Diabetes (corticosteroids/hyperkalaemia) Flashcards
What is fetor hepaticus?
Sweet smelling breath that happens in a DKA?
What drug protects kidney function in diabetes?
SGLT2 inhibitors
What is diabetes
Diabetes mellitus is anetdeficiencyofinsulinleading to imbalance in glucose production and utilization
Criteria for diabetes diagnosis
- Characteristics of Diabetes Mellitus AND 1 of:
- Random Blood Glucose >11.0mmol/L
- Fasting blood Glucose >7.0 mmol/L
- HbA1c >48mmol/mol
What genes are associated with T1DM?
HLA-DR3/4
Pathophyisiology of T1DM
Autoimmune complete destruction beta cells in islets of Lange than in pancreas - antibody destruction
Bloods to investigate T1DM?
- HBA1c
- Cpeptides
- Islet cells
- GADS
- IA2
- ABG/VBG
Pathophysiology of T2DM
Increased glucose transport ion, decreased incretin effect in gastro, impaired insulin secretion, increased glucagon secretion, increased hepatic glucose production, neurotransmitter dysfunction, decreased glucose uptake
Mechonism of action of SGLT2 inhbiitors
prevents re-absorption of glucose and sodium
What groups can DPP4s be used in
use in elderly, can be used in low eGFR,
GLP-1 mechanism of action
works on GI tract - slows digestion, feel full for longer, help lose weight. Improves insulin sensitivity, decreased lip plus is, neurotransmitter
Sulfonureas mechanism of action
target insulin secretion in beta cells, produce more insulin. Causes weight gain. Tackle steroid therapy.
What type of diabetes do you not treat with sulfynureas
T1DM
monogenic, not overweight
What is LADA, how does it present and how treated?
Latent autoimmune diabetes
Autoimmune condition slowly and progressively destroys pancreas insulin producing cells
Often present with DKA
Treat as having type 1 DM - insulin dependent
What conditons can cause pancreatic damage and therefore secondary diabetes?
Pancreatitis
Pancreatic cancer
Cystic fibrosis
Haemochromatosis
Pancreatectomy
What genes causes monogenic diabetes?
HBF-alpha
HNG4- alpha
HNF1- beta - insulin manage, predisposed to renal cysts, electrolyte imbalances (70% of cases, manage with glucozide)
When does monogenic diabetes develop?
Below 25
What does insul,in allow in fed state
- Promotes glycognesis - storage of glucose
- inhibiting gluconeogenesis and ketogenesis - (glucose and ketone release)
- Inhibits breakdown of current fuel storage proteolysis, lipolysis, glycogenolysis
What is kussmarul breathing?
Deep and laboured breathing associated with severe metabolic acidosis - eg ketoacidosis
Symtptoms of diabetes
- Frequent urination
- More stressed/tired
- Being thirstier
- Blurred vision
- Loss of weight
-Slower healing time
History qs for diabetes
- Onset
- Physical exam - Dark pigmentation in skin folds
- Age
- Weight loss - gradual/sudden
- Recent environmental trigger
- Antipsychotics
- Family histroy
- Prev HBA1c prev HB
- Cute or breaks in skin that don’t heal
Risk factors for T2DM
- Family history - 15% chance on parent, 75% if 2 parents
- Ethnicity - south Asian
- History of gestational diabetes
- High GI diet, low fibre diet
- PCOS
- Central obesity
- Metabolic syndrome
Complciations diabetes
- Macrovascular - stroke/MI
- Microvascular
- Retinopathy
- Nephropathy - micro alumni creatinine ratio urine
- Gastroparesis - makes diabetes more difficult to manage
- Sexual dysfunction
- Quality of life
- DKA/HHS and hypos
Treatment for DKA
- Crystalloid fluid to restore circulating volume
- Insulin - correct acidosis
- Potassium
- Glucose - allow to continue use insulin without becoming hypoglycaemic
- Never stop basal insulin A give alongside DKA protocol and VRII
HSS symptoms
- Frequency of urination
- Thrust
- Dry skin
- Dosrientstion
- Drowsiness and gradual LOC
HSS parameters
NOT acidotic on blood gas
- Blood glucose > 20 mmol/L
- Blood ketones < 3 mmol/L
- Serum osmolarity > 320 (2(Na+K)+glucose+urea)
Symptom histroy IBD
- ptom history IBD
- Pain/discomfort
- Bowels opening
- Consistency
- Blood/mucus
- Timing noctural
- Sensation/tenesmus
- SOCRATES
- Bristol stool chart
- Melana
- Haematochezia
What are the diagnositc levels of glucose on fasting and random/oral 75g glucose tolerance test?
