Diabetes mellitus Flashcards
Screening
- >40 yo/ 3 years with AUSDRISK 2. All ATSI >18yo 3. High risk FG/year
High risk groups on screening
- IFG/IGT 2. >40 w/ BMI >30 3. Women w/ history of GDM/PCOS 4. Pacific islanders >35 5. Previous CV event 6. Antipsychotic
Risk of developing diabetes w/ AUSDRISK scores
- For scores of 12–15, 1 in 14 will develop 2. 16–19, 1 in seven will develop diabetes. 3. 20 and above, 1 in three will develop diabetes.
At what AUSDRISK is increased risk
When score is >12
History
- Symptoms: Glycosuria: polyuria, polydipsia, polyphagia, weight loss hyperglycaemia: malaise/fatigue, altered vision, delayed wound healing. Bacterial infections Loss of sensation 2. Risk assessment: Risk factors for complications: personal or family history of CVD, smoking, hypertension, dyslipidaemia, mental health problems 3. SNAP 4. Other aspects of history age, family history, cultural group, overweight, physical inactivity, hypertension obstetric history of large babies or GDM medication causing hyperglycaemia personal or family history of haemochromatosis personal or family history of other autoimmune diseases (e.g. hypothyroidism or hyperthyroidism). 5. Complications cardiovascular symptoms, neurological symptoms, bladder and sexual function, foot and toe problems and any recurrent infections
Physical examination
General: adiposity, pigmentation, endocrinological features, acanthosis nigricans, skin tags, infections CV system, including postural BP Eyes->with fundoscopy, nerve palsies Abdomen->hepatomegaly Feet Urinalysis Evidence of impaired glucose tolerance: obesity, acanthosis nirgicans, hirsutism, skin tags, menstrual irregularities
Investigations
Serum glucose: random and fasting HbA1C UEC LFTs Urine protein:creatinine, albumin Fasting lipids FBE Urine Consider opthalmology, podiatry
Diagnostic criteria
Fasting blood glucose >7 Random blood glucose >11.1= diagnostic FBG 5.5-6.9/RBG5.5-11/ HbA1c >6.5–>consider
DIagnostic criteria post OGTT
FBG >7 mmol/L, BG 2h ≥11 mmol/L= diagnostic FBG
Management overview for T2DM
- Lifestyle modification 2. Refer to allied health professionals 3. Medication 4. Problem areas in Diabetes tool 5. Vaccinations 6. General support, psychosocial 7. Management of co-morbidities 8. Driving 9. Annual diabetes screen, care plan 10. BP, Lipids->Statin and ACEi 11. BMI, kidney and liver function
Lifestyle modification
- Smoking cessation 2. Alcohol within guidelines (risk hypoglycemia) 3. Weight->5-10% loss= prevention, delay, control 4. Diet->balanced, wholefoods, mediterrenean 5. Physical activity
Advice on physical activity
- Minimum 210 minutes/week 2. No more than 2 consequetive days without activity 3. Strength training included 4. 6-12 hour hypoglycemic delay if on insulin or sulphonylureas 5. Monitor BG before, during and post activity 6. If on insulin or sulphonylureas be mindful of delayed hypoglycemia 6-12 hours post activity
Vaccinations
- Influenza annually 2. Tetanus booster after 50 3. Pneumococcal Non-ATSI single dose then another >65, or 10 years after first dose (whichever is first) Non ATSI >65, ATSI >50->single dose then repeat in 5 years
Management algorithm
- Lifestyle + metformin (or sulfonylurea if cannot tolerate) 2. Stop rule! 3-6 months r/v->if not achieved add Sulfonylural, thiazolinedione, DPP4 inhibitor, acarbose, Injectable insulin or GLP1 agonist 3. Stop rule! 3-6 months r/v->add/change If after 6 mo and appropriate titration not achieve Stop. Check health literacy, lifestyle changes, review non-adherence, occult infection? Ask about hypoglycemia and side effects 4. Add a. Insulin (continue MF if tolerated). If glycosuric symptoms or rising HbA1c (e.g >8.5%) –>Basal insulin or premixed insulin initially –>Add prandial insulin with time if required b. PBS: Thiazolidinedione (only pioglitazone is PBS listed), If no congestive heart failure-> acarbose, DPP4 inhibitor
Glucose monitoring targets
Targets for SMBG levels are 6–8 mmol/L fasting and pre-prandial, and 6–10 mmol/L 2 h postprandial
Reasons for abnormally high HbA1C
IDA Splenectomy Alcoholism Steroid/stress/surgery
Reasons for abnormally low HbA1C
Hemolysis Blood loss Chronic renal failure
Components of the 3-6 monthly review
Hx: SNAP, home testing, feet, symptoms Physical: wt, ht, BP, feet, waist Ix: HbA1C, lipids Reviews goals of management
Components of annual review
History and PE as 3 monthly Referrals as new issues develop Evaluate care plan, suitability, goals 1. Ask: symptoms, goal setting, issues, glycemic control 2. Asses risk factors: wt, ht, CVD, foot, psychological, eyes, dental, cognition 3. Advise: SNAP, driving, immunisation, sick day, medication, self monitoring 4. Assist: Eye examination/2 years, podiatrist/shoes, register with NDSS, care plan, psychological 5. Arrange: register and recall, referrals, review, liscence, investigations->Lipids, HbA1C, LFTs, kidney function, albumin:creatine, urinalysis
Targets for lipids
Lipids: TC <4.0 mmol/L;
HDL-C ≥1.0 mmol/L;
LDL-C <2.0 mmol/L;
Non-HDL-C <2.5 mmol/L;
TG <2.0 mmol/L.
