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Diabetes Flashcards

1
Q

Why does blood glucose rise is patients with diabetes despite fasting

A

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

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2
Q

What is HbA1c

A 
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
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3
Q

What is c peptide

A

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

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4
Q

Diagnostic criteria WHO

A

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

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5
Q

What colour tube is the blood test taken in

A

Venous sample in a fluoride tube with a grey top
HbA1c is EDTA purple top
Capillary readings are not suitable for diagnostic purposes

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6
Q

What are the typical symptoms

A 
Thirst 
Unexplained polyuria
Unexplained weight loss 
DKA
HHS
one biochem test needed to confirm 
No confirmatory that is only in asymptotic patients
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7
Q

Risk factors for type 1 diabetes

A 
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
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8
Q

Type 2 risk factors for diabetes

A 
Obesity 
FHx
Ethnicity
Age >40
Previous GDM, PCOS
metabolic syndrome 
INSULIN RESISTANCE 
RELATIVE INSULIN DEFICIENCY
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9
Q

How to measure risk factors to T2D

A

qdscore.org

Then tests can be done appropriately

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10
Q

Ehh so to determine the type of Diabetes depending on the signs and symptoms

A

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

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11
Q

What is the other type of type one diabetes

A

LADA
Latent onsets autoimmune diabetes in adults
Type one diabetes in adulthood

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12
Q

What is the other type of type two diabetes

A

MODY
Maturity onset diabetes of the young
Defect in HNI
Respond to sulfonylureas

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13
Q

What are the implications to the patient

A

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

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14
Q

What is the immediate management

A

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

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15
Q

What is metabolic syndrome

A

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

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16
Q

What is metformin

A

It is a Biguanide

And it increases insulin sensitivity

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17
Q

What is a sulfonylurea

A

Inc secretion of glucose

Gliclazide

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18
Q

What is a gliptin

A

Block DPP 4 which stop incretin from being destroyed

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19
Q

What can the complications be

A

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

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20
Q

Different types of retinopathy

A

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

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21
Q

What regime is usually used in T1F

A

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

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22
Q

What are hypos

A

When the blood sugar falls below 4

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23
Q

How to manage a hypo

A

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.

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24
Q

How is hypo awareness rated

A

GOOD score
That they rate themselves 1-7
1 always aware
7 not aware ever

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25
Q

Causes if hypo

A

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

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26
Q

How does hyperglycaemia promote atherosclerosis

A

Inc inflammation by sowing blood flow
Inc oxidative stress protein kinase c activation alters growth factor expression
Non enzymatic glycosylation of proteins and lipids

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27
Q

Who is treated in an antenatal diabetes clinic

A

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

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28
Q

What is gestational diabetes

A

Hormones in pregnancy inc insulin resistance

  • progesterone
  • growth hormone
  • human placental lactogen
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29
Q

When does screening occur and who is screened

A 
24-28;weeks
High BMI
FHx
Prev GDM
Prev still birth 
Black or Asian
Macrosomia 
Polyhydraminos
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30
Q

Which test is used to screen for GDM

A

Diagnostic OGTT 75g

31
Q

What are the diagnostic criteria for GDM

A

Different to normal
Fasting is >5.6
2hr >7.8

32
Q

Treatment given

A

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

33
Q

What obstetric complications are we trying to avoid

A 
Mother
Preeclampsia
Diabetic eye disease
Baby
Fetal malformation 
Macrosomia
Early delivery
Polyhydraminos
Birth trauma
Neonatal jaundice and hypoglycaemia
Still birth and neonatal death
34
Q

What abnormalities are being looked for in a diabetic eye clinic

A

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

35
Q

What is released in the eye when these diabetes has caused damage to the vessels

A

VEGF

Causes friable new vessel to form which then leak and bleed into the vitreous humour causing vision loss

36
Q

What convictions can be caused by VEGF

A 
Rubeosis iridisis
Or neovasculatisation of the the iris 
It is sight threatening and is bleeding into the anterior chamber 
Glucaoma 
Cataract
37
Q

