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PHA 332 > diabetes in practice andrew > Flashcards

diabetes in practice andrew Flashcards

1
Q

what occurs when a person has hypoglycaemia?

A

glucagon -alpha cells are activate
this causes an increase in glycogenolysis and gluconeogenesis
this allows for glucose release and an increase in blood glucose

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2
Q

what happens when a person has hyperglycaemia?

A

insulin secreted - beta cella
increase glucose uptake and glycogeneiss
decrease glycogenolysis and glucogenesis
decrease in blood glucose

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3
Q

define diabetes mellutus

A

Diabetes mellitus is a group of metabolic disorders in which persistent hyperglycaemia (random plasma glucose more than 11 mmol/L) is caused by deficient insulin secretion, resistance to the action of insulin, or both

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4
Q

what is the difference between type 1 and type 2 diabtes?

A

Type1 diabetes—an absolute insulin deficiency causes persistent hyperglycaemia (insulin activity is normal).
Type2 diabetes—insulin resistance and a relative insulin deficiency result in persistent hyperglycaemia

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5
Q

how many people with diabetes have had a medication error?

A

about 1/3

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6
Q

how would you assess and diagnose a person with suspected diabetes in children and young adults?

A

hyperglycaemia- plasma glucose >11mmol/L

features: polyuria, polydipsia, weight loss, excessive tiredness

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7
Q

how would you assess and diagnose an adult with diabetes?

A

random plasma glucose >11mmol/L

typically one or more of the following : ketosis, weight loss, <50 yr, BMI <25kg/m2, Hx/fhs autoimmune diseases

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8
Q

how do you monitor glucose levels?

A

hba1c - most accurate over a period of time

self monitoring: plasma glucose/ urine glucose

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9
Q

why is it so important to measure glucose levels?

A

as symptoms are not really a reliable guide to blood glucose control
in emergency sceneraios
to adjust doses of insulin

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10
Q

what effects does a 1% reduction in HBa1c have?

A

–21% reduction in diabetes related death
–14% reduction in myocardial infarctions
–37% reduction in microvascular complications

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11
Q

how often should one monitor their blood glucose levels?

A

use frequent self-monitoring :
min 4 times a day before meals and bed
increased frequency of monitoring during illness and driving

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12
Q

what are the optimal targets for the blood glucose levels?

A

–5-7mmol/L on waking (fasting)
–4-7mmol/L before meals and at other times of the day
–5-9mmol/L at least 90 minutes after meals

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13
Q

what is the HBA1c recommendations?

A

Aim for a HbA1c<48mmol/mol (6.5 %) without disabling hypoglycaemia

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14
Q

what do the targets for hba1c set a balance around?

A

Targets set around balance between risk of hypoglycaemia & risk of long-term vascular complications

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15
Q

how often should the hba1c be tested?

A

every 3-6 months, more if poor control

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16
Q

how is the natural profile of insulin made up?

A

basal - steady low level of background insulin

meal time bolus: increased secretion in response to glucose absorbed from food and drink

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17
Q

what is the aim of T1DM insulin therapy?

A

mimic the physiological insulin secretion from a functional pancreas of a person without diabetes
maxamise the chances of attaining the normal blood glucose levels
the more time in nomra glucose levels the lower the risk of complications

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18
Q

what types of insulin are there?

A

animal insulin
human insulin- recomninant DNA technology
insulin analogues- modified human insulins
biosimilars

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19
Q

what types of insulin regimes are there?

A

1,2, or 3 insulin injections per day
MDI- multiple daily injection
CSII- continuous subcutaneous insulin infusion

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20
Q

describe 1,2,3 insulin injection per day regieme

A

rapid or short acting insulin, mixed with intermediate acting insulin
can be premixed or self-mixed

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21
Q

describe MDI

A

most perfered choice
rapid or short acting insulin before meals and one or more separate daily injections of intermediate or long acting insulin analogue

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22
Q

describe CSII

A

portable electromechanical pump that can gives vasal infusion and individual doses when required

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23
Q

when is 1 injection per day suitable?

A

long term control in a person with type 2 diabetes

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24
Q

what is the first line treatment for type 2 diabtes

A

basal-bolus insulin regime
long acting- twice daily insulin detemir
once daily glargine if not tolerated
rapid acting- rapid acting insulin analogues before meals

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25
Q

what should you measure insulin in?

