diabetes meadhbh Flashcards
what is diabetes mellitus?
is a group of metabolic disorders in which
persistent hyperglycaemia (random plasma glucose more than 11.1 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 diabetes?
Type 1: absolute deficiency of insulin
* Type 2: insulin resistance with relative deficiency of
insulin
what are the risk factors of diabetes?
Obesity and inactivity; diet; family history of type 2 diabetes; Asian, African, and Afro-Caribbean ethnicity; drug treatments such as long-term corticosteroids; and history of gestational diabetes.
what are the complications associated with diabetes?
Macrovascular: CVD including ischaemic heart disease, stroke and peripheral arterial disease
* Microvascular: chronic kidney disease, retinopathy, peripheral and autonomic neuropathy
* Foot problems- ulcer, deformity, infection
* Metabolic: dyslipidaemia, potentially life-threatening hyperglycaemic emergencies (diabetic ketoacidosis and
hyperosmolar hyperglycaemic state).
* Psychosocial impact: anxiety, depression, eating disorders, behavioural and emotional problems.
* Reduced life expectancy.
what lifestyle advice should be given to patient with diabetes?
diet, exercise, weight management
* Refer to retinal screening programme
* Annual foot checks
* Alcohol
* Smoking
what is type 1 diabetes?
Metabolic disorder characterised by hyperglycaemia due to
absolute insulin deficiency.
* The condition develops due to destruction of pancreatic beta
cells, mostly by immune-mediated mechanisms.
* Without insulin replacement, people with type 1 diabetes
would die within days or weeks.
how do you diagnose type 1 diabetes?
– hyperglycaemia random plasma glucose ≥11.1 mmol/L AND characteristic features
what are the typical signs of type 1 diabetes?
– ketosis
– rapid weight loss
– age of onset under 50
– body mass index (BMI) below 25 kg/m2
– personal and/or family history of autoimmune disease.
what are the targets for type 1 diabetes?
– Aim for HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the
risk of long-term vascular complications.
– Ensure HbA1c target is not accompanied by hypoglycaemia
what are the 3 different types of insulin regimens?
1,2,or 3 insulin injections per day
multiple daily injection
continuous subcutaneous insulin infusion
how does MDI regime work?
– Rapid- or short-acting insulin before meals
AND
– One or more separate daily injections of intermediate- or long-acting insulin analogue
how does CSII regime work?
– Portable electromechanical pump that gives basal infusion & individual bolus doses when required
what is first line insulin therapy?
Multiple daily injection basal–bolus insulin regimen
– Twice-daily insulin detemir as basal insulin
– Or
* Once-daily insulin glargine if insulin detemir is not tolerated or preference for once-daily basal injections
* Once-daily insulin degludec if concern about nocturnal hypoglycaemia or if need healthcare professional/ carer to administer
* AND Rapid-acting insulin analogues that are injected before meal
how often should you monitor blood glucose for type 1?
- Blood glucose monitor, lancets and test strips
- Routine self monitoring at least 4/day including before meals and bed
- Increase monitoring during illness, sport, driving, pregnant, frequent
hypoglycaemia
what are the targets for blood glucose monitoring?
waking- 5-7mmol/L
before meals+ other times of day- 4-7 mmol/L
after meals-90min- 5-9mmol/L
how do you flash monitor?
– Sensor on arm which lasts 14 days.
– Flexible and sterile fibre within the sensor is inserted in the skin to a depth of
5 mm.
– Draws interstitial fluid from the muscle into the sensor, where glucose levels are
automatically measured every minute and stored at 15-minute intervals for
8 hours
– Scan with smartphone app or meter reader
– Current glucose reading, previous 8 hours, trend
– Optional alarms for hypo/ hyperglycaemia
how do you continouus glucose monitor?
– Continuous glucose monitor.
– Sends signal to device/ mobile via bluetooth at 5-minute intervals.
– Sensor 10-14 days
what is hypoglycaemia?
When blood glucose levels fall to less than 3.5 mmol/L
* Levels where signs and symptoms appear may vary
* Cognitive function deteriorates when blood glucose levels fall to less than 3.0 mmol/L.
what is the signs of hypoglycaemia?
hunger, anxiety, palpitations, sweating, tingling lips, weakness, leathery, visual disturbances, confusion, convulsions, loss of consciousness, coma
how do you manage hypoglycaemia?
- 10–20 g of a fast-acting form of carbohydrate, preferably in liquid form as
this is easier to take– 3–6 glucose tablets - Recheck blood glucose levels after 10–15 minutes
– No response or an inadequate response, repeat as above and re-test blood
glucose levels after another 15 minutes - If the person is unconscious and unable to swallow (severe hypoglycaemia):
– Intramuscular (IM) glucagon should be administered immediately.
* Adults - 1 mg of glucagon should be given.
– If no response to glucagon treatment within 10 minutes, emergency transfer
to hospital should be arranged for treatment with IV glucose.
what is hba1c?