Fast > or = to 7.0mmol/l
Random/oral test > or = 11.1 mmol/l
What are the diagnositc levels of glucose on fasting and random/oral 75g glucose tolerance test?
Fast > or = to 7.0mmol/l
Random/oral test > or = 11.1 mmol/l
When do you have to do two glucose tests to confirm a diagnosis?
When the patient is asymptomatic
What HbA1c level is diagnositc of diabetes?
greater than or equal to 48
a value below doesnt exclude diabetes
What conditions mean HbA1c testing for diabetes is unreliable?
Conditions caused by increased red cell turnover eg
Haemoglobinopathies
Haemolytic anaemia
Untreated iron deficiency anaemia
Suspected gestational diabetes
Children
HIV
CKD
Hyperglycaemia causing meds eg corticosteroids
What glucose level suggests impaired fasting glucose? (IFG)
Fasting glucose between 6.1 and 7.0
How is impaired glucose tolerance (IGT) defined diangostically?
Fasting plasma glucose < 7mmol/l
Oral glucose tolerance test - 2 hour value between 7.8 and 11.1
What levels of potassium are considered hyperkalaemia?
> 5.5 = hyperkalaemai
Mild – 5.5-5.9 mmol/L
Moderate – 6.0-6.4 mmol/L
Severe – >6.5 mmol/L
Hyperkalaemia on ECG
Tall tented T waves
Loss of P waves
Broad QRS complexes
Prolonged PR interval
Sinusoidal wave pattern
AV block
Bradycardia
When is hyperkalaemia treated?
> 6.5/7mmol/l and/or hyperkalaemia with ECG changes
Management of hyperkalaemia
Calcium gluconate 10% slow IV 10-20ml
Actrapid - 10U in 50ml of 50% glucose
Consider:
Nebulised salbutamol
Correcting acidosis with HCO3- infusion
Aim of calcoum gluconate treatemtn in hyperkalaemia
Stabilise cardiac membrane
Does NOT lower serum K+ levels
Why do yuo give insulin/dextrose infusion/ nebulised salbutamol in hyperkalaemia?
Shifts K+ from ECF into cells (ICF) due to cotransport with glucose
Further management of hyperkalaemia
Stop offending drugs eg ACEis
Treat underlyig cause
Lowe total body potassium
How do you lower total body K+?
Calcium resonium
Loop diuretics
Dialysis (AKI + persistent raised K+)
What is IV adenosine used for?
Cardiac arrhytmias
Opioid toxicity symptoms
Respiratory supression
Decreased GCS
Pinpoint pupils
What should you do with corticosteroid dose when patient has intercurrent illness?
Double it
Why can long term corticosteroid use precipitate an Addisonian crisis?
Corticosteroids supress the natural production of endogenous steroids
Endoscrine side effects of glucor=corticoids?
impaired glucose regulation
increased appetite/weight gain
hirsutism
hyperlipidaemia
Cushings syndrome
MSK side effects of glucocorticoids
osteoporosis
proximal myopathy
avascular necrosis of the femoral head
Psychiatric side effects of glucocorticoids
insomnia
mania
depression
psychosis
Why can glucocorticoids cause reactivation of TB?
Immunosuppression
GI side effects of glucocorticoids
Peptic ulceration
Acute pancreatitis
Opthalmic side effects of glucocorticoids
Glaucoma
Cataracts
Side effects of mineralocortocoids
Fluid retention
HPTN
Why are glucocoticoids often not used in chidlren?
Growth suppression
What may precipitate infection due to glucocorticoids?
Imunosuppression and neutrophilia
When is gradual withdrawak from systemic corticosteroids recommended?
> 40mg prednisolone daily > 1 week
3 weeks treatemnt
Recently repeated courses
What is empagliflozin?
SGLT2 inhibitor
What is the target range for diabetes control?
HbA1c - <48
When should an SGLT2 inhibitor be prescribed in T2DM?
CVS disease risk >10% QEISK
CVS disease have
Chronic HF
What is the maximum daily dose of metformin?
2g
When should you add a second drug for diabetes control?
when HbA1c is over 58 mmol/mol/7.5%
Diet advice diabetes
High fibre, low glycaemic index
Low fat dairy and oily fish
Limit sat fat and sucrose
target weight loss 5-10%
How often should HbA1c be checked in T2DM>
3-6 months until stable then 6 monthly
2nd line if metformin not tolerated
(try modified release first if can)
DPP4 inhibitor or pioglitazone or sulfonylurea IF not at risk of CVD/ no HF
Otherwise SGLT2
Why is metformin titrated up slowly
Avoid GI upset
3rd line therapy
Add another drug from 2nd line OR
Insulin based treatemnt
WHen Switch to GLP-1 mimetic in T2D,?
if BMI >35kg or
insulin would have occupational complications
when triple therapy is not effective or tolerated
Switch one of drugs for GLT 1 mimetic
Specialist med
What insulin start with if need in T2DM?
