KEY DIABETES MELLITUS Flashcards
5 main pathological features in DKA.
Hyperglycaemia. Dehydration. Ketosis. Metabolic acidosis (low bicarbonate) Potassium imbalance.
S+S of DKA.
Polyuria. Polydipsia. N+V. Acetone smell to breath. Dehydration + hypotension. Altered consciousness. Symptoms of underlying trigger (e.g. infection)
Cause of T1DM?
Pancreases does not produce insulin (genetic predisposition + environmental trigger).
What environmental triggers have been linked with development of T1DM?
Viruses such as cocksackie virus B and enterovirus.
Priorities in management of DKA?
Fluid resuscitation + FRII.
3 diagnostic criteria for DKA?
1) Hyperglycaemia (glucose >11)
2) Ketosis (blood ketones >3)
3) Acidosis (blood pH <7.3)
Management for DKA?
1) Fluids
2) FRII (e.g. Actrapid 0.1 unit/kg/hour)
3) Glucose (keep >14)
4) Potassium
5) Infection (treat underlying triggers)
6) Chart fluid balance
7) Ketones (monitor)
What should you do in a patient treated for DKA before stopping insulin and fluid infusions?
Establish them on their normal subcutaneous insulin regimen.
What is the maximum rate that potassium can be infused at?
10mmol/ hour.
Management for T1DM?
Basal-bolus regimen of insulin.
Briefly describe the basal-bolus regimen of insulin administration.
Background long-acting insulin given once daily
Short acting insulin injected 30 minutes before intake of carbohydrates
1 unit of ActRapid reduces blood glucose levels by roughly how much?
4mmol/ litre.
Complication of injecting insulin into the same place repetitively?
Lipodystrophy - subsequent injections into lipodystrophied areas causes a poorer uptake of insulin.
2 short term complications of diabetes.
Hypoglycaemia.
Hyperglycaemia/ DKA.
Acceptable blood sugar range in diabetics before meals (i.e. fasted blood glucose)?
4 - 7
Acceptable blood sugar range in a person with T1DM 90 minutes after their last meal?
<9.
Acceptable blood sugar range in a person with T2DM 90 minutes after their last meal?
<8.5.
Normal blood sugar range in a person without diabetes upon fasting?
4 - 5.9.
Normal blood sugar range in a person without diabetes 90 minutes after their last meal?
<7.8.
Management of hypoglycaemia?
1st line > 15-20g quick acting carbohydrate (+ long acting carbohydrate)
2nd line > glucose gel
3rd line > IM glucagon/ dextrose IVI
Main effect of chronic hyperglycaemia?
Damage to endothelial cells of blood vessels = leaky + malfunctioning vessels.
2 other effects of chronic hyperglycaemia?
Suppression of immune system.
Optimal environment for infectious organisms to thrive.
Name 3 microvascular complications of diabetes.
Peripheral neuropathy
Retinopathy
Diabetic nephropathy
Name 3 microvascular complications of diabetes.
CAD
Peripheral ischaemia (poor healing, ulcers, diabetic foot)
Stroke
HTN
Name 3 infection related complications of diabetes.
UTIs
Pneumonia
Skin + soft tissue infections
Fungal infections
Frequency of diabetic eye screening?
Every 2 years if low risk of sight loss
Annually for anyone else
Frequency of diabetic foot checks?
Annually.
Frequency of diabetic kidney disease screening?
Annually.
Frequency of CV risk factor assessment?
Annually.
How often is HbA1c measured in those with T1DM?
Every 3-6 months.
Basic pathophysiology of type 2 diabetes?
Repeated exposure to insulin + glucose > cells become resistant to effects > more insulin required to produce a response > pancreas become fatigued + damaged > pancreas produces less insulin > chronic hyperglycaemia > complications of diabetes.
Non-modifiable risk factors for T2DM?
Older age
Ethnicity (BAME origin)
FHx
Modifiable risk factors for T2DM?
Obesity
Sedentary lifestyle
High carbohydrate diet (particularly refined carbs)
How is diabetes screened for?
Usually HbA1c
S+S of T2DM that should prompt screening?
