Diabetes: T1DM, T2DM, Management, 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
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
- Symptomatic RPG or GTT => 11mmol/L+
- FPG => 7mmol/L+
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
If symptomatic - single abnormal reading can be used but repeat testing is sensible
If asymptomatic, repeat test to confirm
Not routinely done for T1DM
- Cpeptide - low
- Urinary ketones
- GAD, Islet antigen, ZnT8
Management - lifestyle
Will be supported with self monitoring
- Balanced diet, smoking cessation, physical activity to reduce CV risks
- Alcohol reduction - cause hyperglycemia, potentiate hypoglycemic effects of insulin
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
HbA1c under 6.5
Describe how you might dose insulin
-how might you support this
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
Describe how you would manage T2DM
-medically
1st LINE - metformin -DPP4inh if metformin not tolerated 2nd LINE - dual therapy 3rd LINE - triple therapy -DPP4inh (-gliptin)/sulfonylurea(-ide)/SGLT2inh (-glifozin) Last line - insulin
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
- 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
Investigations to consider if trying to find cause
DKA management
- FLUID RESUS
- 500ml saline bolus in 15mins if hypotensive
- 1000ml saline bolus in 60mins if normotensive - INSULIN TO CORRECT ACIDOSIS
- K will fall, monitor this - K INFUSION (hyperkalemia results from acidosis but lost in diuresis)
- REASSESS PATIENT AND IDENTIFY CAUSE
- MONITOR FOR ARRYTHMIAS, CEREBRAL EDEMA
- VTE prophylaxis
Describe the
- presentation
- investigations for HHS
Presentation over several days
- polyuria, polydipsia => dehydration, shock
- confusion, fatigue
- no acidosis or ketosis
- shallow breaths
Investigations
- hypovolaemia
- hyperglycaemia (30+) without ketones (U3) or metabolic acidosis (HCO3 15+)
- hyperosmolality (>320 mOsm/kg)
Investigations to consider if trying to find cause
HHS management
- FLUID RESUS
- 500ml saline bolus in 15mins if hypotensive
- 1000ml saline bolus in 60mins if normotensive - INSULIN TO CORRECT GLUCOSE
- at a lower rate than DKA
3.REASSESS PATIENT AND IDENTIFY CAUSE
- 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 for hypoglycemia
-BG U3.5
How would you manage hypoglycemia
- conscious and can swallow
- unconcious
Conscious and can swallow
- 3-6 glucose tablets/50-100ml lucozade/4 jelly babies/7 jelly beans
- recheck BG after 15mins and repeat oral intake if inadequate response
- when symptoms improve, eat long acting carbs to maintain BG
Unconscious, no swallow, confused
- IM glucagon
- if no response or unable to give glucagon => 999
- once responsive => oral carbohydrates
Insulin
- mode of administration
- side effects
SC - Acts on NaKATPase
Increases adipose, muscle glucose uptake
Inhibits liver glucose release
SC
- Lipohypertrophy => erratic insulin uptake
- Hypoglygemia, weight gain
Metformin
- mode of administration
- positive effects
- side effects
- CI
PO - Biguanide - increases insulin sensitivity
- Decreases hepatic gluconeogenesis
- Decrease GI uptake of carbohydrates
No hypoglycemia, weight loss
GI upsets (N+V+D+A) Reduced B12 uptake Lactic acidosis
CKD (renal excretion)
Use of radiocontrast
Tissue hypoxia => increases lactic acidosis risk
