Diabetes e-learning

Question 1

Diabetic Ketoacidosis signs

Answer 1

Tachycardia
Rapid resp rate
Low BP

Question 2

Diagnosing DKA

Answer 2

Urine ketones >++
Blood glucose > 11mmol
Venous pH <7.3
Serum Bicarbonate < 16mmol

Question 3

Causes of hypoglycaemia in hospital patients

Answer 3

1. Too much insulin/ sulphonylureas
2. Not enough food
3. Delayed/ missed meals or snacks
4. Other illnesses esp. renal impairment
5. Exercise (e.g. physio)

Question 4

Examples of sulphonylueas

Answer 4

glicazide or tolbutamide

Question 5

Why do sulphonylureas cause hypoglycaemia?

Answer 5

Trigger the pancreas to release insulin

Question 6

Why does renal impairment lead to hypoglycaemia?

Answer 6

Most diabetic medications are renally excreted so stay in the system for longer when renal function is impaired, leading to hypoglycaemia.

Question 7

Adrenergic Hypoglycaemia

Answer 7

• Noradrenaline, adrenaline and hypoglycaemia
• work with glucagon to oppose insulin
• raise blood glucose

Question 8

Neuroglycopenic Hypoglycaemia

Answer 8

• consequence of low blood glucose on the brain

- brain function is impaired below blood glucose of 3.5 mmol

Question 9

Signs of Adrenergic Hypoglycaemia

Answer 9

Pallor, Perspiration, Bradycardia, Tremor, Tachycardia

Question 10

Symptoms of Adrenergic Hypoglycaemia

Answer 10

Sweating, Shaking, Anxiety, Palpitations, Tingling Lips

Question 11

Signs of Neuroglycopenic Hypoglycaemia

Answer 11

Confusion, Irritability, Lethargy, Fitting, Odd Behaviour, Slurred Speech, Coma, Hemi-paresis

Question 12

Symptoms of Neuroglycopenic Hypoglycaemia

Answer 12

Difficulty speaking/concentrating, visual disturbances, Drowsiness, Hunger, Dizziness

Question 13

Treating Hypos- conscious pt, able to swallow

Answer 13

glucojuice/ glucotabs

Question 14

Treating Hypos- conscious pt, able to swallow not able to cooperate

Answer 14

Glucogel

Question 15

Treating Hypos- pt unconscious, maybe fitting, has IV access

Answer 15

10% glucose with giving set

3 way tap, 50ml syringe for 50ml boluses

Question 16

Treating Hypos- pt unconscious, no IV access

Answer 16

Glucagen

Question 17

Dose Reduction after Hypoglycaemia

Sulphonylureas

Answer 17

• BG may be low for 24-48 hours
• continue 100mls/hr 10% glucose after hypoglycaemia coma
• omit further doses until Diabetes review if BG <3mmol
• Reduce dose by 50% if BG between 3-3.9 mmol without cause (e.g. missed meal)

Question 18

Dose Reduction after Hypoglycaemia

Insulin

Answer 18

• do not omit next dose if Type 1 DM –> May reduce

- next dose may be omitted if T2DM with review from DM team.

Question 19

Quick Acting Insulin

Answer 19

• usually given with meals (3x daily)
• not given at bedtime
• Short acting insulin - Actrapid and Humulin S. Peak at 2 hours
• rapid acting insulin analogues (genetically engineered, usually quicker than short acting insulin) Humalog and Novarapid. Peak at 15 mins

Question 20

Medium or Long Acting Insulin

Answer 20

• usually given twice a day (morning and bed time)
• medium acting insulins - Humulin I and Insulatard
• long acting insulin analogues - Lantus and Levemir

Question 21

Insulin Mixtures

Answer 21

Normally BD. Provide basal and meal time coverage. Never given before bed. Sometimes OD in the elderly.

• Premixed Insulins e.g. Humulin M3 - give 15-20 mins before a meal
• Biphasic Analogue Mixtures e.g Novomix30 or Humalog Mix25 - with or 15mins after carbs

Question 22

Multiple Injection Insulin Regime

Answer 22

quick acting insulin with each meal
1-2 background long acting insulin

T1DM, some T2DM

Question 23

Twice Daily Insulin Regime

Answer 23

Insulin mixtures. T2DM

Question 24

Once Daily Insulin Regime

Answer 24

Medium/long acting insulin at bedtime, plus oral hypoglycaemics in T2DM.

