Diabetes Flashcards
In adults, type 1 diabetes should be diagnosed on clinical grounds if the person presents with hyperglycaemia and one or more of the following features (which may not always be present)…… (5)
- Ketosis.
- Rapid weight loss.
- Age of onset younger than 50 years (although type 1 diabetes should not be discounted if the person is aged 50 years or older).
- Body mass index (BMI) below 25 kg/m2 (although type 1 diabetes should not be discounted if the person presents with a BMI of 25 kg/m2 or above).
- Personal and/or family history of autoimmune disease.
In a child or young person, type 1 diabetes should be suspected if they present with hyperglycaemia and the characteristic features of…. (4)
- Polyuria.
- Polydipsia.
- Weight loss.
- Excessive tiredness.
If you suspect/diagnose T1DM in an:
- Adult
- Child
… what is your management in primary care?
- Adult: same day referral to multidisciplinary diabetic team
- Child: same day referral multidisciplinary paediatric diabetes care team with the competencies needed to confirm the diagnosis
NOTE: if presented with features of HHS or DKA would send to A&E
Is C-peptide and autoantibodies routinely measured in adults with susecpted T1DM?
No… only measure if atypical features, suspect monogenic form of diabetes or unsure if it is T1DM or T2DM
When diagnosing diabetes in a child you should assume it is type ______ diabetes mellitus unless there are strong indicators for type _____ diabetes melliltus such as…
When diagnosing diabetes in a child or young person, assume type 1 diabetes unless there are strong indications of other types of diabetes.
- Features of type 2 diabetes include:
- A strong family history of type 2 diabetes.
- Obesity.
- Black or Asian family origin.
- No insulin requirement, or have an insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase.
- Evidence of insulin resistance (for example acanthosis nigricans).
What autoantibodies may be present in T1DM?
Do we routinely test for these in children?
Do we routinely test for these in adults?
Autoantibodies:
- ICA (islet cell antibodies)= 70-90%
- GAD 65 (glutamic acid decarboxylase) antibodies= 80%
- IAA (insulin autoantibodies)
- IA-2A (antibody to protein tyrosine phosphatase)= 55-75%
CHILDREN: CHECK
ADULTS: don’t routinely do
State some risk factors for T1DM
- FH
- Enviromental risk factors e.g. early exposure to viruses related to ilset inflammation
Describe how type 1 diabetes typically presents to GPs
- Polydipsia
- Polyuria
- Weight loss
- Excessive tiredness
- Hyperglycaemia
*Remember, first presentation of diabetes may also be DKA
Discuss the management of T1DM
Referral to specialist.
Conservative
- Education e.g. via structured education programmes such as DAFNE or via alternative if pt unwilling to participate in group education
- Lifestyle changes e.g. healthy diet, regular exercise, reducing alcohol intake
- Provide information n support groups, disability benefits etc, hypoglycaemia & driving
- Stop smoking
- Education surroudning management of diabetes when sick
- Monitoring for complications
Pharmacological
- Insulin
What is the DAFNE programme?
“Dose adjustment for normal eating”
Structured education programme for type 1 diabetics (across 5 days) that teaches them about carbohydrate coutning, managing insulin around exercise, around illness, and around social activities including drinking alcohol. Aim is to help them live as normal a life as possible.
What advice, regarding alcohol consumption, should you give to Type 1 diabetics?
- Avoid drinking on empty stomach as will be absorbed faster
- May prolong hypoglycaemic effect of insulin/nocturnal hypoglycaemia and may be more difficult to spot hypo signs
- Wear medic alert bracelet or carry ID card when drinking as hypos can be confused with alcohol intoxication
Discuss self-monitoring of gluose in T1DM, include:
- How often they should monitor glucose
- Optimal targets
- Self-monitor glucose at least 4 times a day (including before meals and before bed). More frequent monitoring may be required in situations such as target HbA1c not achieved, increased freqeuncy of hypoglycaemic episodes, eriods of illness, sporting acitivities, legal requirement e.g. before driving
Targets
- Fasting plasma glucose upon waking: 5-7mmol/L
- Before meals: 4-7mmol/L
- After meals: 5-9mmol/L at LEAST 90mins after meal
- Bedtime plasma glucose is individualised & agreed by pt and clinician based on timing of last meal and its related insulin dose
What are the sick day rules for type 1 diabetics?
- Never stop or omit insulin
- Dose of insulin may need to be altered- seek advice if unsure
- Check blood glucose more frequently e.g. every 1-2hrs
- Consider checking blood or urine ketones every few hours. If urien ketones 2+ or blood ketones >3mmol/L seek medical attention
- Maintain normal meal pattern where possible
- Aim to drink 3L flid per day
- Even when feeling better, keep close eye on plasma glucose until it returns to normal
How should you monitor/manage cardiovascular disease risk factors in type 1 diabetics?