Human NPH insulin - isophane, intermediate acting at bed/ 2x a day
What is cpeptide blood test testing for
Parameters and when require
- how well function pancreas is with a random glucose.
Early is fine
under 0.3 = T1DM, under 0.6 requires insulin
WHy do you give potassium with IV dextrose in DKA?
allow to continue to use insulin without → hypokalaemIa or hypoglycaemia - gradual return to normal
Environmental triggers for T1DM
viral, bereavement, toxin, drug or chemical - if have autoimmune genes for type I
Why do annual eye test and retinal test in diabetes?
Microvascular damage to eyes and kidneys
Why need Hb level to determine if HbA1c is accurate
glycosylation of blood cells - if don’t have HB in range not accurate HBA1c
Why ask about history of antipsychotics in diabetes?
Risk factors
What is DKA?
Complex disordered state characterised by hyperglycaemia, acidosis and ketonaemia
Range for tests in DKA - ketones, bicard, blood glucose, VBG
- Blood ketones > 3 mol/L (normal under 0.3)
- Capillary ketones more accurate than urinary
- Bicarbonate < 15 mmol/L and/or pH <7.3
- Blood glucose > 11 mmol/L
- Venous blood gas in ketonaemia, rule out acidemiA
Levels of glucose, ketones and osmolarity in HSS
- Blood glucose > 20 mmol/L
- Blood ketones < 3 mmol/L
- Serum osmolarity > 320 (2(Na+K)+glucose+urea)
Why caustionin fluid replacement in HSS?
Risk of cerebral oedema
Is blood gas acidotic in HSS?
No
What exam is important in diabetes?
Foot exam - pulse, sensation, skin integrity
Peripheral neuro[athy risk
Signs of DKA
Tachycardia
Hypotension
Reduced skin turgor
Dry mucous membranes
Reduced urine output
Altered consciousness (e.g. confusion, coma)
Kussmaul breathing
What would an ABG show in DKA?
PaO2: may be reduced in the context of pneumonia (e.g. DKA precipitated by a respiratory infection).
PaCO2: may be low in the context of DKA due to respiratory compensation as a result of metabolic acidosis.
pH: low in the context of DKA due to the presence of acidic ketones.
HCO3-: low in the context of DKA due to metabolic acidosis.
rISK FACTORS FOr T1DM triggering
diet, vitamin D exposure, obesity, early-life exposure to viruses associated with islet inflammation (such as enteroviruses), and decreased gut-microbiome diversity.
What other diseases are people with T1DM at risk of?
Other autoimmune diseases
Graves disease, Hashimotos thyroiditis, autoimmune gastritis and/or perniciious anaemia, coeliac disease, vitiligo, addisons disease
When to suspect T1DM in an adult
Ketosis.
Rapid weight loss.
Age of onset younger than 50 years.
Body mass index (BMI) below 25 kg/m2.
Personal and/or family history of autoimmune disease.
When to suspect T1DM in a child
Polyuria.
Polydipsia.
Weight loss.
Excessive tiredness.
How does mild hypoglycaemia present?
Hunger.
Anxiety or irritability.
Sweating.
Tingling lips.
Irritability.
Palpitations.
Tremor.
How does severe hypoglycaemia present?
Weakness and lethargy.
Impaired vision.
Incoordination.
Reduced orientation.
Confusion.
Irrational behaviour.
Emotional lability.
Deterioration of cognitive function (when blood glucose levels fall lower than 3.0 mmol/L).
COMplications of severe hypoglycaemia
Convulsions.
Inability to swallow.
Loss of consciousness.
Coma.
Insulin manangement in most T1DMS
Basal bolus regimine
Basrline longer acting insulin
Bolus short acting insulin for meals and snakcs
What is acanthosis nigricans?
Skin condtions causng dark pigmentation of ksin folds suggesting insulin resistance
What drugs increase risk of T2DM?
Statins, corticosteroids, and combined treatment with a thiazide diuretic plus a beta-blocker
wHAT conditions increase risk of T2DM
PCOS
metabolic eg fatty liver disease, BP high etc
What is it important to monitor with metformin?
Renal function
B12 levels - risk of low as higher metformin dose
What is a pioglitazone?
Diabetes drug that can be used with metformin, sulfonylurea or insulin.
Thiazolidinediones
Increases sensitivity to insulin
