Management of Diabetes & Insulin Flashcards
Aims of diabetes care
Prevention of life-threatening diabetes emergencies like diabetic ketoacidosis and hypoglycaemia.
Treatment of hyperglycaemic symptoms
Minimization of long-term complications
Avoidance of iatrogenic side-effects like hypoglycaemia
Outcomes of stringent glycaemic control
No hypo
Less complexity and polypharmacy
Lifestyle of metformin only
Short disease duration
Long life exp
No CVS
Outcomes of less stringent control
Severe hyper
High burden of therapy
Longer disease duration
Limited life exp
Co-morbidities
CVS
Explain self-management education.
Educate about risks of diabetes.
Benefits of glycaemic control
Maintaining lean weight.
Stopping smoking
Taking care of their feet.
Exercise.
Diet.
Dietary advice in diabetes.
Low glycaemic index foods
Mediterranean style diet.
Reduce salt intake
Two portions of oily fish each week
Wholegrains, fruit and veggies.
Nuts and legumes.
Less red, processed meat and refined carbs.
Less sugary drinks.
Less saturated fats.
Limiting alcohol.
Explain glycaemic index.
Show how the durations of the carbohydrates.
Sugary drinks have a high glycaemic index.
Foods such as pasta will have a lower glycaemic index.
Why is carbohydrate counting important?
This is especially important in type 1 diabetes.
In order to optimize glycaemic control people need to match their insulin dose to the carbohydrates in the meal.
This is important to avoid hypoglycaemia or persistent hyperglycaemia.
Why are foods with a low glycaemic index encouraged?
To prevent rapid swings in plasma glucose.
Give an example of a good program to manage a good diet and carbohydrate count.
Dose Adjustment for Normal Eating (DAFNE)’
Used in T1
Why is it important to lose weight in T2DM?
People who can be supported to lose 10-15kg of body weight through lifestyle, pharmacological or surgical treatment can enter remission.
What is a treatment option for people with severe obesity?
Bariatric or metabolic surgery.
Absorption rate of soluble human insulin.
Absorbed slowly reaching a peak 60-90 minutes after subcut.
Risks of soluble human insulin.
Hypoglycaemia as its action tends to persist after meals.
Explain the delayed absorption of soluble human insulin.
Soluble human insulin forms stable hexamers which need to dissociate to monomers or dimers before entering circulation.
Why is the delay in absorption a problem in diabetes?
Because the insulin should be injected 2-30 minutes prior to a meal.
This is often not feasible.
Give examples of short-acting insulin analogues.
Insulin lispro
Insulin aspart
Insulin glulisine
How have short-acting insuline analogues been engineered?
To dissociate more rapidly after injection.
They enter and disappear from circulation more rapidly than soluble human insulin.
Benefits of short-acting insulin analogues in T1DM.
Reduces total and nocturnal hypoglycaemic episodes and improves glycaemic control.
How can action of human insulin be prolonged?
By addition of zinc or protamine.
Most common form of Human insulin with Zinc or protamine.
NPH (Neutral protamine Hagedorn) / Isophane insulin.
An intermediate form of insulin!
Issues with NPH/Isophane insulin.
Variability from one injection to another.
Peak action might occur in the middle of the night.
Give examples of long-acting analogues.
Insulin glargine (similar pH to subcutaneous pH = prolongs duration)
Insulin detemir (fatty acid tail binding to serum albumin)
Insulin degludec (forms long multihexamer chains at site of injection dissociating slowly)
Benefit of long-acting insulin analogues.
Reduce hypoglycaemia risk for people with both T1DM and T2D particularly at night.
Most common strength of insulin.
100 units/mL
Insulin glargine e.g. is available as 300 units/mL (U300)
Available concentrations of insulin degludec.
100U
200U
What is the risk of withdrawing the insulin from the pen and administering it in a syringe instead?
Hypoglycaemia as pen devices indicate how many units of insulin are given.
When might U500 insulin be given?
In severe insulin resistance.
Give examples of insulin regimens.
Basal-bolus regimen
Twice-daily mixed insulin regimen
Basal only insulin regimen
Basal-plus insulin regimen
Explain basal-bolus regimen.
Administration of both short-acting and long-acting insulin.
Long acting is injected 1-2 times per day to provide a basal insulin to keep the glucose conc. consistent during periods of fasting.
Short acting is given shortly before a meal.
