Diabetes Flashcards
Which part of the pancreas secretes insulin and glucagon?
Endocrine pancreas - the islets of Langerhans with the beta cells secreting insulin, and the alpha cells secreting glucagon
What does insulin do?
It decreases hepatic glucose production
Binds to cells throughout the body to stimulate glucose uptake and storage.
Type 1 vs Type 2 DM?
Type 1 is a genetic condition leading to a lack of insulin secretion
Type 2 is an acquired insulin desensitization due to increased and prolonged need for insulin
What is pre-diabetes?
Impaired fasting glucose (6.1-6.9) or IGT (7.8-11) or A1C of 6.0-6.4%
Signs/ presentation of Type 1 DM
May come in with DKA, usually younger age demographic and may have cachexia and fatigue. Most classically presents with polydispia, uria as well. Check family hx .
Signs and sx for hyperglycaemia and DKA
Polyuria, polydipsia, nocturia, blurred vision, weight loss
As progresses into DKA - decreased LOC, lethargy, fruity smelling breath, decreased cognition
Goals of Tx for T1DM?
Avoid complications (DKA, hypoglycaemia) and long-term effects (kidney damage, retinopathy)
Need to be started on insulin therapy, self-monitor of blood glucose and diet. Allow for slightly higher A1C in children that are unlikely to know if they are having a low - <7.5 usually but can be anywhere from 6.0-10.0
Tx of DKA?
Dehydration - give IV fluids using NS bolus beware of cerebral edema in children with over hydration
Electrolytes - NS may have also corrected the Na levels/ check for other electrolyte abnormalities and correct if needed - particularly potassium
Acidosis - see potassium Managment above as well as consider bicarbonate if needed
Treatable causes - infection/ infarct/ ischemia/ insulin missed
Hyperglycaemia - start insulin therapy and give glucose at the same time
Criteria and clinical features for metabolic syndrome?
Weight circumstance - 102M and 88F
Elevated TGs, and BP, low HDL, high fasting glucose
Abdominal obesity and Fhx of obesity, diabetes, HTN
Risk factors for T2DM
Obesity, sedentary lifestyle, poor diet, family hx, long term steroid use, atypical anti-psychotics, HIV medications, PCOS, metabolic syndrome, CF , certain ethnicities, having gestational diabetes,
Diagnostic Criteria T2DM
Fasting - greater than 7 (8 hours)
Random plasma - 11.1 (or 2 hour)
A1C - 6.5
Who should be screened?
Monitor for CVD, and for retinopathy as well as kidney function.
People should be screened ever 3 years, greater than 40 years of age, or if they are high risk.
Elevated Cr/ Albumin ratio in T2DM
Sign of diabetic nephropathy, a nephrotic disease
Do not correlate well with severity of disease to kidneys. Can stage the diabetes based on the ratio - see diabetes canada
Exercise recommendations
At least 150 mins of moderate to vigorous activity, aerobic, resistance.
Target control for T2DM
A1C - less than 7
BP - 130/80
LDL-C - less than 2
Make sure to counsel about diet, exercise, smoking cessation
Diet recommendations for T2DM
Limit sodium, alcohol intake and simple sugars, saturated/ trans fats less 10% of daily intake, eat low-glycemic index foods - fibres for more measured release of sugar.
Indication for starting oral hypoglycaemics
Failure to manage on diet and exercise alone for A1C less than 8.5 for 2-3 month trial
Start on metformin if over 8.5 if not meeting targets in a couple of months add on other agents
Indications for insulin therapy T2DM?
Symptomatic hyperglycaemia with metabolic decompensation (DKA)
First starting dose 10 unit at night long acting. And then increase dose by one unit every night until fasted BG is between 4-7
Diabetes medications that can cause hypoglycaemia?
Glyburide, megagliptides, and insulin
HbA1C over 11.5 on a medicated type 2 DM, with a high fasting glucose?
Need to start on long acting insulin as well
For difficult to control A1C and high post-prandial sugars can try biphasic 70/30 insulin
Stop insulin before surgery?
Cardiothoracic surgery, orthopedic, and neurosurgical procedures are considered major surgeries, and usually, there is perioperative diabetes treatment modification, especially on the day before surgery and the day of surgery. Metformin should be stopped the evening before the surgery. It should not be taken on the day of surgery. Premixed insulin such as biphasic insulin Aspart 70/30 should be taken as 80% usual nighttime dose.
