Diabetes Flashcards
What is the ideal plasma glucose concentration?
4.4-6.1mmol/L
Remind youself, for insulin and glucagon, of:
- Where each hormone is produced
- Effect on blood sugar
- Anabolic or catabolic
Insulin
- Beta cells in Islet of Langerhans
- Decrease blood sugar
- Anabolic
Glucagon
- Alpha cells in Islet of Langerhans
- Increase blood sugar
- Catabolic
State some actions of insulin
Which of the common GLUT transporters is insulin dependent?
Glut 4
For GLUT 1-4 state whether they are:
- Insulin dependent
- Where they are found
State some actions of glucagon
- Liver: stimulates glycogenolysis and gluconeogenesis
- Adipose: break down fats into FA to be used as fuel
Discuss the pathophysiology of T1DM
- Autoimmune destrution of beta-islet cells which causes pancreas to stop producing insulin
- Cause is unclear; may be genetic component and it may be triggered by certain viruses e.g. Coxsackie B virus & entorovirus
- When there is no insulin being produced, cells of body can’t absorb glucose from blood
State some risk factors for T1DM
- Family history
- Other autoimmune disease
*
What gene mutations are thought to be associated with T1DM?
HLA D3 & HLA D4 (>90% children with T1DM)
Describe the typical presentation of someone with T1DM
- Adolescent
- Polydipsia
- Polyuria
- Weight loss
- Blurred vision
If pt presents with DKA may also have:
- Nausea & vomitting
- Abdo pain
- Tachypnoea
- Lethargy
What investigations would you do if you suspect T1DM, include:
- Bedside
- Bloods
- Imaging
*Where appropriate, justify why you would do each one
Bedside
- Urine dipstick: check for glucosuria & ketones
-
Check plasma glucose:
- Random plasma glucose
- Fasting plasma glucose
- 2-hour plasma glucose
- Plasma ketones
Bloods
- HbA1c
- Then usual FBC, U&Es etc…: check for other causes/abnormalities
- ? Fasting C peptide
- ? Autoantibodies (NOT required but can distinguish other forms of diabetes from T1DM)
Discuss how many ‘abnormal’ diabetic results are required to diagnose diabetes according to WHO
-
If symptomatic, only need on abnormal result
- e.g. fasting glucose ≥ 7mmol/L
- e.g. random glucose ≥ 11.1mmol/L
- e.g. glucose ≥11.1mmol/L after oral glucose tolerance test
- If asymptomatic, must have abnormal result on two separate occasions
What is prediabetes?
What are Hba1c and fasting glucose values for pre-diabetes?
Explain what the fasting C-peptide result can tell you
C peptide is released at same time as insulin. It links A & B polypeptide chains but is removed by golgi before secretion of insulin. Hence, plasma C-peptide can tell you information about insulin secretion. C peptide has a longer half life than insulin (30 mins compared to 5 mins).
*NOTE: insulin is hepatic clearance & C-peptide is renal clearance
Discuss the long term management of T1DM
Lifestyle
- Education
- Dietary advice
Pharmacological
- Subcutaneous insulin (basal-bolus)
- NICE recommend considering adding metformin if BMI ≥25kgm2
Monitoring
- Recommend monitor at least 4x per day (target of 5-7mmol/L on waking, target of 4-7mmol/L before meals)
- HbA1c every 3-6 months with targe to ≤48mmol/L (6.5%)
- Monitoring of other complications (e.g. retinopathy, diabetic foot disease etc..)
