Diabetes CUE CARDS Flashcards
What is Type 1 Diabetes?
> Primarily caused by immune-mediated destruction of the pancreatic beta cells
Diagnosed younger, some elder
What is Type 2 Diabetes?
Cause from range of things such as predominant insulin resistance with relative insulin deficiency to predominant secretory defect
What is Gestational Diabetes?
Glucose intolerance first detected during pregnancy
What are the Classical Symptoms of Type 1 Diabetes?
> 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
What is ketoacidosis?
> Due to insulin deficit, body utilises fatty acids, producing acidic ketone bodies
Often tiggered by an intercurrent illness
What are the differences in Type 1 and Type 2 diabetes?
> 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
How is diabetes diagnosed?
> 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)
What are the measures of diabetes control?
> HbA1c: longer term diabetes control
> Plasma glucose: important in patients using insulin (provide measure of current state of patient)
Discuss how HbA1c and plasma glucose are related
> 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
What is an oral glucose tolerance test/
> 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
What symptoms are patients with type 2 diabetes likely to present with?
> Retinopathy
Nephropathy
Neuropathy
Macrovascular Disease
Eye examnination should begin at the time T2 diabetes is diagnosed and within 5 yrs of T1 diabetes diagnosed
What are the symptoms associated with diabetic neuropathy?
> Sensory, motor or autonomic neuropathy
> Symptoms of diabetic peripheral neuropathy may include: burning and pain, tingling and numbness
What problems does autonomic neuropathy cause?
> Erectile dysfunction
Gastroparesis
Bladder dysfunction
What sorts of patients need to be careful with diabetic foot care?
Poorly controlled diabetes > develop neuropathy
What predisposes diabetic patients to foot problems?
> The combination of peripheral sensory neuropathy and impaired circulation predisposes patients
Gangrene of the toes and feet (amputations if not treated properly)
What do patients need to be educated on in diabetes regarding foot care?
> Patient education is important
> Care with treating athletes foot
How do we assess diabetes control in T2D?
> Monitor HbA1c
> Not a lot of blood glucose monitoring compared to T1D
How do we assess diabetes control in T1D?
> Reliant on blood glucose monitoring > Will measure @ different times > Fasting: fasted > Pre prandial: just before meal > Post prandial: after meal
What are HbA1c levels of >7% associated with?
> A significantly increased risk of microvascular and macrovascular complications
Above 7%, rapid rise in risk of diabetes complications
What changes in diet should be made in diabetes?
> 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
What are the 3 predominant administration schedules of insulin?
> Continuous Subcutaneous Insulin Infusion (CSII)
Basal Bolus
Split Mix
3 predominant administration schedules of insulin: Discuss Continuous Subcutaneous Insulin Infusion (CSII)
> 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
3 predominant administration schedules of insulin: Discuss Basal Bolus
> 2 different products that that patient will use
Long acting insulin product (baseline - inj 1 d)
Ultra short/short acting injection with meals
3 predominant administration schedules of insulin: Discuss Split Mix
> Fixed ratio of short/ultra short acting and long acting bd
> Not as physiological
Are the targets the same for adults and children?
> 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
Briefly describe why there’s a difference in PK between 100 units and 300 units of insulin glargine?
The smaller volume of injection, results in slower distribution away from injection site
How can split mix be improved?
> 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
What are the risks of split mix?
Glucose levels all over the place
How do you inject insulin?
- Attach needle
- 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
- Select required dose
- Swab injection site, pinch skin and insert needle @ 90° and slowly depress injector
- Count to 10 before removing needle then replace outer cap and discard needle in sharps container
Discuss insulin injection sites
> 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
What are the 2 groups of symptoms of Hypoglycaemia?
> 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
When may hypoglycaemic symptoms occur?
> 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
What can a hypoglycaemic episode over night cause?
> 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
How are Hypo’s managed?
> 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
How do you monitor blood glucose?
- Insert strip into meter
- Swab finger and lance
- Obtain blood drop
- Apply drop to test strip
- Obtain result
How do you store insulin?
> vial/pen being used currently can be stored at room temperature for 1 month
Other containers stored in the refrigerator
Don’t freeze
What are the treatment targets for Type II diabetes?
> 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
What drug characteristics determine position in therapy?
> Magnitude of HbA1c reduction > Risk of hypoglycaemia > Risk of weight gain > Drug specific risks > Patient preferences
Discuss the use for BGM in T2D?
> 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
Discuss the use of beta blockers in HF and T2D
> 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
What are non-glycaemic targets in diabetes?
> 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)
Briefly discuss diabetic nephropathy
> 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
Briefly discuss gestational diabetes
How can it be controlled?
> 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
What complications are associated with poorly controlled GD?
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
