Diabetes Mellitus Flashcards
What is the classical presentation of Type 1 Diabetes?
Polydipsia Polyphagia Polyuria Glycosuria Weight loss
What is the presentation of DKA?
Abdominal pain Vomiting Reduced GCS Dehydration Kussmaul breathing
What is the diagnostic criteria for Diabetes Mellitus?
If the patient is symptomatic…
Fasting glucose = equal to 7.0mmol/l
Random glucose = greater than or equal to 11.1mmol/l (or after 75g oral glucose tolerance test)
If the patient is asymptomatic…
Evidence of the above is needed on two occasions
Also, a HbA1c of greater than or equal to 6.5% (48mmol) is diagnostic of DM.
What values would you have to have to be diagnosed as ‘pre-diabetic’?
HbA1c 42-47 (6.0-6.4%)
Fasting glucose: 6.1-6.9mmol/l
What electrolyte abnormality can insulin produce?
Hypokalaemia
What is the diagnostic criteria for DKA?
Plasma glucose >13.9mmol/L
pH <7.3
Presence of ketonaemia/ketonuria
If metformin is tolerated, what is the treatment algorithm for Type 2 Diabetes?
1) Metformin If HbA1c still >58 (7.5%) 1) metformin + DPP4 inhibitor 2) metformin + pioglitazone 3) metformin + sulfonylurea 4) metformin +SGLT2
If HbA1c still >58 (7.5%)
Either start insulin or triple therapy
Triple therapy:
metformin + gliptin + sulfonylurea
metformin + pioglitazone + sulfonylurea
metformin + sulfonylurea + SGLT2 inhibitor
metformin + pioglitazone + SGLT2 inhibitor
If metformin is contra-indicated, what is the treatment algorithm for Type 2 Diabetes?
1) gliptin or sulfonylurea or pioglitazone
If HbA1c is still >58 (7.5%)
Start double therapy
gliptin + pioglitazone
gliptin + sulfonylurea
pioglitazone + sulfonylurea
If still HbA1c >58 (7.5%)
Start insulin
What are the guidelines on fasting during Ramadan for patients with diabetes?
Try and eat a meal containing long acting carbohydrates prior to sunrise
For patients taking metformin, split the dose one third before sunrise and two thirds after sunset
For patients taking once daily sulfonylureas, take this after sunset
For patients taking gliclazide, take the majority of the dose after sunset
In which conditions may HbA1c not be used for a diagnosis of diabetes?
Anaemia CKD Children HIV Haemoglobinopathies Splenectomy
In a patient with Type 1 Diabetes, how often should HbA1c be checked and blood glucose levels?
Check HbA1c every 3-6 months.
Self monitoring: monitor 4 times each day. More frequent monitoring is recommended if the patient is ill, playing sports, during pregnancy and while breastfeeding
What are the daily blood glucose targets for Type 1 Diabetics?
5-7 on waking
4-7 before meals at any other time
What type of insulin is recommended for Type 1 Diabetics?
Multiple daily injection basal-bolus insulin regimens
Twice daily insulin determir
Rapid acting insulin analogues before meals
When should you give a Type 1 Diabetic metformin?
If there BMI is >25
What is the management of diabetes if a patient is ill?
Increase frequency of BG monitoring to four hourly
Drink 3L in 24h
If unable to eat any food, may need sugary drinks
Continue taking oral hypoglycaemic medications and insulin despite a poor food intake
What are the indications for an unwell diabetic patient being admitted to hospital?
Inability to keep fluids down
Persistent diarrhoea
BG persistently >20
Lack of support at home
For a diabetic patient to hold a HGV license, what criteria need to be met?
No severe hypoglycaemic events in the last 12 months
Driver has full hypoglycaemic awareness
Adequate control of BG = measure at least twice a day
Understand the risk of hypoglycaemic attacks
What are the DVLA requirements for driving with diabetes?
Patients on insulin must inform the DVLA and must have full hypoglycaemic awareness and must not have had >1 hypo in the past 12 months
If on tablets or exenatide no need to inform DVLA. If on tablets that induce hypoglycaemic episodes then no more than >1 in the preceding 12m
What are the blood pressure targets for diabetics?
What are the first line antihypertensives for diabetic patients?
If end organ damage; 130/80mmHg
If no end organ damage in Type 1; 135/85mmHg
If no end organ damage in Type 2; 140/80
First line; ACEi as they have a renoprotective effect in diabetes. Afro-Caribbean patients should be offered an ACEi and thiazide diuretic/CCB.
What education about insulin should you give patients?
Self adjust in light of exercise How to finger prick Carbohydrate counting education Phone support available 24/7 Avoid binge drinking
Partner can abort hypoglycaemia; GlucoGel, sugary drinks
When would you give fast acting insulins (Humalog, NovoRapid)?
Inject at start of meal
When are long acting human insulin analogues given?
Insulin glargine (S/C) is an example
At bedtime
Good if nocturnal hypoglycaemia is an issue
What is the pathophysiology of HHNS?
Occurs in Type 2 Diabetics
Relative insulin deficiency so the ketogenesis pathway is inhibited
Hyperglycaemia leads to hyperosmolarity and osmotic diuresis, thus thirst and frequent urination, signs of dehydration, and altered mental status
How would you treat HHNS?
Admit to ICU
Administer IV insulin
IV rehydration with fluids (replaces fluid loss that occurs with osmotic diuresis)
What is the ideal treatment for MODY?
Sulfonylureas (gliclazide)
What is a severe complication of Fluid resuscitation following DKA particularly in young patients?
Cerebral oedema
