Diabetes and Hypertension Flashcards
what does hyperglycaemia lead to within tissues?
-Thickening of basement membranes
-Loss of pericytes in vessel walls causing leakage and damage of capillaries
-Long term problems in vasculature, kidneys and eyes
how bad is undiagnosed diabetes?
bad - Nearly 50% of adults worldwide have diabetes undiagnosed
how is type 2 diabetes managed?
with diet or tablets but may also need insulin later on. The aim is to keep the sugar levels within an acceptable range to prevent persistent hyperglycemia
why can type 2 diabetes undiagnosed be a problem?
as it can cause complications due to hyperglycaemia that is not being controlled
how can blood glucose levels be monitored?
give some complications of diabetes
-Diabulimia is a complication in type 1 diabetes patients where patients deliberately reduce the amount of insulin they take to reduce body weight and or shape
-Ketoacidosis due to hyperglycemia causing the body to break down fat for energy. Its More likely to occur in type 1 diabetics but can occur in type 2 diabetics with low insulin levels
give 5 type 2 diabetes drugs
-DPP4 inhibitors
-Metformin
-Pioglitazone
-SGLT2 inhibitor
-sulfonylurea
for DPP4 how does it work as a type 2 diabetes drug?
oral drugs which block DPP4 enzymes which would normally hydrolyse the incretin hormone in the gut. This allows for increased concentration of incretin which increases insulin production so causing glucagon secretion to be lowered which reduces blood glucose levels
for metformin, how does it work as a type 2 diabetes drug?
inhibits gluconeogenesis hence reducing glucose levels in the blood
for pioglitazone, how does it work as a type 2 diabetes drug?
improves insulin sensitivity allowing glucose levels to reduce
for SGLT2 inhibitor, how does it work as a type 2 diabetes drug?
inhibit sodium- glucose co- transporter protein in the renal PCT which reduces glucose reabsorption back into the blood
for sulfonylurea, how does it work as a type 2 diabetes drug?
stimulates natural insulin production from the pancreas and increases number of insulin receptors in the body.
give some symptoms of type 2 diabetes that may mean a px needs insulin
-persistent hyperglycaemia with max oral hypoglycaemic agents
-acute symptoms
-continual weight loss
-presence of complications
-poor healing or recurrent infections
compare and contrast type 1 and type 2 diabetes
-type 1 is acute onset while type 2 is insidious onset
-type 1 is insulin dependent while type 2 can be controlled with just diet and tablets
-type 1 usually onset in youth whereas type 2 usually onset in >50s
-type 1 usually non obese whereas type 2 usually are obese
-in type 1 family history is in 10% of cases whereas in type 2 family history in 30%
what is gestational diabetes during pregnancy due to ?
temporary insulin deficiency
why is increasing incidence of type 1 diabetes worrying?
as age of onset is becoming younger which increases risk of chronic microvascular and macrovascular cases
give some examples of microvascular and macrovascular disease caused by hyperglycaemia in type 2 diabetes
-microvascular - nephropathy, retinopathy
-macrovascular - increased risk of coronary heart disease, stroke, hypertension and obesity
what are the risk factors of type 2 diabetes
-obesity
-lack of exercise and poor diet, smoking
-ethnicity
-family history
-high blood pressure
-gestational diabetes
-impaired glucose tolerance
what are the criteria for diabetes diagnosis apart from typical diabetes symptoms
-elevated plasma glucose level of 11.1mmol/l or above
-fasting (8hr) plasma glucose of 7.0mmol/l or above
-oral glucose tolerance tests
what are the 4 modes of insulin administration?
-syringes
-pen devices (good for patients with poor sight or dexterity)
-pre load pens - (px who have difficulty loading a cartridge)
-continuous subcutaneous insulin infusion
what are sites of insulin injection?
-abdomen
-upped and outer thights
-upper arms
-buttocks
site should be relaxed and quick needle insertion
how long after insulin injection can the Px eat a meal?
20-30 mins after
give some signs and symptoms of hypglycaemia
-hunger
-trembling
-sweating
-pallor
-palpitations
-tingling of lips
give some causes of hypoglycaemia in diabetics
-delayed food
-too much insulin
-increased activity
-alcohol on an empty stomach
what is the long term impact of diabuliamia?
severe hyperglycaemia and weight loss
what are the symptoms of ketoacidocis?
