Management of Diabetes Flashcards
Types of insulin administration
Short acting insulin Rapid acting insulin Long acting insulin Intermediate acting insulin Biphasic insulin
Characteristic of short acting insulin
Soluble insulin
Characteristic of rapid acting insulin
Bolus insulin
Characteristic of long acting insulin
Basal insulin
How often is biphasic insulin given?
Twice daily mixed insulin
Why would there be a possible increased risk of mortality associated with tight glycaemic control?
Due to myocardial strain as a result of more hypos/severe hypos
Insulin and glucose levels in T1DM
Hypoinsulinaemia
Hyperglycaemia
Insulin and glucose levels in T2DM
Initially hyperinsulinaemia and hyperglycaemia
Then hypoinsulinaemia and hyperrglycaemia
Before initiating treatment, switching or increased treatment, what must be considered?
Adherence to medication
Diet
Exercise levels
What type of insulin would be taken at every meal?
Rapid acting insulin (basal bolus)
What dose is usually started with insulin in T1DM?
0.5 units/kg
Basal bolus split dose 50/50 into basal and bolus sections - more control, more injections
What pump can be used in T1DM?
Insulin pump - continuous subcutaneous insulin infusion (CSII)
What dose of insulin is usually started in T2DM?
Normally started on basal regime
1st line NPH -although often insulin analogue
Start basal at 10 units then increase in 10% increments until fasting sugar controlled
Classes of oral antidiabetic medications
Biguanide/metformin Sulfonylurea PPAR agonist DPP4 inhibitor SGLT2 inhibitor Dual SGLT2/SGLT1 inhibitors
What is biguanide/metformin?
Peripheral insulin sensitizer
What does metformin do?
Sensitises insulin
Inhibits hepatic gluconeogenesis
Does metformin cause hypos?
No
Side effects of metformin
Diarrhoea
Cramps
Flatulence
Nausea
Rare side effect of metformin and therefore what must it be avoided in?
Lactic acidosis
Renal, hepatic, cardiac or resp failure
Can sulphonyureas cause hypos?
Yes
Side effects of sulphonyureas
GI S/Es
Weight gain
May cause hypos
What is meant by a “healthy lifestyle”?
Eat a well balanced diet Dont smoke Regular physical activity Moderate alcohol use Dont use recreational drugs Good work/life balance Learn to deal with stress appropriately
What are dietary allowances?
Quantative guidelines for different population subgroups for the essential macro and micro-nutrients to prevent nutritional deficiencies
What are dietary goals?
Quantitative guidelines for different population subgroups for the essential macro and micro-nutrients aimed at preventing long term chronic disease e.g. stroke, cancer. Aimed at national population level
What are dietary guidelines?
Broad targets aimed at the individual to promote nutritional well-being. Used for macro and micro nutrients.
What is a dietary reference value (DRV)?
A series of estimates of the amount of energy and nutrients needed by different groups of healthy people in the UK population
Benefits of exercise
CV benefit Reduces cancer risk Consumes energy Builds lean tissue and consumes fat Improves strength, endurance, balance and flexibility Improves mood and self esteem Can be sociable
What has to be considered in young people with diabetes?
Sports Nights out Alcohol / drugs Learning to drive Leaving home Festivals Travel Sex/contraception Tattoos/piercings
Alcohol effect of glycogenolysis
Reduces glyconeolysis
Alcohol considerations in DM
It contains calories (results in rise followed by a fall in glucose)
More than 2-3 units at one time increases hypo risk
Advise to eat before and snack at bedtime
Note other activity at time of alcohol e.g. dancing
Smoking with diabetes risk
Increases risk of DM by 1.5x
DM and exercise
Reduce insulin before and after (up to 24 hours)
Reduction hypo risk
Eat more (appropriate carbohydrate)
Use different insulin regime (maximise flexibility)
Driving and DM
Risk of hypos, poor vision, neuropathy
Take carbohydrate in vehicle
Do not drive for 45 minutes after hypo
Check blood glucose within 2 hours of starting driving and 2 hourly in long car journeys
What jobs are you excluded from if you are diabetic?
Armed forces
Police
What two ways can insulin be administered?
Subcutaneously
Intravenously
How long is soluble insulin given before eating and why?
30 mins before eating
Because insulin hexamers need to dissociate into monomers before absorption through the capillary bed
Do rapid acting insulin analogues dissociate? How much time are they given before eating?
No
Can be injected just before eating
What should the amount of insulin injected for meals balance?
