Diabetes Mellitus And Hypoglycaemia Flashcards
What is type 1 diabetes mellitus?
Insulin deficiency
Pancreatic beta islet cells are destroyed causing insufficient insulin
Treat with insulin
What is type 2 diabetes mellitus?
Insulin resistance
Reduced insulin secretion/peripheral resistance to insulin
Treat with diet, oral antidiabetic drugs or insulin
What are the symptoms of diabetes mellitus?
Polyphagia Polydipsia Polyuria Weight loss Fatigue Blurred vision Poor wound healing
When do you start reviews for children with diabetes?
After 12 years old or 5 years after diagnosis
Is diabetes a strong risk factor for cardiovascular disease?
Yes
When is a statin given as primary prevention in diabetes?
Type 1 diabetes
Type 2 diabetes with a 10 year cardiovascular risk score of > 10%
Low dose aspirin is not recommended for primary prevention
ACEi may have a role in preventing cardiovascular disease
What are the microvascular complications of diabetes mellitus?
Retinopathy - treat hypertension
Nephropathy - give ACEi/ARB
What happens when ACEi are used in diabetes?
Potentiates hypoglycaemic effects of antidiabetic drug and insulin, especially in renal impairment
Which nerves can be affected in diabetes mellitus?
Sensory, painful neuropathy
Autonomic neuropathy
Gustatory neuropathy
Neuropathic postural hypotension
What is used to treat diabetic foot?
Analgesics - oxycodone/morphine
Duloxetine, TCAs
Pregabalin, gabapentin, carbamazepine
What is used to treat autonomic neuropathy in diabetes mellitus?
Diabetic diarrhoea - codeine or tetracycline
Gastroparesis - erythromycin
Erectile dysfunction - sildenafil
What is the treatment for gustatory neuropathy in diabetes mellitus?
Sweating face, scalp, head and neck - antimuscarinic/antiperspirant
What is the treatment for neuropathic postural hypotension in diabetes mellitus?
Fludrocortisone and increased salt intake
When do insulin requirements increase in pregnancy?
In the second and third trimester
Why should you plan pregnancies in pre-existing diabetes?
Reduces risk of congenital malformations
Aim for HbA1c level below 48mmol/mol (6.5%)
Give 5mg folic acid daily to prevent neural tube defects
What insulin should be used when planning a pregnancy?
Longer acting is the first choice - isophane insulin
(glargine or detemir)
Continuous subcutaneous infusion pump
Increased risk of hypoglycaemia postnatal period - reduce insulin immediately after birth
What are the counselling points for pre-existing diabetes in pregnancy?
Hypoglycaemic risks in all pregnant women treated with insulin (especially in first treatment)
Carry fast acting form of glucose
For type 1 - glucagon if needed
How do you treat type 2 diabetes in pregnancy?
Stop all oral antidiabetic drugs except metformin, substitute with insulin
Metformin alone or with insulin
How do you treat type 2 diabetes in breast feeding?
Continue metformin or resume glibenclamide post birth
How do you treat gestational diabetes if fasting blood glucose < 7 mmol/L at diagnosis?
Dietary and exercise first line
Second line - metformin if blood glucose target not met in 1-2 weeks. Alternative insulin
How do you treat gestational diabetes if fasting blood glucose > 7 mmol/L at diagnosis?
First line insulin with or without metformin + dietary and exercise measures
How do you treat gestational diabetes when the fasting blood glucose is 6-6.9 mmol/L with hydramnios or macrosomia?
First line insulin with or without metformin
How do you treat gestational diabetes in women intolerant of metformin and do not want insulin?
Glibenclamide (from 11 weeks gestation; after organogenesis)
What are the symptoms of diabetic ketoacidosis?
Severe hyperglycaemia High blood ketones Fruity breath Dehydration Polyuria Nausea and vomiting Convulsions
How do you treat diabetic ketoacidosis?
Soluble insulin
Fluids
Potassium do not give if anuria
Continue established long acting insulin
Add glucose to infusion when below 14 mmol/L
Continue until patient able to eat and drink and blood pH above 7.3
Give SC fast acting insulin and meal. Stop infusion one hour later
Do you need to notify the DVLA in diabetes mellitus?
Yes, but not in diet controlled diabetes
What are the complications of diabetes mellitus that can affect driving?
Visual complications, renal and limb complications
When should you notify the DVLA if you have diabetes mellitus?
If on any medication
2 episodes of severe hypoglycaemia in past 12 months (1 if group 2)
Impaired awareness
Disabling hypoglycaemia while driving
When do you need to monitor glucose levels in regards to driving?
No more than 2 hours before driving and every 2 hours for long journeys
Those on insulin, sulphonylureas, glinides
Record readings at least twice a day even when not driving
What levels should your glucose be before driving?
