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MBChB - Y2 - Endocrine > Management of Type 1 Diabetes > Flashcards

Management of Type 1 Diabetes Flashcards

1
Q

What are the aims of management of type 1 diabetes?

A

Prompt diagnosis

Encouragement of the appropriate self-management skill set

Correction of acute metabolic upsets at diagnosis and thereafter

Facilitate long term health and well being

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2
Q

What are the HLA associations of type 1 diabetes?

A

B8

DR3

DR4

DR3/4

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3
Q

What is the disease mechanism in autoimmune type 1 diabetes?

A

HLA class 2 association

Islet autoantibodies

Beta-cell antigen specific T cells found in human islets

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4
Q

What is the pathogenesis of type 1 DM?

A

Genetic tendancy + environment

Islet inflammation / lymphocyte infiltration / beta cell damage

Abnormal beta cell autoantigen arises

T cell recognition to autoantigens

Beta cell destruction

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5
Q

What antibodies does a diabetes screening test detect?

A

Anti GAD antibodies

(glutamate decarboxylase)

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6
Q

What other autoimmune diseases are associated with type 1 diabetes?

A

Hashimotots

Grave’s disease

Addisons

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7
Q

What is the evidence that type 1 diabetes is an autoimmune disorder?

A

Asssocaited with other immune conditions

Lymphocytic infiltration in islets

Islet cell antibodies

Insulin antbodies

Glutamate decarboxylase antibodies

Evidence of response to immunosuppressive therapy

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8
Q

What is the major risk associated with late diagnosis of diabetes?

A

Diabetic ketoacidosis

Leading to complications such as death and permanent neurological disability

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9
Q

What are the symptoms of diabetes?

A

Thirsty

Thinner

Tired

Toilet

Thrush and balanitits

A return to bedwetting or day-wetting in a previously dry child is a “red flag” symptom for diabetes

In children under five also think:

heavier than usual nappies

blurred vision

candidiasis (oral, vulval)

constipation

recurring skin infections

irritability, behaviour change

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10
Q

What should you do if you suspect diabetes?

A

Test immediately - finger prick capillary glucose test

If result is greater than 11 mmol/l then telephone urgently - make a same day appointment with a local specialist team

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11
Q

What are the symptoms of diabetic ketoacidosis?

A

Nausea and vomiting

Abdominal pain

Sweet smelling ‘ketotic breath’

Drowsiness

Rapid, deep ‘sighing’ respiration

Coma

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12
Q

What are the current strategies to support people with type 1 diabetes?

A

Education:

MDT - practice nurse, dietician, podiatrist, doctors

Structured: DIANE (diabetes insulin adjustment for normal eating)

Person with diabetes is main team member (self-management)

Probably organisiations such as DiabetesUK - (relevant information, puts people in touch with other diabetic patients, campaigns for better quality of care)

Nutrition and Lifestyle Management:

CHO counting

Exercise

Skills training:

Home blood glucose monitoring, injection technique, hypos

Insulin - Analogues, pens and pumps

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13
Q

What things do you have to check before injecting insulin?

A

Is it the correct insulin?

Is it the correct dose?

Is it the correct time?

Is it the correct formulation (syringe, pen or pump)?

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14
Q

Why does insulin need to be injected subcutaneously?

A

It is inactivated by the GI tract

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15
Q

What are sources of patient information?

A

Patient handbooks

Leaflets

My diabetes my way

Diabetes, think check act

Diabetes UK

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16
Q

What should you do if you have blood ketones and blood sugar level is 14 or above?

A
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17
Q

What are the different durations of action of insulin?

A

Rapid

Short

Intermediate

Long acting

Continuous

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18
Q

What are the current insulin regimens?

A

Twice daily

Rapid acting mixed with intermediate acting

Before breakfast (BB) and evening meal (BT)

Three times daily

Rapid acting mixed with intermediate acting BB

Rapid acting BT

Intermediate acting at bedtime BBed

Four times daily

Short acting BB BL BT

Intermediate BBed or long acting insulin at a fixed time once daily

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19
Q

What is the mechanisms of insulin control without the need for injections?

A

Continuous subcutaneous infusion

20
Q

When do you have to make adjustments to your control of diabetes?

A

Lifestly

Exercise

Driving

Alcohol

Conception

Drugs

Holidays

Employment

21
Q

What is the definition of hypoglycaemia?

A

Any episode of low blood glucose (below 4mmol/l) with or without symptoms and may occur in patients taking insulin or sulphonylureas

22
Q

What are the reasons for hypoglycaemia?

A

Food

too little / wrong type

Activity

during /after

Insulin (or some Oral Hypoglycaemics)

dose, injection technique

23
Q

What are the autonomic symptoms of hypoglycaemia?

A

Sweating

Palpitations

Shaking

Hunger

24
Q

What are the neuroglycopenic symptoms of hypoglycaemia?

A

Confusion

Drowsiness

Odd behaviour

SPeech difficulty

Incoordination

25
Q

What are the general malaise symptoms of hypo?

