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
