Lecture ILO’s Flashcards
Normal blood sugar
What is ‘normal’?
NICE says:
Adult fasting: 4 - <6mmol/L, post-prandial <7.8 mmol/L plasma glucose
HbA1c
<59 mmol/mol (7.5%) under 18 <53 mmol/mol (<7) for adults
Diagnosis measures of type 2 diabetes
• Random venous plasma glucose concentration ≥ 11.1 mmol/L
• Fasting plasma blood glucose level ≥ 7.0 mmol/L
• HbA1c of 48 mmol/mol (6.5%) or more (shows previous 3 months)
Must have diabetes symptoms
HbA1C targets
• Educate the person about their individual recommended HbA1c target, and encourage measures to achieve and maintain it, where possible.
• Lifestyle including diet management—48mmol/mol(6.5%).
• Lifestyle including diet combined with a single drug not associated with
hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%).
• Drug treatment associated with hypoglycaemia (such as a sulfonylurea): 53
mmol/mol (7.0%).
If HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher: Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).
Glycaemic targets
HbA1c
Agree a personalised target usually between 48 and 58 mmol/mol (6.5% and 7.5%)
Avoid pursuing highly intensive management to below 48mmol/mol (6.5%)
Blood glucose
Before meals 4 – 7 mmol/l
Two hours after meals lless than 8.5 mmol/l
Monitoring of type 2 diabetes
• The HbA1c should be checked every 3-6 months until it is stable, then every 6 months.
• Currently it is not recommended to offer self monitoring blood glucose levels in Type 2 unless
• The person is on insulin
• Evidence of hypoglycaemia episodes
• On oral medication that may increase their risk or hypo whilst driving or operating machinery
• The person is pregnant or planning pregnancy
• Short term on corticosteroids
• Continuous Glucose monitoring
• Type 2 on multiple daily insulin injections
• Recurrent hypos
Lifestyle advice for type 2 diabetic
Diet:
Carbohydrates with a low glycaemic index (fruit and vegetables).
• High fibre, low saturated fat.
Stick to appropriate meal patterns to reduce risk of hypoglycaemia.
Control alcohol intake.
Exercise and weight loss- Can help reduce cardiovascular risk.
Smoking cessation.
• Type 2 diabetes may be completely manged through lifestyle changes alone!
What is the Desmond programme
• “Diabetes Education and Self Management for Ongoing and Newly Diagnosed”
• Patient education and support programme.
• Can also provide training and guidance for health care professionals.
• Type 1 equivalent = DAFNE
What is included in the yearly screening for type 2 diabetes?
• Retinopathy (Starting at diagnosis)
• Diabetic foot problems (Starting at diagnosis)
• Cardiovascular risk factors (Starting at diagnosis)
• Nephropathy
Also quite common:
Peripheral vascular
Infections due to increase sugar (breeding ground for bacteria) ie uti and thrush
Retinopathy with diabetics
Common symptoms - blurred vision
• Caused by microvascular occlusion, which progresses to retina ischemia.
• Most common cause of serious sight impairment in people 18-55.
• Ideally should be screened for once a year in Type 2 diabetics.
Have a proper eye test
Kidney disease and diabetes
• The glomerulus is very sensitive to vascular damage, and results in albumin excretion, which is not usually excreted in the urine.
• The Urine AcR (Albumin to Creatinine ratio) is routinely done in Type 2 diabetes to monitor for kidney disease.
(Protein leaking from kidney so protein tested to see if in urine)
What is the target blood pressure for type 2 diabetics?
Type 2 DM
• Blood pressure should be checked annually, and kept below 140/90.
• Or below 130/80 if evidence of nephropathy, retinopathy, or cerebrovascular damage.
Name the types of anti-diabetic medication for type 2 diabetes
1st step- diet and lifestyle
Metformin
Sulfonylureas
DPP- 4 inhibitors (gliptins)
GLP- I agonist
Thiazolidinediones (glitazones)
SGLT-2 inhibitors (gliflozins)
Insulin
Hypoglycaemia in type 2 diabetics
• Type 2 diabetics on sulphonylureas/insulin are at increased risk of hypoglycaemic events.