-vomiting
-thirst
-increased urination
-weight loss
-tiredness
what are the signs of ketoacidosis?
-tachycardia
-hypotension
-dehydration
-warm/dry skin
-hyperventilation
-hypothermia
-impaired consciousness
what is ketoacidosis?
where fat is broken down for energy causing ketones to be released in urine and on breath as well as build up in the blood
what is treatment for ketoacidosis?
fluids and insulin
name 6 causes of death in diabetic ketoacidosis
-myocardial infarction
-infection (frequently pneumonia)
-acute pancreatitis
-cerebrovascular accident
-adult respiratory distress syndrome
-cerebral oedema
what are the outcomes of the UKPDS study for diabetes?
found that strict blood pressure control reduces the risk of:
-number of deaths
-diabetic complications
-progression of retinopathy
-loss of visual acuity
what are some of the outcomes of the DCCT study (diabetes)
intensive treatment Vs CT reduced
-retinopathy development by 76%
-progression of DR by 54%
-development of PDR or severe non proliferative DR by 475
-development of clinical neuropathy by 60%
-development of microalbinuria by 39%
what is the WHO definition of hypertension and normotension?
-hypertension is where the blood pressure is >140/90mmHg (either of the numbers can be increased to be hypertension)
-Normotension = normal blood pressure <140/90mmHg
what is normal blood pressure around?
90/60mmHg - 120/80mmHg
in a blood pressure of 140/90 mmHg what do each of the numbers mean?
-140 is the pressure of the blood at the point which your heart contracts = systolic pressure
-The 90 is the diastolic pressure = pressure of blood when the heart is relaxed
what is accelerated hypertension? what is the blood pressure?
very high blood pressure that is a medical emergency due to there now being high risk of vascular complications
180/120mmHg
what is the average blood pressure used to diagnose hypertension following NICE guidlines?
average >135/85
what is a sphygmomanometer?
a device used to measure blood pressure, you can get manual ones where you also need a stethoscope or you can get automatic ones (like in the hospital)
how do you carry out manual sphygmomanometry?
- Inflatable cuff is placed over arm above the elbow
- This should be at roughly the same height as the heart with the patient seated and the arm supported
- Person should ideally be relaxed and sat up for 10-15 mins before taking the measurement
- Cuff is then inflated usually to about 180mmHg to stop blood flow
- Pressure is then gradually reduced until blood flow identified by the korotkoff sound is heard and the pressure is recorded at this point as the systolic pressure
- Pressure is then further released until you can no longer hear the korotkoff sound at which point pressure is recorded as the diastolic pressure
name 3 common errors when using a sphygmomanometer
-having an incorrect bladder and cuff size, too large can lead to over estimation of blood pressure and vice versa
-having a deflation rate too rapid which underestimates systolic pressure and overestimates diastolic pressure (low BP), too slow overestimates blood pressure
-arm is not resting at heart level and is not unrestricted - BP increases as your arm is lowered
-you have not taken 2-3 readings at least 1 minute apart
when measuring blood pressure, what should the cuff size be?
around 12-14cm for most adults
what is the blood pressure in hypotension?
90/60mmHg or lower
what do you do if you find someones blood pressure to be 180/120mmHg?
urgent referral to a and e
what are the two types of hypertension?
primary (90-95% of cases) and secondary
what are the causes for primary hypertension?
usually idiopathic as there’s no identifiable cause
give 3 causes of secondary hypertension
-renal diseases like chronic renal failure and renal tumours
-endocrine problems like diabetes, hyperthyroidism
-congenital coarctation of the aorta (rare)
how are diabetes and hypertension linked?
-both conditions have similar complications
-people with type 2 diabetes are pretty likely to have hypertension also but likelihood of people having hypertension with diabetes is more likely with type 2 diabetes over type 1
give 4 behavioural causes of increased risk of hypertension
-unhealthy diet
-smoking
-physical inactivity
-alcohol
give 3 metabolic causes of increased risk of hypertension
-obesity
-diabetes
-raised blood lipids (total cholesterol)
what specific personal traits can have an affect on risk of hypertension?
-age
-ethnicity
-family history of vascular disease
what are general hypertension symptoms?