A

units never mls

usually manufactured in concentrations of 100 units/ ml but not always

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26
Q

when would a person be considered hypoglycaemic?

A

when blood glucose falls to less than 3.5mmol/L

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27
Q

how should you manage hypoglycameia?

A

10–20g of a fast-acting form of carbohydrate
Recheck blood glucose levels after 10–15minutes
•No response or an inadequate response,repeat as above and re-test blood glucose levels after another 15minutes
If the person isunconscious and unable to swallow (severe hypoglycaemia):
•Intramuscular (IM) glucagon should be administered immediately.

28
Q

what is a person of type 1 diabetes at risk from?

A

microvascular/macrovasuclar complications

poorly controlled insulin patients also at risk of DKA

29
Q

what are the sick day rules that dont require admission?

A
  • Do not stop insulin therapy (may require dosing adjustment)
  • Increase monitoring áup to every 1-2 hours
  • Ketone monitoring
  • Maintain meal pattern where possible
  • 3L of fluid
  • Seek medical attention if violently sick, drowsy or unable to keep fluids down
  • Monitor until blood glucose returns to normal
30
Q

how do you diagnose type 2 diabetes?

A
  • Hyperglycaemia (random plasma glucose > 11 mmol/L) or HbA1c >48 mmol/mol (6.5%)
  • Fasting plasma glucose >7 mmol/molCharacteristic features (not always present or severe)–Polyuria, polydipsia, weight loss, tiredness, blurred vision, infections
31
Q

what are the benefits of self-monitoring in type 2 diabetes?

A 
none it produeces a lower quality of life
only do it unless: 
- on insulin treatment
-evidence of hypoglacemic epsoides
to ensure safety e.g. work
32
Q

give an example of biguanides, sulphonylureases, intestinal a-glucosidases inhibitors, glitazones, megliyinides, SGLT2 inhibitors, gliptins, GLP-1 mimetics

A 
1- metfomnin
2- gliclazine
3- acarbose
3-pioglitazone
4- repaglinide
5-dapagliflozin
6- sitagliptin
7-exenatide
33
Q

is maintenance leve of glucosed ahcieved in many type 2 diabetes patients?

A

no-for most type 2 patients progressive failure of insulin secretion
therefore therapy has to be stepped up with time

34
Q

what are you drug choice recommendations base on to maintain glucose control T2?

A

–control of blood glucose levels–prevention of microvascular and macrovascular damage–patient factors (e.g. compliance) –side effects

35
Q

why is metformin started on a low dose?

A

usually started on 500 mg OD and titrated up after 8 days due to the GI related side effects
also there is a risk of lactic acidosis

36
Q

when should you avoid metformin?

A

Avoid if eGFR <30mL/minute /1.73m2

37
Q

how should sulphonylurea- gliclazide be taken?

A

Initially 40–80mg OD, increased if necessary up to 160mg OD, dose to be taken with breakfast, doses higher than 160mg to be given in divided doses; maximum 320mg per day.

38
Q

what are the side effects of glicalazide?

A

can cause weight gain

risk of hypoglycaemia

39
Q

how should pioglitazone be taken?

A

15–30mg once daily, adjusted according to response to 45mg once daily

40
Q

what are the risks associated with pioglitazone?

A

Increased incidence of bladder cancer, educate patients to report haematuria, dysuria, or urinary urgency
•Increased fracture risk

41
Q

what do gliptins help with?

A

may help with weight loss as it reduces appetite

42
Q

what does gliptins increase chances of?

A

pancreatitis

43
Q

what problems are assoicated with gliflozins?

A

restrictions of renal impairment

increased risk of UTI and DKA

44
Q

When do you consider adding exenatide to metformin and sulfonlyurea ?

A

if
BMI > 35kg/m and there are problems associated with high weight
or
BMI< 35kg and insulin is unacceptable because of occupational implications or weight loss would be of benefit

45
Q

what is first line drug treatment?

A

Metforminor (gliptin or pioglitazone or sulphonylurea)

46
Q

what is second line drug treatment?

A

Metformin + gliptin
Metformin + pioglitazone
Metformin+ sulphonylurea
(Metformin+ SGLT-2i)

47
Q

what is 3rd line drug treatment?

A

Metformin + gliptin + sulphonylureaMetformin+ glitazone+ sulphonylureaMetformin + Insulin

48
Q

why insulin therapy in type 2 diabetes?