Fatigue Polydipsia Polyuria Unintentional weight loss Opportunistic infections Slow healing Glycosuria
3 ways in which pre-diabetes can be diagnosed?
1) HbA1c 42-47
2) Impaired fasting glucose 5.5-6.9
3) Impaired glucose tolerance 7.8 - 11.1 at 2 hours on OGTT
General rule of diagnosing diabetes?
Symptomatic + 1 positive result = diabetes.
Asymptomatic + 2 positive results = diabetes.
HbA1c level for diagnosing diabetes?
48 and above
Random glucose level for diagnosing diabetes?
> 11.1
Fasting glucose level for diagnosing diabetes?
> 7
OGTT level for diagnosing diabetes?
> 11.1
Normal HbA1c?
<42
Conservative management for T2DM?
Dietary modification > vegetables + oily fish + low glycaemic index foods. Exercise and weight loss Smoking cessation Optimise treatment for other illnesses Monitor for complications
HbA1c target for newly diagnosed T2 diabetics?
=48
HbA1c target for T2 diabetics managed with higher steps than metformin?
=53
Time of onset and total time of action of rapid-acting insulins?
Work within 10 minutes, last for 4 hours.
Time of onset and total time of action of short-acting insulins?
Work within 30 minutes, last for 8 hours.
Time of onset and total time of action of intermediate-acting insulins?
Work within an hour, last for 16 hours.
Time of onset and total time of action of long-acting insulins?
Work within an hour, last for 24 hours.
Examples of rapid acting insulins?
Novorapid
Humalog
Apidra
Examples of short acting insulins?
Actrapid
Humulin S
Insuman rapid
Examples of intermediate acting insulins?
Insulatard
Humulin I
Insuman basal
Examples of long acting insulins?
Lantus
Levemir
Degludec (lasts over 40 hours)
What is contained in combination insulins?
Rapid acting + intermediate acting insulins.
Examples of combination insulins?
Humalog 25
Humalog 50
Novomix 30
**Number is proportion of intermediate acting insulin in combination.
1st line medical management in T2DM?
Metformin titrated as tolerated starting at 500mg OD
2nd line medical management in T2DM?
Dual therapy: Metformin + one of:
- Sulfonylurea
- Pioglitazone
- DPP-4 inhibitor
- SGLT-2 inhibitor
3rd line medical management in T2DM?
Triple therapy: Metformin + 2 second line drugs
OR
Metformin + insulin
Preferred anti-glycemic drugs to be used in CVD?
SGLT-2 inhibitors or GLP-1 mimetics.
Name a biguanide.
Metformin.
MoA of Metformin?
Increases insulin sensitivity.
Side effects of Metformin?
‘Weight neutral’
Diarrhoea + abdo pain
Lactic acidosis
Name a thiazolidinedione.
Pioglitazone.
MoA of Pioglitazone?
Increases insulin insensitivity.
Side effects of Pioglitazone?
Weight gain Fluid retention Anaemia Heart failure Bladder cancer in extended use
Name a sulfonylurea.
Gliclazide.
MoA of sulfonylureas?
Stimulate insulin release from the pancreas.
Side effects of sulfonylureas?
Weight gain
Hypoglycaemia
Increased risk of CVD + MI when used as mono therapy.
Name a DPP-4 inhibitor.
Sitagliptin.
MoA of DPP-4 inhibitors?
Inhibit DPP-4 enzyme + increased GLP-1 activity (which reduces blood glucose levels).
Side effects of DPP-4 inhibitors?
GIT upset
Symptoms of URTI
Pancreatitis
Name a GLP-1 mimetic.
Exenatide
Liraglutide
MoA of GLP-1 mimetics?
Mimic the action of GLP-1 which reduces blood sugar levels.
Side effects of GLP-1 mimetics?
GIT upset
Weight loss
Dizziness
LOW risk of hypoglycaemia
Name an SGLT-2 inhibitor.
Empagliflozin
Canagliflozin
Dapagliflozin
MoA of SGLT-2 inhibitors.
Block SGLT-2 protein from reabsorbing glucose in the proximal tubules = more glucose excreted in urine.
Side effects of SGLT-2 inhibitors.
Glycosuria
Increased rate UTIs/ candidiasis
Weight loss
DKA
