Managing T1DM Flashcards
What issues do patients with T1DM typically present with?
Typically acute sudden onset
Osmotic symptoms:
-polyuria
-Polydipsia
-weight loss
-nocturia
Fatigue
When structuring the history for a patient with ?T1DM (polyuria, Polydipsia, weight loss, nocturia) what are some questions you want to ask about the presenting complaint?
How much urine?
How frequently?
How many times in the night?
How much weight loss?
What is considered significant weight loss?
More than 10kg in 6months
Why is it important to ask about family history with ?T1DM?
Appears to be a genetic component with both T1DM and T2DM
Ethnic origin important
Why is drug history important when ?T1DM?
Certain medications can causes diabetes Mellitus
What are some examples of drugs that can causes diabetes?
Corticosteroids
Levothyroxine
Anti-retrovirals (HIV)
Beta agonists
Thiazides
Why is past medical history important when ?T1DM?
Many pre-existing conditions can lead to diabetes Mellitus
What are some categories of medical conditions that can cause diabetes?
Endocrinopathies
Pancreatic disorders
Autoimmune diseases
What are some endocrinopathies that can cause diabetes?
Cushing’s
Acromegaly
Phaeochromocytoma
Thyrotoxicosis
Glucagonoma
PCOS
What would you be looking for on examination when assessing for T1DM?
BP
BMI
Signs of insulin resistance
Foot examination (neuropathy?)
Retinal screen
What are some signs of insulin resistance on examination that you might find in a patient with diabetes?
Central obesity
Acanthosis nigricans
Hyperandrogenism in females
What investigations would you do for ?T1DM?
Why?
Routine bloods (FBC)
HbA1c
Beta cell antibodies
Anti GAD antibodies
Anti islet cell antibodies
U+Es (diabetic nephropathy)
LFTs ( fatty liver disease linked to T2DM)
Thyroid function test (thyrotoxicosis can cause diabetes)
Coeliac screen ( both are linked HLA-DQ2 mutation)
Lipid profile (CVS health)
When do you test for C-peptide when ?diabetes and why?
3 years after diagnosing diabetes of unknown cause
If c-peptide is low/absent then it suggests T1DM
If C-peptide is high suggests T2DM
If did C-peptide at time of presentation, patient might still have some functioning B cells
What is the pathophysiology of T1DM?
Absolute insulin deficieny secondary to T cell mediated autoimmune destruction of pancreatic beta cells
What are the 2 main components to managing T1DM?
Education
+
Insulin therapy
What is involved in the education part of managing T1DM?
What is T1DM?
Why do we need to treat T1DM? Risks of hypo and hyper and DKA
How to monitor blood glucose?
How to adjust dosing?
HbA1c target between 42-58mmol/mol
Annual screening
DVLA advice
Advice about pregancy
What is the DVLA advice for T1DM?
Must inform if going to be on insulin for >3months (so dont with gestational diabetes)
Check blood sugar every time before driving, must be over 5mmol before driving (eat a sugary snack)
Must stop the vehicle if experiencing hypoglycaemic symptoms or glucose < 4mmol
What levels of HbA1c indicates diabetes if it’s measured at least twice?
HbA1c > 48mmol/mol
How much insulin does the typical adult need per day?
0.5 units/kg
How much insulin may a growing adolescent require?
0.8 - 1 unit/kg
What is the most common insulin dosing regime?
Basal bolus
What are the 4 types of insulin regime?
Basal bolus
Twice daily fixed mixture
Twice daily free mixing
Continuous subcutaneous insulin infusion (pump)
What are some examples of basal/long acting insulins?
Lantau
Levemir
What are some examples of bolus short acting insulin?
Novorapid
Humilin S
How much of a patients daily insulin dosing should be rapid acting and how much should be short acting?
50/50
What would the insulin regime be for a patient using basal bolus dosing who is 60kg assuming they have 3 meals a day?
60 x 0.5 =30
30 units required
15 units basal/slow acting
15 units bolus/rapid acting
15 / 3 =5
5 units rapid acting before each meal
15 units Lantus before bed
5 units novorapid at each meal
What affects the amount of background/basal insulin required?
Weight
Stress
Exercise
Lots of alcohol
What affects the amount of rapid acting bolus. Insulin required?
Carbohydrate intake
What should the starting point for bolus dosing of insulin be?
How many units for 10g of carbohydrate?
1 unit for 10g or carbs
What is considered a pattern of hypo or hyperglycaemia?
3 or more times at the same time of day
A patient has had hypoglycaemia at 2pm for the last 3 days, how can you determine whether it’s the basal or the bolus dosing that needs reducing?
Don’t eat lunch
If become hypoglycaemic then basal dosing needs to be reducuecd
If patients blood glucose doesn’t change then bolus dose needs adjustment
A patient has had hyperglycaemia at 2pm for the last 3 days, how can you determine whether it’s the basal or the bolus dosing that needs increasing?
Don’t eat lunch
If become hyperglycaemic basal dosing needs increasing
If stays normal then bolus dose needs increasing
What is insulin sensitivity/correction factor?
How much 1 unit of insulin will drop the blood glucose
Normal starting point is 1 unit of insulin should drop. The blood glucose by 3mmol/L
When are you able to adjust a patients dosing of insulin without having a pattern (more than 3 hypo/hypers)?
1 overnight hypoglycaemia
What is dawn phenomena?
Rise in blood glucose between 4am-8am due to rise in blood cortisol, growth hormone and Catecholamines mainly in diabetics
What blood glucose should a diabetic measure ketones?
When blood glucose > 14mmol/L
What level of ketones is considered DKA?
Ketones > 3mmol/L
What is the issue with continuous glucose monitoring?
Readings lag about 15mins behind since its measuring glucose levels in subcutaneous tissue not directly from the blood
