Diabetes Flashcards
Type 1 diabetes
- Definition
Absolute endogenous insulin deficiency characterised by hyperglycaemia.
Type 1 diabetes symptoms
Fatigue
Polydipsia
Polyuria
Weight loss
Complications of diabetes
Macrovascular
- Ischaemic heart disease
- Cerebrovascular disease
- Peripheral vascular disease
Microvascular
- Retinopathy
- Nephropathy
- Neuropathy
Auto-antibodies in T1 DM
Islet cell antibodies
Insulin
ZnT8
Glutamic acid decarboxylase
Islet auto-antigen (IA-2)
Genetic predisposition to diabetes
Polymorphic HLA DR and DQ
- DR3, DR4
- DQ2, DQ8
DR15, DQ6 is protective
Environmental risk factors for DM
Viral infections
- Coxsackie
- Enteroviruses
Consequences of insulin deficiency
- Inability for cells to utilise glucose.
- Glucose is eventually excreted in urine
- Leading to polyuria, polydipsia, glycosuria. - Triggers increase in hormones to stimulate increase in glucose.
- Adrenaline
- Cortisol
- GH
- Glucagon - Stimulate of gluconeogenesis, glycogenolysis
- Lipolysis in disinhibited
- Proteolysis to release amino acids. - Ketosis
- Lack of insulin to prevent lipolysis
- Ketones and fatty acids= acidosis
Diagnosis of DM
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.
Short acting insulin
15-30 mins onset
- Give right before meals
Examples:
- Actarapid
- Humulin S (Neutral insulin)
- Novorapid
- Fiasp
- Humulog
- Apidra
Intermediate acting insulin
Peak around 6-12 hours
- Given as basal under bolus
Examples
- Humulin I
- Isuman Basal
- Insulatard
Insulin regimes
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
Type 2 diabetes
- Definition
Insulin deficiency and peripheral insulin resistance
Diet management of DM
In T2Dm
- Reduce caloric intake
- Decrease refined carbs, increase complex carbs
- Increase soluble fibres
- Decrease fat and sodium
Pharmacological management of T2 DM
- Metformin monotherapy
Causes of inaccurate HbA1c
High erythrocyte turnover
- Haemolysis
Abormal haemoglobin
- Sickle cell
HbA1c targets
If managed by lifestyle/ with or without monotherapy
- 6.5%
If on drug associated with hypoglycaemia
- 7% (53 mmol/mol)
Indication and steps for pharmacological intervention for T2 DM
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
Indication and steps for pharmacological intervention for T2 DM
- If metformin not appropiate to use
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
Vascular disease prevention
Smoking cessation
Target BP for <140/80
Consder statin + aspirin
Nephropathy prevention/ management
For albuminuria
- ACE-i / ARB
Hypoglycaemia
- Symptoms
Autonomic
- Sweating
- Palpitations, dizziness
- Tremor
Neuroglycopenic
- Confusion
- Drowsiness
- Blurred vision
- Seizure
- Coma
Hyopogylcaemia
- Treatment
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
Hypoglycaemia is defined as…
Blood glucose <4mmol/L
When should IM glucagon should not be used?
History of severe liver disease
Starved patients
Biochemical features of HHS
Blood glucose >30mmol/L
Ketonaemia <3mmol/L
pH >7.3, serum bicarbonate >15mmol/L
Serum osmolality >320mosmol/L
- Hypernatraemia
- derranged K
Presentation of HHS
Hypovolaemia
- Dry mucous membranes
- Reduced skin turgor
- Drowsiness/ reduced GCS
Hypotension
Reduced urinary output, AKI
Hypothermia
Complications of HHS
VTE- MI, stroke
Death
Investigations for HHS
Venous blood gas
Serum osmolality
Fluid balance chart (urinary catheter)
U+Es
LFTs, clotting
CRP
Urine/ blood culture
ECG
CXR
Initial management of HHS
- Slow infusion of IV fluids
- 500ml- 1L of saline over 1 hour
- 2-3L positive in 6 hours. - IV fixed rate insulin if ketones >1
- Prophylactic LMWH
- IV antibiotics is infection suspected
- Cardiac monitoring
Follow-up management of HHS
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.
Aims of management in DKA
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
DKA is defined as resolved when…
Ketones <0.3mmol/L
pH >7.3
DKA is characterised by what 3 features
Ketones >3mmol/L
Blood glucose >11mol/L
Metabolic acidosis (pH <7.3, bicarbonate <15mmol/L)
Risk factors for DKA
Poorly managed DM / poor compliance to medication
Acute illness- infection, ACS, stroke
Surgery
Dehydration
Alcohol
Stress
Presentation of DKA
Abdominal pain
Nausea, vomiting
Kaussmal breathing
Dehydration: reduced skin turgor, dry mucous membranes
Ketone breath
Initial management of DKA
- IV fluids
- fluid bolus 500mL over 15-20mins - Fixed-rate rapid IV insulin
- 50units in 50mls of saline
- 0.1units/kg/hr - Correct K+
- If hypokalaemic= 40mmol KCl in 1L NaCl over 4 hours. - Treat underlying cause (i.e. antibiotics)
- Start IV 10% dextrose when CBG <12mmol/L
Management after DKA has resolved
- Variable rate insulin
- Restart s/c long-acting insulin when eating and drinking
- Overlap with IV insulin, at least 4 hours before stopping
