Diabetes Assessment and Management Flashcards
What is diabetes?
Group of metabolic disorders Characterised by hyperglycaemia Due to - Insulin secretion - Insulin action - Both
What is chronic hyperglycaemia associated with?
Long-term damage
Dysfunction and failure of organs
What is type 1 diabetes?
Autoimmune
Idiopathic
Absolute insulin deficiency secondary to pancreatic beta cell destruction
What is type 2 diabetes?
Spectrum
Insulin resistance
Varying degrees of insulin secretion
Why are people commonly overweight with type 2 diabetes?
They’re commonly hyperinsulinaemic > causes weight gain
What causes gestational diabetes?
Pregnancy hormones
Generally have family history of diabetes
What is the outcome in type 1 diabetes without insulin?
Death
What is the pathophysiology of type 1 diabetes?
Genetic susceptibility
Environmental event triggers process in susceptible people
Pre-diabetic stage
- Multiple Abs in blood
Diabetes
- Insufficient insuline produced to maintain normal blood glucose
- Most beta cells destroyed
Which antibodies are tested for in type 1 diabetes?
Anti-glutamic acid decarboxylase (GAD) Abs
Anti-islet Abs
How can endogenous insulin production be tested for?
C-peptide in blood
What is the duration of the pre-diabetic stage?
Very variable
How is the pre-diabetic stage managed?
Give something to lower sugar; eg: metformin
Insulin too strong
Why do you get insulin deficiency in type 2 diabetes?
Beta cell burnout
What syndrome is type 2 diabetes often part of?
Metabolic syndrome
What is the pathophysiology of type 2 diabetes?
Beta cell defects and insulin resistance Major environmental factor = obesity Genetics - Very important - Polygenic
What is the normal fasting plasma glucose?
Less than 6.1 mmol/L
What is the fasting plasma glucose if you have impaired fasting glucose?
6.1-6.9 mmol/L
How is diabetes diagnosed?
Symptoms + random blood glucose >11.1 mmol/L OR
Fasting plasma glucose >7.0 mmol/L OR
HbA1c > 48 mmol/mol (6.5%)
2 hour value >11.1 mmol/L in oral glucose tolerance test
When should the tests to diagnose diabetes be repeated?
In absence of unequivocal hyperglycaemia with acute metabolic decompensation
Can you diagnose someone with diabetes with a finger-prick blood glucose test?
No
What are the aims of treatment in diabetes?
Relieve symptoms
Prevent/delay long-term complications
Assist psychological adjustment and improve quality of life
Why is it important to control blood sugar levels early?
Increases fatigue of islet beta cells
What are the two categories of chronic complications of diabetes?
Microvascular disease
Macrovascular disease
What are the microvascular diseases that occur as a result of diabetes?
Retinopathy
Nephropathy
Neuropathy
What are the macrovascular diseases that occur as a result of diabetes?
Cardiovascular disease
Peripheral vascular disease
Cerebrovascular disease
What are the risks of microvascular complications of diabetes mainly related to?
Degree of glucose control - High HbA1c correlates with complication Duration of diabetes Degree of blood pressure control - Especially nephropathy Control of other cardiovascular risk factors - Lipids - Smoking Genetic susceptibility
What other major risk factors for macrovascular complications are more likely due to diabetes?
Hypertension - 2x prevalent as general population - Even more common in renal failure Dyslipidaemia - Worse with poor metabolic control - Often present in type 2 diabetes even when glycaemic control good
What is often the presentation of myocardial ischaemia in diabetes?
“Silent”
- Dyspnoea on exertion common symptom
- Need high degree of clinical suspicion
What cerebrovascular diseases are common in diabetes?
Transient ischaemic attack
Stroke
Multi-infarct dementia
Which areas are prone to ischaemia in peripheral vascular disease?
Great toe
Medial surface of 1st metatarsal head
Lateral surface of 5th metatarsal head
Secondary infection common
What are the principals of type 2 diabetes management?
1st line
- Healthy eating/weight loss if overweight
- Exercise
2nd line
- Oral anti-diabetic agents
Self blood glucose monitoring for some patients
Regular surveillance for microvascular complications
Risk reduction for macrovascular complications
- Blood pressure
- Lipids
- Smoking
How does exercise help with blood glucose control?
Increases glucose uptake into muscle
Stimulates release of stress hormones > short-term glucose increase
- Variable depending on intensity and duration
Longer term, blood glucose levels usually decrease
Improved sensitisation of muscle to exercise can last 2-3 days
When can hypoglycaemia occur after exercise?
Up to 24 hours later - if treated with insulin/sulphonylureas
What forms HbA1c?
Non-enzymatic glycation of Hb
Elevation of glucose increases percentage of glycated Hb
What is the HbA1c level proportional to?
Average blood glucose over previous 1-3 months
When is HbA1c unreliable?
Blood transfusion
Blood loss
Anaemia
Thalassemia
What is the gold standard, or goal of control level of HbA1c?
53 mmol/mol (7%) = mean plasma glucose of 9.5 mmol/L
What complications of diabetes are benefited from intensive glycaemic control?
Microvascular
What happens with tight glycaemic control if you already have cardiovascular disease?
Increased mortality
What is the legacy effect?
Early glycaemic control reduced cardiovascular disease many years later
What is the target for HbA1c in older people, or those with multiple medical problems where hypoglycaemia poses a risk?
Higher HbA1c target
What is the current management of type 2 diabetes?
Diet and exercise > Oral monotherapy > Oral dual combination > Oral triple combination > Oral + insulin > Insulin
What is the first line therapy in type 2 diabetes?
Metformin, unless contraindicated/not tolerated
When is metformin often commenced?
At time of diagnosis in conjunction with diet and exercise
What are the advantages of metformin?
No weight gain
No major hypoglycaemia
What are the side effects of metformin?
GI intolerance main
- Nausea > minimised by using slow-release form
- Diarrhoea
What are the contraindications for metformin?
Renal failure
- Risk of lactic acidosis
