Diabetes CUE CARDS

Question 1

What is Type 1 Diabetes?

Answer 1

> Primarily caused by immune-mediated destruction of the pancreatic beta cells
Diagnosed younger, some elder

Question 2

What is Type 2 Diabetes?

Answer 2

Cause from range of things such as predominant insulin resistance with relative insulin deficiency to predominant secretory defect

Question 3

What is Gestational Diabetes?

Answer 3

Glucose intolerance first detected during pregnancy

Question 4

What are the Classical Symptoms of Type 1 Diabetes?

Answer 4

> Polyuria, polydipsia, polyphagia, weight loss, fatigue, diabetic ketoacidosis
often symptoms a T1D would experience (those with high levels of glucose)
associated with underlying physiology - something triggers immune system to cause destruction of pancreatic beta cells - patients go from normal to loss of insulin quickly - spike in blood glucose triggering symptoms

Question 5

What is ketoacidosis?

Answer 5

> Due to insulin deficit, body utilises fatty acids, producing acidic ketone bodies
Often tiggered by an intercurrent illness

Question 6

What are the differences in Type 1 and Type 2 diabetes?

Answer 6

> Type 1: generally young, ketosis prone, recent weight loss, rapid onset, insulin deficient

> Type 2: Middle-aged, slow onset, insulin resistant, overweight, strong family hx, not prone to ketoacidosis

Question 7

How is diabetes diagnosed?

Answer 7

> In the presence of symptoms of hyperglycaemia (a signle elevated fasting blood glucose >7mmol/L and random blood glucose >11mmol/L)

> In those at high-risk or with clinical suspicion for diabetes (fasting plasma glucose >7mmol/L, HbA1C >48mmol/mol (6.5%) and 2 hr plasma glucose >11.1mmol/L during OGTT)

Question 8

What are the measures of diabetes control?

Answer 8

> HbA1c: longer term diabetes control

> Plasma glucose: important in patients using insulin (provide measure of current state of patient)

Question 9

Discuss how HbA1c and plasma glucose are related

Answer 9

> In certain circumstances, investigating plasma glucose levels may provide important context for HbA1c values
E.g. if patients cannot attain target HbA1c values, despite having a good fasting BSL, it’s likely that post-prandial BSLs are being poorly controlled and therapy should be directed at controlling these

Question 10

What is an oral glucose tolerance test/

Answer 10

> Performed following an overnight fast
3 days of adequate CHO intake (> 150g/day)
A 75g load of oral glucose is given
Diagnosis of diabetes can be made if venous plasma glucose level is 2 hr post glucose load of >11.1mmol/L

Question 11

What symptoms are patients with type 2 diabetes likely to present with?

Answer 11

> Retinopathy
Nephropathy
Neuropathy
Macrovascular Disease

Eye examnination should begin at the time T2 diabetes is diagnosed and within 5 yrs of T1 diabetes diagnosed

Question 12

What are the symptoms associated with diabetic neuropathy?

Answer 12

> Sensory, motor or autonomic neuropathy

> Symptoms of diabetic peripheral neuropathy may include: burning and pain, tingling and numbness

Question 13

What problems does autonomic neuropathy cause?

Answer 13

> Erectile dysfunction
Gastroparesis
Bladder dysfunction

Question 14

What sorts of patients need to be careful with diabetic foot care?

Answer 14

Poorly controlled diabetes > develop neuropathy

Question 15

What predisposes diabetic patients to foot problems?

Answer 15

> The combination of peripheral sensory neuropathy and impaired circulation predisposes patients
Gangrene of the toes and feet (amputations if not treated properly)

Question 16

What do patients need to be educated on in diabetes regarding foot care?

Answer 16

> Patient education is important

> Care with treating athletes foot

Question 17

How do we assess diabetes control in T2D?

Answer 17

> Monitor HbA1c

> Not a lot of blood glucose monitoring compared to T1D

Question 18

How do we assess diabetes control in T1D?

Answer 18

> Reliant on blood glucose monitoring
> Will measure @ different times
> Fasting: fasted
> Pre prandial: just before meal
> Post prandial: after meal

Question 19

What are HbA1c levels of >7% associated with?

Answer 19

> A significantly increased risk of microvascular and macrovascular complications
Above 7%, rapid rise in risk of diabetes complications

Question 20

What changes in diet should be made in diabetes?

Answer 20

> Managing weight is very important to slow progression
Type I diabetics: the type of food consumed influences the dose of insulin needed to inject
Quantity and GI of CHO will affect blood glucose levels (replace high GI with low GI)
Heavier consumption of alcohol may cause hypoglycaemia

Question 21

What are the 3 predominant administration schedules of insulin?

Answer 21

> Continuous Subcutaneous Insulin Infusion (CSII)
Basal Bolus
Split Mix

Question 22

3 predominant administration schedules of insulin: Discuss Continuous Subcutaneous Insulin Infusion (CSII)

Answer 22

> Most physiological approach
Rate of infusion different throughout day
Can change rate of infusions that matches profile
Short or ultra short insulin
Need good patient understanding
Requires pump and expensive
Reserved for patients with difficult with basal/bolus treatment

Question 23

3 predominant administration schedules of insulin: Discuss Basal Bolus

Answer 23

> 2 different products that that patient will use
Long acting insulin product (baseline - inj 1 d)
Ultra short/short acting injection with meals

Question 24

3 predominant administration schedules of insulin: Discuss Split Mix

Answer 24

> Fixed ratio of short/ultra short acting and long acting bd

> Not as physiological

Question 25

Are the targets the same for adults and children?

