DM Flashcards
Type 1 is also known as juvenile onset diabetes or
______
insulin dependent diabetes mellitus (IDDM).
Type 2 is also known as maturity onset diabetes
or ________
non-insulin dependent diabetes mellitus
NIDDM
The onset of type 2 diabetes can be subtle and by
stealth. Studies have demonstrated that it takes, on
average,______ before a patient is diagnosed.
7–9 years
In Australians older than 25 years the prevalence
of diabetes is _____, with another ____ having
impaired glucose tolerance
- 5%
10. 6%
About 30% of these people will develop clinical
diabetes within _____
10 years
Type 2 diabetes is not a mild disease. About _____
of those surviving 15 years will require insulin
injections to control symptoms or complications
onethird
Endocrine disorders causing secondary DM
Cushing syndrome
Acromegaly
Phaeochromocytoma
Polycystic ovarian syndrome
Pancreatic disorders causing secondary DM
Haemochromatosis
Chronic pancreatitis
Drug induced DM
Thiazide diuretics
Oestrogen therapy (high dose—not with low-dose HRT)
Corticosteroids
Other possible Sx of DM
What is the cause?
- vulvovaginitis
- pruritus vulvae
- balanitis
Candida albicans
Investigations for DM
• Initial: fasting or random blood sugar, follow-up
oral glucose tolerance test (OGTT) if indicated
• Other tests according to clinical assessment (e.g.
glycated haemoglobin (HbA1c), lipids, kidney
function, ECG)
Screening for Type 2 DM
- People with impaired_____
- Age >40 years
- Age >30 years with: _______
- Age >20 years_______
fasting glucose/impaired glucose tolerance
family history (firstdegree relative with type 2), obesity (BMI >30), hypertension
from high prevalence ethnic groups (e.g. ATSIs, Pacific Islanders)
Screening for Type 2 DM
• People on long-term steroids • People on \_\_\_\_\_ • \_\_\_\_\_\_\_, especially if overweight • Cardiovascular disease and other risk factors
atypical antipsychotics
Polycystic ovarian syndrome
Dx of DM
If symptomatic (at least two of polydipsia,
polyuria, frequent skin infections or frequent
genital thrush):
• \_\_\_\_\_\_\_\_ or • \_\_\_\_\_\_\_\_\_ or • HbAIc >6.5%
fasting venous blood glucose (VBG)
≥ 7.0 mmol/L on two separate occasions
random VBG (at least 2 hours after last eating) ≥ 11.1 mmol/L on two separate occasions
If asymptomatic:
at least two separate elevated values, either
_____, ______, ________
fasting, 2 or more hours post-prandial, or the
two values from an oral glucose tolerance test
(OGTT)
If random or fasting VBG lies in an uncertain
range (5.5–11.0 mmol/L) in either a symptomatic
patient or a patient with risk factors (over 50 years,
overweight, blood relative with type 2 diabetes or
high blood pressure), perform an ________
OGTT
The cut-off point for further testing has now been reduced to ___
5.5 mmol/L.
The ________ is still the
gold standard for the diagnosis of uncertain diabetes,
i.e. >11.1 mmol/L
2 hour blood sugar on an OGTT
The OGTT should be reserved for ________
true borderline
cases and for gestational diabetes.
A screening (oral glucose challenge) test at _______ weeks gestation is sometimes used during pregnancy.
26–30 (usually 28)
2 states of Pre DM
- impaired fasting glucose (IFG)
* impaired glucose tolerance (IGT)
A study by Sinah and colleagues detected impaired
glucose tolerance in ____ of 55 obese children (4 to
10 years of age) and ______ of 112 obese adolescents
(11 to 18 years of age
25%
21%
However, over 30% of
newly diagnosed diabetes in children and adolescents
is upon presentation with _____
diabetic ketoacidosis
Children with type 1 diabetes usually exhibit the
classic features of _____
polyuria, polydipsia, weight loss
and lethargy
UNusual presentations of DM in children
enuresis or daytime
wetting accidents when a misdiagnosis of urinary
infection or some other condition is sometimes
forthcoming.
Dx of DM in children
elevated random or fasting blood sugar
_____tests are inappropriate in the very young
Oral glucose
tolerance
_________ is the onset or initial
recognition of abnormal glucose tolerance during
pregnancy
Gestational diabetes
The WHO definition of gestational diabetes is ____
fasting blood sugar of ≥ 7 mmol/L or a
2-hour level of ≥ 7.8 mmol/
COD for Type 1 DM
diabetic
nephropathy and vascular disease (myocardial
infarction and stroke).
