Diabetes - COPIED

Question 1

Type I defined

Answer 1

autoimmune condition causing destruction of the pancreatic B cells resulting in absolute insulin deficiency.

(70-90% of cells must be destroyed before symptoms)

Question 2

What are the EM physiological side effects of type I diabetes causing hypoglycaemia? (3)

Answer 2

>>> sugar in blood, none in cells.

Breakdown of fats and proteins; ketones and acidosis

leads to dehydration, Potassium loss and acidosis.

Dehydration because water follows excretion of sugar (osmotic diuresis)

Question 3

what could be triggers for hypoglycaemia attacks?

Answer 3

infections; UTI, pneumonia

physiological stressors including cold, status epilepticus.

Question 4

What is a big danger of px with long-standing diabetes and neuropathy?

Answer 4

MI or abdominal conditions such as infection or pancreatitis may be painless. Maybe osteomyelitis in the feet..

Question 5

Tests for diabetes

Answer 5

Blood glucose

urine or blood test for ketones

pH (venous fine)

Question 6

Symptoms of hypoglycaemia

Answer 6

confusion, sweating, fatigue and feeling dizzy.

maybe pale, weak, blurred vision, tachycardia, unconsciousness

Question 7

EM tx of hypoglycaemia

Answer 7

50ml of glucose 50% if IV access available.

otherwise 1 mg glucagon

(as PAs 10% glucose IV okay)

non-emergency; dextrose, then more complex carbohydrates.

Question 8

What is Kussmaul breathing?

Answer 8

Deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.

Question 9

What is diagnosis of DKA based on?

Diabetic ketoacidosis is a serious complication of Type I DM.

Answer 9

Diagnosis based on

diabetes (blood glucose >11 mmol/L)

ketones (urine or blood)

acidosis (pH <7.30 venous blood)

Question 10

Diagnositic symptoms of DKA?

Answer 10

polydipsia

weight loss

dehydration

+ Kussmaul breathing

Question 11

Tx for DKA

(Sickness and vomiting, abdominal pain, muscular weakness)

Answer 11

500ml then another 500ml then another 500ml (saline). MUST ensure patient is rehydrated before giving insulin. 0.1units per kilo per hour.

As sugar moves into cells (insulin taking effect) potassium follows therefore px becomes hypokalaemic. Normal potassium 3.5 to 5.

Watch urine output to check hydration.

Red flag; peds until 22-23 yr old. Can die from cerebral oedema; therefore don’t give insulin until properly hydrated.

Question 12

Why rehydrate gradually with DKA?

Answer 12

to avoid rapid intracellular osmotic/ sodium shifts that may cause fatal CNS oedema.

Remember: with DKA and polydipsia, rapid fluid shift from intracellular compartments.

Question 13

What factors cause cause a hypoglycaemic attack?

Answer 13

Too high a dose of medication (insulin or hypo causing tablets)

Delayed meals

Exercise

Alcohol

Question 14

Obese px; type I or type II diabetes more likely?

Answer 14

type II

Question 15

What is HONK?

Answer 15

hyperosmolar non-ketotic coma

induced by prolonged hyperglycaemia and dehydration and hypernatraemia.

* require careful management with fluid replacement and small doses of insulin to restore euvolaemia and euglycaemia.

Question 16

Px advise for type II diabetes to reduce risk?

Answer 16

lose weight

stop smoking

• these are additional risk factors for hypertension and CV disease, both common in type II diabetes.

Question 17

What’s the most prevalent cause of death for diabetic patients

Answer 17

coronary artery disease

(diabetic px after develop hypertension, dyslipidemia, and a decline in HDL, and a rise in triglyceride levels)

Question 18

What is glipizide?

SE: weight gain

Can be combined with metformin for better control.

Answer 18

Sulfonylurea drug; increases the secretion of insulin and secondarily decreases the secretion of glucagon.

‘hypoglycaemic drug’

Question 19

What the the two groups of antidiabetic drugs?