Measure of glycosylated haemoglobin
what is the aim for the hba1c?
Aim for HbA1c <48mmol/mol without disabling hypoglycaemia in type 1 diabetes
why is the target for the Hba1c set around that?
Targets set around balance between risk of hypoglycaemia & risk of long-term vascular complications
how often should you test Hba1c levels?
every 3-6 months
what are the limitations of Hba1c?
- Not used for diagnosis in the following groups
– <18 years
– Type 1 diabetes suspected or symptoms <2 months
– Medication that can cause hyperglycaemia (corticosteroids)
– Acute pancreatic damage, end stage renal disease, HIV - Interpret with caution if abnormal red blood cell turnover
– Severe anaemia, recent transfusion
what is type 2 diabetes associated with?
Associated with obesity, physical inactivity, hypertension, disturbed blood lipid levels and increased cardiovascular risk
what are the clinical features of type 2 diabetes?
Polydipsia, polyuria, blurred vision, unexplained weight loss, recurrent
infections, and tiredness, acanthosis nigricans.
how do you diagnose type 2 diabetes?
- HbA1c of 48 mmol/mol (6.5%) or more.
- Fasting plasma glucose level of 7.0 mmol/L or more.
- Random plasma glucose of 11.1 mmol/L or more in the presence of
symptoms or signs of diabetes. - No additional features of type 1 diabetes (rapid onset, often in
childhood, insulin dependence, ketoacidosis).
what are glucose lowering agents used in type 2 diabetes?
biguanide- metformin
sulfunurea- gluclazide
SGLT2 Inhibitors- dapagliflozin
DPP4 inhibitors- gliptins
GLP-1 -exenatide
insulin- human insulin
thiazolidinedione-pioglitazone
what are the benefits of metformin?
CV protection
Moderately-effective
glycaemic control
Hypo risk: low
Weight: neutral to loss
Cost effective
what are the risks of using metformin?
Caution in renal
impairment.
Max 1g <45mL/min.
Stop <30mL/min
Lactic acidosis :
what are the benefits of using sulfonylureas?
High glucose
lowering efficacy
CV neutral
Cost effective
what are the risks for sulfonylureas?
Hypo risk: HIGH
Weight GAIN
Caution in renal
impairment- increased
hypo risk
what are the benefits of DPP-4 inhibitors?
Hypo risk: LOW
Weight: neutral
Linagliptin no dose
reduction in renal
impairment
what are the risks of DPP-4 inhibitors?
Least effective
glycaemic control
Pancreatitis
Cancer?
IBD and heart failure
Pancreatitis: report persistent
severe abdominal pain.
Cholangiocarcinoma: increased
risk (almost double) but very
rare disease
IBD and HF? Possible risk
what are the benefits of GLP-1 inhibitors?
Weight: LOSS
Highly-effective
glycaemic control
CV and renal
benefits
what are the risks of GLP-1 mimetics?
Pancreatitis
Expensive
Cancer?
what is the benefit of pioglitazone?
Moderate glycaemic
control
Hypo risk: LOW
Safe in renal
impairment
Cost effective
what are the risks of pioglitazone?
Heart failure
Weight GAIN
Cancer
Fracture
how should you review the risks of pioglitazone?
Review at 3-6 months and continue only if benefits outweigh risk
* Heart failure: contraindicated in heart failure and can increase the risk of
developing heart failure in patients with risk factors: insulin or history of MI
* Bladder cancer: contraindicated if history of bladder cancer.
* Report haematuria, dysuria, urinary urgency.
* Risk factors: increased age, smoker, previous radiation to bladder.
what are the benefits of SGLT2 inhibitors?
CV and Renal
benefits
Weight: neutral to loss
Hypo risk: LOW
Moderate
glycaemic control
what are the risks of SGLT2 inhibitors?
Urinary and genital inf
Diabetic ketoacidosis
Lower limb
amputation
Fournier’s gangrene
Renal impairment?
what are the signs of DKA?
- Report rapid weight loss, nausea or vomiting, ab pain, fast breathing, sleepiness,
sweet smelling breath/ metallic taste. Discontinue if suspected and do not restart. - Test for ketones even if blood sugar only mildly raised (>14mmol/L)
- Risk factor: low beta cell reserve, dehydration, acute illness, alcohol abuse. Monitor
ketones during surgery
what is first line insulin for type 2 diabetes?
NPH (isophane) insulin injected once or twice daily according to need
when should NPH+ short acting insulin be considered?
– If HbA1c is 75 mmol/mol or higher, to be administered either separately or as a pre-mixed (biphasic) human insulin preparation.
when should you consider insulin deteminr or insulin glargine?
– Carer or healthcare professional injects insulin, and the use of insulin
detemir or insulin glargine would reduce the frequency of injections
from twice to once daily
– The person’s lifestyle is restricted by recurrent symptomatic
hypoglycaemic episodes, or
– The person would otherwise need twice-daily NPH insulin injections in
combination with oral antidiabetic drugs.
what are the sick day rules?
