Diabetes, DM, DI and SIADH Flashcards
1
Q
Glucose levels needed diabetes diagnosis
A
Fasting >7mmol/L
Random >11.1mmol/L
Detected once with symptoms
Or detected on 2 separate occasions
2
Q
HbA1c diagnosis level
A
> 48mmol/L (6.5%)
3
Q
Cause of type 1 diabetes
A
Insulin deficiency from autoimmune destruction of insulin-secreting pancreatic beta cells
4
Q
T1DM patients are prone to
A
Ketoacidosis and weight loss
5
Q
MZ concordance for T1DM
A
30% therefore some environmental influence
6
Q
Populations with higher prevalence of T2DM
A
Elderly, men and Asians
7
Q
Cause of T2DM
A
Decreased insulin secretion with or without insulin resistance
8
Q
Things which increase risk of t2dm
A
Obesity
Lack of exercise
Calorie
Alcohol excess
9
Q
MZ concordance of T2DM
A
> 80%
10
Q
What precedes onset of t2dm
A
Pre-diabetes, new term which refers to previous IGT and IFG
Increased likelihood of developing t2dm
11
Q
HBa1c needed for pre-diabetes diagnosis
A
6.0-6.4%
or 42-47mmol
12
Q
Fasting glucose needed for pre-diabetes diagnosis
A
6.1-6.9mmol/l
13
Q
Other causes of diabetes - drugs
A
Steroids
Anti-HIV drugs
Newer antipsychotics
Thiazides
14
Q
Other causes of diabetes - medical
A
Pancreatic insufficiency
Cushings, acromegaly, phaeochromocytoma, hyperthyroidism and pregnancy
15
Q
Increased risk of gestational diabetes
A
>25 Family history Weight gain Non-causasian HIV +ve
16
Q
Medications in gestational DM
A
Nothing other than insulin or metformin
17
Q
Antibodies in t1dm
A
Islet cell antibodies
Anti-glutamic acid decarboxylase (GAD) antibodies
18
Q
Ketonuria in which diabetes
A
T1DM
19
Q
Metabolic syndrome criteria
A
Central obesity (BMI>30 or waist circumference) Plus 2 of; BP >130/85 Triglycerides >1.7 HDL 5.6 or DM
20
Q
Ideal DM diet
A
Low sat fats
Low sugar
High starch and carb
Moderate protein
21
Q
First medication for T2DM
A
Metformin (biguanide)
500mg bd after food
22
Q
How does metformin work? And side effects/contraindication
A
Increases insulin sensitivity - helps weight
SE: nausea, diarrhoea, abdominal pain NOT hypoglycaemia
Renal failure - Gfr
23
Q
When do you need to stop metformin
A
Morning before GA and contrast medium containing iodine
24
Q
When do you add another drug to metformin and what?
A
16 weeks after starting metformin and Hba1c >53
Add sulfonylurea - eg. gliclazide 40mg/day
25
How do sulfonylurea work and SE?
Increase insulin secretion
| SE: hypoglycaemia, weight gain - therefore is BMI >35 or hypoglycaemia an issue - use gliptin
26
When do you add something to metformin + gliclazide and what
If 6 months hba1c >57
Consider
Insulin
Glitazone eg. Pioglitazone - replaces either metformin or sulfonylurea
27
How does glitazone work?
| Side effects and contraindications
Increase insulin sensitivity
SE: hypoglycaemia, fractures and fluid retention - LFT increase
Contraindication - past or present CCF, oestoporosis
Need to monitor weight and stop if oedema
28
Good drug if irregular mealtimes - t2dm
Sulfonylurea receptor binders
Eg. Nateglinide or repaglinide
Target post prandial hyperglycaemia
29
What are exenatide and sitagliptin or vilagliptin
Exenatide is a Glucagon-like peptide analogue (incretin)
Sitagliptin and vilagliptin - inhibit dpp-4 which breaks down GLp-1
Decrease appetite therefore good for obesity
30
Acarbose?
