Management of Diabetes Flashcards
What are the aims of management with regards to type 1 diabetes?
Prompt diagnosis
Encouragement of self management
Correction of acute metabolic upsets
Facilitate long term health and wellbeing
Why is a prompt diagnosis important in type 1 diabetes?
DKA can develop and cause death if diabetes is left undiagnosed
What steps can be taken to make an early diagnosis of type 1 diabetes?
Remember symptoms- thirsty, thinner, tired and more frequent toilet visits (4 Ts)
Test immediately- use a finger prick glucose test
Contact local team for a same day review
What are some symptoms specific to children that may indicate type 1 diabetes?
A return to bed-wetting in a previously dry child Heavier than usual nappies Candidiasis Constipation Skin infections Irritability/ behaviour change
What are the symptoms of diabetic ketoacidosis?
Nausea & vomiting Abdominal pain Sweet smelling breath Drowsiness Rapid, deep respiration Coma
What steps should be taken in cases of diabetic ketoacidosis?
Test blood glucose with a finger prick test to confirm cause but DO NOT arrange for any laboratory tests
In children call a specialist for a same day review
What are the current strategies to support people with type 1 diabetes?
Education- can be team based, structured or personal
Help with nutrition/lifestyle management
Skills training
Methods of receiving insulin
When do type 1 diabetics need to be able to check their blood glucose levels?
To adjust insulin levels
Before driving
To tighten control of their diabetes
What levels of ketones are considered normal, at risk of DKA and in DKA?
<0.6mmol/L-normal
- 6-2.9 mmol/L- at risk of DKA
- 0 or above- DKA
What are the different kinds of insulin?
Rapid acting Short acting Intermediate acting Long acting Continuous acting
What adjustments in lifestyle are necessary after a diabetes diagnosis?
Exercise Diet Driving Smoking Alcohol Conception/contraception Drugs Holiday Employment
Under what blood glucose measurement is somebody considered hypoglycaemic?
> 4mmol/L
What drugs put patients at risk of experiencing hypoglycaemic episodes?
Insulin and sulphonyureas
What causes a hypoglycaemic episode?
An imbalance between nutrition, exercise and insulin
What are the symptoms of a hypoglycaemic episode?
Sweating Palpitations Hunger Shaking Headache Nausea Confusion Drowsiness Odd behaviours Speech difficulty Incoordination
What volume of carbohydrate should be used to treat a hypo?
15-20g
How can hypos be treated if the patient cannot take CHO orally?
Out of hospital- 1mg glucagon or Glucogel/Dextrogel
In hospital- 75-80ml 20% glucose or 25-50ml of 50% glucose
How can hypos be avoided in insulin dependent diabetics?
Blood glucose monitoring Site rotation and checking Review diet Consider change in insulin regimen Deliver insulin before and after exercise
What are the signs of DKA?
Dry mucus membranes Sunken eyes Tachycardia Hypotension Ketotic breath Kussmaul resp. Altered mental state Hypothermia
What are the possible complications of DKA?
Hyper/hypokalaemia Hypoglycaemia Cerebral oedema Aspiration pneumonia Arterial and venous thromboembolism ARDS
What measures may need to be taken in treating DKA?
Measure glucose, Us + Es, ketones, bicarbonate and arterial blood gases Give IV saline Give IV insulin Give IV potassium in saline May need antibiotics Consider heparin and NG tube
What factors help facilitate long term health and well being in cases of type 1 diabetes?
Optimal blood glucose (HbA1c to reduce microvascular disease)
Optimal blood pressure control (to reduce risk of nephropathy)
Manage cardiovascular risk factors
Screen for early detection of complications (feet, kidneys, eyes)
What should patients with type 2 diabetes expect from their care?
Blood glucose levels Blood pressure checked Blood lipids Eyes and feet screened Kidney function tested Weight management Smoking cessation An individual care plan Structured education Psychological/emotional support
What are the aims of treatment of diabetes?
Relief of primary symptoms
Prevention of complications
Preservation of quality of life
Describe the 5-step framework that should be considered when choosing a glucose lowering drug
- Set a target HbA1c
- Are there other risk factors that are more important?
- Are the current treatments optimised?
- What are the glucose lowering options?
- Agree a review date and HbA1c target with the patient
In what cases should you consider relaxing a HbA1c target?
People who are older or frail Adults with type 2 diabetes that have: -reduced life expectancy -high risk of hypoglycaemia -where intensive management not appropriate (eg multiple comorbities)
What are the first line treatments of antihyperglycaemic therapy in type 2 diabetes and when is each recommended?
Metformin first line
Sulfonyureas if weight loss or osmotic symptoms are present
What are the second line treatments of antihyperglycaemic therapy in type 2 diabetes and when is each recommended?
Sulfonyureas- if not already prescribed
Thiazolidinedione- if hypos are a concern and no congestive heart failure
DPP-IV inhibitor or SGLT-2 inhibitor- if hypos and weight gain are concerns
What are the third line treatments of antihyperglycaemic therapy in type 2 diabetes and when is each recommended?
Add an additional one of the second line treatments
Also can use injectable medications:
GLP-1 agonist- if BMI >30 with a desire to lose weight
Insulin- if osmotic symptoms/rising HbA1c
Give examples of the following classes of medications: Sulfonyureas Thiazolidinedione DPP-IV inhibitor SGLT-2 inhibitor GLP-1 agonist
Sulfonyureas- glimepiride/gliclazide Thiazolidinedione- pioglitazone DPP-IV inhibitor- sitagliptin SGLT-2 inhibitor- empagliflozin GLP-1 agonist- lixisenatide
Why is metformin the first choice in treating hyperglycaemia?
Improves outcomes
Well tolerated
Cheap
What is the mechanism of metformin treating hyperglycaemia?
Affects glucose production and decreases fatty acid synthesis
Improves receptor function
Inhibits gluconeogenic pathways
What are the disadvantages of metformin?
Risk of lactic acidosis
GI side effects common
Risk of vitamin B12 malabsorption
Describe the mechanism of action of sulfonyureas
Bind to sulfonyurea receptors on functioning pancreatic beta-cells, closing the linked ATP-sensitive potassium channels. This causes a decreased potassium influx depolarisation of the cell membrane so voltage-gated calcium channels open and cause an influx of calcium. This causes translation and exocytosis of secretory granules of insulin into the cell
What are the advantages of sulfonyureas?
Can be used with metformin Rapid improvement of control and systematic improvement Rapid titration Well tolerated Cheap
What are the disadvantages of sulfonyureas?
Risk of hypoglycaemia
Weight gain
Caution needed in renal and hepatic disease
Contraindicated in pregnancy and breast feeding
Side effects include hypersensitivity and blood disorders
Describe the mechanism of action of thiazolidinedione
Selectively stimulates the PPAR-gamma and modulates the transcription of insulin-sensitive genes involved in the control of glucose and lipid metabolism in muscle, adipose tissue and the liver. It reduces insulin resistance in the liver and peripheries, increases the expense of insulin-dependent glucose, decreases withdrawal of glucose from the liver and reduces quantity of glucose, insulin and glycated haemoglobin in the bloodstream
What are the advantages of pioglitazione?
Helpful in cases where insulin resistance is significant
Reduces HbA1c marginally
Cheap
Cardiovascular safety established
What are the disadvantages of pioglitazione?
Increased risk of bladder cancer
Fluid retention
Weight gain
Increases risk of fractures in females