This regimen most closely mimics normal insulin physiology.
In which diabetes is basal-bolus regimen the tx of choice?
In T1DM
Main disadvantage of basal-bolus regimen.
Number of injections.
Explain twice-daily mixed insulin regimen.
(Also called BD biphasic regimen)
Mixture of short and lonc-acting insulin is injected before breakfast and the evening meal.
It’s a premixed insulin.
Novomix 30 is used e.g.
Useful in type 2 DM or type 1 with regular lifestyle.
When might twice-daily mixed insulin regimen be used?
In type 2 diabetes.
Or in T1DM when you cannot inject 4 times a day.
Main disadvantage of Twice-daily mixed insulin regimen.
Lack of a lunch-time bolus
Higher basal levels between meals.
Increased risk of hypoglycaemia.
Explain basal-only insulin regimens.
Basal long-acting insulin at night and then non-insulin treatments during the day.
This can be used in T2DM.
It’s a good initial insulin regimen when switching from tablets in T2DM.
Consider retaining metformin if needed for tight control and patient is unable to use BD regimen.
What types of administration of insulin exists?
Subcut by intermittent injection (syringe or more commonly a pen)
Insulin pumps
Usual injection sites of insulin.
Front and outer upper side of thigh
Abdo wall
Buttocks
Upper outer arms.
Benefits of insulin pens vs syringes.
More convenient
More accurate
Easier to use
Produce less painful injection
Explain insulin pumps.
Continuous glucose monitors allow the pump to suspend insulin infusion if the glucose levels are low or predicted to become low.
Benefits of insulin pumps in T1DM.
Improves glycaemic control
Reduces hypoglycaemia
Better quality of life
Disadvantages of insulin pump.
Nuisance of being attached to a gadget
Skin infections
Risk of ketoacidosis if flow of insulin is interuppted
Cost
Side effect of insulin injection in the same site.
Lipohypertrophy
Cause of lipoatrophy due to insulin injections.
Immunoglobulin G immune complexes agains the insulin can be formed.
This can cause local atrophy of fat tissue.
Side-effects of lipohypertrophy and lipoatrophy.
Interferes with insulin absorption.
Comprimising insulin action.
Challenges of insulin therapy.
Therapeutic index of insulin is low.
Insulin req. are highly variable from one person to the other. Can also vary throughout the day in the same person.
Bolus insulin doses should ideally be adjusted to the carbohydrate content of the meal.
Carb counting can be difficult and requires maths.
Rate of absorption of glucose is affected by the glycaemic index.
No holidays from diabetes
Aim of blood glucose levels.
4-7 mmol/l before meals
4-10 mmol/l after meals
What should you do if the blood glucose is persistently too high before breakfast?
Increase evening long-acting insulin or pre-mixed.
What should you do if blood glucose is persistently too low before breakfast?
Reduce evening long-acting or pre-mixed insulin.
Blood glucose is persistently too high before lunch.
Increase morning short-acting or pre-mixed insulin.
Blood glucose is persistently too low before lunch.
Reduce morning shortacting or premixed insulin
Can also have a mid-morning snack
Blood glucose is persistently too high before evening meal.
Increase morning long acting or premixed insulin.
Or increase lunch short-acting.
Blood glucose is persistently too low before evening meal.
Reduce morning long-acting or pre-mixed insulin.
Or reduce short-acting insulin of lunch.
Mid-afternoon snack.
Blood glucose is persistently too high before bed.
Increase evening short acting or premixed insulin.
Blood glucose is persistently too low before bed.
Reduce evening short-acting or pre-mixed insulin.
Six steps of insulin safety.
Right person
Right dose
Right insulin
Right device
Right way
Right time
Most common side-effects of insulin.
Hypoglycaemia (most common)
Weight gain
Definition of clinically significant hypoglycaemia.
<3.0 mmol/L
What is the recognised alert value of hypoglycaemia that requires treatment?
Any value below 4.0 mmol/l
Definition of severe hypoglycaemia.
Hypoglycaemia requiring external help for recovery.
In which diabetes is hypo more common?
T1DM
In which patients does hypo more commonly occur?
In young children and those trying to achieve a tight glycaemi control.
Psychological aspect of hypoglycaemia.
Impairs quality of life and induces fear and anxiety.
“Fear of hypo”.
What is hypoglycaemia caused by?