5 mmol/L take carbohydrate before driving
< 4 mmol/L do not drive
What do you do if hypoglycaemia occurs during driving?
Stop and switch off engine
Fast acting sugar then long acting carbohydrate
Wait 45 mins after levels return to normal
What is insulin?
Polypeptide hormone responsible for the metabolism of carbohydrates, fat and protein
What are the types of insulin?
Human insulin - soluble human
Human insulin analogues - rapid and long-acting
Beef/pork insulin - soluble animal
What are the short acting soluble insulins?
Human soluble
Beef/pork
Bolus insulin - take 15-30 minutes before a meal. Consume meal within 30 minutes to avoid hypoglycaemia
What are the rapid acting analogue insulins?
Lispro - humalog
Aspart - novorapid
Glulisine - apridra
Lower risk of hypo before lunch + late dinner, then soluble
Alternative to soluble in emergency
Bolus insulin - take immediately before or after meal
What are the intermediate acting insulins?
Isophane
Never give IV = thrombosis
Protamine causes allergic reactions
Basal insulin - take BD in conjunction with soluble insulin
What are the long acting analogue insulins?
Glargine - lantus
Detemir (OD/BD) - levemir
Degludec - tresiba
Protamine zinc - never give IV (thrombosis), don’t mix with soluble (binds in syringe)
Basal insulin - take OD at same time each day to cover 24 hour period
When is insulin used?
Type 1 diabetes
Type 2 diabetes
Surgery, when hospitalised for an illness or DKA
When are insulin requirements increased?
Infections or illness
Stress/trauma
Puberty
Pregnancy 2nd and 3rd trimester
When are insulin requirements decreased?
Endocrine disorders
Coeliac disease
Where do you administer insulin?
SC injection to buttocks, upper arm, abdomen or thigh
IV reserved for urgent treatment
What is a multiple injection regimen?
Short/rapid acting insulin before meals
plus intermediate/long acting OD or BD
What is a biphasic mixtures regimen?
Short/rapid acting insulin pre mixed with intermediate/long acting insulin OD/BD before meal
For patients who have difficulty with or prefer not to use MIR
Not for acutely ill patients
What is a long/intermediate acting regimen?
OD/BD with or without short/rapid acting insulin before meals
Long acting insulin not for Type 2 unless in certain criteria
When is a continuous subcutaneous infusion used?
Type 1 diabetes in certain criteria
What is the first line treatment for type 1 diabetes?
Multiple injection regimen
What is the treatment for type 2 diabetes?
Isophane insulin OD or BD + short acting soluble insulin as a biphasic or multiple injection regimen
What is a continuous subcutaneous infusion pump?
Delivers basal insulin and patient activated bolus doses at meal times
Must be highly motivated to monitor blood glucose regularly
Not recommended in type 2 diabetes
Who is a continuous subcutaneous infusion pump recommended for?
Type 1 diabetics who…
Suffer recurrent unpredictable hypoglycaemia
Glycaemic control > 8.5%
Children under 12
What are the side effects of continuous subcutaneous infusion pump?
Hypoglycaemia - don’t miss meals
Lipodystrophy
Local injection site reactions
What are the counselling points for a multiple injection regimen in regards to food?
Must adjust insulin dose to carbohydrate intake
What are the counselling points in relation to food for a biphasic, fixed dose regimen?
Must regulate and distribute carbohydrate intake through the day to match regimen
What are the medications that interact with insulin that then enhance insulins hypoglycaemic effect?
ACEi (hyperkalaemia + hypoglycaemia linked)
Beta blockers masks symptoms of hypoglycaemia
Alcohol
What are the medications that interact with insulin that then antagonise insulins hypoglycaemic effect?
Corticosteroids
Oral contraceptives
Loop/thiazide diuretics
What are the sick day rules?
SICK
Sugar - check levels every 3-4 hours, still monitor even when feeling better until controlled
Insulin - never stop taking insulin
Carbs - maintain normal meal pattern, 3 L fluid, urgent help if drowsy, can’t keep fluids down, persistent vomiting or diarrhoea
Ketones - check ketones every 3-4 hours, if 2+ or >3mmol/L immediately see GP
Do you stop metformin or gliflozins if you are sick?
Stop metformin if dehydrated due too increased risk of lactic acidosis
Consider stopping gliflozins if dehydrated as they cause volume depletion
What are the NPSA alerts regarding insulin?
Prescribe as unit
Never give IV syringe for SC injection as can cause overdose
Check injection technique
Check insulin container, pen and needle size
Store in fridge, when opened store at room temp and use by 28 days
If left outside fridge at 15-30 degrees > 48 hours - discard
If frozen must discard
What are the conversion rates for beef to human insulin?
