Endocrinology Flashcards
DKA management
Treating DKA (FIG-PICK) Follow local protocols carefully.
F – Fluids – IV fluid resuscitation with normal saline (e.g. 1 litre stat, then 4 litres with added potassium over the next 12 hours)
I – Insulin – Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour)
G – Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l)
P – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required
I – Infection – Treat underlying triggers such as infection
C – Chart fluid balance
K – Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable)
Establish the patient on their normal subcutaneous insulin regime prior to stopping the insulin and fluid infusion.
Remember as a general rule potassium should not be infused at a rate of more than 10 mmol per hour.
DKA diagnosis
Hyperglycaemia (i.e. blood glucose > 11 mmol/l)
Ketosis (i.e. blood ketones > 3 mmol/l)
Acidosis (i.e. pH < 7.3)
DMII medical management
First line: metformin titrated from initially 500mg once daily as tolerated.
Second line add: sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor. The decision should be based on individual factors and drug tolerance.
Third line:
Triple therapy with metformin and two of the second line drugs combined, or;
Metformin plus insulin
SIGN Guidelines 2017 suggest the use of SGLT-2 inhibitors and GLP-1 mimetics (e.g. liraglutide) preferentially in patients with cardiovascular disease.
Metformin mechanism
Metformin is a “biguanide”. It increases insulin sensitivity and decreases liver production of glucose. It is considered to be “weight neutral” and does not increase or decrease body weight.
Metformin SE
Diarrhoea and abdominal pain. This is dose dependent and reducing the dose often resolves the symptoms
Lactic acidosis
Does NOT typically cause hypoglycaemia
Pioglitazone mechanism
Pioglitazone is a “thiazolidinedione”. It increases insulin sensitivity and decreases liver production of glucose.
Pioglitazone SE
Weight gain Fluid retention Anaemia Heart failure Extended use may increase the risk of bladder cancer Does NOT typically cause hypoglycaemia
Sulfonylurea mechanism
The most common sulfonyluria is “gliclazide”. Sulfonylureas stimulate insulin release from the pancreas.
Sulfonylurea SE
Weight gain
Hypoglycaemia
Increased risk of cardiovascular disease and myocardial infarction when used as monotherapy
DPP-4 inhibitor mechanism
The most common DPP-4 inhibitor is “sitagliptin”. It inhibits the DPP-4 enzyme and therefore increases GLP-1 activity.
GLP-1 mimetics mechanism
These medications mimic the action of GLP-1. A common GLP-1 mimetic is “exenatide”.
Exenatide is given as a subcutaneous injection either twice daily by the patient or once weekly in a modifiable-release form.
Another GLP-1 mimetic is liraglutide, which is given daily as a subcutaneous injection. They are sometimes used in combination with metformin and a sulfonylurea in overweight patients.
SGLT-2 Inhibitors mechanism
SGLT-2 inhibitors end with the suffix “-gliflozin”, such as empagliflozin, canagliflozin and dapagliflozin.
The SGLT-2 protein is responsible for reabsorbing glucose from the urine in to the blood in the proximal tubules of the kidneys.
SGLT-2 inhibitors block the action of this protein and cause glucose to be excreted in the urine.
SGLT-2 Inhibitors SE
Glucoseuria (glucose in the urine)
Increased rate of urinary tract infections
Weight loss
Diabetic ketoacidosis, notably with only moderately raised glucose. This is a rare complication
Lower limb amputation appears to be more common in patients on canagliflozin. It is not clear if this applies to other SGLT-2 inhibitors
