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Victor BNF Notes > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

What is Diabetes Mellitus characterised by

A

Hyperglycaemia

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2
Q

What is Type 1 diabetes

A

Insulin Deficiency
- pancreatic beta islet cells are destroyed cause insufficient insulin release

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3
Q

What type 1 diabetes overall treatment

A
  • Insulin
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4
Q

What is type 2 diabetes

A

Insulin resistance
- reduced insulin secretion or peripheral resistance to insulin

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5
Q

What type 2 diabetes overall treatment

A
  • Insulin
  • Diet
  • Oral Anti-diabetic drugs
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6
Q

Symptoms of Diabetes

A
  • Polyphagia (hunger)
  • Polydipsia (thirst)
  • Polyuria (excessive urination)
  • weight loss
  • fatigue
  • blurred vision
  • poor wound healing
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7
Q

Diabetes Complications: Macrovascular complication

A

cardiovascular disease

Primary Prevention: Statin in…
- Type 1 diabetes
- Type 2 diabetes with QRISK of above 10%

(low dose aspirin is not recommended)

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8
Q

Diabetes Complications: Microvascular Complications
(Eyes)

A

Retinopathy
- treat hypertension

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9
Q

Diabetes Complications: Microvascular Complications
(Kidneys)

A

Nephropathy
- treat hypertension (ACEi / ARB)

be careful with ACEi as they act with hypoglycaemia effect especially in renal impairment

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10
Q

How often should Adults be reviewed

A

Annually

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11
Q

How often should children be reviewed

A

start screening after 12 years old or after 5 years after diagnosis

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12
Q

Diabetes Complications: Nerves
(Sensory Neuropathy) and treatment

A

Diabetic foot

For pain:

  • Antidepressants (Duloxetine)
  • Tricyclic Antidepressants (Amitriptyline and Nortriptyline)
  • Anti-epileptic drugs (gabapentin, pregabalin and carbamazepine)
  • Strong opioids
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13
Q

Diabetes Complications: Nerves (Autonomic Neuropathy) and treatment

A

Diabetic Diarrhoea
- codeine or tetracycline

Gastroparesis: delayed gastric emptying
- erythromycin

Erectile Dysfunction
- Sildenafil

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14
Q

Diabetes Complications: Nerves (Gustatory Neuropathy)

A

Sweating, Scalp, head and neck
- antimuscarinics / antiperspirant

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15
Q

Diabetes Complications: Nerves (Neuropathic Postural Hypotension)

A
  • fludrocortisone
  • increase salt intake
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16
Q

How should the dose of insulin change during pregnancy

A

increases during 2nd and 3rd trimester

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17
Q

Pre-existing diabetes
(pregnancy planning)

A

reduce the risk of congenital malformations

  • aim for HbA1C levels <48mmol (6.5%)
  • folic acid 5mg daily to prevent birth defects
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18
Q

What birth birth defects is diabetes most common for

A

neural tube defects (CNS system affecting)

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19
Q

What length of Insulin treatment should be used for pre-existing diabetes and pregnancy

A

Long acting insulin

  • Insulin Isophane
    (e.g Humulin I, Insulatard)
  • long acting Insulin analogues (Lantus, Semglee, and Toujeo)
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20
Q

What should women who have it difficult controlling glycemic levels even when using multiple daily injections

A

Continuous subcutaneous insulin infusion pump

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21
Q

What is at risk of happening after birth with glycemic levels

A

reducing a lot (hypoglycaemic)

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22
Q

What should happen to the dose of insulin after birth

A

reduce, to reduce hypoglycaemia

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23
Q

Pregnancy and Pre existing diabetes counselling

A
  • risk of hypoglycaemia (especially in 1st trimester)
  • always carry fast acting glucose (glucose drink/gum/sweat)
  • prescribe glucagon if needed for type 1 diabetes
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24
Q

Pre existing type 2 diabetes and pregnancy

A
  • stop all oral antidiabetic drugs except metformin
  • use insulin instead
  • either metformin alone or with insulin
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25
Q

pre existing type 2 diabetes an breastfeeding

A
  • continue metformin
  • or resume glibenclamide post birth
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26
Q

Gestational diabetes: fasting blood glucose <7mmol treatment

A

1st Line:
dietary and exercise

2nd Line:
Metformin or Insulin

3rd Line:
Combined

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27
Q

Gestational diabetes: fasting blood glucose >7mmol treatment

A

1st Line:
Insulin with or without insulin and dietary and exercise

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28
Q

Gestational diabetes: fasting blood glucose 6 to 6.9 mmol with hydramnios or macrosomia treatment

A

1st Line:
Insulin with or without metformin

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29
Q

What is Hydramnios

A

Hydramnios is a condition that occurs when too much amniotic fluid builds up during pregnancy.