Answer 25

> In younger age group, HbA1c is higher and also blood glucose higher target, compared to older age group because:

> Risk of insulin: pushing blood glucose too low = hypoglycaemia
Young children: hypoglycaemia has negative effects on cognitive function - brain relies on glucose to function
Hypoglycaemia too many times can impair cognitive capacity

Question 26

Briefly describe why there’s a difference in PK between 100 units and 300 units of insulin glargine?

Answer 26

The smaller volume of injection, results in slower distribution away from injection site

Question 27

How can split mix be improved?

Answer 27

> Using some of the newer analogues (lispro [USA] and protamine conjugate)
Lispro conjugated to protein to make it longer again

> Don’t get as much stacking because of the difference in pharmacokinetic profile - don’t get hypo risk but still not getting physiological profile - 2 spikes not 3

Question 28

What are the risks of split mix?

Answer 28

Glucose levels all over the place

Question 29

How do you inject insulin?

Answer 29

1. Attach needle
2. Perform safety test to ensure that needle is not blocked and purge air. Select a dose of 2 units, remove needle cap, hold pen vertically and tap insulin reservoir to dislodge air bubbles, depress injector
3. Select required dose
4. Swab injection site, pinch skin and insert needle @ 90° and slowly depress injector
5. Count to 10 before removing needle then replace outer cap and discard needle in sharps container

Question 30

Discuss insulin injection sites

Answer 30

> Insulin injections should cause minimal discomfort
Rate of absorption differs between sites
Fastest to slowest = abdomen, arms, legs, buttocks

> Abdomen and arms = use for USA product @ meal times due to rapid onset of effect
Legs and buttocks = use for long acting basal products

Question 31

What are the 2 groups of symptoms of Hypoglycaemia?

Answer 31

> Adrenergic symptoms (mediated by the sympathetic nervous system): Pale, sweating, shaking, palpitations, anxiety

> Neuroglycopenic Symptoms (due to altered brain function): hunger, suboptimal intellectual function, confusion and inappropriate behaviour, coma, seizures

Question 32

When may hypoglycaemic symptoms occur?

Answer 32

> May occur at night when patient asleep
May not recognise symptoms and may cause severe hypo. episode because they haven’t recognised and intervened but may not be severe = wake up sweaty
This is wear BGM in middle of night would benefit

Question 33

What can a hypoglycaemic episode over night cause?

Answer 33

> Trigger increased glucose production and release from the liver leading to some hyperglycaemia in the morning
Body trying to compensate
Can cause BSL in morning to be high
Patient increase insulin dose in evening to deal with it but makes it worse

Question 34

How are Hypo’s managed?

Answer 34

> Important to note that families (as well as patients) must be educated to recognise these symptoms
Management of mild to moderate (conscious and cooperative): initially a readily available and fast acting glucose containing food or drink followed by a lower GI CHO meal = sandwich, dry fruit
Management of severe (unconscious or uncooperative): glucagon, IV glucose

Question 35

How do you monitor blood glucose?

Answer 35

1. Insert strip into meter
2. Swab finger and lance
3. Obtain blood drop
4. Apply drop to test strip
5. Obtain result

Question 36

How do you store insulin?

Answer 36

> vial/pen being used currently can be stored at room temperature for 1 month
Other containers stored in the refrigerator
Don’t freeze

Question 37

What are the treatment targets for Type II diabetes?

Answer 37

> The general target is HbA1c <7% but may be raised or lowered depending upon specific characteristics
Aggressive treatment to a lower target may be dangerous in some patients while for other patients, a lower target isn’t appropriate given their life expectancy

Question 38

What drug characteristics determine position in therapy?

Answer 38

> Magnitude of HbA1c reduction
> Risk of hypoglycaemia
> Risk of weight gain
> Drug specific risks
> Patient preferences

Question 39

Discuss the use for BGM in T2D?

Answer 39

> In T1D, patients adjust insulin dose depending on BGL
In T2D, BGM doesn’t need to be intensive
The benefit of BGM in T2D is that if they’re changing diet and lifestyle and see BGL go down - positive feedback

Question 40

Discuss the use of beta blockers in HF and T2D

Answer 40

> Beta blockers will mask specifically the sympathetic symptoms of hypoglycaemia
Concern: masking symptoms of hypo and they go on to have serious event that causes harm
In T2D, metformin, SGLTi or DPP-IVi don’t have significant hypo risk
Why do they need BB? HF = major benefit, Angina = use CCB instead

Question 41

What are non-glycaemic targets in diabetes?

Answer 41

> BP and lipid management in patients w/ diabetes
Comorbidity benefits in HTN: ACEi, ARB has benefit in diabetes with microalbuminuria (nephroprotective through intefering with the pathophysiology of hyperfiltration)

Question 42

Briefly discuss diabetic nephropathy

Answer 42

> Angiotensin II drives hyperfiltration at the kidneys
Too much is getting filtered out
This eventually causes damage resulting in proteinuria
If we block ATII with ACEi or ARB, we stop this process, protecting the kidneys
Combination of ARB and ACEi doesn’t provide additional protection

Question 43

Briefly discuss gestational diabetes

How can it be controlled?

Answer 43

> All pregnant women should be tested @ approximately 26 weeks gestation using glucose tolerance test

> Can be controlled adequately by diet and exercise alone in about 50% of women (if not, a modified basal bolus regimen is often used - short acting before meals)

> All women w/ gestational diabetes should have a glucose tolerance test at 6-12 weeks post partum

Question 44

What complications are associated with poorly controlled GD?

Answer 44

For example, babies will often be large in size which can lead to difficulties during birthing, but there is a longer term risk of babies going on to develop CVD later in life