Autoimmune conditions associated with diabetes
Celiacs, Thyroid disease
Secondary causes of diabetes
Pancreatitis, medications (anti-psychotics and steroids), PCOS,
GLP-1s SE/ MOA
-TIDE, injectable, increased satiety + leads to weight loss, N/V/pancreatitis
Biguanides
Metformin - stops gluconeogenesis, can use with no islet function - risk of anion gap lactic acidosis, renal (GFR less than 30), liver dysfunction, cardiac dysfunction. Can rarely cause megaloblastic anemia
Glitazones
Increases insulin sensitivity, less FFA - weight gain, increased risk of heat failure/ cardiac events - not a great drug class - last ditch effort. Do not combine with insulin do not combine HF
DPP -4
Increase incretin - influences insulin release - increased risk of infections - Januvia is the one we tend to see
SGLT-2
Block resorption of glucose, more excretion, jardiance - is a common, UTI/ yeast infections, but need to watch out for hyperkalemia and hypotension.
Alpha-glucosidase
Decreases the absorption of sugar - main side effects are GI, IBS/ severe liver disease
Insulin secretogues
Need functioning pancreas, sulfonyureas and metglitinides - both carry a risk of hypoglycaemia - avoid in the elderly
Types of insulin?
Rapid acting - for post-prandial/ emergency - lispro (humlogue)/ aspart (novorapid) 3-5 hours duration of effectiveness
Short acting - post-prandial - regular - duration 2-6h IV longer for SubQ
Intermediate- Humulin-N - NPH - often combined with others - 18h duration
Long-acting - glargine, detemir - lantus- 24hrs duration for basal insulin.
Age greater than 40 with DM?
Start on a statin
DM with BP > 140/90
Start on a ACE
Screening for DM patients
Retinopathy - annually
Neuropathy - annually
Nephropathy - annually (Cr/ ACR)
A1C - less than 7
B - BP >130/80
C - cholesterol LDH >2
D - drugs - ACE/ARB if CVD risks age over 55, statins age over 40, ASA - CVD risks, Consider SGLT-1 or GLP-1 for CVD
E - 150 mins a week of exercise
S - screening - ECG every 3-5 years if over 40 or if complications, foot testing yearly, Cr - EGFR/ACR - yearly, retinopathy - yearly, smoking cessation
Target blood sugar control
5-8 average for good control.
4-7 - fasting
5-10 after 2 hrs after meal
Glucose metabolism and regulation in T2DM
Insulin resistance, impaired secretion and excessive glucose production, abnormal fat metabolism.
Initially, glucose tolerance remains normal - insulin production increases, then eventually the beta cells are unable to compensate, there is a comparative glucagon over production,
Results in less skeletal muscle use of glucose, and accumulation of lipids in muscles, and increased VLDL production from the liver,
Diabetic dyslipidemia mechanism
Insulin resistance in adipose tissue - increases lipolysis and FFA flux leading to the liver producing more VLDL synthesis and secretion
Sx of hyperglycaemia
Weight loss, fatigue, polydipsia/ polyuria, fatigue, weakness blurry vision, infections
Why increased CVD in diabetes?
The combination of hyperglycaemia and the diabetic dyslipidemia in relation to other likely co-morbidities. With the dyslipidemia playing the larger role
Criteria for DKA
BG - >15
Ketone - serum positive (not just urines)
pH - <7.30
Work up for DKA
Blood and urine cultures, CXR, tox screen, ECG, BHCG, will need lytes, CBC, ABG
DKA Tx
3-4L of fluid (foley make sure are not aneuric)
IV insulin - check the potassium - give 0.1/ ideal body weight - usually for adult 7 unit bonus then infusion per hour
Give K+ if less than 5 - will need to add potassium to fluids if the potassium is less than 3.5 HOLD the insulin.
When done DKA?
AG closed, tolerate PO intake, shift to sub q, stop the IV insulin 2 hrs after and then recheck AG to make sure it is still closed
How to differentiate between type 1 and type 2 DM?
Measure their C-Peptide (if not present then T1), can check for islet cell antibodies, also check their HbAIC
