Diabetes Flashcards
Treatment of hyperglycaemia
Oral fluids - 1L water or sugar free squash over 1 hour
Metformin - if eGFR > 45
Basal insulin
Aim for 6-10 mmol CBG
Criteria for hyperglycaemia
CBG > 12mmol/L
Criteria for hypoglycaemia
CBG < 4mmol/L
Features of DKA
Hyperglycaemia
Metabolic acidosis
Ketotic
Features of HHS
Hyperglycaemia
High serum osmolarity
Volume Depletion
Absence of significant acidosis
What is HHS
Hyperosmolar hyperglycaemic state
Definition of DKA
Ketonuria > 2 or blood ketone > 3mmol/L
Blood glucose > 11 mmol.L
Bicarbonate < 15mmol/L or venous pH < 7.3
Management of DKA
Insulin - fixed rate IV invusion (FRIII) Fluid Potassium Avoid hypoglycaemia Identify and treat underlying cause
HHS definition
Hypovolaemia
Marked hyperglycaemia > 30mmol/L or acidosis pH > 7.3
Osmolality > 320mosmol/kg
Management of HHS
Insulin - FRIII IV fluid - 0.9% Sodium Chloride Potassium Low molecular weight heparin Identify and treat underlying cause
Features of hypoglycaemia
Autonomic symptoms
- pallor, sweating, tremor, tachycardia
Neuroglycapaenic symptoms
- loss of concentrations, behavioural changes, fits, transient neurological defects, reduced level of consciousness
Causes of hypoglycaemia
Medical reasons - inappropriately timed medication - insulin error - discontinuation of long term steroid therapy - recovery from acute illness/stress - change in activity levels Reduced carbohydrate intake - missed/delayed meals - smaller meals - change of time of meals - lack of access to usual snacks - prolonged starvation time - NBM, vomiting
Management of hypoglycaemia
Glucojuice or gluocse gel
Indications for insulin sliding scale
Type 1 diabetes
- unable to eat/drink
- recurrent vomiting
Type 1 or 2 with severe illness
Features of sliding scale
Prescribe dextrose too - prevent hypoglycaemia
Hourly CBG
Risk factors for HHS
Infection
Inadequate insulin or oral anti-diabetic therapy
Acute illness in pt with known diabetes
Nursing home residents
Investigations for HHS
Plasma glucose - elevated
Serum/urinary ketone level - negative/low
Serum urea - elevated
Serum creatinine - elevated - due to volume depletion
Serum osmolality - raised - > 320 mOsm/kg
Complications of HHS
Insulin related hypoglycaemia Treatment related hypokalaemia Stroke MI PE DIC Cerebral oedema Coma
Define type 1 diabetes
Autoimmune destruction of beta-cells in the Islet of Langerhans
Complete insulin insufficiency -> hyperglycaemia
Risk factors for type 1 diabetes
Genetic predisposition
Human enterovirus
Autoimmune disorders
Clinical features of type 1 diabetes
Young age Weight loss Fatigue Polydipsia Polyuria
Investigaitons for diabetes mellitus
Random blood glucose > 11mmol/L
Fasting blood glucose > 7mmol/L
HbA1c > 6.5% / 48mmol/mol
Management for type 1 diabetes
Insulin
- basal bolus + pre-meal corrections
DAPHNIE courses
Complicagtions of diabets
DKA (type 1) / HHS (type 2) Hypoglycaemia Hyperglyceamia Microvascular - neuropathy - nephropathy - retinopathy Macrovascular - increased cardiovascular disease risk
Risk factors for type 2 diabetes
Overweight/obese Non-white heritage Increasing age Gestational diabetes Pre-diabetes - HbA1c > 6% Hypertension Stress PCOS FHx
Clinical features of type 2 diabetes
Commonly asymptomatic Recurrent UTIs/candidial/skin infections Fatigue Polydypsia Polyuria
Management of type 2 diabetes
Lifestyle Metformin Sulfonylures - if metformin contraindicated/not tolerated SGLT2 inhibitors DPP-4 inhibitors GLP-1 agonists Basal insulin
Lifestyle management of type 2 diabetes
Nutrition advice - weight loss - low GI index Increased activity - 3-4 40 min sessions Smoking cessation Reduced alcohol consumption
Metformin
Reduces hepatic gluconeogensis and glycogenolysis - reduces HbA1c - reduces LDL CVS benefit Inexpensive GI side effects - diarrhoea - N+V - titrate up to reduce - can give modified release 1st line
SGLT2 inhibitors
Empagliflozin
Reduces CVD risk
Risk of ketoacidosis
Increase amputation risk
Sulfonylureas
Gliclazide Increases plasma-insulin concentrations - modest weight gain Risk of hypoglycaemia 1st line if metformin contraindicated or not-tolerated
DPP-4 inhibitors
Gliptins No weight gain Low hypoglycaemia incidence No CVS benefit Few side effects
GLP-1 agonists
Suppresses glucagon levels Stimulate glucose dependent release of insulin Delay gastric emptying - weight loss Increased CVS/kidney risk Last line
Basal inuslin
Added to metformin - bed time
Periodic home glucose monitoring
Educate on signs of hypoglycaemia
Piogitazene
Several long term risk
- heart failure
- fluid retention