- If persistent vomiting or diarrhoea
– Withhold - Metformin due to risk of lactic acidosis
- SGLT2i due to risk of DKA
- Restart only AFTER patient has been eating normally for AT LEAST
24 HOURS AND no longer acutely unwell
– Insulin- increase monitoring, do not stop
– Sulfonylurea- monitor blood glucose for symptoms of
hypoglycaemia - Drink plenty of fluids
what are the CV risk factors for type 2 diabetes?
– QRISK: primary prevention- atorvastatin 20mg if >10%
– All people with CKD stage 3 or more and/or confirmed urine
microalbuminuria, should be offered atorvastatin 20 mg once daily,
irrespective of lipid profile.
– Now also factors into decision making for diabetes treatment
what is the cv risk for type 1 diabetes?
– Offer statin treatment with atorvastatin 20 mg for the primary
prevention of CVD if the person:
* Is older than 40 years of age, or
* Has had diabetes for more than 10 years, or
* Has established nephropathy, or
* Has other CVD risk factors (such as obesity and hypertension).
what is first line treatment for hypertension with type 2 diabetes?
– Differences: ACEi first line
* ARB preferred if African or African-Caribbean origin
what is the guidelines for hypertension and type 1 diabetes?
– No albuminuria or features of the metabolic syndrome, start antihypertensive treatment in if BP ≥135/85 mmHg.
– Albuminuria or two or more features of the metabolic syndrome, start antihypertensive treatment if BP ≥130/80 mmHg.
– ACEi first line
* ARB preferred if African or African-Caribbean origin
what is an early indicator of diabetic nephropathy?
Microalbuminuria
what are the limits for ARC ratio?
– First-pass morning urine specimen
– If ACR is 3 mg/mmol or more start ACEi or ARB and titrate to
highest tolerated dose
– If ACR 3-30 mg/mmol consider SGLT2i.
– If ACR >30 mg/mmol offer SGLT2i
* Not all SGLT2i licensed. Dapagliflozin licensed
what is DKA?
Life-threatening emergency
* Metabolic triad of hyperglycaemia,
ketonaemia, and metabolic acidosis, with
rapid symptom onset.
* Mainly type 1 diabetes, SGLT2i increases
risk in type 2
What are the landmarks for DKA?
glucose>11mmol/l or known
diabetic
ketone >3.0 mmol/L or significant
ketonuria
bicarbonate concentration of <15.0 mmol/L or
venous pH <7.3
what are the causes of DKA?
– Infection, inadequate insulin, new onset diabetes, medication (SGLT2i,
corticosteroids)
– Insulin deficiency + increase in counter regulatory hormones e.g. glucagon,
cortisol, growth hormone and catecholamines
– Enhanced gluconeogenesis and glycogenolysis causing severe hyperglycaemia
– Increased lipolysis and metabolism of free fatty acids resulting in ketogenesis-
Increased ketones
– Subsequent metabolic acidosis
– Fluid depletion and electrolyte disturbances
what are the symptoms of DKA?
– Rapid presentation of polyuria, polydipsia, rapid weight loss, nausea or vomiting,
ab pain, fast breathing, sleepiness, sweet smelling breath/ metallic taste,
reduced consciousness.
– May be delayed in type 2 diabetes
how do you treat DKA?
– Fluid replacement- correct hypotension, counteract osmotic diuresis and
correct electrolyte disturbances. Potassium to prevent hypokalaemia
* NaCl 0.9% by IV infusion, with potassium chloride adjusted according to plasma levels
– Fixed rate insulin infusion 0.1 unit/kg/hour based on estimated weight made
up to 50mL with 0.9% NaCl
* If patient takes long-acting insulin analogue- continue
* If blood glucose falls <14mmol/L add 10% glucose to prevent rebound hypoglycaemia
* Consider reducing insulin to 0.05units/kg/hr when glucose <14 mmol/L
how do you monitor DKA?
– Hourly capillary glucose and ketones
– Bicarbonate and potassium at 60 mins, 2 hours and then 2 hourly
– U+E (4 hourly) and FBC
– BP, pulse, temperature, oxygen saturation
– Further Ix: blood culture, ECG, CXR, MSU
when is surgery needed in diabetes?
Elective surgery—minor procedures in patients with good glycaemic control
* Good glycaemic control (HbA1c less than 69 mmol/mol)
* Managed during the operative period by adjustment of their usual
insulin regimen
how should insulin be given on a day of surgery?
On the day before the surgery, the patient’s usual insulin should be
given as normal, other than lunchtime and evening once daily long-
acting insulin analogues, which should be given at a dose reduced by
20 %. If it is given in the morning- no need to reduce dose
Major surgery/poor glycaemic control….more complicated