- Lifestyel factors
- Waist circumference
- Blood glucose control
- BP
- Albuminuria
- Lipid profile
- Family history of CVD
What are BP targets for type 1 diabetic:
- Without albuminuria or features of metabolic syndrome
- With albuminuria or two or more features of metabolic syndroome
- Without albuminuria or features of metabolic syndrome: 135/85
- With albuminuria or two or more features of metabolic syndroome: 130/80
Which type 1 diabetics should be offer statins as primary prevention of CVD?
Offer 20mg of atorvastatin if:
- >40yrs
- Had diabetes >10yrs
- Established nephropathy
- Other CVD risk factors
For all other adults with T1DM consider statin if think appropriate.
State some risk factors for T2DM
- FH
- Obesity
- Sedentary lifestyle
- Diet
- Ethnicity (asian, african & afro-carribean)
- History of gestational diabetes
- PCOS
- Metabolic syndrome
- Drugs e.g. statins, corticosteroids, and combined treatment with a thiazide diuretic plus a beta-blocker
How do we diagnose T2DM?
Persistent hyperglycaemia that may be accompanied by clinical features e.g.: polydipsia, polyuria, blurred vision, tireness, recurrent infections, aconthosis nigricans.
Persistent hyperglycaemia can be defined as:
- HbA1c of 48 mmol/mol (6.5%) or more.
- Fasting plasma glucose level of 7.0 mmol/L or more.
- Random plasma glucose of 11.1 mmol/L or more in the presence of symptoms or signs of diabetes.
Describe how type 2 diabetes typically presents to GPs
- Hyperglycaemia
- Asymptomatic
- Vague symptoms: tiredness, recurrent infections, poor wound healing, polydipsia, polyuria, aconthosis nigricans
- More common in adults with risk factors
Discuss how your investigations for T2DM may differ if thet pt is:
- Symptomatic
- Asymptomatic
- If symptomatic, a single abnormal HbA1c result or fasting plasma glucose can be used to confirm diagnosis of T2DM (although repeat testing is sensible to confirm diagnosis)
- If asymptomatic, do not diagnose diabetes on the basis of a single abnormal HbA1c or plasma glucose result. Arrange repeat testing, preferably with the same test, to confirm the diagnosis. If the repeat test result is normal, arrange to monitor the person for the development of diabetes, the frequency depending on clinical judgement.
Severe hyperglycaemia can occur in acute infection, trauma, circulatory or other stress may be transitory and is not diagnostic of diabetes; true or false?
TRUE
Which groups of people should HbA1C NOT be used in to diagnose diabetes?
- <18 years of age.
- Pregnant women or women who are 2 months postpartum.
- People with symptoms of diabetes for less than 2 months.
- People at high diabetes risk who are acutely ill.
- People taking medication that may cause hyperglycaemia (for example long-term corticosteroid treatment).
- People with acute pancreatic damage, including pancreatic surgery.
- People with end-stage renal disease (ESRD)
- People with HIV infection.
Which groups of people should HbA1c be interpreted with caution in?
Those with abnormal red blood cell turnover or abnormal haemoglobin type:
- Abnormal haemoglobin, such as haemoglobinopathy.
- Severe anaemia (any cause).
- Altered red cell lifespan (for example post-splenectomy).
- A recent blood transfusion.
Hypoglycaemia is generally defiined as blood glucose less than…?
<3.5mmol/L
When diagnosing diabetes discuss whether pts need to have symptoms or not
Outline the principles of the first line management of T2DM; include when you would consider adding medications and what medications you would consider adding
Remember, if HbA1c rises to 58mmol/L then further treatment is indicated/next step of treatment
*NOTE: SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure
Outline the principles of the further management of T2DM; include when you would consider adding medications and what medications you would consider adding
Remember, if HbA1c rises to 58mmol/L then further treatment is indicated/next step of treatment
Following options are possible:
- metformin + DPP-4 inhibitor + sulfonylurea
- metformin + pioglitazone + sulfonylurea
- metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
- insulin-based treatment
What are blood pressure targets for patients with T2DM?
Which patients with T2DM should be offered a statin?
Only those with 10yr Qrisk >10%
Notes from passmed on IFG and IGT
State some side effects of the following common diabetic drugs:
- Biguanides (e.g. metformin)
- Sulphonylureas (e.g. gliclazide)
- Thiazolidinediones (e.g. pioglitazone)
- DPP-4 inhibitors (e.g. sitagliptin)