The carbohydrate intake consumed
Definition of hypoglycaemia
Any episode of low blood glucose (4 mmol/l) with or without symptoms
Causes of hypoglycaemia
Too much insulin/SU Inappropriate timing of insulin/SU Injection site problems (lumpy sites) Inadequate food intake/fasting Increased exercise relative to usual Alcohol Irregular lifestyle Breast feeding Inadequate blood glucose monitoring Food malabsorption e.g. gastroenteritis, coeliac Drugs e.g. warfarin, NSAIDs Loss of anti-insulin hormone function (addions, GH defieincy, hypothyroid, hypopituitarism)
At risk groups for hypoglycaemia
Tight glycaemic control Impaired awareness Cognitive impairment Extremes of age Malabsorption/gastroparesis Hypoadrenalism/abrupt steroid withdrawal Coeliac disease Renal/hepatic impairment Pancreatectomy Pregnancy
Presentation of hypoglycaemia
Sweating Palpitations Shaking Hunger Confusion Drowsiness Odd behaviour Speech difficulty Incoordination Headache Nausea
Causes of inability to perceive the normal warning symptoms of hypoglycaemia
Recurrent severe hypoglycaemia
Long duration of disease
Over tight control
Loss of sweating/tremor
Treatment of mild hypoglycaemia (<4)
15 - 20g of quick acting carbohydrate e.g. Lucozade, fruit juice, dextrosol tablets
Recheck (10-15 mins)
Repeat treatment up to 3 times
Recheck
If gets severe, IV glucose and call for help
Treatment of moderate hypoglycaemia (< 4)
1.5 - 2 tubes of glucose gel Recheck (10-15 mins) Repeat up to 3x IM glucagon (once only) Recheck If severe IV glucose and call for help
Treatment of severe hypoglycaemia or during a fast (<4)
ABC stop IV insulin Give IV glucose over 10-15 minutes - 75ml 20% glucose or - 150ml 10% glucose or - 1mg Glucagon IM once only Recheck 10 minutes Repeat IV glucose
Ongoing management of hypoglycaemia once blood glucose is > 4 mmol/L
give 20g of long acting carbohydrate e.g.
- two biscuits
- slice of bread
- 200-300ml of bilk
- or next meal
What is found in a hypobox?
Fruit juice Dextro energy Glucogel 50% dextrose Hypo management protocol
How to avoid hypoglycaemia in insulin treated diabetes
Blood glucose monitoring Rotate and check injection sites Review snacks and diet - carb counting Consider a change of insulin regime e.g. basal bolus Avoid low glucose (4 is the floor) Alter insulin before AND after exercise
What should glucose level be before bed?
7
What should glucose level be before driving?
5
Risk factors for DKA
Known T1DM Inadequate insulin Infection Severe stress Other precipitant
Symptoms of DKA
Polyuria Polydipsia Weight loss Weakness Nausea/vomiting Abdominal pain Breathlessness
Signs of DKA
Dry mucous membranes Sunken eyes Tachycardia Hypotension Ketotic breath Kaussmaul respiration Altered mental state Hypothermia
What does DKA stand for?
Diabetic ketoacidosis
What does DKA result from?
Too little insulin leading to fat breakdown
What MUST you remember when treating DKA?
NEVER stop taking your insulin
What blood ketone result indicates risk of DKA?
> 1.5
Investigations of DKA
ABC Glucose Venous blood gases Urinalysis/blood ketones U and Es FBC Culture blood/urine ECG and cardiac monitor Consider CXR
Management of DKA in first 60 minutes
Commence IV sodium chloride (saline) 0.9% over 1 hour within 30 mins of admission
Commence soluble insulin IV 6 units/hour within 30 mins of admission
Give IV K in saline
Complications of DKA
Hyper and hypokalaemia Hypoglycaemia Cerebral oedema Aspiration pneumonia Arterial and venous thromboembolism ARDS
Who is more susceptible to cerebral oedema as a complication of DKA?
Children
Before you inject insulin in T1DM, what must you check?
Right insulin
Right dose
Right time
Right way
If blood ketones are between 0.6 - 1.4 mmol/L, what should the patient do?
Drink plenty of sugar free fluids
Give a correction dose of insulin
Retest blood sugar and ketones 1 - 2 hourly
Symptoms of uncontrolled T2DM
Frequent urination Increased thirst Blurry vision Increased hunger Feeling drowsy or sleepy Tingling, pain or numbness in hands and feet Slow or improper healing of cuts and bruises Asymptomatic or mild
Prevention of complications of T2DM
Stop smoking Dietary change Mood Statins BP Physical activity
Who would you consider relaxing the target HbA1c level on?
Elderly Frail T2DM with - reduced life expectancy - high risk of consequences of hypoglycaemia - multiple co morbidities
First line option of a glucose lowering drug
Metformin or sulphonyurea
How does metformin work?
Affects glucose production
Decreases fatty acid synthesis
Improves receptor function
Inhibits gluconeogenic pathways (half life 6 hours)
Side effects of metformin
Lactic acidosis risk
GI side effects 20-30%
Vit B12 malabsorption
How do sulphonyureas work?
Bind to sulfounyurea receptors (SUR-1) on functioning pancreatic B cells
Translocation and exocytosis of secretory granules of insulin to the cell surface
Side effects of sulphonyureas
Hypos
Weight gain
Insulin therapy regime - the main one that is suitable for a flexible life style
Rapid (short) acting insulin to cover CHO meals
Basal long acting insulin as a background
At what HbA1c should a second drug be added in T2DM?
> 58mmol/mol
