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Year 3 - Preparation for Clinical Practise > Diagnosing and management of type 1 diabetes in adults in primary care > Flashcards

Diagnosing and management of type 1 diabetes in adults in primary care Flashcards

1
Q

What is the target level of HbA1c in diabetes

A

A target HbA1c of 48 mmol/mol (6.5%) or lower (targets should be individualised for each patient)

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2
Q

What is the target level blood pressure for someone with type 1 diabetes

A

A blood pressure of below 135/85 mmHg (unless the adult with type 1 diabetes has albuminuria or two or more features of metabolic syndrome, in which case it should be below 130/80 mmHg)

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3
Q

What is the fasting plasma glucose target level for someone with type 1 diabetes

A

A fasting plasma glucose of 5 mmol/l to 7 mmol/l on waking, 4 mmol/l to 7 mmol/l before other meals, and 5 mmol/l to 9 mmol/l at least 90 minutes after eating

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4
Q

What are the acute symptoms for someone with type 1 diabetes

A
  • Thirst
  • Polyuria
  • nocturia
  • Weight loss
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5
Q

What are the subacute symptoms for someone with type 1 diabetes

A
  • Tiredness and lethargy
  • Recurrent skin infections
  • Thrush infections (genital)
  • Blurred vision.

These symptoms develop over weeks to several months

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6
Q

what is the peak onset for type 1 diabetes

A

9 -14 years

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7
Q

if a patient has suspected type 1 diabetes what should you do on the same day

A

You should refer adults with suspected type 1 diabetes for insulin initiation on the same day

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8
Q 
what levels in 
- fasting glucose test
- oral glucose tolerance test 
- random glucose test
do you have to have to be diagnosed with diabetes
A
  • Fasting = 7 or more
  • Oral glucose tolerance test = 11.1 or more
  • Random = 11.1 or more
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9
Q

it is not appropriate to use….

A

It is not appropriate to use HbA1c for diagnosis of diabetes in patients of any age suspected of having type 1 diabetes

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10
Q

What examinations should be carried out at the time of diagnosis of type 1 diabetes

A
  • Measurement of weight, height, and body mass index (weight (kg)/(height (m))2)
  • Measurement of blood pressure
  • Eye examination (including fundoscopy, or ideally, dilated fundal digital photography)
  • Cardiovascular examination
  • Foot examination (including peripheral pulses and sensory examination).
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11
Q

What investigations should be used in type 1 diabetes as a baseline

A
  • Full blood count
  • Urea and electrolytes
  • Liver function tests
  • Thyroid function tests
  • Fasting lipid profile
  • HbA1c
  • Urinalysis for glucose, ketones, and protein (analyse midstream urine if protein is detected)
  • Albumin:creatinine ratio
  • Electrocardiogram.
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12
Q

If a patient has type 1 diabetes and a low BMI or unexpected weight loss what should you check for

A
  • coeliac disease
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13
Q

What should you be alert to in type 1 diabetes

A
  • development of other autoimmune diseases such as Addison’s disease and pernicious anaemia
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14
Q

when should the measurement of C peptide and diabetic specific autoanitbody titrates be done

A
  • The clinical presentation includes atypical features (eg age ≥50 years, BMI ≥25 kg/m2, slow evolution of hyperglycaemia or long prodrome)
  • The classification of diabetes is uncertain, and confirming type 1 diabetes will have implications for the availability of therapy, for example continuous subcutaneous insulin infusion (CSII or “insulin pump”) therapy
  • There is a clinical suspicion that the patient may have a monogenic (single gene mutation) form of diabetes after initial diagnosis of type 1 diabetes
  • Four autoantibodies are markers of beta cell autoimmunity in type 1 diabetes: insulin autoantibodies (IAA), protein tyrosine phosphatase islet antigen-2 (IA2), antibodies to glutamic acid decarboxylase (GAD-65), and zinc transporter 8 (ZnT8).
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15
Q

What are the autoantibody markers of beta cell autoimmunity in type 1 diabetes

A
  • insulin autoantibodies (IAA)
  • protein tyrosine phosphatase islet antigen-2 (IA2)
  • antibodies to glutamic acid decarboxylase (GAD-65)
  • zinc transporter 8 (ZnT8).
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16
Q

When is long acting insulin taken

A
  • In the morning and/or before the patient goes to bed
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17
Q

