diabetes in practice andrew Flashcards
what occurs when a person has hypoglycaemia?
glucagon -alpha cells are activate
this causes an increase in glycogenolysis and gluconeogenesis
this allows for glucose release and an increase in blood glucose
what happens when a person has hyperglycaemia?
insulin secreted - beta cella
increase glucose uptake and glycogeneiss
decrease glycogenolysis and glucogenesis
decrease in blood glucose
define diabetes mellutus
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
what is the difference between type 1 and type 2 diabtes?
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
how many people with diabetes have had a medication error?
about 1/3
how would you assess and diagnose a person with suspected diabetes in children and young adults?
hyperglycaemia- plasma glucose >11mmol/L
features: polyuria, polydipsia, weight loss, excessive tiredness
how would you assess and diagnose an adult with diabetes?
random plasma glucose >11mmol/L
typically one or more of the following : ketosis, weight loss, <50 yr, BMI <25kg/m2, Hx/fhs autoimmune diseases
how do you monitor glucose levels?
hba1c - most accurate over a period of time
self monitoring: plasma glucose/ urine glucose
why is it so important to measure glucose levels?
as symptoms are not really a reliable guide to blood glucose control
in emergency sceneraios
to adjust doses of insulin
what effects does a 1% reduction in HBa1c have?
–21% reduction in diabetes related death
–14% reduction in myocardial infarctions
–37% reduction in microvascular complications
how often should one monitor their blood glucose levels?
use frequent self-monitoring :
min 4 times a day before meals and bed
increased frequency of monitoring during illness and driving
what are the optimal targets for the blood glucose levels?
–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
what is the HBA1c recommendations?
Aim for a HbA1c<48mmol/mol (6.5 %) without disabling hypoglycaemia
what do the targets for hba1c set a balance around?
Targets set around balance between risk of hypoglycaemia & risk of long-term vascular complications
how often should the hba1c be tested?
every 3-6 months, more if poor control
how is the natural profile of insulin made up?
basal - steady low level of background insulin
meal time bolus: increased secretion in response to glucose absorbed from food and drink
what is the aim of T1DM insulin therapy?
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
what types of insulin are there?
animal insulin
human insulin- recomninant DNA technology
insulin analogues- modified human insulins
biosimilars
what types of insulin regimes are there?
1,2, or 3 insulin injections per day
MDI- multiple daily injection
CSII- continuous subcutaneous insulin infusion
describe 1,2,3 insulin injection per day regieme
rapid or short acting insulin, mixed with intermediate acting insulin
can be premixed or self-mixed
describe MDI
most perfered choice
rapid or short acting insulin before meals and one or more separate daily injections of intermediate or long acting insulin analogue
describe CSII
portable electromechanical pump that can gives vasal infusion and individual doses when required
when is 1 injection per day suitable?
long term control in a person with type 2 diabetes
what is the first line treatment for type 2 diabtes
basal-bolus insulin regime
long acting- twice daily insulin detemir
once daily glargine if not tolerated
rapid acting- rapid acting insulin analogues before meals
what should you measure insulin in?
units never mls
usually manufactured in concentrations of 100 units/ ml but not always
when would a person be considered hypoglycaemic?
when blood glucose falls to less than 3.5mmol/L
how should you manage hypoglycameia?
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.
what is a person of type 1 diabetes at risk from?
microvascular/macrovasuclar complications
poorly controlled insulin patients also at risk of DKA
what are the sick day rules that dont require admission?
- 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
how do you diagnose type 2 diabetes?
- 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
what are the benefits of self-monitoring in type 2 diabetes?
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
give an example of biguanides, sulphonylureases, intestinal a-glucosidases inhibitors, glitazones, megliyinides, SGLT2 inhibitors, gliptins, GLP-1 mimetics
1- metfomnin 2- gliclazine 3- acarbose 3-pioglitazone 4- repaglinide 5-dapagliflozin 6- sitagliptin 7-exenatide
is maintenance leve of glucosed ahcieved in many type 2 diabetes patients?
no-for most type 2 patients progressive failure of insulin secretion
therefore therapy has to be stepped up with time
what are you drug choice recommendations base on to maintain glucose control T2?