A

Headache

Nausea

26
Q

When do you experience loss of warnings of hypoglycaemia?

A

Recurrent severe hypoglycaemia

Long duration of disease

Over tight control

Loss of sweating / tremor

27
Q

What are the complications of hypoglycaemia?

A

Coma

Hemiparesis - neurological defecits can become permanent if hypoglycaemia is prolonged

Seizures

28
Q

What is the treatment of hypoglycaemia?

A

Simple CHO if able

If nill by mouth, take im glucagon or glucogel / dextrogel

If the patient is nill by mouth and is in hospital - take glucose IV or glucose/dextrose IV mixture

Follow up with long acting CHO

29
Q

What can be found in a hypobox?

A

Fruit juice

Dextro energy

Glucogel

50% Dextrose

Hypo management protocol

30
Q

What is important to establish after a hypo has happened?

A

Why the hypo happened?

Wrong regimen; dose/insulin

Control and monitoring

Hypoglycaemia unawareness

Discuss driving / work etc

Food/activity/insulin

Injection sites

31
Q

How can you avoid hypos?

A

Blood glucose monitoring

Rotate and check injection sites

Review snacks and diet –Carb counting

Consider a change of insulin regimen eg basal bolus ,CSII

Avoid low glucose -“4 is the floor” (7 at bedtime & 5 to drive)

Alter insulin before and after exercise

32
Q

What are the limitations to driving your car if you have diabetes?

A

Patients should be advised to check their blood glucose before/within 2 hours of driving and during long car journeys and should always carry carbohydrate in the car.

No awareness then no driving

No more than one episode of severe hypo (Group 1) in a year

33
Q

What are the symptoms of DKA?

A
  • Polyuria
  • Polydipsia
  • Weight loss
  • Weakness
  • Nausea/vomiting
  • Abdo pain
  • Breathlessness
34
Q

What are the signs of DKA?

A
  • Dry mucus membranes
  • Sunken eyes
  • Tachycardia
  • Hypotension
  • Ketotic breath
  • Kussmaul resp.
  • Altered mental state
  • Hypothermia
35
Q

What guidance is given to those with diabetes when they become ill?

A

NEVER stop insulin

Increase/adjust insulin dose according to blood glucose

perform more frequent blood glucose checks

check urine or blood for ketones

carbohydrate intake must be maintained by fluids (eg fruit juice) if unable to tolerate food

36
Q

What causes fiabetic ketoacidosis?

A

Usualy too little insulin causing fat breakdown

Associated with high blood sugar

Fluid deplete

May be caused by infection / severe stress / insulin omission

37
Q

What are the counter regulatory hormones that increase when insulin levels are low?

A

Glucagon - increases lipolysis - ketacidosis

Cortisol - decreases glucose utilisation - hyperglycaemia

Growth hormone - increases proteolysis and therefore increases gluconeogenesis

Catecholamines - increase glycogenolysis

38
Q

What is treatment for starvation ketoacidosis and normal ketoacidosis

A

Starvation: Carbohydrate to eat or drink - keep non-CHO fluids up as well

DKA: Give extra dose of fast acting insulin - dose is 1/6 of the daily intake

39
Q

What are the initial investigatinos for DKA?

A

Rapid A,B,C

i.v. access

Vital signs

Clinical assessment

Full clinical examination

THEN

INVESTIGATIONS

Glucose

Venous blood gas

Urinalysis/Blood ketones

U+E, FBC

Culture blood/urine

ECG + cardiac monitor

Consider CXR

40
Q

What are complications associated with DKA?

A

•Hyper and hypokalaemia

•Hypoglycaemia:

  • Rebound ketosis
  • Arrhythmias
  • Acute brain injury

•Cerebral oedema

  • Children more susceptible
  • 70-80% diabetes related deaths in children <12

•Aspiration pneumonia

•Arterial and venous thromboembolism

•ARDS - there is a reduction in the oncotic pressure and so there is accumulation of water in the lungs

41
Q

Treatment of DKA in hospital

A

Measure glucose / U and E’s / ketones / bicarbonate / arterial blood gas

Give iv saline (5 l in 24 hours)

Give iv insulin (drives glucose and potassium into cells)

Give iv potassium in saline

May need antibiotics

Consider heparin, NG tube

Mortality Rate 2%

42
Q

How do we facillitate long-term health and well-being?

A

Optimal blood glucose control (HbA1c)

to reduce microvascular disease e.g. retinopathy

to improve pregnancy outcome

Optimal blood pressure control

to reduce nephropathy

Manage cardiovascular risk factors

e.g. smoking, cholesterol

Screen for early detection of complications

feet, eyes & kidneys

43
Q

What piece of technology has the potantial to act like a sensor augmented pump?

A

Sensor augmented pumps

Full integration of insulin delivery with real time blood glucose monitoring - closed loop

44
Q

What is the structured education programme associated with type 1 diabetes?

A

STEP

Scottish Type 1 Education Programme

Structured education is always indicated in the care plan for diabetes patients

45
Q
A

MBChB - Y2 - Endocrine (25 decks)

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