• Defined as a blood sugar level<4mmol/l.
• Symptoms:
-Headache and double vision
-Sweating
-Fatigue
-Dizziness
In severe cases can lead to coma and death
Hyperosmolar hyperglycaemic state (HHS)
Type 2 diabetics
Insidious in onset – usually weeks
High blood sugars & resulting high osmolality without ketosis BG >30mmol , Osmolarity >320
Symptoms : dehydration ,weakness , leg cramps, confusion Triggered by example an infection , MI etc
Diabetic hyperglycaemic crises
DKA vs HHS
Diabetic ketoacidosis:
Younger type 1 diabetes
No hyperosmolality
Volume depletion
Electrolyte disturbances
Acidosis
Hyperglycaemic hyperosmolar state (HHS)
Older, type 2 diabetes
Hyperosmality
Volume depletion
Electrolyte disturbances
No acidosis
Diabetic foot infections
Which bacteria?
Which antibiotics?
How long for?
• Which bacteria?
• Commonly Gram positive : Staphylococcus & Streptococcus
• Some Gram negative : pseudomonas , E coli, Klebsiella,
• Which antibiotics?
Depends on local guidelines
• Antibiotic formulary
• Oral or IV?
• Mild / Moderate / Severe
• Higher doses due to absorption
• How long for?
• Prolonged courses 7 days +
Difference between type 1 and type 2 diabetes
Type 1:
• Absolute lack of insulin
• Insulin required at all stages of treatment
• Need insulin to prevent hyperglycaemia and ketoacidosis
Type 2:
• Relative insulin lack/insensitivity
• Diet control - oral hypoglycaemic agents - insulin
What is checked in the regular diabetes review?
- HbA1c, cholesterol and BP
- Diet and lifestyle
- Eye checks
- Urine tests
- Foot checks
- Sensory tests
- Blood tests – FBC, U+Es, BMs
Types of insulin
Animal
Beef (Bovine) – cattle pancreas
Pork (Porcine) –pig pancreas
Human
Most commonly used
Genetically engineered using either yeast or bacteria
Analogue insulin
• Both effectively obsolete but available for patients who have been using it for a long time
Types of acting insulin
• Classed according to duration of action:
Types of Insulin
– Ultra fast acting analogue insulin
– Rapid acting analogue insulin
– Short acting human soluble insulin
– Intermediate acting human insulin
– Long-acting analogue basal insulin
– Ultra long-acting analogue basal insulin
– Biphasic insulin (mixture of rapid/short and intermediate acting insulin)
Rapid acting insulin
• Onset: 10 - 20 minutes
• Peak: 1-3 hours
• Duration of action: up to 5 hours
• Clear (no need to suspend)
– E.g.Novorapid (insulinaspart), Humalog (insulin lispro), Apidra (insulin glulisine)
– Inject immediately before or just after meals
– FIASP (insulin aspart)–ultrafast within 2.5mins ! – quicker but shorter action
Short acting insulin
• Onset: within 30 minutes (5mins if IV)
• Peak:1.5- 3.5hours
• Duration of action: Up to 8 hours
• Clear (no need to resuspend)
E.g Actrapid, Humulin S,
• Inject 15-30 mins before meals
• Advantage that it can be given IV, IM, SC,
Intermediate acting insulin
• Onset: 1.5 hours
• Peak: 4 - 12 hours
• Duration of action: up to 24 hours
• May require twice daily
• Crystals in suspension (cloudy) needs re- suspending
Humulin I, Insulatard,Insuman Basal (NPH / Isophane)
Long acting insulin
• Delayed and prolonged absorption from injection site
• Onset: 0 – 2 hours
• Peak: Levemir = 5 hrs, others = no peak
• Duration of action: up to 24 hours
• Clear - no need for re-suspension
– E.g. Lantus, Abasaglar ( both insulin
glargine*), Levemir (insulin detemir) (start with this one)
– Prolonged plateau, providing a fairly stable level of insulin for most of 24 hr period, reduced hypoglycaemia
