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
What are the macrovascular complications of diabetes
Atherosclerosis leading to increased risk of:
- CVD
- MI
- Stroke
- Peripheral arterial disease
- Heart failure
Explain why diabetes have increased risk of atherosclerosis/CVD
High levels of glucose in blood can damage the walls of your arteries, and make them more likely to develop fatty deposits (atherosclerosis)
What are the microvascular complications of diabetes?
- Diabetic nephropathy
- Diabetic retinopathy
- Peripheral neuropathy
- Autonomic neuropathy
Aside from macrovascular & microvascular complications of diabetes, state some other complicaitons
- Diabetic foot uclers/disease (combination of neuorpathy and peripheral arterial disease)
- Dyslipidaemia
- DKA
- HHS
- Psychosocial e.g. depression, anxiety, behaviour problems
- Reduced life expectancy
What is the:
- Fasting plasma glucose
- OGTT
… threshold for gestational diabetes?
- Fasting plasma glucose: >/= 5.6mmol/L
- OGTT: =/> 7.8mmol/L
Discuss the conservative management of T2DM
- Offer referral to structured education programmes e.g. DESMOND
- Provide advice/information on diabetes
- Lifestyle advice
Discuss the HbA1c thresholds for stepping up type 2 diabetic treatment
- Try lifestlye interventions, if still >48mmol/L add first line drug Metformin
- If still >58mmol/L (7.5%) after monotherapy, add second drug e.g. SU, thiazolidinediones, DPP-4 inhibitor, SGLT inhibitor
- If >58mmol/L (7.5%) after dual therapy, add third drug or consider using metformin + insulin
Explain how dose of metformin is titrated to try and minimise GI symptoms
Gradually titrate up to a max of 2g/day:
- 500mg with breakfast for about 1 week
- 500mg with breakfast and 500mg with dinner for about 1 week
- 500mg with breakfast, lunch and dinner
- etc…..
FOR EACH OF THE T2DM DRUGS GO REVISE CPT: DIABETES. Must know MOA, contra-indications & ADRs
For biguanides (e.g. metformin), discuss:
- MOA
- Benefits
- Cautions/contraindications
- ADRs
Mechanism of action
- Decrease hepatic glucose output
- Increase skeletal muscle utilisation
- Decrease glucose absorption in intestines
- Supress appetite
Benefits
- Little risk of hypoglycaemia
- Cardioprotective
Cautions/contraindications
- Metabolic acidosis
- GFR <30ml/min
ADRs
- GI upset
- Lactic acidosis
- B12 deficiency
For DPP4 inhibitors (gliptins), discuss:
- MOA
- Benefits
- Cautions/contraindications
- ADRs
MOA
- Prevents breakdown of GLP-1 to increase actions of GLP-1
Benefits
- Little risk hypoglycaemia, can help with weight loss
Cautions/contraindications:
- Hepatic or renal impairment
- Pregnancy & breast feeding
- Heart failure
For thiazolidinediones (glitazones), discuss:
- MOA
- Cautions/contraindications
- ADRs
Mechanims of action
- Activate PPAR-gamma which is involved in transcription of genes involved in glucose & lipid metabolism. Helps to increase insulin sensitisation in skeletal muscle and decrease hepatic glucose output.