A

Blood glucose control deteriorates
Oral-glucose lowering therapies no longer maintain blood glucose control
Insulin replacement becomes necessary

49
Q

what are the diabetic complications?

A
  • Cardiovascular risk–Blood pressure –Lipids–Anti-thrombotic therapy
  • Kidney Damage
  • Eye Damage
  • Nerve Damage–Diabetic neuropathic pain management–Autonomic Neuropathy
50
Q

what is the cardiovascular blood pressure up to date treatment?

A

Offer lifestyle advice
↓Start ACE inhibitor or ARB* (titrate dose)(if black African-Caribbean consider an ARB in preference to ACE
↓Add calcium-channel blocker or diuretic (usually thiazide)
↓Add diuretic (usually thiazide) or calcium-channel blocker
↓Resistant Hypertension -Add α-blocker, β-blocker or K-sparing diuretic –Specialist Advice

51
Q

are people with t2 diabetes at high cardiovascular risk?

A

yes- usualy start statin e.g. atorvastatin 20mg

unless they are assessed as being low cardiovascular risk

52
Q

when should you offer anti-thrombotic therapy to patients?

A

NEVER unless there is established risk of CV disease- aspirin 75mg daily

53
Q

what is the primary prevention of kidney damage?

A

prevention of microvascular damage and aterial damage

54
Q

how do we identify and treat kidney damage?

A

annually we use first pass monitoring urine specimen for estimation of albumin: creatinine ratio
measure serum creatinine and calculated eGFR

55
Q

what do we do if there is conformed diabetic nephropathy?

A

start ACEi

56
Q

what readings confirm diabetic nephropathy?

A

i.e. 2 or more raised ACR results:
>2.5 mg/mmol(men)
>3.5 mg/mmol(women)

57
Q

when should a person with diabetes have their eyes monitored?

A

around time of diagnosis and frequent eye testing according to the findings
at least annually

58
Q

what is the general lifestyle advice you would give a person who has diabetes?

A
  • Balanced diet
  • Fibre, low GI carbohydrates, low fat dairy, oily fish
  • Control saturated and trans fatty acids
  • Reduce alcohol intake (max units?)
  • Physical activity (how much?)
  • Smoking cessation (how?)
  • Foot care
  • Eye care (frequency?)
59
Q

what is periodontitis and how does it affect diabetic people?

A

a chronic inflammatory disease caused by bacterial infection of the supporting tissues surrounding the teeth
Two way relationship
if you can reduce one you reduce other

60
Q

what OTC products can you not give a person with diabetes?

A

systemic decongestants- due to unwated side effects e.g. CV risk and increased BP
topical decongestants less of an issue but can still cause probelms
Sugar contents of liquids- sugar freee if possible

61
Q

what happens if a person has a throat infection with diabetes?

A

treated as normal but questioned about their blood glucose control

62
Q

give an example of infections people with diabetes are more prone to?

A

throat infections, cystitis and thrush

63
Q

what happens when a person with diabetes has diarrhoea?

A

caution as:
could be side effect of medications
-could also be due to autonomic nervous system damage

64
Q

what is dka?

A

Diabetic Ketoacidosis
•Life threatening emergency
•Ketosis, hyperglycaemia and acidaemia
•Insulin deficiency + increase in counter regulatory hormones
•Enhanced gluconeogenesis and glycogenolysiscausing severe hyperglycaemia

65
Q

how does ketogenesis occur?

A

Increased lipolysis and metabolism of free fatty acids resulting in ketogenesis
•Increased ketones
•Subsequent metabolic acidosis
•Fluid depletion and electrolyte disturbances

66
Q

how do you diagnose ketoasidosis?

A
  • Ketonaemia> 3.0mmol/L or significant ketonuria(more than 2+ on standard urine sticks)
  • Blood glucose > 11.0mmol/L or known diabetes mellitus
  • Bicarbonate (HCO3-) < 15.0mmol/L and/or venous pH < 7.3
67
Q

how do you manage DKA?

A
  • Fluid replacement –correct hypotension, counteract osmotic diuresis and correct electrolyte disturbances
  • Insulin –fixed rate infusion 0.1 units/kg
  • Often necessary to administer IV glucose to avoid hypoglycaemia. Usually when blood glucose falls below 14mmol/L.Continue until normal eating and drinking resumes

PHA 332 (42 decks)

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