Diabetes Finals Flashcards
How often shoudl Hba1c be monitored in T1DM
What is the target in T1DM
HbA1c
should be monitored every 3-6 months
<48/6.5%
How many times a day to monitor blood glucose in T1DM
recommend testing at least 4 times a day, including before each meal and before bed
NOTE: do more frequent if pregnant, sick or breastfeeding and sport
Autoantibodies in T1DM
Anti-islet cell antibodies
Anti-GAD antibodies
Anti-insulin antibodies
Mx of Type1DM
Basal Bolus Regime
or Insulin pumps
Describe a Basal Bolus regime
SC
Basal - a long acting insulin once or twice daily:
Long-acting insulins in the background
insulin determir (Levemir): given once or twice daily
insulin glargine (Lantus): given once daily
Bolus
Short Acting/Rapid Insulin before meals
Actrapid (short)
Humulin S (S for short)
Rapid -
insulin aspart: NovoRapid
insulin lispro: Humalog
Disadvantages of an Insulin Pump
Advantages
Difficulties learning to use the pump
Having it attached at all times
Blockages in the infusion set
A small risk of infection
Good:
better blood sugar control, more flexibility with eating and less injections.
Dx of T2DM
If the patient is symptomatic:
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
When HbA1c is used for the diagnosis of diabetes:
a HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus ( NOTE - cannot use this in children, CKD, gestational diabetes, HIV, anaemia, people taking steroids)
If not:
If the patient is asymptomatic the above criteria apply but must be demonstrated on **two **separate occasions.
Tx of Diabetic Neuropathy
Duloxetine
Features of Diabetic neuropathy
Sensory ‘glove and stocking’ loss
T2DM mx ladder
Lifestyle
Lifestyle + Metformin
Dual Therapy - Lifestyle+ Metformin and Another drug
ex:
metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea
metformin + SGLT-2 inhibitor (if high heart disease present)
**Triple Therapy: **
Lifestyle, Metformin + 2 other drugs
ex:
metformin + DPP-4 inhibitor + sulfonylurea
metformin + pioglitazone + sulfonylurea
(Or can have SGLT2 as one of them if requirements met)
Or INSTEAD - Insulin Based treatment as third line
If none of this works, consider adding GLP-1 mimetic
* *If a triple therapy line has failed consider switiching one of the drugs to a GLP-1 mimetic, especially if BMI>35**
SGLT-2 inhibitor
Glycosuria (glucose in the urine)
Increased urine output and frequency
Genital and urinary tract infections (e.g., thrush)
Weight loss
Diabetic ketoacidosis
Pioglitazone SE
Weight gain
Heart failure - CI in heart stuff
Increased risk of bone fractures
A small increase in the risk of bladder cancer
DPP-4 inhibitors SE
Headaches
Low risk of acute pancreatitis
DPP-4 inhibitor mechanism
examples
DPP-4 inhibitors block the action of DPP-4, allowing increased incretin activity.
sitagliptin and alogliptin.
GLP-1 mimetics action
GLP-1 examples
GLP-1 mimetics imitate the action of GLP-1. Examples are exenatide and liraglutide.
GLP-1 SE
Reduced appetite
Weight loss
Gastrointestinal symptoms, including discomfort, nausea and diarrhoea
Hypersomalar Hyperglycaemic State features and mx
(hyperglycaemia) and the absence of ketones
IV fluids and careful monitoring.
Sick Day Rules T1 DM
if a patient is on insulin, they **must not **stop it due to the risk of diabetic ketoacidosis, check blood glucose more frequently,
maintain normal meal pattern if possible - if LOA, try to at least eat carbohydrate-containing drinks (such as milk, milkshakes, fruit juices, and sugary drinks)
Ramadan Rules
for patients taking metformin the expert consensus is that the dose should be split one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar)
expert consensus also recommends switching once-daily sulfonylureas to after sunset. For patients taking twice-daily preparations such as gliclazide it is recommended that a larger proportion of the dose is taken after after sunset
no adjustment is needed for patients taking pioglitazone
Hypoglycaemia Mx
If awake: oral glucose 10-20g should be given in liquid, gel or tablet form
unconscious or unable to swallow: subcutaneous or intramuscular injection glucagon
Or if no response - intravenous 10% glucose solution
DVLA rules
there has not been any severe hypoglycaemic event in the previous 12 months, they can drive
SICK day Rules T2DM
STOP oral hypoglycaemics during acute illness
medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours
metformin: stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.
sulfonylureas: may increase the risk of hypoglycaemia - so stop
SGLT-2 inhibitors: check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA
GLP-1 receptor agonists: stop treatment if there is a risk of dehydration, to reduce the risk of AKI
if on insulin therapy, do not stop treatment, as above
T2DM Morning Surgery Rules
Metformin - If taken once or twice a day - take
as normal. If taken three times per day, omit lunchtime dose
Sulfonylurea - If taken once daily in the morning - omit the dose that day If taken twice daily - omit the morning dose that day
SGLT-2 inhibitors (-flozins) - omit that day of surgery
DPP4/GLP-1 - Take as normal
Gestational Diabetes RFs
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Gestational Diabetes Dx
oral glucose tolerance test (OGTT)
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
If women with prev GD, do this at booking scan and at 24-28 weeks
women with RFs at 24-28 weeks
T2DM Day before surgery Rules
Metformin - NORMAL
Sulfonylurea - NORMAL
SGLT2 - NORMAL
DPP4/GLP-1 - NORMAL
T2DM Afternoon Surgery
Metformin - If taken once or twice a day - take as normal If taken three times per day, omit lunchtime dose
Sulfonylurea - If taken once daily in the morning
omit the dose that day If taken twice daily - omit both doses that day
SGLT-2 - OMIT that day
DPP4/GLP1- take as normal
GD mx
newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered**
If targets not met in 1-2 weeks, then do exercise + metformin
If targets STILL not met - then add SHORT-ACTING INSULIN
OR
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started immediately
OR
If 6-6.9 mmol and evidence of complications (macrosomia ex) - START insulin
DKA mx
F – Fluids – IV fluid resuscitation with normal saline (e.g., 1 litre in the first hour, followed by 1 litre every 2 hours)
I – Insulin – fixed rate insulin infusion (e.g., Actrapid at 0.1 units/kg/hour)
G – Glucose – closely monitor blood glucose and add a glucose infusion when it is** less than 14 mmol/L**
P – Potassium – add potassium to IV fluids and monitor closely (e.g., every hour initially - normally cannot exceed 10 mmol/hour, but in DKA up to 20mmol/hour)
I – Infection – treat underlying triggers such as infection
C – Chart fluid balance
K – Ketones – monitor blood ketones, pH and bicarbonate
What is alcoholic Ketoacidosis?
Mx
Non-diabetic form of ketoacidosis, in people who drink a LOT.
Often alcoholics will not eat regularly and may vomit food that they do eat, leading to episodes of starvation. Body may break down ketones
Presents with a raised Anion Gap and Metabolic acidosis
Mx - Saline and Thiamine
