Diabetes Flashcards
Give 2 examples of human quick-acting insulins
Humulin-S
Actrapid
Give 2 examples of analogue quick-acting insulins
Insulin lispro (Humalog) Insulin aspart (Novorapid)
give two examples of Human isophane (NPH) insulins
Insulatard
Humulin-I
give an example of a human biphasic insulin (mixture)
Humulin-M3
Give 2 examples of analogue biphasic insulins (mixutres)
Humalog Mix25
Novomix 30
Give two examples of analogue long-acting insulins
Insulin glargine (Lantus) Insulin degludec (Tresiba)
What should all people with DM who take insulin carry with them?
an insulin passport with details of their treatment
How would you treat hypoglycaemia in a pt who was conscious?
sugary foods or drinks
how would you treat hypoglycaemia in someone who is unconscious?
oral glucose or glucose gel or IV injection of 20% glucose. glucagon can be given IM if venous access is not available, followed by a sugary drink on waking.
What is the difference between rapid-acting and long-acting insulin analogues?
Rapid-acting insulin does not readily form dimers and hexamers so are more rapidly absorbed from the injection site with a faster onset and shorter duration of aciton.
Long acting insulin analogues either form muliple hexamers in subcutaneous tissue or precipitate in subcutaneous tissue after injection which delays absorption so it has a slower and longer duration of action.
What is DAFNE?
Dose Adjusted For Normal Eating
It is an educational course for type 1 diabetics to provide the skills to administer the right amount of insulin for the amount of carbohydrate eaten. The aim is to allow diabetics to lead a more normal life with better health outcomes
What is used to match the quick-acting insulin dose to the carbohydrate being ingested at that meal time?
CHOC (carbohydrate counting)
What is the first line hypoglycaemic to offer to someone newly diagnosed with T2DM?
Metformin
What do you need to consider before prescribing metformin?
Renal function.
Avoid if eGFR below 30 as there is a risk of accumulation and theoretically of lactic acidosis.
How would you start a patient on metformin?
Gradually increase the dose of standard-release metformin over several weeks to minimise the risk of GI side effects.
let pt know that GI side effects are initially common.
Name 3 common side effects of metformin
abdominal pain anorexia diarrohoea nausea taste disturbance vomiting
What is the level of HbA1c at whcih you should offer an oral hypoglycaemic?
48 mmol/mol
What level of HbA1c should you consider dual therapy hypoglycaemics?
If HbA1c rises to 58 mmol/L
With a pt who’s HbA1c rises to 58 mmol/mol, you should support the pt to aim for an HbA1c level of what?
53 mmol/mol
If a person on dual therapy can’t get their HbA1c below 58mmol/mol, what can you try?
triple therapy.
insulin
in 1 in 5 people, metformin is not tolerated. If this is the case, what hypoglycaemic should you try next?
DPP-4
pioglitazone
Sulphonylurea
Can sulfonylureas cause weight gain?
yes
can you cause hypoglycaemia with sulfonylureas?
yes
Give an example of a thiazolidinedione
pioglitazone
What is the mechanism of action of thiazolidinediones (e.g. pioglitazone)?
They are synthetic ligands for the transcription factor PPARy. PPARy stimulation upregulates the expression of genes involved in lipid and glucose metabolism, insulin transduction and adipocyte differentiation. It also causes an increase in GLUT4 transporters which increases the ability of cells to take up glucose
Can pioglitazone cause weight gain?
yes
Name 4 things pioglitazone increases the risk of
oedema
HF (especially when given alongside insulin).
Small bone fractures (esp women).
Small increased risk of bladder cancer
Can you get hypoglycaemia with DPP4 inhibitors?
No
Can you get weight gain with DPP4 inhibitors?
No they are weight neutral
What is the MOA of DPP4 inhibitors
DPP-4 inactivates incretins (GLP-1 & GIP) whcih are associated with increased insulin release and reduced glucagon release. Inhibiting DPP-4 therefore means you get insulin release and reduced glucagon release for longer
Can you get hypoglycaemia with SGLT2 inhibitors?
no
What is the effect of SGLT2 inhibitors on weight?
weight neutral or may aid weight loss
What is the MOA of SGLT2 inhibitors?
Prevents glucose reabsorption through the sodium-glucose transporter (SGLT-2)
What can SGLT2 inhibitors make someone more prone to due to their MOA?
Urine infections and candidiasis due to increased glucose in the urine (glycosuria).
Can you get hypoglycaemia with GLP1 analogues?
no
what is the effect of GLP1 analogues on weight?
cause weight loss
what is the MOA of GLP1 analogues?
Increase insulin secretion,
delay gastric emptying,
reduce glucagon levels (glucagon promotes glycogen breakdown to release glucose),
reduce food intake by CNS effects causing suppressed appetite.
What do you need in order to diagnose DKA?
Hyperglycaemia
Ketonaemia or ketonuria
Acidosis
What are the diagnostic levels needed to diagnose DKA?