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30
Q

What is fetal macrosomia

A

A baby who is diagnosed as having fetal macrosomia weighs more than 8 pounds

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31
Q

Gestational diabetes: intolerance to metformin and do not want insulin treatment

A

Glibenclamide

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32
Q

Which type of diabetes is Diabetic ketoacidosis DKA more common

A

Type 1

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33
Q

What is Diabetic ketoacidosis DKA

A
  • when the body lacks insulin
  • which means it can’t use sugar for energy and instead breaks down fat for energy

-releasing chemicals called ketones.

  • Too many ketones build up in the blood, making it acidic, a process known as acidosis.
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34
Q

What can DKA cause

A
  • bad breath
  • high blood ketones
  • diabetic coma
  • mental confusion
  • convulsions
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35
Q

What is the DKA Treatment

A
  • Soluble insulin
  • Fluids to rehydrate your body
  • potassium (do not give if kidneys cant produce urine)
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36
Q

DKA treatment points

A
  • continue on long acting insulin
  • add glucose to infusion when below 14 mmol
  • continue until patients can eat and drink and blood pH is above 7.3
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37
Q

When should you notify the DVLA
about Diabetes and Driving

A
  • if using insulin
  • if have a group 2 drivers license (larger vehicles)
  • visual, renal or limb complications
  • 2 episodes of severe hypoglycaemia in past 12 months (1 if group 2 license)
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38
Q

When should one check blood glucose levels before driving

A
  • no more than 2 hours before
  • then every 2 hours during the journey
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39
Q

How many times a day should those on insulin and group 2 license record their insulin

A

2 times

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40
Q

if glucose level is 5mmol/L before driving

A

take a carbohydrate before driving

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41
Q

if glucose is <4mmol/L before driving

A

do not drive

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42
Q

What must drivers on insulin always carry

A

fast acting glucose (tablet)

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43
Q

How long should one wait after taking a fast acting glucose tablet to continue driving

A

45 mins after glucose levels return to normal

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44
Q

What is Insulin

A

polypetide hormone responsible for metabolism of carbs, fat and protein

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45
Q

What is Bolus Insulin

A
  • quick acting
  • taken just before meals
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46
Q

What is Basal Insulin

A
  • longer acting
  • usually for all day steady levels and night
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47
Q

Examples of Short acting soluble insulin

A
  • human soluble (actrapid, humulin s)
  • animal soluble
    (hypurin)
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48
Q

Examples of Rapid Acting analogues

A
  • Lispro (Humalog)
  • Aspart (Novorapid)
  • Glulisine (Apridra)
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49
Q

Examples of Intermediate acting insulin

A
  • Isophane (Humulin I)
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50
Q

Examples of Long acting analogue

A
  • Glargine (Lantus)
  • Detemir OD/BD (Levemir)
  • Degludec (Tresiba)
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51
Q

When to take short acting soluble insulin

A
  • take within 15 to 30 mins before a meal
  • consume meal within 30 mins to avoid hypoglycaemia
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52
Q

When to take rapid acting analogue insulin

A
  • take immediately before or after meal
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53
Q

When to take intermediate acting insulin

A
  • take BD with soluble insulin
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54
Q

When to take Long acting analogue insulin

A
  • take OD at the same time each day to cover 24 hour period
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55
Q

Which circumstances and how is short acting soluble insulin used

A
  • diabetic emergencies and surgeries
  • via S/C, I/M, I/V
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56
Q

Which Bolus insulin has a lower risk of hypoglycaemia before lunch?