Ultra long acting analogue insulin
• Duration of up to 42 hours
• Use once a day with rapid acting analogue insulin
• Steady state after 2-3 days
Biphasic insulin
Useful for district nurses visiting patients twice daily
– E.g.Novomix30,HumalogMix25, Humalog Mix 50, Mixtard 30, Humulin M3, etc
– Mixtureof:
• Short acting insulin plus intermediate acting insulin
• Rapid acting plus intermediate acting insulin
Soluble pre mixed insulin
• Premixed combinations of short and intermediate acting insulin (biphasic)
• Cloudy (needsre-suspending).Crystals in suspension
• Onset: within 30minutes
• Peak:2–8hours
• Duration of action: Upto24hours
Eg humulin M3, insuman comb 15, 25, 50
Analogue pre mixed insulin
• Pre mixed combinations of short and intermediate acting insulin (biphasic)
• Cloudy (needs re-suspending). Crystals in suspension
• Onset:10-20minutes
• Peak:1-4hours
• Duration of action:Upto24hours
Eg Novomix 30, Humalog Mix 25, Humalog Mix 50
Basal boils regime for T1 diabetics
Gold standard
Short acting/rapid acting insulin at meals (bolus)
• Long acting/intermediate acting insulin at bedtime (basal)
• E.g. Novorapid 8 units TDS (three times daily) with meals and Lantus 24 units at night
Basal Bolus Soluble / NPH Insulin
Once daily NPH with short acting soluble insulin cover for each main meal (onset, peak & duration as described previously)
Examples of basal bolus soluble / NPH combinations
Insulatard once daily NPH with Humulin S short acting insulin
Humulin I once daily NPH with Actrapid short acting insulin
Basal Bolus Analogue Insulins
• Once daily basal analogue with rapid acting analogue cover for each main meal (onset, peak and duration as described previously)
• Examples of basal bolus analogue combinations:
– Lantus, Abasagalar, Toujeo, Degludec or Levemir once daily basal analogue with Novorapid, Humalog or Apidra rapid acting analogue
Twice daily insulin
• Use biphasic e.g. Novomix 30, Mixtard 30, Humalog Mix 25
• Twice a day pre-breakfast and pre-evening meal
Carbohydrate counting for type 1 diabetics
• determining the dose of insulin from the amount of carbohydrate the patient is about to eat
• A long-acting insulin is given once a day
• Rapid acting insulin is given at meal times; the dose will vary depending on how carbohydrate will be consumed
• Should only be used in patients specifically trained to use such regimens
• Examples include:
DAFNE Dose Adjustment For Normal Eating.
• Either count in grams or as carb portions
• Identify your insulin-to-carbohydrate ratio
• Combining allows you to work out the number of units bolus need for the meal
• E.g. 70g carb meal, ration is 1:10 insulin to carb, you need 7 units of insulin
Starting doses of insulin for type 1 diabetics
Starting doses
An initial total daily dose of insulin in adults can be 0.2 to 0.4 units/kg/day.
• In children an initial daily dose will be 0.5 to 1.0 units/kg/day, and
• during puberty the requirements may increase to as much as 1.5 units/kg/day.
One half of the total dose is given as basal insulin and one half as bolus dosing
The simplest approach to covering mealtime insulin requirements is to suggest a range of doses, such as 4 units for a small meal, 6 units for a medium-sized meal, and 8 units for a larger meal.
For greater flexibility of carbohydrate content of meals can be calculated one unit of mealtime insulin for every 15 g of carbohydrate in the meal.
Using a food diary and 2-hour postprandial blood glucose measurements, the insulin-to- carbohydrate ratio can be adjusted.