Flash glucose monitoring (e.g. Freestyle Libre) is a relatively new technology used to monitor plasma glucose. It is quite expensive and NHS funding only available in certain areas (at present time). Describe how it works
- Sensor on skin measure interstitial glucose concentration
- Interstitial glucose concentration lags 5 mins behind plasma glucose concentration
- Sensor records glucose readings at short intervals allowing pt to see what glucose levels are doing over time
- User uses a reader to swipe over sensor and the reader shows the blood sugar readings
- Sensors need replacing every 2 weeks
*NOTE: due to 5 min delay, if you suspect hypoglycaemia but sensor doesn’t show hypoglycaemia do capillary blood glucose
Discuss the pathophysiology of T2DM
- Insulin resistance
- Repeated exposure to glucose & insulin makes cells in body become resistant to effect of insulin; therefore more insulin is required. Over time pancreas- particularly beta cells- become fatigued and damaged (after having to produce extra insulin) resulting in the Beta cells dysfunctioning and producing less. Insulin resistance which can then be later combined with decreased insulin secretion leads to chronic hyperglycaemia
State some risk factors for T2DM (think about modifiable & non-modifiable risk factors)
Modifiable
- Older age
- Ethnicity (black, chinese, south asian)
- Family history
Modifable
- Obesity
- Sedentary lifestyle
- High carbohydrate diet (particularly refined carbohydrates)
- Dyslipideamia
Describe the typcial presentation of someone with T2DM
Pt may not necessarily have symptoms and hence you should screen for T2DM in those with risk factors. However, symptoms & signs include:
- Fatigue
- Blurred vision
- Polydipsia
- Polyuria
- Slow healing
- Glucosuria
- Acanthosis nigricans
What investigations would you do if you suspect T2DM, include:
- Bedside
- Bloods
- Imaging
*For each, justify why where appropriate
Bedside
- Urine dipstick: check for glucosuria & ketones
-
Check plasma glucose:
- Random plasma glucose
- Fasting plasma glucose
- 2-hour plasma glucose
- Plasma ketones
Bloods
- HbA1c
- Then usual FBC, U&Es, LFTs, lipids etc…: check for other causes/abnormalities
- ? Fasting C peptide (NICE recommend doing this if T1DM suspected but clinical presentation has atypical features e.g. >50yrs old, BMI >25, slow evolution/long prodrome)
- ? antibody titres (same as above)
Discuss the long term management of T2DM, consider:
- Lifestyle
- Monitoring (include HbA1c targets)
- Pharmacological
Lifestyle
- Patient education
- Diet & lifestyle:
- Regular exercise
- Veg & oily fish
- High fibre diet
- Limited sugar and saturated fats
- Weight loss
- Stop smoking
- Optimising treatment for other conditions e.g. hypertension, hyperlipidaemia, CVD
- Frequent monitoring & treatment of complications
Monitoring
- HbA1c every 3-6 months until stable then 6 monthly
- Targets should be agreed with pt to encourage motivation, example targets:
- Lifestyle only= 48mmol/L
- Lifestyle + metformin= 48mmol/L
- Taking a drug that can cause hypoglcyaemia (e.g. sulphonylurea)= 53mmol/L
- Taking two or more antidiabetic medications= 53mmol/L
Pharmacological
- First line= metformin
- If pt has high risk CVD (QRISK >10%), established CVD or chronic heart failure SGLT-2 inhibitor should also be started (start and titrate metformin first before starting)
-
If HbA1c has risen to 58mmol/L, add second line: add any of the following:
- DPP-4 inhibitor
- Pioglitazone
- Sulfonylurea
- SGLT-2 inhibitor (if NICE criteria met and not already on one)
- Add a third agent
- Consider insulin and GLP-1 mimetics
Further summary of T2DM management
State some short term complications of diabetes
- Hypoglycaemia
- Hyperglycaemia
- DKA
State some symptoms & signs of hypoglycaemia
Sympathetic
- Tremor
- Sweating
- Irritability
- Dizziness
- Pallor
Impaired CNS function
- Reduced consciousness
- Seizures
- Focal neurology
- Coma
Discuss how you would manage hypoglycaemia if pt is:
- Alert & able to swallow
- Confused/drowsy but able to swallow
- Unconscious or swallowing concerns
Alert & able to swallow
- Rapid acting glucose 15-20g (E.g. 200ml of orange juice)
- Followed by slower acting carbohydrate (e.g. piece of toast) once glucose >4mmol/L
Confused/drowsy but able to swallow
- Buccal glucogel
- Consider IV access
- Followed by slower acting carbohydrate (e.g. piece of toast) once glucose >4mmol/L
Unconscious or swallow impaired
- IV glucose 20% (volume and time over depends on blood sugar- see UHL summary image)
- Or glucagon 1mg IM
State some potential causes of hypoglycamia (don’t just think about diabetes)
- Fasting
- Exercise
- Medications e.g. sulphonylureas
- Insulinoma
- Endocrine failures
- Liver failure
- Anorexia nervosa
Glucagon intramuscular injection may be considered in a hypoglycaemic pt who is unconscious or unable to swallow; discuss:
- Indications for glucagon injection
- How long it takes to work
- Pts you shouldn’t use it in
- Risks
- Indications:
- Refractory (other treatment not working)
- Exogenous insulin induced
- Dificult IV access
- 15-20 mins
- Requires glycogen stores hence don’t use in pts with liver disease and hence little glycogen stores. Don’t use in pts with insulinoma
State some symptoms & signs of hyperglycaemia
(similar to inital presentation). MUST CHECK not in DKA
Long term complications of diabetes can be classified into macrovascular, microvascular and infection related complications; state some of each
Macrovascular
- Coronary artery disease
- Peripheral vascular disease/ischaemia causing poor healing, ulcers
- Stroke/cerebrovascular disease
- Hypertension
- Renal artery stenosis
Microvascular
- Peripheral neuropathy
- Retinopathy
- Kidney disease (particularly glomerulosclerosis)
Infection Related
- UTIs
- Pneumonia
- Skin & soft tissue infections
- Fungal infections e.g. oral or vaginal candidiasis
*NOTE: diabetic foot is a combination of a microvascular (in terms of blood supply to nerves) and macrovascular complications
Discuss what should be monitored in a pt with T1DM (and include how we monitor it and how frequently we monitor it)
- Plasma glucose: HbA1c (every 3-6 months)
- Blood pressure (each visit_
- CKD: urinary albumin excretion (yearly)
- Diabetic retinopathy: opthamologist (yearly)
- Diabetic neuropathy: diabetic foot clinic (yearly)
Explain how diabetes can lead to :
- Coronary artery disease
- Infection related complications
- Coronary artery disease & hypertension: chronic exposure to hyperglycaemia causes damage to endothelial cells leading to endothelial dysfunction
- Infection related complications: hyperglycaemia causes immunosupression & also provides optimal environment for organisms to thrive
What is meant by diabetic neuropathy?
State and describe the 6 types of diabetic neuropathy
Damage to nerves caused by chronic hyperglycaemia, can cause:
-
Poly neuropathy
- Parasthesia, loss of sensation (DCML or spinothalamic modalities), burning or shooting pains often worse at night. Bilateral & symmetrical
-
Mononeuropathy
- One nerve affected. Often presents as sudden motor loss
-
Mononeuritis multiplex
- More than one peripheral nerve
-
Autonomic neuropathy
- Gastroparesis, incontinence, erectile dysfunction, irregular heart beats, problems with sweating
-
Diabetic amyotrophy
- Acute, asymmetrical, focal lim pain then proximal lower limb muscle wasting. Reversbile.
-
Radiculopathy
- Affects nerve roots- usually pain over spinal dermatomes
Discuss the management of diabetic neuropathy
- Good glycaemic control
- Regular attendance at diabetic foot clinics
- Education
- Pain relief e.g. gabapentin
What is meant by diabetic retinopathy?
Weakening and damage of small blood vessels in retina due to chornic hyerglycaemia. This may cause haemorrhages, exudates and even swelling of the retina.This then starves the retina of oxygen, and abnormal vessels may grow. May present with:
- Sudden changes in vision
- Floaters & spots
- Double vision
- Eye pain