Insulin over dose
Irregular eating habits
Unusual exertion
Alcohol excess
Insulin errors
Variation in insulin absorption
Lipohypertrophy
Times of risk of hypo.
Before meals
During the night
During and after exercise
Why does the mechanisms protecting against hypoglycaemia not work?
Abnormal islet cell function
Defective counter-regulatory hormone secretion
Glucagon secretion is impaired because its main regulator is a fall of intra-islet insulin.
How can symptoms of hypoglycaemia be divided?
Into autonomic and neuroglycopenic symptoms.
Which division of symptoms occur first in hypoglycaemia?
Autonomic symptoms.
This is due to activation of the adrenergic and cholinergic parts of the autonomic nervous system.
Why is it important to note that autonomic symptoms appear before neuroglycopenic symptoms?
Because these symptoms alert the individual to hypoglycaemia and prompt them to take action before neuroglycopenic symptoms kick in.
When neuroglycopenic symptoms kick in the patient may be unable to correct the hypo themselves.
What can happen in long-standing diabetes and repeated hypoglycaemic episodes?
The autonomic symptoms may only develop after neuroglycopenic symptoms.
This increases the risk of severe hypoglycaemia.
Acute autonomic symptoms of hypoglycaemia.
Sweating
Paraesthesiae
Feeling hot
Shakiness
Anxiety
Palpitations
Pallor
Acute neuroglycopenic symptoms.
Slurring of speech
Altered behaviour
Loss of conc.
Drowsiness
Low mood
Dizziness
Hemiplegia
Fits
Coma
Death
Medical consequences of hypoglycaemia
Inreased risk of falls
Increased risk of MI
Increased thrombosis
Atherosclerotic plaque instability
Cardiac arrhythmias
Increased risk of hospitalisation
Increased risk of sudden death
Psychological consequences of hypoglycaemia
Poor quality of life
Embarrassment
Fear of hypo -> reduced medication in future -> hyperglycaemia
Financial consequences of hypoglycaemia.
Inability to work effectively
Increased out of pocket expenses
Increased medical costs
Immediate hypoglycaemia treatment.
15-20g of oral glucose.
Repeated after 15 minutes if the glucose concentration has not risen above 4.0 mmol/l.
Liquid or solid food (fast acting carbs)
How is the diagnosis of severe hypoglycaemia usually made?
Clinical grounds of confusion or coma e.g.
+
Bedside blood test
How will diabetic patients let the general public that they have diabetes and will be of risk of hypo?
Usually carry a card or wear a bracelet or necklace saying that they have diabetes.
Treatment of severe hypoglycaemia.
Intramuscular glucagon or intravenous glucose.
The glucagon acts by mobilising hepatic glycogen and works almost as rapid as glucose.
When will IM glucagon not work?
When liver glycogen levels are low, e.g. after a prolonged fast.
What should be given once the patient revives after a severe hypoglycaemic episode?
Eat some longer-acting carbs to replenish glycogen reserves.
Why might weight gain occur in insulin treatment?
It’s an anabolic hormone.
It can also be due to frequent hypoglycaemia leading to a fear of hypo resulting in excess carbohydrates to treat or prevent the hypoglycaemia, this is called defensive eating.
Explain the criteria required to have a driving license with diabetes and the associated hypoglycaemia that might happen.
Explain subcutaneous insulin dosing during intercurrent illnesses like influenza.
Advise patients to not stop insulin during acute illness.
Illness often increase insulin requirements despite reduced food intake.
Maintain calorie intake like using milk.
Check blood glucose more than 4 times a day and look for ketonuria.
Increase insulin doses if glucose is rising.
Advise to get help from a specialist diabetes nurse or GP if concerned.
One option is 2 hourly ultra fast-acting insulin.
Admit if vomiting, dehydrated, ketotic, child or pregnant.
Explain the management of T2DM algorithm.
Treatment of hypoglycaemia.
If conscious => give 15-20g of quick-acting carbohydrate snack like 200ml orange juice.
Recheck blood glucose after 10-15 mins and repeat snack up to 3 times.
If conscious but uncooperative => Squirt glucose gel between teeth and gums.
If unconscious or not responding to tx => Glucose IVI (10% at 200ml/h if conscious or 10% at 200ml/15min if unconscious.
Or give glucagon 1mg IV/IM (will not work if malnourished)
Once blood glucose > 4.0 mmol/L and patient has recovered give long acting carbs.