A

Rapid acting insulin analogues

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57
Q

Which insulin is an alternative to soluble insulin in emergencies

A

rapid acting insulin analogues

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58
Q

What happens if you give IV basal insulin (long acting analogue and intermediate)

A

can cause thrombosis

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59
Q

What happens if you mix long acting insulin analogues with soluble insulin

A

it can bind in the syringe

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60
Q

What can increase the amount of insulin needed

A
  • infections / intercurrent illness
  • stress
  • acidental / surgical trauma
  • puberty
  • pregnancy (2nd and 3rd trimester)
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61
Q

What can decrease the amount of insulin needed

A
  • endocrine disorders (Addison’s disease, hypopituitarism)
  • coeliac disease (gluten intolerance)
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62
Q

How to administer insulin

A

S/C injection to…
- buttock
- upper arm
- upper abdomen
- upper thigh

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63
Q

When would you use I/V insulin

A

for urgent treatment
- DKA
- surgery
- serious illness

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64
Q

What are the insulin injection regimens

A
  • Multiple injection Regimen
  • Biphasic Mixtures Regimen
  • Long/ Intermediate acting regimen
  • continuous subcutaneous infusion
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65
Q

What is the Multiple injection insulin Regimen

A

short/rapid acting insulin before meals
+
Intermediate/long acting insulin ONCE/TWICE daily

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66
Q

What is the Biphasic Mixtures insulin Regimen

A
  • Short/Rapid acting insulin pre-mixed with long/intermediate insulin
  • OD / BD before meal

(not for acutely ill patients as doses can change)

(it is for patients who have difficulty with the multiple injection regimen)

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67
Q

What is the Long/ Intermediate acting insulin regimen

A
  • OD/BD with or without short insulin before meals
  • long acting not for type 2 unless in certain criteria
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68
Q

What is the Continuous subcutaneous infusion insulin regimen

A
  • type 1 diabetes in certain criteria
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69
Q

Type 1 diabetes 1st Line treatment

A
  • start treatment with multiple injection regimens
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70
Q

Type 1 diabetes 1st Line treatment

A
  • start with isophane insulin OD/BD
  • plus short acting (soluble) insulin as biphasic or multiple injection regimen
71
Q

What is a continuous subcutaneous infusion pump

A
  • a device that delivers basal (long acting) insulin and patient activated bolus (short acting) insulin doses at meal time.

(not normal insulin pen)

72
Q

What is type of diabetes is recommended for continuous subcutaneous infusion pump

A

Type 1

73
Q

Which patients groups in type 1 diabetes are recommended for the continuous subcutaneous infusion pump

A
  • glycaemic control >8.5% despite optimised MIR
  • children under 12 where MIR is impractical
  • suffers recurrent unpredictable hypoglycaemia
74
Q

Side effects of insulin injection: Hypoglycaemia

A

Hypoglycaemia
- do not miss meals
- do not miss insulin injection
- do not do strenuous exercise before administration as can increase absorption

75
Q

Side effects of insulin injection: Lipodystrophy

A

Lipodystrophy (build of of fat, protein and tissue
- rotate injection sites

76
Q

Side effects of insulin injection: Local Injection site reactions

A

check injection technique

77
Q

Multiple Injection Regimen food counselling

A
  • must match insulin according to carbohydrate intake
78
Q

Biphasic regimen food counselling

A
  • must regulate and distribute carbohydrates intake throughout the day to match regimen
79
Q

How to ensure safe insulin use

A
  • Must always supply PIL to patient
  • insulin passport
80
Q

Which medication interacts with insulin to enhance hypoglycaemic effect

A
  • ACE inhibitors
  • Beta-blockers (masks symptoms of hypoglycaemia)
  • Alcohol
81
Q

Which medication interacts with insulin to antagonise hypoglycaemia effect

A
  • corticosteroids
  • oral contraceptives
  • loop/thiazide diuretics
82
Q

What is the Diabetes Acronym

A

SICK

S Sugar
I Insulin
C Carbohydrates
K Ketones

83
Q

SICK acronym: S

A

Sugar

  • Check blood glucose levels every 3 to 4 hours even at night
  • still monitor even after feeling better
  • if remains uncontrolled see GP
  • Monitoring not usually needed for type 2 unless on insulin
84
Q

SICK acronym: I

A

Insulin

  • never stop taking insulin
85
Q

SICK acronym: C

A

Carbohydrates

  • maintain normal meal pattern
  • can replace meals with carb drinks or snacks
  • 3L per day of fluid
  • seek help if drowsy or cant keep fluids down
  • seek help if persistent vomiting or diarrhoea
86
Q