–control of blood glucose levels–prevention of microvascular and macrovascular damage–patient factors (e.g. compliance) –side effects
why is metformin started on a low dose?
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
when should you avoid metformin?
Avoid if eGFR <30mL/minute /1.73m2
how should sulphonylurea- gliclazide be taken?
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.
what are the side effects of glicalazide?
can cause weight gain
risk of hypoglycaemia
how should pioglitazone be taken?
15–30mg once daily, adjusted according to response to 45mg once daily
what are the risks associated with pioglitazone?
Increased incidence of bladder cancer, educate patients to report haematuria, dysuria, or urinary urgency
•Increased fracture risk
what do gliptins help with?
may help with weight loss as it reduces appetite
what does gliptins increase chances of?
pancreatitis
what problems are assoicated with gliflozins?
restrictions of renal impairment
increased risk of UTI and DKA
When do you consider adding exenatide to metformin and sulfonlyurea ?
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
what is first line drug treatment?
Metforminor (gliptin or pioglitazone or sulphonylurea)
what is second line drug treatment?
Metformin + gliptin
Metformin + pioglitazone
Metformin+ sulphonylurea
(Metformin+ SGLT-2i)
what is 3rd line drug treatment?
Metformin + gliptin + sulphonylureaMetformin+ glitazone+ sulphonylureaMetformin + Insulin
why insulin therapy in type 2 diabetes?
Blood glucose control deteriorates
Oral-glucose lowering therapies no longer maintain blood glucose control
Insulin replacement becomes necessary
what are the diabetic complications?
- Cardiovascular risk–Blood pressure –Lipids–Anti-thrombotic therapy
- Kidney Damage
- Eye Damage
- Nerve Damage–Diabetic neuropathic pain management–Autonomic Neuropathy
what is the cardiovascular blood pressure up to date treatment?
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
are people with t2 diabetes at high cardiovascular risk?
yes- usualy start statin e.g. atorvastatin 20mg
unless they are assessed as being low cardiovascular risk
when should you offer anti-thrombotic therapy to patients?
NEVER unless there is established risk of CV disease- aspirin 75mg daily
what is the primary prevention of kidney damage?
prevention of microvascular damage and aterial damage
how do we identify and treat kidney damage?
annually we use first pass monitoring urine specimen for estimation of albumin: creatinine ratio
measure serum creatinine and calculated eGFR
what do we do if there is conformed diabetic nephropathy?
start ACEi
what readings confirm diabetic nephropathy?
i.e. 2 or more raised ACR results:
>2.5 mg/mmol(men)
>3.5 mg/mmol(women)
when should a person with diabetes have their eyes monitored?
around time of diagnosis and frequent eye testing according to the findings
at least annually
what is the general lifestyle advice you would give a person who has diabetes?
- 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?)
what is periodontitis and how does it affect diabetic people?
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
what OTC products can you not give a person with diabetes?
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
what happens if a person has a throat infection with diabetes?
treated as normal but questioned about their blood glucose control
give an example of infections people with diabetes are more prone to?
throat infections, cystitis and thrush
what happens when a person with diabetes has diarrhoea?
caution as:
could be side effect of medications
-could also be due to autonomic nervous system damage
what is dka?
Diabetic Ketoacidosis
•Life threatening emergency
•Ketosis, hyperglycaemia and acidaemia
•Insulin deficiency + increase in counter regulatory hormones
•Enhanced gluconeogenesis and glycogenolysiscausing severe hyperglycaemia
how does ketogenesis occur?
Increased lipolysis and metabolism of free fatty acids resulting in ketogenesis
•Increased ketones
•Subsequent metabolic acidosis
•Fluid depletion and electrolyte disturbances
how do you diagnose ketoasidosis?
- 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
how do you manage DKA?
- 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
