line additional treatments
Losing weight is always helpful in T2D
What is metabolic syndrome
Central Obese >30bmi
Plus 2
Hypertension>130/85
Diabetes fasting glucose >5.6mmol/l or T2DM
High cholesterol - HDL <1.03 men and <1.29 women, Triglycerides >1.7mmol/l
Causes weight, genetics, insulin resistance
What is metformin
It is a Biguanide
And it increases insulin sensitivity
What is a sulfonylurea
Inc secretion of glucose
Gliclazide
What is a gliptin
Block DPP 4 which stop incretin from being destroyed
What can the complications be
Injection site there can be infection which you treat lipo hypertrophy so you need to change the injection site
vascular disease can be micro or macro = PVD, MI stroke
Nephropathy - microalbumiuria , urine dipstick or an UA:CR if above 3 put them on ACEin even if BP normal as has kidney protecting actions
Diabetic retinopathy- blindness is preventable with good glycemic control
Earlier cataracts
Needs to be annual screening
Diabetic foot/ neuropathy - glove and stocking
Glove and stocking distribution
Neuropathic deformity - charcots foot
Ischaemia - absent pulses
Foot ulcers - painless, punched out, pressure points
Different types of retinopathy
Background - dots - microaneurysms and blots which are haemorrhages and hard exudates
Pre proliferative - signs of retinal ischaemia- cotton wool spots, haemorrhages, venous bleeding
Proliferative - new vessels
Maculooathy - dec visual acuity can happen at any stage it is when the signs affect the macula not trust the periphery.
Refer to specialist for all these
May need laser therapy at the peripheries and may need anti VEGF if new vessels start to form in proliferative retinopathy
What regime is usually used in T1F
Basal bonus regime
Due to the absolute insulin deficiency require a dose to replace the basal dose
Lantus levemir all day and then before eating a rapid acting insulin such as Humalog and nova rapid
What are hypos
When the blood sugar falls below 4
How to manage a hypo
Test the blood cap blood and then take rapid release glucose such as dextrose tablet, jelly babies, lucozade
The retest 15 mins later if returning to normal ensure you stake a starchy food such as a biscuit or a sandwich to help prevent it happening again.
How is hypo awareness rated
GOOD score
That they rate themselves 1-7
1 always aware
7 not aware ever
Causes if hypo
Missed insulin dose
Triggered by exercise , alcohol, injection in lipodystroohic site preventing absorption
Overcorrection if high glucose
Insulin stacking repeated insulin to correct high dose
Snack without rapid acting
How does hyperglycaemia promote atherosclerosis
Inc inflammation by sowing blood flow
Inc oxidative stress protein kinase c activation alters growth factor expression
Non enzymatic glycosylation of proteins and lipids
Who is treated in an antenatal diabetes clinic
Those with existing diabetes or those with gestational diabetes
Existing -
Conception planning prev feral malformation
Stop statin and ACE
Ensure 48 HbA1c
Folic acid 5 mg dose before and up to 12 was pregnancy
Eye screening x2
Aspirin from 12 weeks to prev pre eclampsia
What is gestational diabetes
Hormones in pregnancy inc insulin resistance
- progesterone
- growth hormone
- human placental lactogen
When does screening occur and who is screened
24-28;weeks High BMI FHx Prev GDM Prev still birth Black or Asian Macrosomia Polyhydraminos
Which test is used to screen for GDM
Diagnostic OGTT 75g
What are the diagnostic criteria for GDM
Different to normal
Fasting is >5.6
2hr >7.8
Treatment given
Told to blood glucose monitor
Carb control
Inc growth more treatment , metformin , insulin
Growth scan
6-13 weeks after delivery post natal fasting glucose to see if normal glucose tolerance occurs
What obstetric complications are we trying to avoid
Mother Preeclampsia Diabetic eye disease Baby Fetal malformation Macrosomia Early delivery Polyhydraminos Birth trauma Neonatal jaundice and hypoglycaemia Still birth and neonatal death
What abnormalities are being looked for in a diabetic eye clinic
Dots -microaneurysm
Boots- haemorrhages
Exudate - lipoprotein leak from the capillaries - cotton wool spots
Background retinopathy - observed signs but not in the macular so not sight threatening
Maculooathy signs in the macular therefore sight threatening
What is released in the eye when these diabetes has caused damage to the vessels
VEGF
Causes friable new vessel to form which then leak and bleed into the vitreous humour causing vision loss
What convictions can be caused by VEGF
Rubeosis iridisis Or neovasculatisation of the the iris It is sight threatening and is bleeding into the anterior chamber Glucaoma Cataract
What treatment is given for retinopathy
Anti VEGF
Monoclonal antibody that neutralise VEGF
What can be seen in the foot in a diabetic foot clinic
Hammer toe or hallux valgus
Can be chased by reduced sensation of the foot also a prime site for a neuropathic ulcer to develop
Sweat less due to autonomic neuropathy - dry foot
Ulcer
Reduced sensation
PVD
Charcot foot
Types of ulcer in diabetic foot disease
Neuropathic
- no feeling, punched out, blood supply present so healing possible
-ischaemic
No blood, no healing can be necrotic or septic and require amputation
How to test sensation in a diabetic foot
Mono filament testing