An analysis of patients with type 2 diabetes in
the HOPE study 11, 12 showed a benefit of ramipril to
reduce the risk of:
- _____ (24%)
- myocardial infarction (22%)
- ______(33%)
- cardiovascular death (37%)
- _______ (24%)
death
stroke
overt nephropathy
In younger patients it takes about _______after diagnosis for the problems of diabetic
retinopathy, neuropathy and nephropathy to manifest
10 to 20 years
Impt dxtic test for DM Nephropathy
Early detection of the yardstick,
which is microalbuminuria, is important as the
process can be reversed with optimal control
T or F, the dipstick method is reliable
F
Screening of DM Nephropathy
Screening is done
simply by an overnight collection (10–12 hours) of all
urine, including the first morning sample
Microalbuminuria is _____ (two
out of three positive collections).
20–200 mcg/minute
Its prevalence is related
to the duration of illness but up to 20% of people with
type 2 diabetes
Retinopathy
The European multicentre study 13, 14
showed that diabetes is the single most common
cause of blindness in European adults in the _____age groups
16–64
years
Assessment of DM Retinopathy
by direct ophthalmoscopy (with
dilated pupils), retinal photography and fluorescein
angiography (depending on the state of the patient’s
fundi).
Common skin infections in DM
mucocutaneous candidiasis (e.g. balanitis,
vulvovaginitis), staphylococcal infections (e.g.
folliculitis)
Common urinary tract infections in DM
urinary tract: cystitis (women), pyelonephritis
and perinephric abscess
Common pulmo infections in DM
staphylococcal, streptococcal
pneumonia), others; tuberculosis
What is the SNAP Guidelines for DM Prevention
(Smoking, Nutrition, Alcohol, Physical activity).
The main objectives for the GP in the optimal
management of the diabetic patient, in order to
prevent the development of cardiovascular disease
and other complications, are:
1 to achieve strict glycaemic control as measured by (most importantly) \_\_\_\_\_ and \_\_\_ 2 to achieve blood pressure control \_\_\_\_\_\_ 3 to achieve control of\_\_\_\_
glycated haemoglobin
(HbA 1c ) and by blood glucose
(≤130/80 mmHg, supine)
blood cholesterol level
Criteria for Metabolic syndrome:
• Upper truncal obesity (waist circumference) \_\_\_\_\_\_ (European population) plus any 2 or more of the following • ↑ triglycerides\_\_\_\_\_ • ↓ HDL cholesterol\_\_\_\_\_\_ • fasting glucose ≥ 5.5 mmol • BP \_\_\_\_\_
> 102 cm : >88 cm
> 1.7 mmol/L
<1.0 : <1.3 mmol/L
≥ 130/85
This syndrome is associated with increased
risk for the development of type 2 diabetes and
atherosclerotic vascular disease. Aggressive treatment
is required.
Metabolic syndrome:
BMI for DM
18–25 where
practicable
Urinary albumin excretion for DM
<20 mcg/min: timed overnight
<20 mg/L spot collection
Albumin creatinine ratio for DM
<2.5 mg/mmol—men
<3.5 mg/mmol— women
Alcohol intake for DM
≤2 standard drinks,
20 g/day (men and
women
Exercise for DM
at least 30 minutes walking (or equivalent) 5 or more days/week (total 150 minutes/ week)
Monitoring of CBG for Type 1
Type 1 diabetes:
— four times a day (before meals and before
bedtime) at first and for problems
— twice a day (at least once)
— may settle for 1–2 times a week (if good
control
Monitoring of CBG for Type 2
Type 2 diabetes:
— twice a day (fasting and 2–3 hours postprandial)
— if good control—once a week or every
2 weeks
The major form
of glycohaemoglobin is haemoglobin A 1c , which
normally comprises __________-of the total haemoglobin
4–6%
What are the insulin regimens for Type 1
• rapid-acting and short duration (ultra-short)—
_____________-
• short-acting—neutral _____________
• intermediate-acting—______
- long-acting—_____________
- pre-mixed short/intermediate—__________
insulin lispro, insulin aspart
(regular, soluble)
isophane (NPH) or lente
ultralente, insulin detemir, insulin
glargine
biphasic
(neutral + isophane)
How to give insulin?
The pre-mixed 2 injection (biphasic) system
________________
Give twice daily, 30 minutes before breakfast
and before evening meal (e.g. Mixtard 30/70,
Humulin 30/70—the most common)
• Typical starting dose: 0.3 IU/kg/day—for a
70 kg person use 10 units bd
When insulin is given as 3 injections per day:
• _________before breakfast and
lunch
• ___________before
evening mea
Short-acting insulin
Intermediate- or long-acting insulin
How to give insulin 4 injections (basal-bolus) system
• Short-acting insulin before breakfast, lunch and dinner (bolus) • Intermediate-acting or long-acting insulin at bedtime (basal)
How to give Insulin injections?