When is rapid acting insulin taken

A
  • taken before each meal
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18
Q

Name the 4 main types of insulin

A
  • rapid
  • short
  • intermediate
  • long
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19
Q

Describe rapid insulin

  • onset of action
  • peak action
  • duration
  • chemical name
A
  • onset of action = within 15 minutes
  • peak action = 30-90 minutes
  • duration = 2-5 hours
  • chemical name = insulin lispro, insulin aspart, insulin glulisine
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20
Q

Describe short acting insulin

  • onset of action
  • peak action
  • duration
  • chemical name
A
  • onset of action = 30-60 minutes
  • peak action = 1-4 hours
  • duration = up to 9 hours
  • chemical name = soluble insulin
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21
Q

Describe intermediate acting insulin

  • onset of action
  • peak action
  • duration
  • chemical name
A
  • onset of action = 1-2 hours
  • peak action = 3-12 hours
  • duration = 11 to 24 hours
  • chemical name = isophane insulin suspension/NPH
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22
Q

Describe long acting insulin

  • onset of action
  • peak action
  • duration
  • chemical name
A
  • onset of action = 1-6 hours
  • peak action = flat without a peak
  • duration = up to 42 hours
  • chemical name = inulin glargine, insulin determiner, degludec, zinc suspension,
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23
Q

What should the choice of insulin regimen for patients be determined by

A
  • Compliance with or resistance to injections
  • Risk of hypoglycaemia
  • Lifestyle
  • Age
  • Complications: good control is needed to reduce the incidence of complications
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24
Q

name some lung acting insulin

A
  • glargine

- determir

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25
Q

What does long acting insulin do

A
  • maintains a basal concentration of insulin in the blood

- this can be raised by a supplementary injections of short acting insulin as required

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26
Q

what long acting insulin do type do you give type 1 diabetes

A

You should offer twice daily insulin detemir as basal insulin therapy for all adult patients with type 1 diabetes

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27
Q

When should you consider an alternative basal insulin therapy

A
  • An existing insulin regimen being used is achieving their target
  • Twice daily basal insulin injections are not acceptable or tolerated by the patient
  • Twice daily basal insulin injections are not achieving agreed targets.
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28
Q

name an ultra long acting insulin

A
  • degludec
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29
Q

how long does ultra long acting insulin

A
  • 42 hours
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30
Q

what are the two strengths of degludec

A

It is available in two strengths: 100 units/ml and 200 units/ml

31
Q

When should you take rapid acting insulin

A
  • before meals
32
Q

In what cases is rapid acting insulin taken after meals

A
  • gastroparesis

- or where carbohydrate absorption may be delayed

33
Q

when is mixed insulin given

A

You should consider a twice daily human mixed insulin regimen if a basal bolus insulin regimen is not possible

34
Q

When is mixed insulin taken

A

Injections of mixed insulin are taken before breakfast and before the evening meal

35
Q

describe what makes up mixed insulin

A

This therapy is usually mixed as 30% short acting insulin and 70% intermediate acting insulin. Two thirds of the total dose is taken at breakfast time and one third at the evening meal

36
Q

who is mixed insulin used for

A

This therapy is useful for patients who are reluctant to inject frequently or need district nurse input for injections

37
Q

What do you need to take regularly when using mixed insulin

A

Regular meals and snacks are needed to prevent daytime hypoglycaemia. Nocturnal hypoglycaemia is common

38
Q

What is a flash glucose monitoring system

A

A flash glucose monitoring system is a small sensor that is worn on the patient’s skin. A reader is held over the sensor to give interstitial blood glucose readings

39
Q

Who should get an insulin pump

A

Been assessed by the specialist clinician and deemed to meet one or more of the following:

  1. Patients who undertake intensive monitoring over eight times daily
  2. Those who meet the current NICE criteria for insulin pump therapy (HbA1c over 8.5% (69.4 mmol/mol) or disabling hypoglycemia as described in NICE TA151) where a successful trial of FreeStyle Libre® may avoid the need for pump therapy
  3. Those who have recently developed impaired awareness of hypoglycaemia.
  4. Frequent admissions (over two per year) with DKA or hypoglycaemia
  5. Those who require third parties to carry out monitoring and where conventional blood testing is not possible
40
Q

Flash monitoring is not ….