Alpha glucosidase inhibitor
Stops breakdown of starch to sugar
Often disappointing
31
Strength of insulin doses
100u/ml
32
Humalog
Ultra-fast acting insulin - at start of meal or just after
33
Novorapid
Fasting acting
34
Novomix
Ultrafast component - 30%
| And long acting insulin - 70%
35
Isophane insulin
Variable peak at 4-12 hour
36
Insulin glargine
Long acting recombinant human insulin analogue
Before bedtime in t1 or t2
Caution in pregnancy
37
Insulin detemir
Long acting insulin
| Good if intense insulin regimes for t2dm
38
Insulin regimen for t2dm or t1dm with regular lifestyle
BD biphasic regimen
| Twice daily premixed insulin by pen - eg novo mix
39
Insulin regimen good for flexibility with t1dm
QDS regimen
| Before meals ultra fast and bedtime long acting
40
Good insulin regimen when switching from medication to insulin in t2dm
Once daily before bed
| Work dose up slowly
41
Insulin during illness
Illness often needs more insulin even if decreased food intake
42
Gliclazide
Sulfonylurea
43
Pioglitazone
Glitazone
44
..glinide
Sulfonylurea receptor binders
45
Background diabetic retinopathy
```
Microaneurysms (dots)
Haemorrhages (blots)
Hard exudates (lipid)
```
Refer if near macula
46
Pre-proliferative diabetic retinopathy
Cotton wool spots (nerve damage)
Haemorrhages
Venous beading
Refer to specialist
47
Proliferative diabetic retinopathy
New vessels form - urgent referral
48
Diabetic maculopathy
Suspect if decreased acuity
| Prompt treatment
49
Cause of diabetic eye problems
Capillary endothelial change due to high retinal blood flow from hyperglycaemia
Causes vascular leak and microaneurysms - also occlusion and hypoxia and ischaemia - then new vessel formation
50
Diabetic neuropathy
Sensory in glove and stocking distribution - symmetrical
- numbness, tingling and pain
Absent ankle jerks
Neuropathic deformity -eg. Pes cavus
51
Other sign of diabetic foot problems
Ischaemia and absent pulses
52
Complication of diabetic foot ulcer and treatment
Cellulitis
IV benzylpenicillin and flucloxacillin
With or without metronidazole
53
Treatment of pain in diabetic sensory poly neuropathy
Paracetamol
Then tricyclic
Then duloxetine, gabapentin or pregabalin
Then opiates
54
Other neuropathies in diabetics x 3
Mono neuritis multiplex
Amyotrophy - painful wasting of muscles
Autonomic neuropathy
55
Hypoglycaemia - glucose level
56
Symptoms of hypoglycaemia
Autonomic - Sweating anxiety hunger tremor palpitations dizziness
Neuroglycopenic - confusion, drowsiness, visual trouble, seizures and coma
57
Hypoglycaemia + hyperinsulinaemia
Insulinoma
Insulin and sulfonylureas
Mutation in insulin receptor gene
58
Hypoglycaemia + undetectable insulin and no excess ketones
Non pancreatic neoplasm
| Anti-insulin receptor antibodies
59
Hypoglycaemia, low insulin and high ketones
Alcohol
Pituitary insufficiency
Addison's disease
60
Treatment of hypoglycaemia if can swallow
Oral sugar 50g glucose followed by long acting starchy snack
61
Treatment of hypoglycaemia if can't swallow
If cannot swallow - IV glucose 50% 25-50ml or glucagon 1mg IM if no IV access
62
What is insulinoma
Benign pancreatic islet cell tumour
63
Presentation of insulinoma
Fasting hypoglycaemia + whippes triad:
1) symptoms associated with fasting or low glucose