The injection should be given at a different place
each time, keeping a distance of 3 cm or more from
the previous injection
CX OF insulin SQ injection
Lipodystrophy
Available insulin
Ultra-short-acting (peak 1 hour, duration 3.5–4.5 hours)
Insulin lispro ____
Insulin aspart ____
Insulin glulisine ____
Humalog*
NovoRapid**
Apidra*
Short-acting (peak 2–5 hours, duration 6–8 hours)
Neutral (regular)
- 2
3
Actrapid**
Humulin R*
Hypurin Neutral
Intermediate-acting (duration 12–24 hours)
Isophane (NPH)
1
2
3
Humulin NPH*
Protaphane**
Hypurin Isophane
Long-acting (analogues
Insulin glargine (duration 24–36 hours\_\_\_\_\_
Insulin detemir (duration up to 24 hours\_\_\_\_
Lantus
Levemir
What to do during sick days?
Never omit the insulin dose even if the illness
is accompanied by nausea, vomiting or marked
anorexia. More ______required
(rapid/fast acting).
top-up insulin is usually
Glycaemic targets for adults with
type 1 diabeites
- HbA1c — _____
- Blood glucose —
53 mmol/mol
fasting preprandial 4–7 mmoL/L
postprandial 5–10 mmoL/L
First line if tx for T2DM
First-line treatment (especially if obese):
• diet therapy
• exercise program
Consider _________as the first-line agent for
all patients with type 2 diabetes, irrespective of
their weight, unless contraindicated
metformin
Starting dose of Metformin
500 BID
If monotherapy does not
provide adequate glycaemic control, a combination
of ______ and _____or other agent is recommended.
metformin with a sulfonylurea
The ________can be used as monotherapy but are used more often
in combination with metformin, sulfonylureas or
insulin but not rosiglitazone.
glitazones
The newest treatment
options in type 2 diabetes include:
• \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ known as gliptins, such as sitagliptin • \_\_\_\_\_\_\_\_\_\_\_\_\_ e.g. dapagliflozin, canagliflozin • \_\_\_\_\_\_\_\_\_\_\_, liraglutide) given by SC injection
dipeptidyl peptidase-IV (DDP-IV) inhibitors
sodium glucose cotransporter 2 (SGLT2)
inhibitors taken orally
glucagon-like peptide-1 receptor (GLP-1) agonist
(e.g. exanatide
Approximately ___________- of type 2 patients
eventually require insulin even after years of successful
oral therapy.
30%
Short-term intensive treatment \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ can induce long-term improvement in glycaemic control to the extent of being off insulin for months to years.
(approximately 2 weeks)
Stepwise approach for insulin
Step 1:
Step 1
• Continue oral agents: metformin + sulfonylurea
± glitazone or acarbose or DPP-4 inhibitor
(limited to 3).
• Add 10 units isophane insulin at bedtime
Stepwise approach for insulin:
Step 2
Titrate insulin therapy according to fasting blood
glucose (6 mmol/L).
Increase insulin in about _________ increments every
3–4 days (or more gradually).
Cease _______
4–5 U
glitazone, acarbose, gliptin or SGLT2
inhibitor (if used).
If larger doses of insulin are required (NPH or mixed
regimen), gradually withdraw _________continue
metformin and review
sulfonylurea,
The combination of a _____________
has been shown to improve control of diabetes
sometimes to the extent of being able to reduce
insulin dosage.
glitazone and insulin
Food breakdown in patients with DM
• protein 10–20%, fat 20–40%, carbohydrate 35–60% • reduce fat, especially saturated fats, sugar and alcohol
__________-are one of the commonest complications
that need special attention; prevention is the
appropriate approach
Foot problems
Studies have highlighted the importance of blood
pressure control to reduce _____________ and ___________complications in diabetes patients
macrovascular and
microvascular
Preferred pharmacological agents for BP control are ____, _____, ________-
ACE
inhibitors or ARBs and calcium-channel blockers
__________is a common finding in
patients with diabetes
Mixed hyperlipidaemia
_________is an independent risk factor
for the macrovascular complications of diabetes and
proper control is important.
Dyslipidaemia (especially
hypercholesterolaemia)
Preferred agents for dyslipidemia
HMG-CoA reductase inhibitors and resins for
hypercholesterolaemia and fibrates and resins for
mixed hyperlipidaemia
Target for chol control
- total cholesterol—<4 mmol/L
- triglycerides—<1.5 mmol/L
- HDL cholesterol— ≥ 1 mmol/L
- LDL cholesterol—<2.0 mmol/L
Hypoglycaemia 5 , 8 occurs when blood glucose levels
fall to less than_____
3.0 mmol/L.
