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303: Medicine > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Type 1 diabetes
- Definition

A

Absolute endogenous insulin deficiency characterised by hyperglycaemia.

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2
Q

Type 1 diabetes symptoms

A

Fatigue
Polydipsia
Polyuria

Weight loss

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3
Q

Complications of diabetes

A

Macrovascular
- Ischaemic heart disease
- Cerebrovascular disease
- Peripheral vascular disease

Microvascular
- Retinopathy
- Nephropathy
- Neuropathy

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4
Q

Auto-antibodies in T1 DM

A

Islet cell antibodies

Insulin

ZnT8

Glutamic acid decarboxylase

Islet auto-antigen (IA-2)

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5
Q

Genetic predisposition to diabetes

A

Polymorphic HLA DR and DQ
- DR3, DR4
- DQ2, DQ8

DR15, DQ6 is protective

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6
Q

Environmental risk factors for DM

A

Viral infections
- Coxsackie
- Enteroviruses

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7
Q

Consequences of insulin deficiency

A
  1. Inability for cells to utilise glucose.
    - Glucose is eventually excreted in urine
    - Leading to polyuria, polydipsia, glycosuria.
  2. Triggers increase in hormones to stimulate increase in glucose.
    - Adrenaline
    - Cortisol
    - GH
    - Glucagon
  3. Stimulate of gluconeogenesis, glycogenolysis
    - Lipolysis in disinhibited
    - Proteolysis to release amino acids.
  4. Ketosis
    - Lack of insulin to prevent lipolysis
    - Ketones and fatty acids= acidosis
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8
Q

Diagnosis of DM

A

Random plasma glucose
- >11.1

Fasting plasma glucose
- >6.7

2 hr glucose challenge (75g glucose)
- >11.1

HbA1c
- >6.5% or 48

Ketosis
- elevated

C-peptide fasting
- undetectable/ low

Autoimmune markers
- ZnT8
- Insulin antibodies
- islet cell antibodies
- Glutamic acid decarboxylase.

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9
Q

Short acting insulin

A

15-30 mins onset
- Give right before meals

Examples:
- Actarapid
- Humulin S (Neutral insulin)
- Novorapid
- Fiasp
- Humulog
- Apidra

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10
Q

Intermediate acting insulin

A

Peak around 6-12 hours
- Given as basal under bolus

Examples
- Humulin I
- Isuman Basal
- Insulatard

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11
Q

Insulin regimes

A

Biphasic
- Rapid acting 30 mins before breakfast and dinner
- Intermediate/ long acting in background

Basal-bolus
- Long acting at bedtime
- Short acting before meal
- Allows flexible lifestyle

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12
Q

Type 2 diabetes
- Definition

A

Insulin deficiency and peripheral insulin resistance

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13
Q

Diet management of DM

A

In T2Dm
- Reduce caloric intake
- Decrease refined carbs, increase complex carbs
- Increase soluble fibres
- Decrease fat and sodium

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14
Q

Pharmacological management of T2 DM

A
  1. Metformin monotherapy
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15
Q

Causes of inaccurate HbA1c

A

High erythrocyte turnover
- Haemolysis

Abormal haemoglobin
- Sickle cell

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16
Q

HbA1c targets

A

If managed by lifestyle/ with or without monotherapy
- 6.5%

If on drug associated with hypoglycaemia
- 7% (53 mmol/mol)

17
Q

Indication and steps for pharmacological intervention for T2 DM

A

HbA1c >6.5% on lifestyle interventions
- Metformin, aim for 6.5%

If rises to 7.5%/ 58= Dual therapy:
- DPP4 inhibitor
- Pioglitazone
- SU
- SGLT-2 inhibit
- Aim for 7.0/ 53

If it is still above 7.5%= triple therapy
- DPP-4i + SU
- Pioglitazone + SU
- Pioglitazone/ SU + SGLT-2i

18
Q

Indication and steps for pharmacological intervention for T2 DM
- If metformin not appropiate to use

A

Hba1c> 6.5, with lifestyle interventions
- DPP-4i/ pioglitazone/ SU
- SGLT-2
- Aim for 6.5%
- Aim for 7% on SU

