Diabetes Flashcards
What is diabetes?
Diabetes mellitus describes a metabolic disorder of multiple aetiology characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both
Function of the pancreas
- Exocrine -> excretes enzymes in the digestive tract that help with digestions
- Endocrine -> creates hormones that help with metabolism. In type 1 diabetes certain parts of the pancreas are destroyed so the production of hormones -> insulin is insufficient.
o Islets of Langerhans: the cells that are responsible for the endocrine functions are located here.
-Two main cells responsible for producing the hormones:
- Alpha cells ->responsible for secreting glucagon
- Beta cells -> responsible for secreting insulin- Both hormones have a responsibility of the body’s metabolism
o Normal function: - Increase in blood glucose -> sense by the beta cells -> secrets insulin in the blood -> lower BG -> cells take up glucose or stored in the liver therefore BG lowers -> BG low -> sensed by the alpha cells-> secretes glucagon -> glucagon BG raises going back to normal -> liver releases glucose which was stored
- Both hormones have a responsibility of the body’s metabolism
What happens in type 1 diabetes?
Destruction of beta cells -> beta cells can’t produce insulin -> BG cannot be lowered -> imbalanced glucagon response -> raises BG more than the norm -> hyperglycaemia
Treatments for Type 1 diabetes
- Complex & demanding treatment regimens
- Expect patients to make adjustments
- Regular blood glucose monitoring
- Always insulin (sometimes + Metformin)
- Forms of insulin
- Animal
- Human
- Analogue: lab grown and modified to affect how quickly or slowly it acts
Insulin types
- Rapid acting: reaches blood within 15 mins - Short-acting: quickly and lasts longer - Immediate-acting - Intermediate acting - Long acting insulin
Injecting insulin
- Need a layer of fat to be absorbed= SC injection= abdomen (rapid absorption), upper arms (not recommended
- Change sites= if not then the insulin might be absorbed well as there is bruising and scar tissue
- CSII - Insulin pump
- CGM - continuous blood glucose monitors
- Proper insulin dosing can require a complex matrix of decisions involving carbohydrate counting, correcting, physical activity, stress, awareness of hypoglycaemia
What is type 2 diabetes?
Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas is unable to produce enough insulin.
Presentation in type 2 diabetes
- Chronic
- May report no symptoms
- Thirst
- Polyuria
- Blurred vision
- Fatigue
- Weight loss –hyperglycaemia therefore late sign 2º to CV event
- No ketoacidosis (usually)
Risk factors for type 2 diabetes
- Caucasian people aged over 40 years, and in people from Black Asian and minority ethnic groups - over 25 years: with one or more of the following risk factors:
- A first degree family history of diabetes and/ or
- Overweight/ obese/ morbidly obese with a BMI of 25kg/m² and above + a sedentary lifestyle and/ or
- People who have ischaemic heart disease, cerebrovascular disease, peripheral vascular disease or treated hypertension
- Women who have had gestational diabetes, who have tested normal following delivery (screen within 6 weeks of delivery and then one year post partum and then three yearly).
- Women with polycystic ovarian syndrome and a BMI ≥30.
- People with Impaired Fasting Glycaemia or Impaired Glucose Tolerance.
- People with severe mental health problems.
- People with hypertriglyceridaemia (fasting plasma triglyceride ≥2.3mmol/L) not due to alcohol excess or renal disease.
Diagnosis of diabetes type 2
- WITH SYMPTOMS: only one test in the diagnostic range is required to make the diagnosis of diabetes
- WITHOUT SYMPTOMS: at least two blood glucose tests must be performed on different days, the results of which must both be in the diabetic range
What is HbA1c?
- Glycated haemoglobin
- Measurement of average blood glucose over 2-3 month period
- Used with capillary blood glucose to establish control
Treatment and management of type 2 diabetes?
