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Endocrine Pathology > Management of Diabetes > Flashcards

Management of Diabetes Flashcards

1
Q

Types of insulin administration

A 
Short acting insulin 
Rapid acting insulin 
Long acting insulin 
Intermediate acting insulin 
Biphasic insulin
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2
Q

Characteristic of short acting insulin

A

Soluble insulin

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3
Q

Characteristic of rapid acting insulin

A

Bolus insulin

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4
Q

Characteristic of long acting insulin

A

Basal insulin

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5
Q

How often is biphasic insulin given?

A

Twice daily mixed insulin

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6
Q

Why would there be a possible increased risk of mortality associated with tight glycaemic control?

A

Due to myocardial strain as a result of more hypos/severe hypos

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7
Q

Insulin and glucose levels in T1DM

A

Hypoinsulinaemia

Hyperglycaemia

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8
Q

Insulin and glucose levels in T2DM

A

Initially hyperinsulinaemia and hyperglycaemia

Then hypoinsulinaemia and hyperrglycaemia

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9
Q

Before initiating treatment, switching or increased treatment, what must be considered?

A

Adherence to medication
Diet
Exercise levels

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10
Q

What type of insulin would be taken at every meal?

A

Rapid acting insulin (basal bolus)

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11
Q

What dose is usually started with insulin in T1DM?

A

0.5 units/kg

Basal bolus split dose 50/50 into basal and bolus sections - more control, more injections

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12
Q

What pump can be used in T1DM?

A

Insulin pump - continuous subcutaneous insulin infusion (CSII)

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13
Q

What dose of insulin is usually started in T2DM?

A

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

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14
Q

Classes of oral antidiabetic medications

A 
Biguanide/metformin 
Sulfonylurea 
PPAR agonist
DPP4 inhibitor
SGLT2 inhibitor 
Dual SGLT2/SGLT1 inhibitors
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15
Q

What is biguanide/metformin?

A

Peripheral insulin sensitizer

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16
Q

What does metformin do?

A

Sensitises insulin

Inhibits hepatic gluconeogenesis

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17
Q

Does metformin cause hypos?

A

No

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18
Q

Side effects of metformin

A

Diarrhoea
Cramps
Flatulence
Nausea

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19
Q

Rare side effect of metformin and therefore what must it be avoided in?

A

Lactic acidosis

Renal, hepatic, cardiac or resp failure

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20
Q

Can sulphonyureas cause hypos?

A

Yes

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21
Q

Side effects of sulphonyureas

A

GI S/Es
Weight gain
May cause hypos

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22
Q

What is meant by a “healthy lifestyle”?

A 
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
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23
Q

What are dietary allowances?

A

Quantative guidelines for different population subgroups for the essential macro and micro-nutrients to prevent nutritional deficiencies

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24
Q

What are dietary goals?

A

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

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25
Q

What are dietary guidelines?

A

Broad targets aimed at the individual to promote nutritional well-being. Used for macro and micro nutrients.

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26
Q

What is a dietary reference value (DRV)?

A

A series of estimates of the amount of energy and nutrients needed by different groups of healthy people in the UK population

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27
Q

Benefits of exercise

A 
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
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28
Q

What has to be considered in young people with diabetes?

A 
Sports
Nights out
Alcohol / drugs
Learning to drive
Leaving home
Festivals 
Travel 
Sex/contraception 
Tattoos/piercings
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29
Q

Alcohol effect of glycogenolysis

A

Reduces glyconeolysis

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30
Q

Alcohol considerations in DM

A

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

31
Q

Smoking with diabetes risk

A

Increases risk of DM by 1.5x

32
Q

DM and exercise

A

Reduce insulin before and after (up to 24 hours)
Reduction hypo risk
Eat more (appropriate carbohydrate)
Use different insulin regime (maximise flexibility)

33
Q

Driving and DM

A

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

34
Q

What jobs are you excluded from if you are diabetic?

A

Armed forces

Police

35
Q

What two ways can insulin be administered?

A

Subcutaneously

Intravenously

36
Q

How long is soluble insulin given before eating and why?

A

30 mins before eating

Because insulin hexamers need to dissociate into monomers before absorption through the capillary bed

37
Q

Do rapid acting insulin analogues dissociate? How much time are they given before eating?

A

No

Can be injected just before eating

38
Q

What should the amount of insulin injected for meals balance?