It is more common
with treated type 1 diabetes but can occur in type
2 diabetes patients on oral hypoglycaemic drugs,
notably__________).
sulphonylureas (biguanides hardly ever
cause hypoglycaemia
Treatment of hypoglycaemia requires ______
one dose of
carbohydrate.
Treatment (severe cases or patient
unconscious)
20–30 mL 50% glucose IV until fully conscious
(instil rectally using the nozzle of the syringe if
IV access difficult)
or
(alternative) 1 mL glucagon IM or SC
This life-threatening emergency requires intensive
management. It usually occurs during an illness (e.g.
gastroenteritis) when insulin is omitted
Diabetic ketoacidosis 5
Management of DKA
• Arrange urgent hospital admission.
• Give 10 units rapid-acting insulin IM
(not SC).
• Commence IV infusion of normal saline.
Patients with this problem may present with an
altered conscious state varying from stupor to
coma and with marked dehydration
HHS
Key features of HHS
The key features are
marked ________ and ___________without
ketoacidosis
hyperglycaemia and dehydration
HHS
The essential
findings are extreme __________ and ________.
hyperglycaemia and high plasma osmolarity
HHS
The condition has a high mortality—even
higher than ketoacidosis
T
Tx of HHS
• IV fluids, e.g. normal to ½ normal saline, given
slowly
• Insulin—relatively lower doses than acidosis
Patients with lactic acidosis present with marked
hyperventilation ‘air hunger’ and confusion
Lactic acidosis
Lactic acidosis
It has
a high mortality rate and must be considered in the
very ill ___________taking metformin, especially
if kidney function is impaired.
diabetic patient
labs of Lactic acidosis
The investigations reveal blood
acidosis (low pH), low bicarbonate, high serum
lactate, absent serum ketones and a large anion
gap.
Tx of lactic acidosis
Treatment is based on removal of the cause,
rehydration and alkalinisation with IV sodium
bicarbonate
The prevalence of _____________in men over
40 years may be as high as 50%. It may be caused by
macrovascular disease, pelvic autonomic neuropathy
or psychological causes
erectile dysfunction
Those with organic-based
ED may benefit from appropriate counselling and
(if not taking nitrates) one of the ________- starting with a low dose
phosphodiesterase
inhibitors,
___________may result in reduced vaginal
lubrication with arousal in women, but not the degree
of sexual dysfunction that affects men.
Autonomic dysfunction
Autonomic neuropathy-related postural hypotension
may be compounded by medication, including
_____ and ______-
antihypertensives and anti-angina agents.
Symptoms of gastroparesis (due to autonomic
neuropathy) with decreased gastric emptying include
a sensation of_____, ______, _____ especially after meals
fullness, dysphagia, reflux or recurrent
nausea and vomiting,
Tx of gastroparesis
medication with domperidone,
cisapride or erythromycin
Recent development in the tx of gastroparesis
A recent development is
injections of ______ into the pylorus
via gastroscopy to facilitate gastric emptying
botulinum toxin type A
In general terms people controlled by diet alone have
no restrictions for driving whereas those on insulin
may obtain a conditional licence subject to ____
annual
or 2-yearly review
The _____is generally
regarded as the most appropriate option for birth
control in women not interested in permanent
sterilisation
combined oral contraceptive pill
Future of DM Tx
_______ for type 1 diabetes
• Increased availability _____ and ____ for type 2 diabetes
• Continuous ______
monitoring
immunomodulators
glucagon-like peptide and amylin-like peptides
implantable venous glucose
Future of DM Tx
• Combination \_\_\_\_ • Inhaled insulin • Transplantation: \_\_\_\_\_\_ \_\_\_\_\_\_
‘type 2 tablet’
— combined kidney/pancreas
— islet cells
Hyperglycaemia is a common cause of tiredness. If
elderly type 2 diabetic patients are very tired, think
of hyperglycaemia and consider giving______ to
improve their symptoms
insulin
If a diabetic patient (particularly type 1) is very
drowsy and looks sick, consider first the diagnosis
of ____
ketoacidosis
Treat associated hypertension with _____ and _____(also good in combination
ACE inhibitors or a
calcium-channel blocker
8 things you have to review in 3 month control of DM 1 2 3 4 5 6 7 8
Discourage smoking and alcohol. Review symptoms. Review nutrition. Check weight (BMI), BP, urine. Review self-monitoring. Review exercise and physical activity. Review HbA1c (test at least every 6 months). Review lipid levels (test at least every 12 months).