Reduce dose by 10%
What are the conversion rates for pork to human insulin?
No dose change
What are the insulin requirements for type 1 diabetes the night before surgery?
Usual insulin
What are the insulin requirements for type 1 diabetes on the day of surgery?
IV glucose with potassium
IV soluble insulin with NaCl piggy backed onto infusion
What are the insulin requirements for type 1 diabetes after surgery once they start eating and drinking?
SC before breakfast and stop IV 30 minutes after
What is the first line treatment for type 2 diabetes?
Lifestyle advice
When do you consider drug treatment in type 2 diabetes?
If HbA1c rises to 48 mmol/mol consider monotherapy
If HbA1c rises to 58 mmol/mol consider dual therapy
What is the first line drug treatment for Type 2 diabetes if HbA1c target is 48 mmol/mol?
- Standard release metformin
2. Consider MR if not tolerated
What is the first line drug treatment for Type 2 diabetes if metformin is not tolerated if HbA1c target is 48 mmol/mol?
DPP - dipeptidyl peptidase 4 inhibitor
Or
Pioglitazone
What is the first line drug treatment for Type 2 diabetes if metformin is not tolerated if target HbA1c is 53 mmol/mol?
Sulfonylurea
If HbA1c has risen to 58 mmol/mol in type 2 diabetes what are the treatments available?
Metformin + DPP
Or
Metformin + sulphonylurea
Or
Metformin + pioglitazone
Or
Metformin + SGLT (sodium glucose cotransporter 2 inhibitors)
If HbA1c has risen to 58 mmol/mol in type 2 diabetes what are the treatments available if metformin is contraindicated?
DPP + pioglitazone
DPP + sulphonylurea
Pioglitazone + sulphonylurea
What are the triple therapy regimes that can be given to type 2 diabetics if the HbA1c is 58 mmol/mol?
Metformin + sulphonylurea + DPP
Metformin + sulphonylurea + pioglitazone
Metformin + sulphonylurea + SGLT
Metformin + pioglitazone + SGLT
Or consider insulin regime
If a type 2 diabetic needs help injecting, has a lifestyle restricted by hypos, would otherwise need BD NPH insulin, that is the insulin treatment regime?
Give insulin detemir or glargine
Continue metformin
If a type 2 diabetic does not need help injecting, doesn’t have a lifestyle restricted by hypos, would not otherwise need BD NPH insulin, what is the insulin treatment regime?
NPH insulin OD/BD
+ short acting insulin
If a patient with type 2 diabetes prefers injecting before meals, their blood glucose rises before meals or hypoglycaemia is a problem, what is the insulin regime?
Short acting insulin analogue
What do you do if a patient is type 2 diabetic and triple therapy fails?
Metformin + sulphonylurea + GLP-1 mimetic
What is metformin?
Biguanide
What is the mechanism of action of metformin?
Decreases liver gluconeogenesis and increases peripheral use
What are the side effects of metformin?
Lactic acidosis
GI disturbances
Weight loss, rarely hypoglycaemia, taste disturbance and reduced vitamin B12 absorption
When should you avoid metformin?
Renal impairment
Tissue hypoxia
How do you reduce GI side effects of metformin?
MR
With or after meal
Increase dose gradually
What are the contraindications of metformin?
General anaesthesia
Iodine containing contrast media
What is the mechanism of action of the sulphonylureas?
Augments insulin secretion
What are the short acting sulphonylureas?
Gliclazide
Tolbutamide
When are gliclazide and tolbutamide preferred?
Lower risk of hypos
Elderly
Renal impairment
What are the long acting sulphonylureas?
Glibenclamide
Glimepiride
Which sulphonylurea is preferred in pregnancy?
Glibenclamide in 2nd and 3rd trimester
What are the side effects of sulphonylureas?
Hyponatraemia - glipizide, glimepiride
Sulphonylurea induced hypoglycaemia
Weight gain
Jaundice
Hypersensitivity
What are the patient counselling points for sulphonylureas?
Recognise symptoms of hypos
Always carry sugary snack
Never miss meals
What other medications interact with sulphonylureas to cause an increased risk of hypos?
Warfarin
ACEi
What is the interaction between sulphonylureas and NSAIDs?
Reduced renal excretion
What is the mechanism of action of pioglitazone?
Reduces peripheral resistance
When does NICE suggest you should continue pioglitazone?
If HbA1c reduced by 0.5% within 6 months
What are the side effects of pioglitazone?
Heart failure
Bladder cancer
Hepatotoxicity
What conditions are pioglitazone contraindicated in?
Heart failure
Bladder cancer
Uninvestigated macroscopic haematuria
What are the counselling points for pioglitazone?