Occasionally elderly pts long acting/mixture in the morning

Question 25

Insulin pumps

Answer 25

- if Hypoglycaemic treat with IV insulin- pump may be broken | - if pump is disconnected at risk of DKA very quickly- give SC insulin

Question 26

DAFNE

Answer 26

Dose Adjustment For Normal Eating - pre-meal/snack short acting, BD medium acting - estimate carb content of food - calculate insulin requirements of food - should be able to self manage - should still record doses and monitoring of self managing pts.

Question 27

Metformin

Answer 27

Doesn't make patients gain weight Biguanide Favourable action on lipids, anti-cancer and cardio-protective Impaired renal function - lactic acidosis in eGFR < 30, diarrhoea and abdominal discomfort

Question 28

Sulphonylureas

Answer 28

gliclazide - stimulate insulin release by binding to B-cell receptors improves glycaemic control at the significant weight gain doesnt prevent gradula failure of insulin secretion can cause hypoglycaemia- occasionally prolonged and fatal- especially in elderly and renally impaired.

Question 29

Thiazolidinediones

Answer 29

``` pioglitazone - activates genes that promote gluocse uptake and utilisation and lipid metabolism improve insulin sensitivity need insulin fro a therapeutic effect relatively rare ```

Question 30

Thiazolidinediones Side Effects

Answer 30

``` Weight gain macular oedema Oedema Heart Failure Increased fracture risk ```

Question 31

Incretin concept

Answer 31

Enteral glucose

Question 32

Effects of GLP-1

Answer 32

``` stimulates insulin secretion suppresses glucagon secretion slows gastric emptying reduces food intake rapidly degraded ```

Question 33

Therapeutic effect of GLP-1 in T@DM

Answer 33

reduces energy intake, blood glucose

Question 34

SGLT2 inhibitors

Answer 34

Block reabsorption of glucose in the kidney, increase glucose excretion and lower blood glucose levels e.g. empagliflozin, canaglioflozin, dapagliflozin may benefit CV mortality

Question 35

SGLT2 inhibitor Side Effects

Answer 35

genital thrush | increased risk of euglycaemic ketoacidosis

Question 36

Bed time insulin

Answer 36

Long acting- maintains liver secretion over night | Combination of bedtime background insulin (NPH) and oral agents

Question 37

weight gain in insulin therapy

Answer 37

- decrease in energy loss as glucosuria ceases and is not compensated for by comparable reduction in energy intake - ? increase in appetite with an anabolic hormone

Question 38

bariatric surgery

Answer 38

can produce profound weight loss and may also alter secretion of incretin hormones - gastric anding/ gastric bypass can cure T2DM in up to 70% even in those treated with insulin

Question 39

DKA

Answer 39

``` raised BG metabolic acidosis (Bicarb <16, pH<7.3) Blood ketones>3mmol / ketonuria >++/4mmol/40mg/l ```

Question 40

Causes of DKA

Answer 40

older age groups- infection | <30 omission of insulin

Question 41

Mortality of DKA

Answer 41

5-10% lower in specialist centres causes - elderly- comorbidities and late presentation -vomiting - 12-24 hours to live without treatment

Question 42

DKA treatment

Answer 42

1. restore circulating blood volume 2. Replace lost electrolytes 3. Return blood glucose towards normal while giving sufficient insulin to inhibit hepatic gluconeogeneis

Question 43

DKA teatment

Answer 43

``` 1l saline in first hour 1 l in next 2 1l in next 4 1l in next 6 - reduce in elderly or in cardiac disease ```

Question 44

DKA potassium

Answer 44

normal or high serum potassium but low total potassium add potassium to the IV when plasma potassium is known >5.5

Question 45

DKA insulin

Answer 45

0.1 unit/kg/hr double concentration if insulin resistant monitor glucose hourly keep high- when BG <14 add glucose to NaCl Target blood glucose is between 8-14 mmol

Question 46

Other measures of DKA

Answer 46

- SpR DM -Urinary catheter -EWS -NG--> HDU commence prophylactic anticoagulation Dont give bicarb

Question 47

Hyperosmolar Hyperglycaemic State

Answer 47

hypovolaemia | hyperglycaemia >30mmol

Question 48

HHS

Answer 48

``` T2DM High mortality Sodium increases normal saline, anticoagulants manage with sulphylureas Don't use insulin routinely slow and steady- prevent rapid fluid shifts treat underlying cause if infection ```