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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
What are dietary guidelines?
Broad targets aimed at the individual to promote nutritional well-being. Used for macro and micro nutrients.
26
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
27
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 ```
28
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 ```
29
Alcohol effect of glycogenolysis
Reduces glyconeolysis
30
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
31
Smoking with diabetes risk
Increases risk of DM by 1.5x
32
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)
33
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
34
What jobs are you excluded from if you are diabetic?
Armed forces | Police
35
What two ways can insulin be administered?
Subcutaneously | Intravenously
36
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
37
Do rapid acting insulin analogues dissociate? How much time are they given before eating?
No | Can be injected just before eating
38
What should the amount of insulin injected for meals balance?
The carbohydrate intake consumed
39
Definition of hypoglycaemia
Any episode of low blood glucose (4 mmol/l) with or without symptoms
40
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) ```
41
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 ```
42
Presentation of hypoglycaemia
``` Sweating Palpitations Shaking Hunger Confusion Drowsiness Odd behaviour Speech difficulty Incoordination Headache Nausea ```
43
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
44
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
45
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 ```
46
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 ```
47
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
48
What is found in a hypobox?
``` Fruit juice Dextro energy Glucogel 50% dextrose Hypo management protocol ```
49
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 ```
50
What should glucose level be before bed?
7
51
What should glucose level be before driving?
5
52
Risk factors for DKA
``` Known T1DM Inadequate insulin Infection Severe stress Other precipitant ```
53
Symptoms of DKA
``` Polyuria Polydipsia Weight loss Weakness Nausea/vomiting Abdominal pain Breathlessness ```
54
Signs of DKA
``` Dry mucous membranes Sunken eyes Tachycardia Hypotension Ketotic breath Kaussmaul respiration Altered mental state Hypothermia ```
55
What does DKA stand for?
Diabetic ketoacidosis
56
What does DKA result from?
Too little insulin leading to fat breakdown
57
What MUST you remember when treating DKA?
NEVER stop taking your insulin
58
What blood ketone result indicates risk of DKA?
> 1.5
59
Investigations of DKA
``` ABC Glucose Venous blood gases Urinalysis/blood ketones U and Es FBC Culture blood/urine ECG and cardiac monitor Consider CXR ```
60
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
61
Complications of DKA
``` Hyper and hypokalaemia Hypoglycaemia Cerebral oedema Aspiration pneumonia Arterial and venous thromboembolism ARDS ```
62
Who is more susceptible to cerebral oedema as a complication of DKA?
Children
63
Before you inject insulin in T1DM, what must you check?
Right insulin Right dose Right time Right way
64
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
65
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 ```
66
Prevention of complications of T2DM
``` Stop smoking Dietary change Mood Statins BP Physical activity ```
67
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 ```
68
First line option of a glucose lowering drug
Metformin or sulphonyurea
69
How does metformin work?
Affects glucose production Decreases fatty acid synthesis Improves receptor function Inhibits gluconeogenic pathways (half life 6 hours)
70
Side effects of metformin
Lactic acidosis risk GI side effects 20-30% Vit B12 malabsorption
71
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
72
Side effects of sulphonyureas
Hypos | Weight gain
73
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
74
At what HbA1c should a second drug be added in T2DM?
> 58mmol/mol

Endocrine Pathology (11 decks)

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