On the big toes and then at three points on the ball of the foot
What tests are done to see if there is PVD
Puleses
Doppler
ABPI
What is Charcots foot
Disorganisation of the the foot bone and joint There is underlying neuropathy as the patient cannot feel the ongoing trauma occurring that is happening by walking on it Mid foot is the common place Pes cavus collapsed arch of the foot Inc temperature due to inflammation Can see mid foot dislocation and fracture Can cause foot ulcers No sensation Treated by boot DH Walker Total contact cast Amputations
What happens in anrenal diabetes clinic
Diagnosed with renal impairment Control progression diabetic nephropathy Management of CKD May need dialysis Transplant
Who uses insulin pumps
T1D
HbA1c above 69
What does an insulin pump help with
Reduces hypos
In glycaemic control
Needs close monitoring as interruptions in pump can cause DKA due to fast acting insulin being released all the time
What education programmes are out there for diabetics
DESMOND T2D lifestyle choices
DAFNE T1D carb count and insulin dose
Impaired glucose tolerance test should be
Fasting plasma glucose <7mmol/L
OGTT to exclude DM 2 hours post glucose >7.8mmol/l but <11.1mmol/l
Impaired fasting glucose results should be
Fasting plasma glucose >6.1mmol/l but <7mmol/l
Other causes of DM
Steroids
Anti-HIV med
Newer antipsychotics
Pancreatic:pancreatitis surgery, trauma, pancreatitis destruction - haemochromatosis, CF; pancreatic cancer
Cushing disease, acromegaly, phaeochromocytoma, hyperthyroidism, pregnancy
What are GLP analogues
Glucagon like peptide analogue
Work as incretin mimetics
They are gut peptides that work by augmenting insulin release
Sub cut
BMI>35 and other psychological/medical problems or insulin would not suit lifestyle or weightloss would help other comorbidities
In order to continue them patients needs to show a significant response cos they so expensive
They need to show a HbA1c dec of 11 and a weight loss of 3% by 6 months
What causes charcot foot
There is a lack of sensation so paincannot be sensed so there is continued mechanical stress which leads to the deformity due to repeated joint injury
It can heal if weight bearing stopped.
Diagnostic criteria for DKA
Acidaemia pH <7.3 of HCO3- <15
Hyperglycaemia glucose >11.1 or known DM
Ketonaemia >3 or 2+on dipstick
What is the first step in mx of DKA
2 large bore cannula
Fluid resus
1l 0.9% saline over an hour
Unless BP systolic <90 then 500ml blous over 15 min if no improvement - another and senior help and if no improvement another and ICU
What tests are done in DKA
Glu
VBG for pH bicarbonate and K+
Lab glucose and ketone and bedside
insulin delivery in DKA
Fixed rate insulin - no matter what the glucose is insulin is delivered at a the same rate
50 units in 50ml of saline
0.1unit/k/hr
Important to continue the long acting basal insulin fo the patient a their normal doses and times
What are the aims bicarb and ketones in DKA
Aim is to get ketones dropping by 0.5mmol/l/h
And Bicarbonate inc by 3mmol/l/h
What to do if ketone and bicarbonate aims are not met in DKA
Inc the insulin to 1unit/l/h until achieved
When do you check the ketones and glucose in DKA
Check capillary hourly
What is the regimen for checking pH, K+ and HCO3- in DKA
2, 4, 8, 12, 24 hr
How to assess for K+ in DKA
Typical deficit is 3-5mmol /kg
Falls with treatment as plasma enters the cells
Don’t add K+ to the first bag, add K+ according to the most recent VBG result
>5.5 don’t add any KCl to IV fluids
3.5-5.5 add 40mmol
<3.5 seek help from HDU/ICU fro higher doses
What to consider is urine not passed in an hour
DKA
Catheter
Urine output aim 0.5ml/kg/hr
What to do if vomiting /drowsy DKA
NG tube
What to give in DKA due to statis
LMWH
What glucose amount should you start adding glucose in DKA
<14
Start 10% glucose at 125ml/hr
To prevent hypoglycaemia
When due to continue fixed rate insulin till DKA
<0.6 mmol/l ketones
>.3 pH venous
>15 venous bicarbonate
Who is hhs seen in
Unwell T2DM
What is the diagnostic criteria HHS
Markers dehydration
Glucose >30
No switch to ketone metabolism so ketonaemia stays <3 and pH<7.3
Osmolality >320
Tx HHS
Rehydrate 0.9% saline over IVI >48hr
Replace K+ when urine starts to flow
Only use insulin if glucose not falling with rehydration by 5mmol/l/h or if ketonaemia
Start slowly 0.05 units/kg/hr
Keep blood glucose 10-15 for 24 hrs to avoid cerebral oedema
Look for cause MI, sepsis,GI infarct
Hypoglycaemia mx
Conscious - fast acting glucose - 200ml orange juice or dextrose tablet
Conscious uncooperative squirt glucose gel into mouth/gums
In unconscious- IV glucose 10% 200ml/hr conscious or in 15min if unconscious
Or give glucagon 1mg/IV/IM will not work on malnourished patients
Recovered one BG >4
Give long acting car such as a slice of toast
Diagnosis of hypoglycaemia
BG <3mmol
Cause of hypo
Insulin
SU tx
Inc activity missed meal. Accidental, non-accidental OD
Symptoms of hypo
Sweating anxiety hunger tremor palpation dizzy
seizure coma, drowsy, confuse,
Causes of hypo in non-diabetics
EXPLAIN
Ex - endogenous insulin , family member insulin, body builders help stamina, alcohol binge no food, aspirin poisoning, ACE-I, B-blockers, insulin-like GF
P = pituitary insufficiency
L.= liver failure
A = Addison’s disease
I = islet cell tumour, immune hypoglycaemia
N = non-pancreatic neoplasm