Answer 19

hypoglycaemic agents

antihyperglycaemic agents

Question 20

What is an inherent problem with Sulfonylurea drugs?

Answer 20

Since they increase insulin secretion, can lead to hypoglycaemic episode if px skips or delays meals.

Alcohol increases hypoglycaemic effect.

Question 21

Examples of 2nd generation sulfonylurea drugs (3)

Answer 21

glimepiride

glipizide

glyburide

Question 22

What are sulfonylureas and meglitinides examples of?

Answer 22

hypoglycaemic drugs

Question 23

Name the two meglitinides drugs that are short-acting and are useful for patients whose meal schedules vary.

Answer 23

Repaglinide

Nateglinide

Question 24

How does metformin (biguanide drug) work?

NB> stop if acidosis suspected due to rare effect of lactic acidosis.

Answer 24

increases insulin receptor affinity in peripheral tissues.

1st line drug for type 2 diabetes. Can be used alone or in combo.

DOES NOT; stimulate insulin secretion, or cause hypoglycaemia, or weight gain.

DIARRHOEA common in 30% of px.

Question 25

What is pramlintide acetate?

Answer 25

Analogue of amylin.

Amylin; co-secreted with insulin. It slows gastric emptying and reduces appetite.

Subcutaneous at mealtimes for type I and 2 diabetes. SE; nausea, vomiting, anorexia, headache.

Question 26

What are the first line drugs for type 2 diabetes?

Answer 26

metformin

sulfonylureas

meglitinides

Question 27

What is the management of type II Diabetes?

Answer 27

Patient education: reduce risk factors -

smoking, sedentary life style, hypertension, dyslipidaemia, and obesity.

Discuss dietary advice. Encourage exercise.

HbA1c testing until glucose levels stabilised.

Drug tx: standard-release metformin. Consider dual therapy if ineffective, or triple therapy.

BP: Aim for 140/80 and below

Question 28

What is glipizide?

SE: weight gain

Can be combined with metformin for better control.

Answer 28

Sulfonylurea drug; increases the secretion of insulin and secondarily decreases the secretion of glucagon.

‘hypoglycaemic drug’

Question 29

What the the two groups of antidiabetic drugs?

Answer 29

hypoglycaemic agents

antihyperglycaemic agents

Question 30

What is an inherent problem with Sulfonylurea drugs?

Answer 30

Since they increase insulin secretion, can lead to hypoglycaemic episode if px skips or delays meals.

Alcohol increases hypoglycaemic effect.

Question 31

Examples of 2nd generation sulfonylurea drugs (3)

Answer 31

glimepiride

glipizide

glyburide

Question 32

What are sulfonylureas and meglitinides examples of?

Answer 32

hypoglycaemic drugs

Question 33

Name the two meglitinides drugs that are short-acting and are useful for patients whose meal schedules vary.

Answer 33

Repaglinide

Nateglinide

Question 34

How does metformin (biguanide drug) work?

NB> stop if acidosis suspected due to rare effect of lactic acidosis.

Answer 34

increases insulin receptor affinity in peripheral tissues.

1st line drug for type 2 diabetes. Can be used alone or in combo.

DOES NOT; stimulate insulin secretion, or cause hypoglycaemia, or weight gain.

DIARRHOEA common in 30% of px.

Question 35

MCQ - important facts about Metformin

MOA, adverse effects, contraindications

Answer 35

Mechanism of action

• increases insulin sensitivity
• decreases hepatic gluconeogenesis
• may also reduce gastrointestinal absorption of carbohydrates

Adverse effects

gastrointestinal upsets are common (nausea, anorexia, diarrhoea), intolerable in 20%

lactic acidosis* with severe liver disease or renal failure (rare but important to know for exams)

Contraindications**

chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)

metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration, iodine-containing x-ray contrast media: there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter

**metformin is now sometimes used in pregnancy, for example in women with polycystic ovarian syndrome