Report haematuria, dysuria, urgency
Report signs of liver toxicity. STOP if jaundice
What are the SGLT2 inhibitors? (Gliflozins)
Canagliflozin
Dapagliflozin
Empagliflozin
What is the mechanism of action of SGLT2 inhibitors?
Inhibits sodium glucose co transporter 2 in renal proximal tubule to reduce glucose reabsorption and increase urinary excretion
What are the side effects of the SGLT2 inhibitors?
Life threatening atypical DKA
Volume depletion
Increased risk of lower limb amputation
What are the counselling points for SGLT2 inhibitors?
Stop and test for ketones if DKA suspected
Report DKA symptoms
Report postural hypotension and dizziness
MHRA - report skin ulceration, discolouration, new pain
What is the MHRA warning fit canagliflozin?
Increased risk of lower limb amputation
What are the DPP4 inhibitors?
Alogliptin Linagliptin Saxagliptin Sitagliptin Vildagliptin
What is the mechanism of action of the gliptins?
DPP4 breaks down hormone incretin
Incretin is made by the gut in response to food to increase insulin secretion and lower glucagon secretion
What are the side effects of the DPP4 inhibitors?
Pancreatitis
Vildagliptin - liver toxicity
What are the counselling points of the gliptins?
Report severe, persistent abdominal pain
STOP and report nausea and vomiting, abdominal pain, dark urine, fatigue, pruritis, jaundice - vildagliptin
What is the mechanism of action of meglitinides?
Stimulates insulin secretion
What are the meglitinides?
Nateglinide
Repaglinide
What are the side effects of the meglitinides?
Hypersensitivity reactions
Flatulence
Diarrhoea
Nateglinide - abdominal pain, constipation, diarrhoea, nausea, vomiting
Repaglinide - visual disturbance
What are the counselling points for the meglitinides?
Avoid hypoglycaemia especially when driving
30 mins before main meal - rapid onset and short duration of action
Flatulence improves with time, antacids do not help
If diarrhoea occurs withdraw or reduce dose
Chew with first mouthful of food or swallow whole with little liquid immediately before food
Carry glucose
What are the GLP 1 agonists?
Exenatide Albiglutide Dulaglutide Liraglitide Lisisenatide
What is the mechanism of action of the GLP 1 agonists?
Binds to and activates GLP1 receptors to increase insulin secretion, suppress glucagon secretion and slows gastric emptying
What are the side effects of GLP 1 agonists?
Pancreatitis
What are the counselling points of the GLP 1 agonists?
STOP if severe persistent abdominal pain
Do not administer missed dose after meal
Use contraception
What are the counselling points for a missed dose for lixisenatide?
Inject within 1 hour of next meal
What are the counselling points for a missed dose for exenatide?
Continue with next scheduled dose
What are the counselling points for a missed dose for dulaglutide and albiglutide?
Inject within 3 days of next weekly dose
How long should you use contraception for after stopping MR exenatide?
12 weeks
What tests are done to diagnose type 2 diabetes mellitus?
HbA1c blood test > 6.5%
Oral glucose tolerance test
What monitoring is needed for type 2 diabetes?
Urinalysis - ketones, protein, glucose
Blood monitoring - ketones, glucose
What are the fasting blood glucose targets in diabetes?
4-7 mmol/L
What are the non-fasting blood glucose targets for diabetes?
< 9 mmol/L
If diabetics are at high risk of arterial disease what is their target HbA1c?
< 6.5%
What is the HbA1c target for diabetics?
6.5-7.5%
What are the hypertension blood pressure targets in diabetics?
Without complications 140/80
With complications 130/80
Diabetic first line is ACEi, African/Caribbean should have ACEi + diuretic or CCB first line
What are the cholesterol targets in diabetics?
< 4 mmol/L
When do you need to use primary prevention of CVD in diabetics?
Type 1
Type 2 and 10 year CVD risk > 10%
What level blood glucose is classed as hypoglycaemia?
< 4 mmol/L
What are the symptoms of hypoglycaemia?
Hunger Pale skin Tingling lips Sweating Dizziness Shakiness Palpitations Blurred vision Drowsiness
What is blunted hypoglycaemia?
Loss of warning signs in insulin treated patients
Too tight glycaemic control lowers level needed to trigger hypoglycaemic symptoms
Avoid frequent hypo episodes
Beta blockers mask symptoms
What is used to treat hypoglycaemia in the community?
10-20g sugar, if necessary repeat after 10-15 mins
Coke - 100-200ml Lucozade original - 55-100ml Sugar lumps - 3-6 Sugar - 2-4 tsp Ribera - 19ml
Long acting carbohydrate
Is sulphonylurea hypoglycaemia treated in community?
No as episodes can persist for hours
What is the treatment if a hypoglycaemic patient is unresponsive?
SC/IM glucagon
If unresponsive after 10 mins
IV glucose
