Diabetes Mellitus: Type1, 2, Emergencies, Complications Flashcards
Describe the
- epidemiology, etiology
- pathophysiology and associations
T1 - common in younger people (HLA DR3-4)
-AI destruction of beta cells => no insulin produced
T2 - common in obese
-relative deficiency of insulin
Metabolic syndrome
-diabetes mellitus
-HTN
-dyslipidaemias
-obesity
predisposes to macrovascular (strokes, PAD, CHD) and microvascular (neuropathy, nephropathy)
Presentation
-T2DM risk factors
-symptoms
-emergency presentations
T2 is often asymptomatic
- frequent UTIs, skin, candida infections
- physical inactivity, CV risk factors
Symptomatic
- fatigue
- polyuria, polydipsia, polyphagia, nocturia
- weightloss
- visual changes
Emergency presentations
- polyuria, polydipsia => dehydration, shock
- confusion, fatigue
DKA
- acidosis => N+V, abdo pain,
- Kussmaul breathing
HHS
- no acidosis
- shallow breaths
Investigations, diagnosis for T1DM, T2DM
Diagnostic criteria if symptomatic
- RPG or GTT => 11mmol/L+
- FPG => 7mmol/L+
If asymptomatic, must be demonstrated twice
HbA1c => 48mmol/mol+ or 6.5%+
-use other measures if HbA1c likely to be unhelpful
Glucose tolerance test
- Fast for 8-10hours before test
- Measure BG 2hrs after 75g oral glucose
Not routinely done for T1DM
- Cpeptide - low
- Urinary ketones
- GAD, Islet antigen, ZnT8
Management
-lifestyle
Will be supported with self monitoring
Diet
-High fibre, low GI index sources of carbs
-low fat dairy, oily fish
-limit sat/trans fats
-avoid foods marketed as diabetic
Smoking cessation, physical activity to reduce CV risks
Alcohol reduction - cause hyperglycemia, potentiate hypoglycemic effects of insulin
If T2DM - initial target weight loss in overweight person = 5-10%
What are the target glucose readings
-on waking
-before meals
-after meals
HbA1c
On waking 5-7
Before meals 4-7
After meals 5-9
Lifestyle only - 48mmol/mol (6.5%)
Lifestyle + metformin - 48mmol/mol (6.5%)
Lifestyle + hypoglycemic drug - 53mmol/mol (7.0%)
On 1 drug but HbA1c has increased to 58mmol/mol (7.5%) - 53mmol/mol (7.0%)
Describe how you might dose insulin
-1st line T1DM
-add on medication in T1DM
Basal bolus - short and long acting injected separately
Mixed regimen - fewer injections as short and long acting are mixed together
Continuous insulin pump
When changing a dosing plan, always
- look for any hypos
- look for any patterns
- change the insulin dose before that reading and make 1 change at a time
- if changing a dose before bed, monitor the 3am reading first
DAFNE programme, learn how to adjust insulin around diet
2x basal detemir
Mealtime short acting
Add metformin if BMI overweight
Describe how you would manage T2DM
1st LINE - metformin
-uptitrated slowly to reduce GI upset
If QRISK 10%+, CVD, CHF => add SGLT2inh (-gliflozin)
-SGLT2inh monotherapy if metformin CI
If none of the risk factors for SGLT2inh use => DPP4 (-gliptin)/pioglitazone/sulfonylurea
If HbA1c 58mmol/mol+
2nd line - dual therapy (metformin + DPP4/pioglitazone/sulfonylurea/SGLT2inh)
3rd line - triple therapy or insulin
4th line - swap 1 drug in triple for GLP1
-BMI 35+ and obesity related medical/psychological problems
-BMI U35 and insulin therapy would have significant occupational implications/weight loss would benefit other obesity related problems
Describe the
-presentation
-investigations for DKA
Presentation within hours
-polyuria, polydipsia, N+V => dehydration
-abdo pain
-fatigue, confusion, blurry vision
-Kussmaul breathing, ketotic breath
DEFINITIVE - TRIAD OF HYPERGLYCEMIA, KETOSIS, MET ACIDOSIS
-urinalysis 2+ OR blood ketone 3mmol/L+
-blood glucose 11mmol/L+
-HCO3 U15mmol/L OR acidotic pH
-U&E - hyperkalemia (5+)
-FBC - high WBC if infective cause
Precipitating factors for DKA
Infection
Missed insulin dose
MI
DKA management
- FLUID RESUS
-500ml saline bolus in 15mins if hypotensive
-1L saline bolus in 60mins if normotensive - INSULIN TO CORRECT ACIDOSIS
-0.1U/kg/hr fixed rate short acting
-continue long acting, stop short acting
-K will fall, must monitor this - K INFUSION - hyperkalemia results from acidosis but lost in diuresis
-1L saline with KCl over 2hrs 2x
-1L saline with KCl over 4hrs 2x
-1L saline with KCL over 6hrs 2x
-add 10% glucose 125ml/hr if BG U14 AND consider halving insulin infusion
Don’t give more K if 5.5+
Add 40mmol/hr if 3.5-5.5
- REASSESS PATIENT AND IDENTIFY CAUSE
- MONITOR FOR ARRYTHMIAS, CEREBRAL EDEMA
-VTE prophylaxis
Describe the
-presentation
-investigations for HHS
Several days
-polyuria, polydipsia => dehydration, shock
-confusion. fatigue
-no acidosis or ketosis
-shallow breaths
Investigations
-hypovolemia
-hyperglycemia (30+) without ketones or met acidosis (HCO3 15+)
-hyperosmolality (320mOsm/kg)
HHS management
- FLUID RESUS - reverse dehydration
-1L 0.9% saline bolus in 60mins
-give 0.5-1L/hr 0.9% saline => positive fluid balance 2-3L by 6hrs
-if fluid balance positive and osmolarity not falling => 0.45% saline
AS OSMOLARITY FALLS, GLUCOSE SHOULD FALL TOO - MONITOR
-biochemical parameters - every 2 hrs
-continue fluid replacement to achieve 3-6L positive fluid balance by 12hrs
-avoid hypoglycemia - IDENTIFY CAUSE, REVIEW FROM SPECIALIST DIABETES TEAM
- MONITOR FOR ARRYTHMIAS, CEREBRAL EDEMA
-VTE prophylaxis (LWMH)
Describe the
-presentation
-investigations for hypoglycemia
Early presentation - glucagon => adrenaline => cortisol release
-hunger fatigue
-shaking, pale, sweating
-headache, dizziness
Late presentation
-confusion
-slurred speech, blurred vision
-fainting, seizures, coma
Investigations
-BG U4
Management of hypoglycemia
-community
-hospital
-once BM4
Community
Conscious - PO 10-20g glucose (3-6 glucose tablets/50-100ml lucozade/4jelly babies/7jelly beans)
Unconscious - SC/IM glucagon from Hypo kit
Hospital
Alert - PO fast carbohydrate
Unconscious/unsafe swallow - SC/IM glucagon
IV access - 20% glucose preferable
Recheck BM after 15mins - repeat PO up to 3x total if BM U4
3 cycles inadequate => IM glucagon/10% glucose infusion 200ml in 15mins
Once responsive and BM 4+ => 20g long acting carbs to maintain BM
-40g if glucagon used
Insulin
- mode of administration
- side effects
SC - Acts on NaKATPase
Increases adipose, muscle glucose uptake
Inhibits liver glucose release
- Lipohypertrophy => erratic insulin uptake
- Hypoglygemia, weight gain