What treatment is given for retinopathy

A

Anti VEGF

Monoclonal antibody that neutralise VEGF

38
Q

What can be seen in the foot in a diabetic foot clinic

A

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

39
Q

Types of ulcer in diabetic foot disease

A

Neuropathic
- no feeling, punched out, blood supply present so healing possible
-ischaemic
No blood, no healing can be necrotic or septic and require amputation

40
Q

How to test sensation in a diabetic foot

A

Mono filament testing

On the big toes and then at three points on the ball of the foot

41
Q

What tests are done to see if there is PVD

A

Puleses
Doppler
ABPI

42
Q

What is Charcots foot

A 
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
43
Q

What happens in anrenal diabetes clinic

A 
Diagnosed with renal impairment 
Control progression diabetic nephropathy 
Management of CKD
May need dialysis 
Transplant
44
Q

Who uses insulin pumps

A

T1D

HbA1c above 69

45
Q

What does an insulin pump help with

A

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

46
Q

What education programmes are out there for diabetics

A

DESMOND T2D lifestyle choices

DAFNE T1D carb count and insulin dose

47
Q

Impaired glucose tolerance test should be

A

Fasting plasma glucose <7mmol/L

OGTT to exclude DM 2 hours post glucose >7.8mmol/l but <11.1mmol/l

48
Q

Impaired fasting glucose results should be

A

Fasting plasma glucose >6.1mmol/l but <7mmol/l

49
Q

Other causes of DM

A

Steroids
Anti-HIV med
Newer antipsychotics
Pancreatic:pancreatitis surgery, trauma, pancreatitis destruction - haemochromatosis, CF; pancreatic cancer
Cushing disease, acromegaly, phaeochromocytoma, hyperthyroidism, pregnancy

50
Q

What are GLP analogues

A

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

51
Q

What causes charcot foot

A

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.

52
Q

Diagnostic criteria for DKA

A

Acidaemia pH <7.3 of HCO3- <15
Hyperglycaemia glucose >11.1 or known DM
Ketonaemia >3 or 2+on dipstick

53
Q

What is the first step in mx of DKA

A

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

54
Q

What tests are done in DKA

A

Glu
VBG for pH bicarbonate and K+
Lab glucose and ketone and bedside

55
Q

insulin delivery in DKA

A

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

56
Q

What are the aims bicarb and ketones in DKA

A

Aim is to get ketones dropping by 0.5mmol/l/h

And Bicarbonate inc by 3mmol/l/h

57
Q

What to do if ketone and bicarbonate aims are not met in DKA

A

Inc the insulin to 1unit/l/h until achieved

58
Q

When do you check the ketones and glucose in DKA

A

Check capillary hourly

59
Q

What is the regimen for checking pH, K+ and HCO3- in DKA

A

2, 4, 8, 12, 24 hr

60
Q

How to assess for K+ in DKA

A

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

61
Q

What to consider is urine not passed in an hour

DKA

A

Catheter

Urine output aim 0.5ml/kg/hr

62
Q

What to do if vomiting /drowsy DKA

A

NG tube

63
Q

What to give in DKA due to statis

A

LMWH

64
Q

What glucose amount should you start adding glucose in DKA

A

<14
Start 10% glucose at 125ml/hr
To prevent hypoglycaemia

65
Q

When due to continue fixed rate insulin till DKA

A

<0.6 mmol/l ketones
>.3 pH venous
>15 venous bicarbonate

66
Q

Who is hhs seen in

A

Unwell T2DM

67
Q

What is the diagnostic criteria HHS

A

Markers dehydration
Glucose >30
No switch to ketone metabolism so ketonaemia stays <3 and pH<7.3
Osmolality >320

68
Q

Tx HHS

A

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

69
Q

Hypoglycaemia mx

A

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

70
Q

Diagnosis of hypoglycaemia

A

BG <3mmol

71
Q

Cause of hypo

A

Insulin
SU tx
Inc activity missed meal. Accidental, non-accidental OD

72
Q

Symptoms of hypo

A

Sweating anxiety hunger tremor palpation dizzy

seizure coma, drowsy, confuse,

73
Q

Causes of hypo in non-diabetics

A

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

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