If >7.5%= dual therapy
- DPP4i + Pioglitazone
- DPP-4i + SU
- Pio + SU

Second intensification= insulin based treatment

19
Q

Vascular disease prevention

A

Smoking cessation

Target BP for <140/80

Consder statin + aspirin

20
Q

Nephropathy prevention/ management

A

For albuminuria
- ACE-i / ARB

21
Q

Hypoglycaemia
- Symptoms

A

Autonomic
- Sweating
- Palpitations, dizziness
- Tremor

Neuroglycopenic
- Confusion
- Drowsiness
- Blurred vision
- Seizure
- Coma

22
Q

Hyopogylcaemia
- Treatment

A

Orally
- Sugar, fast acting (20g glucose tablet, pure fruit juice)
- Followed by long acting starch

IV
- 150ml 10% Glucose IV

No IV access
- 1mg Glucagon IM

23
Q

Hypoglycaemia is defined as…

A

Blood glucose <4mmol/L

24
Q

When should IM glucagon should not be used?

A

History of severe liver disease

Starved patients

25
Q

Biochemical features of HHS

A

Blood glucose >30mmol/L

Ketonaemia <3mmol/L

pH >7.3, serum bicarbonate >15mmol/L

Serum osmolality >320mosmol/L
- Hypernatraemia
- derranged K

26
Q

Presentation of HHS

A

Hypovolaemia
- Dry mucous membranes
- Reduced skin turgor
- Drowsiness/ reduced GCS

Hypotension

Reduced urinary output, AKI

Hypothermia

27
Q

Complications of HHS

A

VTE- MI, stroke

Death

28
Q

Investigations for HHS

A

Venous blood gas

Serum osmolality

Fluid balance chart (urinary catheter)

U+Es

LFTs, clotting

CRP

Urine/ blood culture

ECG

CXR

29
Q

Initial management of HHS

A
  1. Slow infusion of IV fluids
    - 500ml- 1L of saline over 1 hour
    - 2-3L positive in 6 hours.
  2. IV fixed rate insulin if ketones >1
  3. Prophylactic LMWH
  4. IV antibiotics is infection suspected
  5. Cardiac monitoring
30
Q

Follow-up management of HHS

A

Avoid hypoglycaemia
- Maintain blood glucose between 10-15, start IV glucose if <14

Avoid rapid decrease in serum osmolality
- 3-5mosmol/kg/hr
- Reduce saline infusion rate if quicker, increase if Na+ rises or osmolality increases
- start s/c insulin once stabilised.

31
Q

Aims of management in DKA

A

Decrease blood ketones by at least 0.5mmol/L/ hr

Increase bicarbonate by >3mmol/L/hr

Reduce glucose by >3mmol/L/hr

Normalise K+ levels

32
Q

DKA is defined as resolved when…

A

Ketones <0.3mmol/L

pH >7.3

33
Q

DKA is characterised by what 3 features

A

Ketones >3mmol/L

Blood glucose >11mol/L

Metabolic acidosis (pH <7.3, bicarbonate <15mmol/L)

34
Q

Risk factors for DKA

A

Poorly managed DM / poor compliance to medication

Acute illness- infection, ACS, stroke

Surgery

Dehydration

Alcohol

Stress

35
Q

Presentation of DKA

A

Abdominal pain

Nausea, vomiting

Kaussmal breathing

Dehydration: reduced skin turgor, dry mucous membranes

Ketone breath

36
Q

Initial management of DKA

A
  1. IV fluids
    - fluid bolus 500mL over 15-20mins
  2. Fixed-rate rapid IV insulin
    - 50units in 50mls of saline
    - 0.1units/kg/hr
  3. Correct K+
    - If hypokalaemic= 40mmol KCl in 1L NaCl over 4 hours.
  4. Treat underlying cause (i.e. antibiotics)
  5. Start IV 10% dextrose when CBG <12mmol/L
37
Q

Management after DKA has resolved

A
  1. Variable rate insulin
  2. Restart s/c long-acting insulin when eating and drinking
    - Overlap with IV insulin, at least 4 hours before stopping

303: Medicine (19 decks)

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