-early hypertension usually symptomless
-throbbing headaches
-shortness of breath
-palpitations
-dizziness
-fatigue
-nose bleeds
what are the ocular signs of hypertension?
-hypertensive retinopathy
-choroidopathy
-disc oedema
what are the ocular complications of hypertension?
-anterior ischemic optic neuropathy (non-arteritic)
-retinal arteriole and vein occlusions
-retinal macro-aneurysms and retinal emboli
-ocular motor nerve palsy
-glaucomatous optic neuropathy
what are non pharmacological treatments for hypertension?
-weight reduction
-avoid excessive alcohol
-reduce salt intake
-take regular exercise
-avoid high saturated fat intake
-stop smoking
-reduce caffeine intake
how much salt should we take according to the NHS per day?
<6g daily
give 4 common medications for hypertension
-angiotensin converting enzyme inhibitors (MOST COMMON)
-angiotensin receptor blockers
-calcium channel blockers
-diuretic water tablets
give examples of angiotensin-converting enzyme inhibitors for hypertension treatment
captopril
ramipril
give examples of angiotensin receptor blockers for hypertension treatment
candesartan
losartan
give examples of calcium channel blockers for hypertension treatment
-amlodipine
-verapamil
-felodipine
give examples of diuretics for hypertension treatment
Bendroflumethiazide
give some less common medications for hypertension treatment
-alpha adrenergic agonists
-beta blockers
-alpha blockers
-direct renin inhibitor
how do angiotensin converting enzyme inhibitors work for hypertension treatment?
prevent action of ACE which normally constricts vessel walls so works by helping to relax blood vessels in vaso-dilation which hence reduces BP
what are the ocular side effects of angiotensin converting enzyme (ACE) inhibitors?
-reduced vision
-visual hallucinations
-lids and conjunctival redness, inflammation, oedema, brown discolouration
-possible paralysis of accommodation
-retinal haemorrhages
how do angiotensin receptor blockers work to treat hypertension?
-hormone angiotensin II acts to restrict blood vessel diameter and also retain fluids like water
-blocking this leads to vasodilation and recued fluid levels
-hence blood volume is reduced so blood pressure is reduced
what are the side effects of angiotensin receptor blockers?
-relatively few in most patients
-dizziness
-headache
-fatigue
how does calcium channel blockers (CCBs) work to treat hypertension?
- act on calcium channels within smooth muscle of blood vessels
- calcium channels are inhibited leading to vasodilation
- BP is reduced
what should you avoid when taking CCBs?
grapefruit juice because they are shown to have chemicals which interact with enzymes that result in the increase of the uptake of the ccb which can cause more of the side effects
what are the side effects of CCBs for hypertension?
-swollen ankles or foot pain
-constipation
-skin rashes
-headaches
-dizziness/ tiredness
how do diuretics work for hypertension treatment?
increase removal of sodium and water by kidneys hence reducing blood volume which reduced BP
what are the ocular side effects of diuretics?
-transient myopia
-reduced tear secretion
-objects can have a yellow tinge or yellow spots on white background
-slight reduction in IOP
-there is subconjunctival or retinal haemorrhages
how do beta adrenergic blockers (beta blockers) work to treat hypertension?
- B receptors are part of sympathetic nervous system and in heart increase cardiac output
- B receptors are blocked
- cardiac output is reduced
- BP is reduced
what are the ocular side effects of beta blockers
-reduced vision
-visual hallucinations
-decreased IOP
-lids/conjunctiva = redness, inflammation, dry eye, subconjunctival haemorrhage
-retinal haemorrhage
-photophobia
-ocular pain
how do alpha adrenergic agonists work to treat hypertension?
target the brain and alter the heart beat to inhibit signals that cause vaso constriction
what are the systemic side effects of alpha adrenergic agonists to treat hypertension?
-drowsiness, dizziness, headaches
-dry mouth, nausea
-swollen legs or feet
what are the ocular side effects of alpha adrenergic agonists?
-reduced vision
-visual hallucinations
-lids/ conjunctiva = burning, oedema and dry eyes
-reduced IOP
-abnormal EOG (measures the existing resting electrical potential between the cornea and Bruch’s membrane with eye movements during sleep and wakefulness)
