Diabetes Flashcards
Define Diabetes
Diabetes is a metabolic disorder due to an absolute or relative lack of endogenous insulin, characterised by elevated blood glucose levels. Overtime it leads to metabolic and vascular complications.
Tell me about T1DM
Caused by autoimmune destruction of pancreatic B cells which leads to an absolute insulin deficiency.
Usually diagnosed in childhood with patient presenting w/ polyuria, polydipsia, low weight or with DKA.
Can be associated with other Autoimmune conditions
What is DKA?
An acute complication of uncontrolled diabetes ( typically T1DM).
An absolute insulin deficiency and increased glucagon results in no glucose utilisation, the body switches to fat oxidative metabolism to generate ATP with the production of ketone bodies as a by-product.
Ketones bodies accumulate and cause a metabolic acidosis.
The severe hyperglycaemia ( reduced glucose utilisation and increased gluconeogenesis ) causes osmotic diuresis which leads to dehydration. Ketonaemia may also cause vomiting -> further dehydration.
Tell me about T2DM
Occurs due to insulin resistance and B cell dysfunction. Theres a relative insulin deficiency and insufficient glucose uptake. Usually presents later ( though now presenting at younger ages).
Patients present with polyuria, polydipsia, the complications of diabetes
What role does genetics play in diabetes?
T1DM - only 30% concordance in MZs
T2DM - 80% concordance in MZs
What are the complications of Diabetes?
Hyperglycaemia - DKA, HONK Hypoglycaemia Increased risk of infection Poorer wound healing Macrovascular Microvascular
the macrovascular include
- MI, PVD, Cerebrovascular event
Microvascular
- retinopathy, nephropathy and peripheral neuropathy
- > important for patient to engage with regular screening -> fundoscopy, ACR, foot check
Whats significant about the presentation of MI in a diabetic patient?
They may not have chest pain due to autonomic neuropathy
Management of macrovascular complications
Manage the other cardiovascular risk factors
- control BP
- smoking
- Lipids
- HbA1c below 6%
Confirm a diagnosis of DM
- If symptomatic ( polyuria, polydipsia, underweight) and raised venous glucose detected once either fasting ≥7mmol or random ≥11.1mmol
- If asymptomatic with raised venous glucose on 2 separate occasions ( as above ) or a 2hr OGTT value of ≥11.1
What is an OGTT?
Patient fast overnight
given 75g of glucose in 300ml water to drink in the morning
venous plasma glucose measured after 2hrs
value of ≥11.1mmol = diabetes diagnosis
What is included in the conservative management of a patient with diabetes?
MMM
MDT, Monitoring, Modification lifestyle
*MDT - Management of patient with DM should involve GP, endocrinologist, specialist nurses and dieticians and chiropodists.
* Monitor patient ( 4Cs)
- their glycaemic Control
- Complications
- Competency ( with insulin injections, checking injection sites)
- Coping - Depression, occupation, coping at home.
What lifestyle modifications would be recommended for diabetic patients?
!!!SSS
DELAYS
Diet ( cal intak, less refined more complex carbs, more soluble fibre, less sat fat, less salt, avoid excess alcohol )
Exercise
Lipids - statin for primary prevention if over 40yrs
ABP - reduce salt and alcohol intake. keep BP below 130/80
Aspirin
- as 1º CVD prevention if over 50yrs or other risk factors
Yearly / 6 months check ups
Smoking cessation
What is the BP med of choice for diabetics?
ACEinhibitors
because B blockers can mask hypoglycaemic events ( they block sympathetic activity )
and thiazides can increase glucose levels
How would you manage a patient with Diabetes?
engage with MDT .... 1. Lifestyle modification 2. Start metformin 3. Metformin + Sulfonylurea 4 additional therapy regular follow ups
Who is started on metformin
who shouldn’t be given metformin?
someone who’s HbA1c is still higher than target after lifestyle changes
CI in patients with GFR <30,
What is the second line tx for diabetes?