2) recorded hypoglycaemia with symptoms
3) symptoms relieved with glucose
64
Diagnostic test of insulinoma
Suppressive test
| Give IV insulin and measure c-peptide - normally exogenous suppresses c-peptide production but doesn't in insulinoma
65
Why does diabetic Ketoacidosis occur
Ketoacidosis is alternate metabolic pathway in starvation States (diabetes there is glucose but not insulin therefore has to do this)
Ketoacidosis produces acetone as by product (fruity breath) and ketones
66
Typical picture of diabetic Ketoacidosis
Gradual drowsiness
Vomiting
Dehydration
67
Typical patient with Ketoacidosis
T1dm
| Rarely t2dm
68
Triggers of diabetic Ketoacidosis
```
Infections
MI
Surgery
Pancreatitis
Chemo
Non compliance
```
69
3 things needed for Ketoacidosis diagnosis
Acidaemia - blood ph below 7.3
Glucose >13.9
Serum bicarb below 18
70
Severe DKA
If one of more of the following features is present then consider transfer to HDU or ICU for monitoring
Blood ketones >6 (urine ketones don't always equate with Ketoacidosis)
Venous bicarbonate below 10
Ph below 7
71
Symptoms of hyperglycaemia
```
Polyuria
Polydipsia
Unexplained weight loss
Visual blurring
Genital thrush
Lethargy
```
72
First Management of Ketoacidosis if SBP low
Give 500ml bolus saline
| If no response give a second bolus and get ICU advice
73
management of diabetic Ketoacidosis - when fluid stable
Insulin - actrapid 50u with 50ml saline - infuse constantly - only give stat if there is a delay in starting infusion
Continue long acting insulin
74
Aim for managing diabetic ketoacidosis
Fall in blood ketones of 0.5mmol/L/hour
Or rise in venous bicarb of 3mmol/L/hour
Fall in glucose of 3mmol/L/hour
If this isn't achieved then increase to 1u of insulin
75
Other diabetic ketoacidosis management
NG tube if vomiting or drowsy
Catheter if not urinating
Start all patients on LMWH
76
What do you need to avoid when treating diabetic ketoacidosis
Hypoglycaemia
| When glucose is below 14 start giving glucose
77
When do you continue fixed rate insulin until?
Ketones 7.3
| Venous bicarb >18
78
Fluid replacement in DKA
```
Typical fluid deficit is 100ml/kg
For an average 70kg man = 7litres
Give 1L in 1st hour
1L over 2hours
1L over 2 hours
1L over 4 hours
1L over 4 hours
1L over 6 hours
```
79
K+ in DKA
Plasma k+ falls as k+ enters cells with insulin
Don't add K+ to first bag
Monitor UO and start adding k+ when >30ml an hour
80
Presentation of hypoglycaemic coma
Rapid onset
Preceded by odd behaviour - aggression
Sweating, tachycardia and seizures
81
Management of hypoglycaemic coma
20-30g glucose IV - 200-300ml of 10% dextrose rather than 50% glucose because harms veins
Then when conscious give sugary drinks and meal
82
What is HONK, who gets it, presentation and treatment?
Hyperglycaemic hyperosmolar non-ketotic coma
T2dm
1 week hx of marked dehydration and glucose >35 - no acidosis as no switch to ketone metabolism
Osmolality >340
Risk of occlusive events
Rehydrate slowly with 0.9% saline over 48hours - deficits slightly larger than in DKA
K+ replacement and only insulin if blood glucose not falling by 5/hour
83
Egs of sulphonylureas
Glipizide
Gliclazide
Gliquidone
Glimepiride
84
Mechanism of action of sulfonylureas
Bind to k+ channel on beta s
85
What is diabetes insipidus?
