diabetes management Flashcards
what tests can be done to confirm diabetes?
Urine for ketones
Fasting Plasma glucose levels, >6.9mmol/L
HbA1c of >48mmol
OGTT >11.0mmol/L after 2hrs of 75g anhydrous glucose
what signs suggest DKA?
Signs of metabolic acidosis
e.g fruity breath, vomiting, non-specific abdominal pain
BP
Significant ketonuria +2 on dipstick
Ketonaemia >3.0mmol/L
what is HbA1c?
Glycated haemoglobin which reflects blood glucose over previous 8-12 weeks. It can be performed at any time of the day and does not require any special preparation such as fasting. This makes a preferred tests for assessing glycemic control in people with diabetes.
HbA1c >48mmol/mol or > 6.5% used to diagnose diabetes
Used as primary investigation with fasting plasma glucose for type 2 diabetes
Can be used alongside other tests for type 1 diabetes to aid investigation
what are the limitations of HbA1c?
- Erythropoiesis can vary value
- genetic variance in haemoglobin can alter value
- elevated HbF can affect levels
- iron deficiency anaemia can affect levels (higher than expected)
- iron replacement therapies can lower HbA1c
- cant use in kids
- not really useful in type 1 diabetes as its an acute onset compared to type 2, so 3 months wouldn’t work
what are the macrovascular complications of diabetes?
- stroke
- CV disease
- peripheral vascular disease
how can diabetes lead to stroke and MI?
Present acutely
May be due to the prothrombotic state or an embolism thrown by a atherosclerotic plaque.
May also be due to a decrease in blood flow to the brain and heart caused by occlusion of vessels due to plaques
how can diabetes lead to peripheral vascular disease and what are the symptoms?
Caused by atherosclerosis leading to occlusions in the arteries supplying extremities
get
- Leg cramps when walking
- Lower limbs numb or cold
- Pale or blue colouration
- Infections or ulceration/ extended healing process
- Hair loss
how are the macrovascular risk factors for diabetes managed?
Screen for CVD risk factors
Stop smoking
Healthy diet
Frequent exercise
Reduce weight
May be prescribed blood thinners eg aspirin if risk factors are significant
May be prescribed a statin eg atorvostatin to help control cholesterol
If blood glucose is well controlled and CVD risk factors are reduced, there is a significant decrease in the likelihood of patients presenting with macrovascular complications
what are the microvascular complications of diabetes?
Uncontrolled diabetes causes small vessel disease affecting kidneys,nerves and retinas
Microvascular complications include
retinopathy,
neuropathy and
nephropathy
UK national guidance recommends that pts with T1DM aim for a target HbA1c level of 48 mmol/mol or lower to minimise the risk of long-term vascular complications.
describe the management and screening for diabetic retinopathy.
Retinopathy is asymptomatic until its late stages - therefore screening is essential
Primary prevention - strict glycaemic control
Blindness is preventable → annual retinal screening mandatory for all pts
Dilated eye examinations by an ophthalmologist or optometrist should be performed within 5 years of onset in type 1 DM and at the time of diagnosis in type 2 DM, then follow up annually.
In more complex cases, can do intravenous fluorescein angiography and optical coherence imaging.
what is the pathophysiology of diabetic retinopathy?
Persistent damage to the retina leads to areas of ischaemia and release of angiogenic factors VEGF
(Vascular Endothelial Growth Factor)
Promotes new formation of new vessels Weak and friable Leads to complications Haemorrhage Fibrosis Retinal detachment
get 2 types
1) non proliferative = early stage, less severe. get microaneurysms
2) proliferative = more advanced, new blood vessels grow which are sensitive.
describe the screening and management for diabetic nephropathy.
Can progress to ESRD ( End stage renal disease)
Marked by proteinuria. Earliest sign is presence of microalbuminuria
Can be assess with albumin creatinine ratio (ACR)
Microalbuminuria - Marker of systemic microvascular damage and patients should be treated with an ACEi ( even in the presence of normotension
CKD in diabetes is evidenced by persistently low eGFR <60 mmol/L and/or an ACR persistently >3 mg/mmol/L
describe the screening and management for diabetic neuropathy.
Amputations are common and preventable - good care saves legs = Examine feet regularly for ulcers and loss of sensation
Distinguish between ischaemia ( critical toes +/- absent foot pulses and worse outcome) and peripheral neuropathy ( injury or infection over pressure points e.g. metatarsal heads ) with peripheral nerve examinations, in practice may have both
Some major autonomic neuropathies include
- Postural hypotension
- Gastroparesis ( delayed gastric emptying leading to vomiting)
- Diarrhoea
- Bladder dysfunction
- erectile dysfunction
Diabetic foot problems are thought to happen secondary due to a combination of peripheral neuropathy and poor vascular supply.
how can you screen for the macrovascular classifications of diabetes?
Screen with
- Cholesterol
- Fasting Lipid profile, at least annually. (high LDL-cholesterol, low HDL-cholesterol and high triglycerides)
- Monitor BP at check ups
- Check for foot pulses for peripheral vascular disease
- proteinuria/microalbuminuria
- age and smoking
- gender
- blood glucose
do people with type 2 need their blood sugar monitoring?
mostly, no
some circumstances e.g driving guidelines, they may