Metformin + Sulfonylurea
in some patients SGLT2 inhibitors may be considered instead of metformin
- SE includes UTI but are a good option for weight loss
- sulfonylurea is commonly used because it is a cheap option. Newer generations of SUs have less risk of hypoglycaemia
Give an example of of a sulfonylurea
Gliclazide
What are the side effects of sulfonylurea?
Hypoglycaemia
Weight gain
What is the other option to a sulfonylurea?
Rapid acting insulin secretagogue e.g. nateglinide (also to be used with metformin)
> promotes insulin secretion, requires functioning pancreatic B cells
or Pioglitazone
If still uncontrolled with metformin + sulfonylurea, what next?
3 drugs
1st line = met + sulfonylurea + insulin
2nd line = met + self + sitaglipitin/ pioglitazone
If insulin unacceptable - because of lifestyle or if obesity
3rd line
met + sulf + exanatide if insulin unacceptable or BMI>35
What is the most important thing when starting a patient on insulin
Educate them about
- self adjustment with exercise and calories
- how to titrate dose
- having a family member recognise + revert a hypo with sugary drinks
What are common insulin regimes?
BD Biphasic Regime - BD insulin mixture 30min before breakfast and dinner > Rapid -acting > Intermediate / long acting T2 or T1 with regular lifestyle
Basal-Bolus regime
- bedtime long acting ( e.g. glargine) + short acting before each meal ( dose adjusted according to meal size, 50% of insulin is long acting)
- good for T1DM allowing flexible lifestyle w/ best outcome
OD long acting before bed
- this is the initial regime used for T2DM when switching from tablets
e.g. long acting insulin
Glargine
e.g. of intermediate acting insulin
insulatard
e.g. of rapid acting insulin
actrapid
What changes with insulin when a patient is sick?
When patient is ill
- insulin requirements usually increase even if food intake decreases
- try to maintain calorie intake
- check BMs at least every 4hrs and test for ketonuria
- increase insulin dose if glucose levels are rising
What are the side effects of insulin?
Hypoglycaemia
Lipohypertrophy - try to rotate injection sites
Weight gain in T2DM - weight gain is less if insulin is given with metformin
How might a patient with DKA present?
Drowsiness vomiting + abdo pain Hyperventilating ( Kussmaul breathing) Dehydrated Ketotic breath
What confirms a diagnosis of DKA?
Diabetes known or Hyperlgycaemia≥11.1mmol
Ketonamia ≥3mmol
Acidosis pH <7.3
Investigations I would do if I suspected DKA…
Urine - ketones and glucose Cap blood glucose and ketones VBG - acidosis and hyperkalaemia Bloods - U+E, FBC, glucose, cultures ( infective cause that triggered this?) CXR - evidence of infection
What could precipitate DKA?
Infection / stress
stopping insulin
new T1DM
What are the possible complications of DKA?
- Cerebral oedema from excess fluid administration
- Aspiration pneumonia
- Hypokalaemia
- Thromboembolism
What is the management of DKA?
in HDU Gastric aspiration NG tube Rehydrate Insulin infusion ( both to lower Blood glucose but keep going to reduce ketones) Potassium replacement
Hyperosmolar Hyperglycaemic state
THEY ARE DEHYDRATED
because of severe hyperglycaemia ( no acidosis because no ketongenesis because occurs in T2DM where they still have some insulin reserve )
Occlusive events are common so give LMWH as prophylaxis against VTE.
May be precipitated by MI, infection, bowel infarction
Treat by rehydrating
wait 1hr before starting insulin because it may not be needed. Then start low to avoid rapid changes in osmolality
Confused, drowsy, vomiting and hyperglycaemic, what to you need to know?
Are there ketones present - cap blood check
Also ketonuria?
Are they acidotic - VBG
If acidotic with ketonaemia = DKA => give insulin
If not acidotic, no ketonaemia but glucose >35mmol and signs of dehydration = HHS => give fluids + wait to see if they need insulin