SICK acronym: K

A

Ketones

  • check ketone levels every 3 to 4 hours even at night
  • if urine ketone 2+ see GP
  • if blood ketone levels are >3mmol/L see GP
87
Q

Anti-diabetic medication cautions: Metformin

A
  • stop metformin if dehydrated
  • because dehydration can cause increased risk of lactic acidosis
88
Q

Anti-diabetic medication cautions: Gliflozins

A
  • consider stopping gliflozins if dehydrated as they cause volume depletion
89
Q

Signs of Dehydration

A

Signs of Dehydration
- fever
- vomiting
- diarrhoea

90
Q

What does the dose need to have when prescribing insulin

A

Units

91
Q

Insulin syringe caution

A
  • do not give IV syringe for SC injection.
  • as IV is in ml and not units
92
Q

Insulin Injection technique caution

A

check it is SC not IV

93
Q

Insulin fridge cautions

A
  • store in 2 to 8 C
  • once opened store at room temperature and use within 28 days
  • if left outside the fridge at 15 to 30 C for more than 48 hours, must discard
  • if frozen must discard
94
Q

Insulin dose conversions: Beef to human

A

reduce dose by 10%

95
Q

Insulin dose conversions: Pork to human

A

no dose change

96
Q

Metformin mode of action

A

decreases liver gluconeogenesis and increases peripheral use

(1st line in type 2)

97
Q

What type of medication is metformin

A

Biguanide

98
Q

Site effects of Metformin

A

— Lactic acidosis
- avoid in renal impairment
- avoid in Tissue hypoxia (low oxygen levels in tissue)

— Gastro-intestinal disturbances
- nausea, vomiting, Diarrhoea

— Weight loss
— taste disturbances
— reduced vitamin B12 absorption

99
Q

Contra-indications of Metformin

A
  • renal impairment risk
  • general anaesthesia
  • iodine containing media
100
Q

Sulphenylurea mode of action

A

augments insulin secretion

101
Q

Examples of long acting Sulphenylurea

A

Short acting
- Gliclazide
- Tolbutamide

Used in elderly and renal impairment

102
Q

Examples of long acting Sulphenylurea

A

Long acting
- Glibenclamide
- Glimepiride

103
Q

Examples of Sulphenylurea in pregnancy

A

Pregnancy
- Glibenclamide (only 2nd and 3rd tri)

104
Q

Side effects of Sulphenylurea

A
  • hyponatraemia 9low sodium) (glipizide, glimepiride)
  • hypoglycaemai (must treat in hospital)
  • weight gain
  • jaundice
  • skin rashes
105
Q

Sulphenylurea Patient counselling

A
  • recognise symptoms of Hypo (glycaemia, natraemia)
  • always carry surgary snack, do not miss meals
106
Q

What medications interact with Sulphenylureas to increase hypo risk

A
  • warfarin
  • ACE inhibitors
107
Q

What medications interact with Sulphenylureas to reduce renal excretion

A

NSAIDs

108
Q

Thiazolinedione mode of action

A

reduces peripheral resistance

109
Q

Examples of Thiazolinedione

A

Pioglitazone

110
Q

NICE alert for Thiazolinediones

A

Continue if HbA1C reduced by 0.5% within 6 months

111
Q

Side effects of Thiazolinediones: Heart

A

Heart failure
- increased incidence when combined with insulin

(Thiazolinediones are contraindicated in history of heart failure)

112
Q

Side effects of Thiazolinediones: Cancer

A

Bladder Cancer

Thiazolinediones contra-indicated in history of bladder cancer or uninvestigated macroscopic haematuria

113
Q

Patient counselling for Thiazolinediones

A
  • report signs of liver toxicity (nausea, vomiting, abdominal pain, fatigue, dark urine)
  • stop if jaundice occurs
  • report signs of haematuria, dysuria an urgency
114
Q

SGLT-2 Inhibitors mode of action (Gliflozins)

A

Inhibits sodium-glucose co-transport 2 in renal proximal tubule to reduce glucose reabsorption and increase renal excretion of it

115
Q

Examples of SGLT-2 Inhibitors (Gliflozins)