Ketonaemia >3mmol/L or significant ketonuriea (more than 2+ on standard urine sticks).
Blood glucose >11mmol/L or known DM
Bicarbonate <15mmol/L and/or venous pH <7.3
What are your immediate priorities when managing DKA?
ABCDE assessment.
Fluids IV 0.9% NaCl 500mls over 15 mins
How should you manage a pt with DKA?
ABCDE assessment.
Commence IV 0.9% sodium chloride solution.
Commence a fixed rate IV insulin infusion (FRIII) after fluid therapy has been commenced.
establish monitoring regimen appropriate to teh pt. generally hrly blood glucose, hrly ketone measurement, 2hrly potassium and bicarbonate for first 6hrs.
clinical and biochemical assessment of pt
If a DKA pt is shocked, or has severe DKA, what should be done within the first hour?
Give 500ml 0.9% NaCl over 15 mins.
Give another 500ml bolus over 15 mins if SBP still <100mmHg.
If a DKA pt is not shocked, what should be done in the first hour?
give 1L of 0.9% NaCl over 1hr
How does IV insulin work?
reduces blood glucose and supresses lipolysis which resolves ketonaemia.
What are the 4 main themes of DKA management?
Fluid resuscitation and therapy.
treatment of ketosis and hyperglycaemia with IV insulin.
Managemetn of potassium effects.
Transition back to usual insulin regimen
What effect does an IV insulin infusion have on potassium levels?
Can cause life threatening hypokalaemia.
What can be used if a pt with DKA is becomming hypokalaemic after an insulin infusion, to increase the potassium levels?
potassium chloride replacement
What does HHS stand for?
Hyperosmolar hyperglycaemic state
What are the characteristic features of a person with HHS?
Hypovolaemia \+ Marked hyperglycaemia (>30mmol/L) without significant hyperketonaemia (<3mmol/L) or acidosis \+ osmolality >320 mosmol/kg
How is the treatment of HSS different from DKA?
No IV insulin given until glucose stops falling by 5 mmol/hr using IV fluids. If IV insulin is needed, it must be a low dose.
They have a need for thromboprophylaxis.
What would you give a diabetic having a hypo who is not able to cooperate but is able to swallow?
Either 1.5 to 2 tubes of 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums,
or
glucagon 1mg IM
If a diabetic is having a hypo and are able to swallow, how many grams of quick acting carbohydrate should you try to give them?
15-20g
What is the weight in grams of glucose in 100ml of 20% glucose?
20g
What is the weight in grams of glucose in 200ml of 10% glucose?
20g
What choices are there to treat a pt in hospital who is having a hypoglycaemic event who is unconscious and/or having seizures and/or are very aggressive?
If IV access available give 75-100ml of 20% glucose over 15mins (e.g. 300-400ml/hr) or 150-200ml of 10% glucose over 15 mins.
If no IV access give 1mg glucagon IM
If a diabetic is unwell, should they continue to take their insulin?
Yes, may need to take more. they should monitor blood glucose more closely when ill.
Should diabetics stop taking hypoglycaemics before surgery?
Sometimes, it depends on the type of surgery. Some hypoglycaemic drugs need to be taken less frequently on the day of surgery but some are taken as normal.
What should you tell pts that might happen to their blood glucose for a few days after surgery?
It might be raised for a few days
How often should a diabetic on insulin check blood glucose when thery are ill?
every 4hrs
an HbA1c of above what is associated with a higher risk of developing microvascular and neuropathic complications?
53mmol/L.
Target should be 48mmol/L
Why is the target HbA1c for diabetics 48 or less but 53 or less if they are taking more than one hypoglycaemic drug?
To reduce risk of hypoglycaemia
What advice should you give someone with diabetes on how to reduce their weight?
Reduce energy intake.
target weight loss of 5-10%,
eat small, regular meals
ensure that more than half the total E intake is from carbohydrates with controlled intake of saturated and trans fatty acids.
Encourage high-fibre, low-GI sources of carbohydrate and limit sucrose and alcohol intake.
Encourage regular exercise and smoking cessation
how long should a hypoglycaemic drug be tried for before knowing whether or not to add another in?
3 months
What is the target BP for someone with T2DM with and without kidney, eye or cerebrovascualr damage
<140/80
If there is kidney, eye or cerebrovascular damage, <130/80 is target
What is the first line medication for lowering BP in T2DM?
ACEi or ARB - because it reduces progression of diabetic nephropathy.
What should you combine an ACEi or ARB with in an afro-carribean pt with T2DM whose BP is above the target range>
diuretic or Ca-channel blocker
What should you measure to manage CVD risk factors in a pt with T2DM?
BP
lipid profile
List things which can lead to DKA
systemic infection, dietary indiscretion, inappropriate insulin dose reduciton, forgotten dose. DKA may be the presenting problem with new-onset diabetes