A

a replacement for blood glucose monitoring with normal testing steps to meet DVLA driving expectations as it measures interstitial glucose

41
Q

When is continuous subcutaneous insulin infusion therapy or pump therapy recommended as an option for people with type I diabetes

A
  • attempts to achieve HbA1c with multiple injection therapy results in disabling hypoglycaemia
  • HbA1c has remained high on multiple daily injection therapy despite a high level of care
42
Q

How should a person insert insulin into there body

A
  • ## inserted at a 90 degree angle to their skin - administer the insulin and wait for at least 10 seconds after the plunger is depressed before withdrawing the needle
43
Q

what layer should insulin be injected into

A
  • layer of fat between the dermis and muscle
44
Q

What happens if the insertion of the needle is too shallow

A

If the insertion of the needle is too shallow and it goes into the dermis, this may lead to pain and poor absorption of insulin

45
Q

what happens if the insulin is too deep

A

Deep injection into the muscle causes pain and more rapid absorption; this increases the risk of hypoglycaemia

46
Q

who might benefit from longer needles

A
  • obese patients
47
Q

Where is insulin absorbed faster and slowest

A
  • Fastest from the abdomen

- Slowest from the legs and buttocks.

48
Q

What are factors that affect the absorption of insulin

A
  • site injected into

- increases in skin temperature which increases the absorption of insulin

49
Q

why should you rotate the place of insulin injection

A
  • reduce the incidence of skin or fat atrophy and hypertrophy
50
Q

What are the sick day rules for taking insulin

A
  • Never stop taking insulin or reduce it, even if not eating. - There may be a need to increase the dose
  • Test blood glucose more often (at least four times a day)
  • Drink lots of fluids to prevent dehydration
  • Replace normal meals with carbohydrate drinks if necessary
  • If your blood glucose level is 15 mmol/l or more, test urine/blood for ketones
  • Seek medical advice if you develop vomiting or are unsure what to do
51
Q

What is hypoglycaemia

A
  • this is when blood glucose is less than 4mmol/l
52
Q

What should you do if the patient is conscious, orientated and able to swallow but is having hypoglycaemia

A

need around 15-20g of fast acting carbohydrate such as:

  • 150 ml to 200 ml of pure fruit juice, eg orange
  • Five to seven Dextrosol® tablets (or four to five Glucotabs®)
  • One bottle (60 ml) of Glucojuice®
  • Three to four heaped teaspoons of sugar dissolved in water.

repeat measurement of capillary blood glucose should be made after 10-15 minutes - if still less than 4mmol/l should be repeated but with no more than 3 treatments in total

53
Q

What should you do in hypoglycaemia if a patient is confused and uncooperative but is still conscious and able to swallow

A
  • given one and a half to two tubes of GlucoGel®/Dextrogel® squeezed into their mouth between the teeth and gums
  • if this is ineffective give glucagon 1mg IM
  • capillary blood glucose repeated after 10-15 minutes and treatment should be repeated if it is still less than 4mmol/l
  • no more than three treatments should be given in total and no more than one dose of glucagon
54
Q

what should you do in hypoglycaemia if after three cycles with fast acting carbohydrate or glucose or dextrose gel, or after 30 to 45 minutes, the patient’s blood glucose is still less than 4 mmol/l, and IM glucagon

A
  • IV glucose may be needed - 150-200ml of 10% glucose
55
Q

what do you do in hypoglycaemia and the patient is unable to swallow

A
  • Intramuscular glucagon should be given by a family member or friend who has been shown how to use it
  • The patient should be monitored for 10 minutes, and then given intravenous glucose if their level of consciousness is not improving significantly
  • The patient should be given oral carbohydrate and placed under continuous observation by a third party who has been warned of the risk of relapse.
56
Q

What should you review if hypoglycaemia becomes problematic or increased in frequency

A
  • Inappropriate insulin regimens
  • Meal and activity patterns, including alcohol
  • Injection technique and skills
  • Injection site problems
  • Possible organic causes such as gastroparesis
  • Changes in insulin sensitivity (including drugs affecting the renin angiotensin system and renal failure)
  • Psychological problems
  • Physical activity
  • Lack of appropriate knowledge and skills for self management.
57
Q

who should someone with T1D inform when diagnosed

A

DVLA

58
Q

When are T1D not allowed to drive

A
  • They suffer more than one episode of severe hypoglycaemia while awake (needing the
    assistance of another person) within 12 months
  • Either they or their medical team feel there is a high risk of developing hypoglycaemia
  • They develop impaired awareness of hypoglycaemia.
59
Q

