Diabetes and Lipid Disorders

Question 1

Where are most insulin receptors found in human body?

Answer 1

Liver, Muscle and Fat cells

Question 2

Describe how the number of insulin receptors are controlled

Answer 2

In HIGH insulin concentrations, number of receptors decline, responsiveness to insulin decreases –> leads to insulin RESISTANCE
In LOW insulin concentrations, number of receptors increases, and responsiveness to insulin INCREASES

Question 3

List some of the common actions of insulin.

Answer 3

Increases glucose uptake by cells (cells convert to glycogen or fat)
Decreases hepatic output of glucose (by decreased glycogenolysis and gluconeogenesis)
Increases amino acid and potassium uptake by cells
Inhibits Lipolysis
Enhances Protein Synthesis

Question 4

Why can insulin not be taken orally?

Answer 4

It is digested when swallowed

Question 5

Describe the two types of insulin regimens used by patients with Type 1 Diabetes Mellitus.

Answer 5

TWICE DAILY REGIMEN
A biphasic insulin is injected twice a day (pre-breakfast and pre-evening meal)
BASAL BOLUS REGIMEN (most common)
Intermediate or Long Acting Insulin is given at bedtime to cover overnight insulin requirements. Combined with rapid or short acting insulins to cover mealtimes

Question 6

Describe the limitations of the twice daily regimen and how they might be overcome

Answer 6

It assumes the patients eats 3 meals a day
The peak and trough of the evening dose can lead to nocturnal hypoglycemia and then fasting hyperglycemia in the morning. Also means additional snacks often needed in the day to avoid hypoglycemia –>can be difficult to achieve optimum glyceamic control.
Giving rapid acting analogues instead of soluble insulin can help reduce incidence of hypo’s

Question 7

Describe when insulin pump therapy should be considered for patients with Type 1 Diabetes

Answer 7

Attempts to achieve target HbA1c with MDI results in repeated and unpredictable hypoglycemic episodes which leads to persistant anxiety about hypos and reduced quality of life.
HbA1c levels remain high (8.5% or 69mmol/mol or above) despite a high level of care

Question 8

In what patients should rapid acting insulin analagous be considered over traditional soluble insulins

Answer 8

Those who wish to inject shortly before or immediately after meals (helpful for unpredictable meals or young children)
Those prone to hypoglycemia between meals
Those prone to nocturnal hypoglycemia
Avoiding the need for snacks between meals

Question 9

What basal insulin should be used in patients who use rapid acting as bolus

Answer 9

Long acting (rather than intermediate NPH)

Question 10

Describe the ways in which hypoglycemic symptoms can be blunted in patients with diabetes

Answer 10

Very tight control of diabetes - lowers blood glucose concentration needed to trigger hypoglycemic symptoms
Frequent episodes of hypoglycemia - reduce the warning symptoms (esp if hypos happening overnight and patient can’t tell
Beta-blockers can also blunt hypoglycemia awareness
Some patients have reported that switching to human insulin has led to a loss of hypo warning symptoms - clinical trials do not confirm this

Question 11

Briefly described insulin administration peri-operatively

Answer 11

NIGHT BEFORE
Give injection of patients normal insulin
MORNING OF
IV infusion of glucose and KCl at a rate dependent on patients fluid requirements (usually 125ml/hr) alongside a solution of soluble insulin in saline synringe pump piggy backed to IV infusion
Should adjust rate of insulin infusion dependent on patients blood glucose concentration - frequent monitoring necessary.

Question 12

Describe how to restart patients on their normal insulin once patient starts to eat and drink

Answer 12

Give SC insulin before meal and stop IV infusion 30 minutes later

Question 13

Describe the lifestyle interventions recommended in Type 2 Diabetes

Answer 13

DIET
Reduce calorie load and reduce refined sugar
--> Reduce Obesity
--> Reduce Insulin Resistance
INCREASE PHYSICAL ACTIVITY
--> Increase insulin sensitivity

Question 14

Describe when oral hypoglycemic drugs may be considered in Type 2 Diabetes

Answer 14

Only if the patients fails to respond adequately to 3 MONTHS of reduced dietary intake and increased physical activity
Drugs should be used to augment the effect of diet and exercise, not to replace them.

Question 15

Describe how insulin may added to oral hypoglycemic therapy

Answer 15

If given alongside - intermediate or long acting insulin given at bedtime
If replaces oral hypoglycemic agents - twice daily biphasic insulin injections

Question 16

What one thing should be looked for and corrected before starting lipid lowering therapy?

Answer 16

Hypothyroidism

fixing this can fix lipid problem

Question 17

The anion gap is often used to work out the cause of a metabolic acidosis, how is it calculated

Answer 17

Sodium - (Chloride + Bicarbonate)
Potassium usually excluded from clinical calulations
Normal = 3-11 (8-16 if K included)

Question 18

What would you expect the anion gap to be in DKA?

Answer 18

HIGH

Question 19

What is the triad of DKA and the diagnostic criteria for each

Answer 19

TRIAD of ketonaemia, hyperglycemia and acidaemia
Ketonaemia > 3mmol (++ on urine dip)
Blood Glucose > 11mmol
Venous Bicarb

Question 20

Describe the autonomic and neuroglycopenic symptoms of hypoglycemia

Answer 20

AUTONOMIC
sweating, palpitations, shaking, hunger
NEUROGLYCOPENIC
confusion, drowsiness, odd behaviour, speech difficulty, uncoordination
GENERAL
headache and nausea

Question 21

Describe the management of hypoglycemia in the unconscious patient

Answer 21

ABC
IV access
75-80mL of 20% glucose
Glucagon 1mg IM
Recheck BM
If  4 give patient long acting oral CHO when patient recovers

Question 22

What dose of folic acid should diabetic women take?

Answer 22

5mg pre-conception until 12 weeks post-conception

Question 23

Describe the initial appropriate management of DKA

Answer 23

FLUIDS - 0.9% saline
(volume depending on systolic BP > 90mmHg)
INSULIN - IV infusion 50 units of soluble insulin in 50ml saline
ABCDE & Further Ix - bloods
Establish monitoring system

Question 24

Describe the initial fluid management based on systolic BP

Answer 24

90 give 1000mL of saline over 60 minutes