Finding out a patients insulin dose
Finding out a patients insulin dose
• The most reliable source is the patient,so always ask them first
• If they are not able to tell you or don’t administer their insulin, ask the person who does (nursing home, family member, district nurses)
• District nurses notes on EMIS
• Community DSN notes via hospital DSNs
• Recent discharges/transfers/repats/clinicletters
• If all else fails, and you have no idea what dose a patient is on, prescribe a variable insulin after finding out blood sugar
Insulin devices
Vial and injection
Pre filled pen
Cartridges and re usable pen
Continuous subcutaneous insulin infusion (insulin pump)
Lypohypertrophies
Fatty lumps due to repeated insulin injections
Caused by bad technique
• Unsightly
• Painful
• Unpredictable insulin absorption
• To reduce risk:
• Rotate between sites
• Rotate within sites
• New needle for each injection
• Avoid injecting into lumps
Glycaemic targets for children and adults
• It is important that the blood glucose levels being aimed for are as near normal as possible. However, individual target levels must be agreed between the person and their diabetes team
• Children with Type 1 diabetes (NICE)
– On waking and before meals: 4-7mmol/l
– After meals: 5-9mmol/l
• Adults with Type 1 diabetes (NICE)
– On waking: 5-7mmol/l
– Before meals at other times of day: 4–7mmol/l
– 90 minutes after meals: 5-9mmol/l
Blood glucose monitoring targets
Monitor at least four times a day, including before each meal and before bed
Optimal targets are:
• - Fasting level of 5–7 mmol/L on waking
• - Level of 4–7 mmol/L before meals at other times of the day
For adults who choose to test after meals, level of 5–9 mmol/L at least 90 minutes after eating
• - Level of at least 5 mmol/L when driving
Continuous/flash glucose monitoring
(Pump in arm)
•all adults with type 1 diabetes should have access to either Flash or CGM
•all children with type 1 diabetes should have access to CGM and that
•some people with type 2 diabetes who use insulin intensive therapy (2 or more injections a day) should have access to Flash, for example if they experience recurrent or severe hypos, if they have a disability that means they cannot finger-prick test or if they would otherwise be advised to test 8 or more times a day.
What is hypoglycaemia?
Who is at risk?
Common causes
Symptoms
What is hypoglycaemia (a hypo)?
This occurs when the amount of glucose in the blood is below 4mmol/l.
Who is at risk?
People who treat their diabetes with insulin, sulphonylureas or prandial glucose regulators. (repaglinide , nateglinide)
Those who treat their diabetes with diet or metformin alone are generally not at risk
Common causes:
• Taking too much diabetes medication
• Delaying or missing a meal/snack
• Not eating enough carbohydrates
• Taking part in unplanned or strenuous physical activity
• Drinking too much alcohol or drinking alcohol without food
• Sometimes there are no obvious causes
Symptoms
Dizziness, sweating, blurred vision, looking pale, disorientation, tremor, hunger, Tingling of lips, fast pulse, confusion, irrational behavior, unconsciousness
Treatment for a mild hypo
15-20g of fast acting glucose
Eg 4-5 gluco tabs
Or if conscious and able to swallow 1x 60 ml bottle of gluco juice
Treatment of a severe hypo
Airway
Breathing
Circulation
Disability
Exposure
If patient is unconscious stop insulin infusion immediately if in situ
Administer at least 150mls of IV glucose
Or
Administer intramuscular injection of glucagon 1mg
Once patient is conscious administer 1 x 60ml bottle of gluco juice
Hyperglycaemia symptoms
Diabetic symptoms
Dry mouth
Increased thirst
Blurred vision
Weakness
Headache
Polyuria
Initial DKA management
Diagnose:
• CBG >11mmol/l OR known to have diabetes
• pH <7.3 and/or bicarbonate <15mmols Diagnose
• Ketones >3mmol/l
Fluids:
• Fluid resuscitate
• Restore volume
• Replace K+ (monitor K+)
Insulin:
• Fixed Rate Insulin Infusion (FRII) 0.1 units insulin per kg per hour
Monitor:
• Hourly monitoring • Senior review
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 requirements:
Capillary blood glucose > 11 mol/L
Capillary ketones > 3 mol/L and
Venous pH <7.3 and/or bicarbonate <15 mol/L
