Diabetes Pre-work Flashcards
Clinical features T2DM - symptoms
- Polyuria
- Polydipsia
- Unexplained weight loss
- Recurrent infections
- Tiredness
Signs of T2DM
- Acanthosis nigricans
- Presence of risk factors?
Diagnostic criteria for T2DM
- If symptoms, can have 1 hyperglycaemic reading
- If no symptoms, needs repeat test to confirm
Values for diabetes diagnosis for readings
- HbA1C of 48mmol/mol (6.5%) or more
- Fasting glucose of 7mmol/L or more
- Random blood glucose of 11.1mmol/L or more in presence of signs/symptoms
When should HbA1C not be used to confirm diabetes?
- Children and young people under 18 - use fasting/random sample
- Pregnant women or 2 months post partum
- Symptoms for less than 2 months
- High risk of diabetes who are acutely unwell
- Taking medication that can cause hyperglycaemia (eg corticosteroids)
- Acute pancreatic damage
- End stage renal disease
- HIV infection
When to interpret HbA1C with caution?
- Abnormal Hb eg haemoglobinopathy
- Severe anaemia (any cause)
- Altered red cell lifespan (eg splenectomy)
- Recent blood cell transfusion
Management T2 diabetes - general
- Offer referral to structured education program eg DESMOND
- Provide sources of information - Diabetes UK
- Lifestyle advice - diet, exercise etc
- Assess impact on mood - Diabetes and your emotions patient resource
- Influenza and pnuemococcal vaccine
- Wear or carry some form of Diabetes identification - bracelet, necklace, watch, card, wristband
Monitoring for T2DM
- Measure HbA1C at 3-6 monthly intervals until stable on unchanging diabetic treatment
- Then every 6 months after stable
- Screening for complications
How often is screening for T2DM complications?
- Eyes - at diagnosis and every 2 year for those low risk, annually for others
- Diabetic foot check - at diagnosis and then once per year, more frequent if higher risk
- Kidney - annual UACR (early morning sample) and eGFR
- CVD risk assessed annually - smoking, BP, BG, albuminuria, lipids, FH, height weight and waist cicumference - calculate BMI
- Neuropathy - screen for peripheral and autonomic
CKD management/urine microalbuminaemia with diabetes
- CKD 3 - Offer atorvastatin
- Offer ACEi - /ARB can have this at any level of CKD
- Add Dapagliflozin (SGLT2) if eGFR 25-75ml/min or more
- If still nor improving renal function, can offer Finerenone
Peripheral neuropathy screening
Ask about:
* Numbness
* Burning
* Shooting pain
* Tingling
* In hands and feet
* Typically at night
* Relieved by activity
Autonomic neuropathy symptoms/screening
- Postural hypotension
- Gastroparesis - vomitting, bloating
- Urinary symptoms - hestitancy, reduced frequency, incomplete empyting
- Erectile dysfunction
- Unusual sweating - esp hands and feet
- Impaired hypoglycaemia awareness
Managing CVD risk in someone with T2DM
- Normal BP targets - stricter 130/80 target if ACR 70mg/mmol or more
- Atorvastatin 20mg - if 84 years and below and QRISk 10% or more, if 85 and above take into account preferences, or if have CKD - aim for more than 40% reduction in non-HDL cholesterol
- Do not routinely offer antiplatelet treatment
Lifestyle advice T2DM
- High fibre, low glycaemic index carbs (eg fruit, veg, wholegrain, pulses)
- Oily fish
- Low fat dairy products
- Control amounts of high saturated fats, sugary drinks, foods high in salt
- Discourage diabetic marketed foods
- Diabetes UK have good info on diet
- Eat carbohydrate snack before and after alcohol - alcohol can prolong effects of hypoglycaemic treatment
- Need to have regular oral check ups - increased risk peridontitis
- Stop smoking if possible
- Exercise
Sick day medication rules
- On angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (AIIRAs), diuretics, or nonsteroidal anti-inflammatory drugs (NSAIDs) — stop treatment if there is a risk of dehydration, to reduce the risk of acute kidney injury (AKI).
- On metformin — stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.
- On sulfonylureas — may increase the risk of hypoglycaemia, particularly if dietary intake is reduced.
- On SGLT-2 inhibitors — check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA.