A

The carbohydrate intake consumed

39
Q

Definition of hypoglycaemia

A

Any episode of low blood glucose (4 mmol/l) with or without symptoms

40
Q

Causes of hypoglycaemia

A 
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)
41
Q

At risk groups for hypoglycaemia

A 
Tight glycaemic control 
Impaired awareness
Cognitive impairment 
Extremes of age 
Malabsorption/gastroparesis
Hypoadrenalism/abrupt steroid withdrawal 
Coeliac disease
Renal/hepatic impairment
Pancreatectomy
Pregnancy
42
Q

Presentation of hypoglycaemia

A 
Sweating
Palpitations
Shaking
Hunger 
Confusion 
Drowsiness
Odd behaviour
Speech difficulty 
Incoordination 
Headache 
Nausea
43
Q

Causes of inability to perceive the normal warning symptoms of hypoglycaemia

A

Recurrent severe hypoglycaemia
Long duration of disease
Over tight control
Loss of sweating/tremor

44
Q

Treatment of mild hypoglycaemia (<4)

A

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

45
Q

Treatment of moderate hypoglycaemia (< 4)

A 
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
46
Q

Treatment of severe hypoglycaemia or during a fast (<4)

A 
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
47
Q

Ongoing management of hypoglycaemia once blood glucose is > 4 mmol/L

A

give 20g of long acting carbohydrate e.g.

  • two biscuits
  • slice of bread
  • 200-300ml of bilk
  • or next meal
48
Q

What is found in a hypobox?

A 
Fruit juice
Dextro energy 
Glucogel 
50% dextrose
Hypo management protocol
49
Q

How to avoid hypoglycaemia in insulin treated diabetes

A 
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
50
Q

What should glucose level be before bed?

A

7

51
Q

What should glucose level be before driving?

A

5

52
Q

Risk factors for DKA

A 
Known T1DM
Inadequate insulin 
Infection 
Severe stress
Other precipitant
53
Q

Symptoms of DKA

A 
Polyuria
Polydipsia 
Weight loss
Weakness
Nausea/vomiting
Abdominal pain 
Breathlessness
54
Q

Signs of DKA

A 
Dry mucous membranes
Sunken eyes
Tachycardia
Hypotension 
Ketotic breath 
Kaussmaul respiration 
Altered mental state
Hypothermia
55
Q

What does DKA stand for?

A

Diabetic ketoacidosis

56
Q

What does DKA result from?

A

Too little insulin leading to fat breakdown

57
Q

What MUST you remember when treating DKA?

A

NEVER stop taking your insulin

58
Q

What blood ketone result indicates risk of DKA?

A

> 1.5

59
Q

Investigations of DKA

A 
ABC
Glucose
Venous blood gases
Urinalysis/blood ketones
U and Es
FBC
Culture blood/urine
ECG and cardiac monitor 
Consider CXR
60
Q

Management of DKA in first 60 minutes

A

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

61
Q

Complications of DKA

A 
Hyper and hypokalaemia 
Hypoglycaemia 
Cerebral oedema 
Aspiration pneumonia 
Arterial and venous thromboembolism
ARDS
62
Q

Who is more susceptible to cerebral oedema as a complication of DKA?

A

Children

63
Q

Before you inject insulin in T1DM, what must you check?

A

Right insulin
Right dose
Right time
Right way

64
Q

If blood ketones are between 0.6 - 1.4 mmol/L, what should the patient do?

A

Drink plenty of sugar free fluids
Give a correction dose of insulin
Retest blood sugar and ketones 1 - 2 hourly

65
Q

Symptoms of uncontrolled T2DM

A 
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
66
Q

Prevention of complications of T2DM

A 
Stop smoking
Dietary change
Mood
Statins
BP
Physical activity
67
Q

Who would you consider relaxing the target HbA1c level on?

A 
Elderly
Frail 
T2DM with
- reduced life expectancy 
- high risk of consequences of hypoglycaemia 
- multiple co morbidities
68
Q

First line option of a glucose lowering drug

A

Metformin or sulphonyurea

69
Q

How does metformin work?

A

Affects glucose production
Decreases fatty acid synthesis
Improves receptor function
Inhibits gluconeogenic pathways (half life 6 hours)

70
Q

Side effects of metformin

A

Lactic acidosis risk
GI side effects 20-30%
Vit B12 malabsorption

71
Q

How do sulphonyureas work?

A

Bind to sulfounyurea receptors (SUR-1) on functioning pancreatic B cells
Translocation and exocytosis of secretory granules of insulin to the cell surface

72
Q

Side effects of sulphonyureas

A

Hypos

Weight gain

73
Q

Insulin therapy regime - the main one that is suitable for a flexible life style

A

Rapid (short) acting insulin to cover CHO meals

Basal long acting insulin as a background

74
Q

At what HbA1c should a second drug be added in T2DM?

A

> 58mmol/mol

Endocrine Pathology (11 decks)

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