Cautions/contraindications
- Heart failure
- Previous or active bladder cancer
- Uninvestigated macroscopic haematuria
ADRs
- GI upset
- Increased risk bladder cancer
- Increased CVD risk
- Fluid retention
For sulphonylureas discuss:
- MOA
- Cautions/contraindications
- ADRs
Mechanism of action
- Inhibit ATP dependent K+ pump, prevent K+ leaving cell, cause depolarisation, activates Ca2+ channels, Ca2+ influx resulting in insulin release
Cautions/contraindications
- Ketoacidosis
- G6PD deficiency
ADRs:
- Risk of hypoglycaemia
- Abdo pain
- Diarrhoea
- Nausea
For SGLT-2 inhibitors, discuss:
- MOA
- Cautions/contraindications
- ADRs
Mechanism of action
- Inhibit SGLT-2 transporters in PCT to prevent glucose reabsorption
Cautions/contraindications
- DKIA
- Complicatied urinar tract infections
- Hypotension
ADRs:
- Increased risk of infections UTI & STI
- Polyuria
- Thirst
For GLP-1 mimetics, discuss:
- MOA
- Cautions/contraindications
- ADRs
Mechanism of action
- Act on GLP-1 receptors to mimic actions of GLP-1
Cautions/contraindications
- Ketoacidosis
- Pancreatitis
ADRs:
- Decreased appetite
- GI upset
- Headaches
- Skin reactions
- Nausea/vomitting
What monitoring is required for diabetics? For each, discuss:
- How it is monitored (if appropriate)
- How often it is monitored
Every Encounter
- BMI
- Lifestyle
- Depression & anxiety
Every 6 months
- HbA1c
Annually:
- Retinopathy
- Diabetic foot clinic
- Nepropathy (early morning urine sample for ACR & eGFR)
- Cardiovascular risk factors e.g. lipids, waist circumference
- Autonomic neuropathy (can assess by looking at postural hypotension)
Explain the pathophysiology of macovascular complications of diabetes
- Chronic hyperglycaemia can lead to chronic inflammation of vasculature walls
- Increased risk of injury
- Increased risk of atherosclerosis
When is aspirin prescribed for a diabetic?
Not routinely offered to diabetics. Only give if other reason to e.g. ACS, angina, stroke, TIA etc…
If a pt comes in on a Friday afternoon surgery to a GP with thirst & polyuria how do you decide whether or not this is diabetes and if they are safe to leave for the weekend for further investigation? If it is diabetes, with the resources available to you as a GP how would you determine if this is T1DM or T2DM?
- Take thorough history: risk of dehydration, complications e.g. foot ulcer
- Urine dip for ketones- risk of DKA
- Type 1 or type 2: type 1 at greater risk
If someones HbA1c is between 42mmol/L and 48mmol/L what would the management be
- Pre-diabetic stage
- Education is mainstay:
- Advice on lifestyle
- Advice on risks/complications if don’t control
- National diabetic prevention programme (behavior change programme)
What happens in GP diabetic clinic and what information is recorded?
- Discuss blood test results
- BP
- Foot examination
- Discuss visual changes and opthalmology
- Assess for signs of peripheral or autonomic neuropathy
- Assess lifestyle
- Assess mental health
- Assess sexual health
- Discuss immunisations/check up to date
Discuss sick day rules for type 2 diabetics
Advise to temporarily stop some drug tratments during illness. Medication may be restarted oonce person feeling better and eating and drinking for 24-48hrs. HOWEVER, if on insulin therapy do not stop treatment but may need to adjust dose.
What are HbA1c targets for T2DM?
Newly diagnosed: 48mmol/L (6.5%)
T2DM moved beyond metformin alone: 53mmol/L
What are the ranges of the following in someone with prediabetes:
- Fasting plasma glucose
- Oral glucose tolerance test
- HbA1c
- Fasting glucose – 6.1 – 6.9 mmol/l
- Glucose tolerance – 7.8 – 11.1 mmol/l on an OGTT
- HbA1c – 42-47 mmol/mol
What are the ranges of the following in someone with diabetes:
- HbA1c
- Random glucose
- Fasting plasma glucose
- Oral glucose tolerance test
*
- HbA1c > 48 mmol/mol
- Random Glucose > 11 mmol/l
- Fasting Glucose > 7 mmol/l
- OGTT 2 hour result > 11 mmol/l
Extra flashcards with passmed information on…
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
Discuss the criteria for GLP-1 mimetics
If triple therapy is not effective or tolerated consider switching one of the drugs for a GLP-1 mimetic if any of the following criteria are met:
- BMI ≥ 35 kg/m² and specific psychological or other medical problems associated with obesity or
- BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities
- only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
What are blood pressure targets for patients with T2DM?
Which patients with T2DM should be offered a statin?
Only those with 10yr Qrisk >10%
What do NICE reccomend in regards to screening for T2DM?
- NICE recommend using a validated computer based risk assessment tool for all adults aged 40 and over, people of South Asian and Chinese descent aged 25-39, and adults with conditions that increase the risk of type 2 diabetes
- patients identified at high risk should have a blood sample taken
If someone has been identified as pre-diabetic, how should you follow them up?
Yearly blood tests
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)
When do NICE recommend considering adding metformin to T1DM medications?
- NICE recommend considering adding metformin if the BMI >= 25 kg/m²