- On GLP-1 receptor agonists — stop treatment if there is a risk of dehydration, to reduce the risk of AKI.
- If on insulin therapy, do not stop treatment.
Diagnostic criteria of T1Dm
Random plasma glucose of 11.1mmol/L or more and usually (but not always) have associated symptom of one or more:
* Weight loss
* Ketones
* age onset under 50
* BMI less than 25
* Personal or FH of autoimmune disease
Autoantibodies for T1DM?
Do not routinely measure C-peptide and/or diabetes-specific autoantibody titres to confirm the diagnosis of type 1 diabetes
May be done in secondary care if atypical symptoms
T1DM management - general
- Offer structured education program eg DAFNE (dose adjusted for normal eating)
- Provide Diabetes UK source for information
- Individual care plan
- Target 48mmol/mol HbA1C - measure every 3-6 months
- CGM - but need to double check with capillary blood glucose, if just CBG monitor 4x per day at least
Targets for CBG readings for T1DM
- Fasting plasma glucose level of 5–7 mmol/L on waking.
- Plasma glucose level of 4–7 mmol/L before meals at other times of the day.
- For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating.
Diet/lifestyle information T1Dm
- Do not advise low glycaemic index of carbohydrates
- Process of matching insulin dose to carbohydrates in grams
- Low in fat, sugar and salt and contain at least 5 portions of fruit and veg
- Have carbohydrate snack before and after drinking alcohol
- Regular oral check ups for higher risk of peridontitis
- Stop smoking
Sick day rules T1DM
- Never omit insulin
- Check CBG every 1-2hrs so more regularly
- Checking blood/urine ketones regulalry
- Maintain normal eating pattern if possible
- Drink at least 3L of fluids per day
Assessing CVD risk in T1DM
- do not use risk assessment tool
- Consider in all T1DM for primary prevention esp if over 40, more than 10yrs with diabetes, other CVD risk factors, established neuropathy
Treatment targets T2DM
- 48 mmol/mol for new type 2 diabetics
- 53 mmol/mol for patients requiring more than one antidiabetic medication
Medical management T2DM
First-line
* Metformin
* Once settled on metformin, add an SGLT-2 inhibitor (e.g., dapagliflozin) if the patient has existing cardiovascular disease or heart failure. NICE suggest considering an SGLT-2 inhibitor in patients with a QRISK score above 10%.
Second-line
* Add a sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor.
Third-line options are:
Triple therapy with:
* metformin and two of the second-line drugs
* Insulin therapy (initiated by the specialist diabetic nurses)
When triple therapy fails, and BMI is 35kg/m2 or more can offer GLP-1 mimetic.
Management complications of T2DM
- ACE inhibitors are used first-line to manage hypertension in patients of any age with type 2 diabetes.
- ACE inhibitors are started in type 2 diabetics with chronic kidney disease when the albumin-to-creatinine ratio (ACR) is above 3 mg/mmol (as opposed to 30 mg/mmol in patients without diabetes).
- SGLT-2 inhibitors are started in type 2 diabetics with chronic kidney disease when the albumin-to-creatinine ratio (ACR) is above 30 mg/mmol (in addition to the ACE inhibitor).
- Phosphodiesterase‑5 inhibitors (e.g., sildenafil or tadalafil) may be used for erectile dysfunction.
- Prokinetic drugs (e.g., domperidone or metoclopramide) may be used for gastroparesis (slow emptying of the stomach). These medications are used with caution due to cardiac side effects.
Neuropathic pain management
- Amitriptyline – a tricyclic antidepressant
- Duloxetine – an SNRI antidepressant
- Gabapentin – an anticonvulsant
- Pregabalin – an anticonvulsant
DKA management
FIGPICK
* F – Fluids – IV fluid resuscitation with normal saline (e.g., 1 litre in the first hour, followed by 1 litre every 2 hours)
* I – Insulin – fixed rate insulin infusion (e.g., Actrapid at 0.1 units/kg/hour)
* G – Glucose – closely monitor blood glucose and add a glucose infusion when it is less than 14 mmol/L
* P – Potassium – add potassium to IV fluids and monitor closely (e.g., every hour initially)
* I – Infection – treat underlying triggers such as infection
* C – Chart fluid balance
* K – Ketones – monitor blood ketones, pH and bicarbonate
Diabetes drugs