What should patients with type 1 diabetes be tested for every year

A
  • Albuminuria
  • Smoking
  • Blood pressure
  • Blood glucose control
  • Full lipid profile
  • Age
  • Family history of cardiovascular disease
  • Abdominal adiposity
  • Hypoglycaemia awareness, particularly if holding a driving licence.
60
Q

what should be considered for primary prevention of cardiovascular disease in adults with type 1 diabetes

A

Consider statin treatment for primary prevention of cardiovascular disease in adults with type 1 diabetes

61
Q

When should you offer statins to adults with type 1 diabetes

A
  • Are older than 40 years, or
  • Have had diabetes for more than 10 years, or
  • Have established nephropathy, or
  • Have other cardiovascular risk factors
62
Q

What is the target blood pressure of adults with type 1 diabetes

A

135/85
- If there is evidence of albuminuria or two or more features of metabolic syndrome, the target blood pressure should be below 130/80 mmHg

63
Q

What should be used as first line treatment in adults with type 1 diabetes and hypertension

A

A trial of a renin angiotensin system blocking drug should be used as first line treatment for hypertension in adults with type 1 diabetes [

64
Q

How often should you measure HbA1c

A

Measure HbA1c every three to six months, but consider measuring more frequently if blood glucose control is suspected to be changing more rapidly

65
Q

when is HbA1c monitoring invalid

A
  • due to disturbed erythrocyte turnover (e.g. renal failure, recent blood transfusion) or abnormal haemoglobin type (e.g. sickle cell trait and thalassaemia)
66
Q

What should patients aim for in a blood glucose

A
  • 5 mmol/l to 7 mmol/l on waking, and

- 4 mmol/l to 7 mmol/l before meals at other times

67
Q

when should you test up to 10 times a day

A
  • The desired HbA1c target is not achieved
  • The frequency of hypoglycaemia is increasing
  • There is impaired awareness of hypoglycaemia
  • The patient engages in high risk activities
  • There is a legal requirement from the DVLA
  • The patient plays sports
  • The patient is ill
  • The patient is planning pregnancy/during pregnancy/breastfeeding
68
Q

what two scores are used to test for hypoglycaemic awareness

A
  • Gold score

- Clarke score

69
Q

describe how the gold score works

A

this is based on the response to a single question: “Do you know when your hypos are commencing?” Results are expressed by a seven point scale, where 1 = always aware and 7 = never aware. Impaired awareness is suggested by a value of more than or equal to 4.

70
Q

Describe how the clarke score works

A

this is made up of eight questions to assess the glycaemic threshold for, and symptomatic response to hypoglycaemia. A score of more than or equal to 4 indicates impaired awareness of hypoglycaemia.

71
Q

what screening for complications takes place in type 1 diabetes

A

Eye disease: you should refer patients with type 1 diabetes immediately to the local eye screening service; screening should be carried out within three months of referral. They should then have annual screenings with follow up depending on the findings

Diabetic kidney disease: arrange for annual albumin:creatinine ratio testing on an early morning urine sample. This would normally form part of the diabetic annual review.

72
Q

who should be urgently referred

A
  • Acute onset symptoms suggestive of type 1 diabetes: you should refer adults with suspected type 1 diabetes for insulin initiation on the same day as diagnosis. Children with diabetes should always be referred on the same day as diagnosis
  • suspected diabetic ketoacidosis; blood glucose more than 11mmol/l and ketones in the urine or blood
  • pregnant women with diabetes
73
Q

When do you add metformin to insulin therapy in an adult

A

You should consider adding metformin to insulin therapy if an adult with type 1 diabetes has a BMI of 25 kg/m2 (BMI 23 kg/m2 for people of South Asian and related minority ethnic groups) or above, and wants to improve their blood glucose control while minimising their effective insulin dose.

74
Q

When should you assess people for islet cell transplantation

A
  • consider referring adults with type 1 diabetes who have recurrent severe hypoglycaemia

Year 3 - Preparation for Clinical Practise (33 decks)

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