Inadequate secretion of vasopression (ADH) or renal insensitivity to ADH causing lack of water resorption in the collecting duct and therefore a hypotonic polyuria
86
What are the two types of DI
Cranial/central - failure of production of ADH by the posterior pituitary
Nephrogenic - insensitivity of kidneys (failure of aquaporin activation)
87
Causes of central DI
```
Similar to causes of other pituitary problems
Trauma
Vascular (Sheehans)
Tumour
Infiltrative - sarcoid
Infection - meningitis
```
88
Causes of nephrogenic DI
```
Idiopathic
Drugs (lithium)
Post-obstructive nephropathy
Pyelonephritis
Pregnancy
Osmotic diuresis (diabetes mellitus)
```
89
Symptoms of DI
Polyuria
Polydipsia
Nocturia (enuresis in children)
Dehydration if fluid intake is not greater than fluid output
90
What are the two types of DI
Cranial/central - failure of production of ADH by the posterior pituitary
Nephrogenic - insensitivity of kidneys (failure of aquaporin activation)
91
Causes of central DI
```
Similar to causes of other pituitary problems
Trauma
Vascular (Sheehans)
Tumour
Infiltrative - sarcoid
Infection - meningitis
```
92
Interpretation of results of diagnostic test for DI
Give desmopressin which is ADH analogue
Urine osmolality should increase over the test (>600mosmol/kg)
If lack of ADH activity then urine will not become concentrated and osmolality will remain below 400mosm/kg
If cranial cause for DI then desmopressin will cause >50% increase in urine osmolality
If renal DI cause then desmopressin administration will cause urine osmolality to rise less than 45%
93
Treatment of central DI
```
Given desmopressin (Vasopressin analogue) 10ug/day intranasally
In mild disease chlorpropamide or carbamazepine can be used to increase effects of residual vasopressin
```
94
DI Investigations
Raised plasma osmolality
Low urine osmolality
Ca may be high (hypercalcaemia can cause nephrogenic DI)
U&E
95
Diagnostic test for DI
Water deprivation test - 8h (monitor weight and if WL >3%then stop)
Measure plasma and urine osmolality every hour
Desmopressin given after 8h and measure urine osmolality again
96
Interpretation of results of diagnostic test for DI
Urine osmolality should increase over the test (>600mosmol/kg)
If lack of ADH activity then urine will not become concentrated and osmolality will remain below 400mosm/kg
If cranial cause for DI then desmopressin will cause >50% increase in urine osmolality
If renal DI cause then desmopressin administration will cause urine osmolality to rise less than 45%
97
Treatment of central DI
```
Given desmopressin (Vasopressin analogue) 10ug/day intranasally
In mild disease chlorpropamide or carbamazepine can be used to increase effects of residual vasopressin
```
98
Treatment of renal DI
Treat the cause
Sodium and/or protein restriction may help
Thiazide diuretics
99
What is SIADH
Syndrome of inappropriate ADH secretion - continual ADH secretion despite absence of normal stimuli for secretion (high serum osmolality or low blood volume) - as it functions to retain water in the body
100
Causes of SIADH
```
Multiple brain, lung and tumour causes
Also drugs (vincristine, opiates, carbamazepine, chlorpropramide)
```
101
What does SIADH cause
Hyponatraemia due to dilutional affects of water retention
| SIADH is the cause for more than 50% of severe hyponatraemias caused in hospital
102
Symptoms of SIADH
Symptoms of hyponatraemia - headache, n+v, muscle cramp/weakness, irritability, confusion, drowsiness, convulsions and coma
Along with symptoms of the underlying cause
103
Signs of SIADH
Signs of hyponatraemia - decreased reflexes
| Along with signs of underlying cause
104
SIADH diagnosis
Decreased plasma osmolality and sodium
Increased urinary osmolality >100mosm and sodium >20mmol
In the absence of hypovolaemia/hypotension, oedema, renal failure, adrenal insufficiency and hypothyroidism
105
Management of SIADH
Identify underlying cause
Water restriction
If ineffective then give demeclocycline (decrease responsiveness of collecting duct to ADH)
Vasopression receptor antagonists eg. tolvaptan may help
106
Management of severe SIADH
IV slow hypertonic 3% saline + furosemide
Change in Na must not be >10mmol in first 24hrs and 18mmol in 48hrs
Rapid correction can cause central pontine myelinolysis
107
target hba1c in D1m
Below 7%
| Check every 3-6months
108
Causes of secondary diabetes
```
Pancreatic disease (Chronic pancreatitis, HH, pancreatic cancer, surgical removal of pancreas)
Endocrine (Cushing's, acromegaly, phaeochromocytoma, glucagonoma)
Drugs (steroids, atypical antipsychotics, protease inhibitors)
```
109
Side effects of pioglitazone? X6
```
Weight gain
Liver impairment - monitor LFT's
Fluid retention therefore CI in heart failure
Fracture risk
Bladder cancer
```
110
BP target in T2DM
less than 130/80 if end organ damage
| less than 140/80 if no end organ damage