Targets for BP
≤ 130/80 mm Hg for everyone with diabetes, regardless of macro- or micro-albuminuria
Explanation of metformin
Increases the body’s sensitivity to insulin->makes better use of the insulin available Immediate release 500mg orally BD, or extended release 1g with evening meal Take with or immediately after meal, same time each day. Taken lifelong if it works Will required UEC prior to starting, then annually. SE may include nausea, vomiting diarrhea, weight loss. Complication is lactic acidosis Caution: renal impaired, ketoacidosis, low BMI Must be stopped prior to GA or contrast due to ++risk of lactic acidosis If missed dose, take as soon as remember, unless close to next dose.
Initiating insulin
Before starting: ensure adequate use of other oral hypoglycemic agents, adherence and health literacy 1. Premixed biphasic: when both fasting and post prandial elevated 2. Basal insulin->less risk of nocturnal hypoglycemia
Titration of insulin
- Check HbA1C in 3 months 2. If not at target: look for hidden hyperglycemias before/post meals ->Post prandial: consider changing meal size, composition, +activity after meals, adding acarbose, adding a prandial insulin dose or switching to premixed
Intensification of insulin
If goals still not reached, add a second insulin Regimes 1. Basal-bolus 2. Basal-plus 3. Premixed
Basal bolus
Basal + bolus before meals, most number of injections Suitable for those with variable meal times, need post prandial
Bolus ++dose of short acting
Least injections Variable meal times Need post prandial management
Premixed
Suitable when fewest injections wanted, poor congnition/dexterity
Hospital management of hyperglycemia->medication issues, why insulin is best in hospital setting
- Metformin not to be used when possibility of needing contrast 2. Sulfonylureas and metaglinides can cause unpredictable hypoglycemia in patients who are not eating reliably. 3. Thiazolidinediones can cause fluid retention, especially in combination with insulin. 4. Parenteral glucagon-like peptide-1 and amylin agonists can cause nausea and should be withheld in acutely ill patients. 5. For these reasons, inpatient hyperglycemia is best managed with insulin only->Insulin sliding scale 6. Physical activity—depending on the intensity of the activity, decrease insulin dosage 1 to 2 units per 20 to 30 minutes of activity. 7. During illness, administer all of the routine insulin. Many episodes of DKA occur during episodes of illness. 8. Stress and changes in diet require dosing adjustments. 9. Patients undergoing surgery should get one-third to one-half of the usual daily insulin requirement that day, with frequent monitoring and adjustments as necessary
Dosing of basal and bolus
Total insulin = 1unit/kg Basal is 2/3 total insulin Bolus= 1/3->divide by number of meals per day
Insulin sliding scale
Example Order for Typical Insulin Sliding Scale (Regular Insulin) Blood glucose Insulin dose 150—200 (8.3 +)→ 2 units 201—250 (11.1 +)→ 4 units 251—300 (13.9+)→ 6 units 301–350 (16.7+) → 8 units 351–400 (19.4+)→ 10 units >400 (22+) → Call house officer (who will usually give 10 to 14 units and adjust the SSI)