A
  • Dapagliflozin
  • Empagliflozin
  • Canagliflozin
116
Q

Side effects of SGLT-2 Inhibitors

A
  • life threatening atypical diabetic ketoacidosis (only moderately high glycaemic levels)
  • Volume depletion (extracellular fluid loss)
117
Q

Patient counselling with SGLT-2 Inhibitors

A
  • stop and test for ketones if DKA suspected
  • report symptoms of DKA
  • report side effects of volume depletion
118
Q

Patient counselling with SGLT-2 Inhibitors: Specifically Canagliflozin

A

increased risk of lower limb amputation (usually toes)

  • report skin ulceration, discolouration and new pain
119
Q

Symptoms of volume depletion

A
  • postural hypotension
  • dizziness
  • constipation
  • thirst
  • fatigue
  • UTIs
  • genital infection
120
Q

Symptoms of DKA

A
  • nausea
  • rapid weight loss
  • fast/deep breathing
  • metallic taste in mouth
  • unusual fatigue
  • confusion
121
Q

DPP-4 Inhibitors (Gliptins) mode of action

A

DPP-4 breaks down hormone incretin. Incretin is made by the gut in response to food to increase insulin secretion and lower glucagon secretion

122
Q

Examples of DPP-4 Inhibitors (Gliptins)

A
  • Alogliptin
  • Linagliptin
  • Vidagliptin
  • Saxagliptin
  • Sitagliptin
123
Q

Side effects of DPP-4 Inhibitors (Gliptins)

A
  • Pancreatitis (report persistent severe abdominal pain)
  • Vidagliptin can cause liver toxicity
124
Q

Gliides mode of action

A

stimulates insulin secretion

125
Q

Examples of Gliides

A
  • Nateglinide
  • Repaglinide
126
Q

Side effects of Gliides

A
  • hypersensitivity reactions
  • urticaria (rash)
  • Pruritus (severe itching)
127
Q

Side effects of Gliides: Specifically Nateglinide

A
  • abdominal pain
  • constipation
  • diarrhoea
  • nausea
  • vomiting
128
Q

Side effects of Gliides: Specifically Repaglinide

A

visual disturbances

129
Q

Gliides patient counselling

A
  • be careful of hypoglycaemia when driving
  • take these medications 30mins before main meal
  • they are rapid onset and short duration of action
130
Q

Alpha-glucosidase inhibitors mode of action

A

inhibits carbohydrate digestion by competitively inhibiting the alpha glucosidase enzyme in the small intestine lumen.

131
Q

Example of Alpha-glucosidase inhibitors

A

Acarbose

132
Q

Side effects of Alpha-glucosidase inhibitors

A
  • flatulence (improves with time, but antacids do not help)
  • Diarrhoea (withdraw or reduce dose)
133
Q

Alpha-glucosidase inhibitors patient counselling

A
  • chew with first mouthful
    or
  • swallow whole with liquid just before meal
  • Carry glucose (not sucrose) to counteract hypoglycaemia
134
Q

Glucagon-like peptide 1 receptor agonists (GLP-1 Agonists) mode of action

A

Binds to and activates GLP-1 receptors to increase insulin secretion suppress glucagon secretion, slowing gastric emptying

Prevents weight gain (S/C injection)

135
Q

Examples of Glucagon-like peptide 1 receptor agonists (tide)

A
  • Exenatide
  • Albiglutide
  • Dulaglutide
  • Liraglutide
  • Lixisenatide
136
Q

Side effects of Glucagon-like peptide 1 receptor agonists

A
  • Pancreatitis (stop medication if this occurs)
137
Q

Missed Dose Advice: General - Glucagon-like peptide 1 receptor agonists

A
  • Do not administer after meal
138
Q

Missed Dose Advice GLP-1 Agonists: Lixisenatide

A

Inject within 1 hour of next meal

139
Q

Missed Dose Advice GLP-1 Agonists: Exenatide

A

Continue with next schedule dose

140
Q

Missed Dose Advice GLP-1 Agonists: Dulaglutide, Albiglutide

A

Inject within 3 days of next weekly dose

141
Q

Pregnancy and Contraception: Glucagon-like peptide 1 receptor agonists

A
  • use contraception
142
Q

How many weeks after using MR Exenatide should one still be on contraception

A

12 weeks

143
Q

Which Glucagon-like peptide 1 receptor agonists should you use contraception during usage

