Diabetes Mellitus Symposium

Question 1

Describe Diabetes Type I

Answer 1

• Typically develops as a child or young adult
• Autoimmune destruction of pancreatic beta cells
• Sudden onset usually associated with rapid weight loss

Question 2

Describe Diabetes Type II

Answer 2

• Typically affects people > 45 years old
• Insulin resistance and relative insulin deficiency
• Slow onset often associated with patients who are overweight

Question 3

Describe LADA (Type 1.5) Latent Autoimmune Diabetes in Adults

Answer 3

• Gradual autoimmune destruction of pancreatic beta cells
• Commonly presents with a slower onset in patients > 30 years old
• Not linked to insulin resistance

Question 4

Describe MODY Maturity Onset Diabetes of the Young

Answer 4

• Hereditary condition - autosomal gene mutation
• Ineffective insulin production
• Commonly presents with a slow onset in patients > 45

Question 5

What is diabetic ketoacidosis and what are the associated symptoms?

Answer 5

• Occurs when your body produces high levels of blood acids called ketones.
• Develops when your body can’t produce enough insulin. Insulin normally plays a key role in helping glucose enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.
• Symptoms:
• Vomiting
• Dehydration
• Sweet smelling breath
• Deep laboured breathing or hyperventilation
• Rapid heartbeat
• Confusion and disorientation

Question 6

How do you manage diabetic ketoacidosis?

Answer 6

1. Fluid replacement
   - Restoration of circulatory volume
   - Clearance of ketones
   - Correction of electrolyte imbalance
2. Continuous IV insulin infusion
   - To inhibit gluconeogeneis and lipolysis
   - To facilitate the uptake of glucose into cells
3. Start SC insulin once out of ketoacidosis

Question 7

What is the HbA1c target in a patient with DM?

Answer 7

• For patients on lifestyle or monotherapy with low risk of hypoglycaemia, e.g. metformin = < 48 mmol/mol (6.5 %)
• For patients on monotherapy with risk of hypoglycaemia, e.g. gliclazide = < 53 mmol/mol (7.0 %)

Question 8

What are the NICE recommended target blood glucose level ranges?

Answer 8

• T2DM:
• Before meals = 4-7 mmol/L
• Atleast 90 mins after meals = < 8.5 mmol/L
• T1DM:
• Upon waking = 5-7 mmol/L
• Before meals = 4-7 mmol/L
• Atleast 90 mins after meals = 5-9 mmol/L
• T1DM (12-18 years):
• Upon waking = 4-7 mmol/L
• Before meals = 4-7 mmol/L
• Atleast 90 mins after meals = 5-9 mmol/L

Question 9

What are the 4 main types of insulin?

Answer 9

• Rapid/short action = Lispro, Aspart/Humulin S:
• Onset = 5-15/15-60 mins
• Peak = 1/1-2 hours
• Duration = 3-5/3-8 hours
• Intermediate = Insulatard, Humulin I:
• Onset = 1-2 hours
• Peak = 6-10 hours
• Duration = 12-18 hours
• Long = Glargine, Determir (Degludec is very long acting):
• Onset = 1-2 hours
• Peak = Flat profile
• Duration = 18-36 hours
• Mix (biphasic) = Novomix:
• Onset = 15-60 mins
• Peak = 1-10 hours
• Duration = 12-18 hours

Question 10

Which patients are considered appropriate for using continuous subcutaneous insulin pump?

Answer 10

-Patients with recurrent hypoglycaemia and HbA1c levels have remained high ( > 69 mmol/mol)

Question 11

How do you monitor a DM patient?

Answer 11

• HbA1c levels: 3-6 monthly
• BP
• Lipid profile
• Annual monitoring for complications

Question 12

What are the risk factors of hypoglycaemia?

Answer 12

• Increasing age
• Insulin and sulphonylureas
• Rigid glycemic control
• Poor eating habits
• Impaired renal function
• Alcohol intake
• Medication errors
• Accelerated absorption, e.g by exercise of changing site of injection

Question 13

What are the symptoms of hypoglycaemia?

Answer 13

• Autonomic symptoms: tremor, sweating, palpitations, hunger
• Neuroglycopenic symptoms: atypical behaviour, visual disturbance, speech difficulty, drowsiness
• Symptoms may be masked by beta blockers

Question 14

How would you manage hypoglycaemia?

Answer 14

• Give short-acting carbohydrates:
• 120 mL glass of non-diet soft drink
• 4 or more glucose glucose tablets
• Give long-acting carbohydrates:
• Half a sandwich
• Biscuits and milk

Question 15

Guidelines for diabetes

Answer 15

-1st line:
*Biguanide:
>Metformin (can be used in combination with sulphonylureas), reduces weight gain

-2nd line:
*Sulphonylureas:
>Gliclazide (used when metformin is contraindicated due to impairment or poorly tolerated), causes increased risk of hypoglycaemia

-3rd line:
*Thiazolidinediones:
>Pioglitazone (used as a single agent in overweight patients where metformin is contraindicated or poorly tolerated) (used as a 2nd agent to metformin or a sulphonylurea where blood glucose control is inadequate) (used as a 3rd agent as an alternative to insulin)