- Improved diet
- Regular exercise, healthy weight
- Medication to control blood sugar
- self-management through lifestyle
Chronic complication of diabetes
- Damage to blood vessels then potentially nerves due to high blood glucose
- Retinopathy – damage to retina
- Nephropathy –loss of kidney function
- Neuropathy – damage to nerves
- Cardiovascular disease
- Stroke
- Gastroparesis – inadequate emptying of stomach, thought to be a problem with the nerves and muscles controlling the emptying of the stomach
Screening for complication
- Annual review – usually done in primary care unless being seen in secondary care
- Bloods for HbA1c, Renal Profile, Lipids
- Urine for microalbuminuria/protein
- Blood pressure
- Foot check
- Eye screening
- Blood glucose review
- Medication review
Acute complications of diabetes
Diabetic Ketoacidosis
Diagnosis
- Glucose > 11mmol/L
- Bicarbonate (HC03) <15mmol/L and/or pH <7.3
- Ketonaemia ≥ 3mmol/L or significant ketonuria (> ++ on standard urinalysis sticks)
Signs and symptoms
- Polyuria +/- Nocturia
- Polydipsia
- Weight loss
- Tiredness
- Urine or blood ketones
- Vomiting
- Abdominal Pain
- Kussmaul Breathing
- Drowsiness
Aims of therapy to resolve DKA
- Restoration of circulatory volume
- Clearance of ketones
- Correction of electrolyte imbalance
- Suppression of ketogenesis
- Reduction of blood glucose
- Precipitating factors identification
- Prevention of recurrence
- Education
- INSULIN – fixed rate insulin infusion followed by variable rate once ketones cleared
Hypoglycaemia
- A blood glucose of under 4mmol/l
- May be symptomatic or non-symptomatic
- Hypo unawareness
Recognising symptoms Adrenergic (relating to nerve cells): Sweating Palpitations Shaking or tremor Hunger
Neuroglycopenic (shortage of glucose to brain): Confusion/poor co-ordination Drowsiness Slurred speech Unusual/aggressive behaviour Visual disturbances
Causes of hypoglycaemia
- Too much oral hypoglycaemic agents such as Gliclazide
- Increased exercise
- Malnutrition/ not eating enough
- Alcohol (Liver related – releases glucose into blood)
- IM Injection sites (increases insulin absorption)
Treating hypoglycaemia
Conscious orientated and able to swallow
- 15-20 grams CHO
- 5-7 dextrosol tablets or 4-5 glucotabs
- 1 bottle of Glucojuice
- 150-200ml pure fruit juice
- 3-4 heaped teaspoons of sugar dissolved in water
- Re-measure 10-15 minutes later if still less than 4.0 mmol/l repeat (no more than 3 treatments in total)
- Follow up with Long acting CHO – if needed
Conscious but confused. Able to swallow
- 1.5-2 tubes of 40% glucose gel (Glucogel)
- Remeasure 10-15 minutes later if still less than 4.0 mmol/l repeat (no more than 3 Rx)
Unconscious, seizures or aggressive behaviour
- If IV access
- 75-100mls of 20% IV Glucose over 15 minutes.
- 150-200mls 10% IV Glucose over 15 minutes
- Glucagon 1mg IM
What is GDM?
DM- Defined as carbohydrate intolerance resulting in hypoglycaemia of variable severity with onset or first recognition during pregnancy.
- Usually no significant symptoms for the mother
- Develops in 2nd or 3rd trimester
- Related to changes in carbohydrate metabolism and increase insulin resistance
- Found:
- on routine/ selective screening or when investigating for i.e. large-for-dates baby, polyhydramnios, glycosuria
- Retrospective diagnosis if IUD (intrauterine death)
Physiological changes in pregnancy
- GT tolerance decreases progressively with increasing gestation
- Anti-insulin hormones secreted by the placenta in normal pregnancy (HPL, glucagon and cortisol)
- Approximate x2 of insulin production from 1st trimester to 3rd trimester
- Increasing insulin requirement as pregnancy progresses
- May reach 2-4 normal dosage
o Rapid increase at 28-32 weeks (fetal growth) - The renal tubular threshold for glucose falls during pregnancy: tendency for glycosuria