A
  • Exenatide
  • Lixisenatide
  • Albiglutide
144
Q

Type 2 Diabetes: 1st Line

A

Lifestyle and Diet control

145
Q

Type 2 Diabetes: 2nd Line

A

Metformin

or if not tolerated use
DPP or Pioglitazone or Sulfonylurea

Ideal HbA1c target: 48

146
Q

Type 2 Diabetes: 3rd Line

A

Dual Therapy

Ideal HbA1c target: 53

147
Q

Type 2 Diabetes: 4th Line

A

Triple therapy

or…

Insulin Programme

Ideal HbA1c target: 53

148
Q

What is the Insulin Programme

A

continue metformin

+

Insulin

149
Q

Insulin Programme:
- Person prefers injecting before meals
- blood glucose rises markedly before meals
- Hypoglycaemia is a problem

If any of these apply which insulin should be used?

A

Rapid acting insulin Analogues

  • Lispro (Humalog)
  • Aspart (Novorapid)
  • Glulisine (Apridra)
150
Q

Insulin Programme:
- Person needs help injecting
- Lifestyle restricted y hypoglycaemic episodes
- Would otherwise need twice daily NPH insulin

If any of these apply which insulin should be used?

A
  • Insulin Detemir (Levemir)
  • Glargine (Lantus)
151
Q

Insulin Programme:
- Person needs help injecting
- Lifestyle restricted y hypoglycaemic episodes
- Would otherwise need twice daily NPH insulin

If none of these apply which insulin would be used?

A
  • NPH Insulin (Isophan)
  • Short acting insulin
152
Q

What Diabetes Diagnostic tests are there

A
  • HbA1c blood test
  • Oral glucose tolerance test
153
Q

What is the HbA1c test

A
  • recommended by who
  • 48mmol/mol (6.5%) or above to diagnose diabetes
154
Q

What is the Oral glucose tolerance test

A
  • diagnosis of impaired glucose tolerance
  • not needed for patients with severe hyperglycaemic symptoms
155
Q

What are the 2 types of Diabetic monitoring

A
  • Urinanalysis (Ketones, Protein (Albumin), Glucose)
  • Blood Monitoring
    Ketones, glucose
156
Q

Blood glucose target preprandial (before dinner)

A

4-7mmol/L

157
Q

Blood glucose target postprandial (after dinner)

A

> 9mmol/L

158
Q

HbA1c levels if Diabetic

A

48 to 59 mmol/L

(6.5 - 7.5%)

159
Q

HbA1c levels if diabetic with high risk of arterial disease

A

> 48mmol/L

(6.5%)

160
Q

Hypertension targets in Diabetes with complications

A

140/80

161
Q

Hypertension targets in Diabetes without complications

A

130/80

162
Q

Cholesterol targets for normal people

A

<5mmol/L

163
Q

Cholesterol targets for high risk patients e.g Diabetics

A

<4mmol/L

164
Q

When would a statin be used in diabetes

A
  • Type 1 diabetes
  • Type 2 diabetes and 10% QRISK score
165
Q

At which level does glycaemia level show hypoglycaemia

A

<4mmol/L

166
Q

Hypoglycaemia symptoms

A
  • hunger
  • pale skin
  • sweating
  • chills
  • dizziness
  • blurred vision
  • palpitations
  • confusion
  • coma
167
Q

What is blunted hypoglycaemia

A

Over time, the brain adapts to the lower glucose levels, resetting the threshold for glucose sensing to lower values. As a consequence, individuals with impaired hypoglycemia awareness exhibit a blunted response to falling glucose levels,

168
Q

Which medication can mask symptoms of hypoglycaemia and delays recovery

A

Beta-blockers

169
Q

How to treat a hypoglycaemia medical emergency in the community

A

10-20g glucose/ sucrose
- coke
- lucozade
- sugar

  • avoid chocolate/ biscuits as fat delays glucose absorption
170
Q

What diabetic medication can cause hypoglycaemia that can last for hours?

A

Sulphonylurea

170
Q

How to treat Sulphonylurea induced hypoglycaemia

A

Hospital

171
Q

What to do if hypoglycaemia is unresponsive or is unconscious?

A

SC/IM glucagon

172
Q

What to do if hypoglycaemia is unresponsive to glucagon after 10 minutes?

A

IV Glucose

Victor BNF Notes (25 decks)

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