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Endocrinolgy > More Diabetes (Drugs And Monitoring Etc) > Flashcards

More Diabetes (Drugs And Monitoring Etc) Flashcards

1
Q

What 4 main things does insulin withdrawal cause?

A
  • Uncontrolled endogenous glucose production
  • Tissue glucose deprivation
  • Lipolysis
  • Proteolysis
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2
Q

What is the average threshold for glucose to be found in the urine?

A

10 mmol/litre - glucose in urine

- lower threshold in pregnancy and elderly

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3
Q

What are the consequences of having high glucose levels in bodily secretions such as sweat?

A
  • infection -
    UTIs
    skin infection
    thrush
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4
Q

What are the consequences of the effect of high glucose on WBCs?

A
  • recurrent infection

- leucocytosis, pyrexia - can be affected

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5
Q

See lecture on Pathophysiology of & signs/symptoms of diabetes for diagram

A

-

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6
Q

What are the differential diagnosis for polyuria?

A

True polyuria:
• Heart failure • Diuretic therapy • polyuric renal failure
• hypercalcaemia • diabetes incipidus • water intoxication
Other:
• Urinary tract infection • Prostatism

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7
Q

Why might a patient with heart failure for example get up to urinate a lot in the night?

A

Backing up of fluid in lungs and legs - get up in the night to pass urine because legs elevated

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8
Q

What questions 3 central questions should you ask a patient with polyuria?

A

• How often? • How much? • Associated symptoms (flow problems, pain)

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9
Q

Name 4 main areas that are associated with infection in diabetes?

A
  • Skin
  • Mucosae
  • Chest
  • Urine
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10
Q

Name three symptoms/features of macrovascular complication in diabetes.

A
  • Angina
  • Claudication
  • TIA
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11
Q

What are the 3 types of microvasular complication in diabetes?

A
  • Retinopathy
  • Nephropathy
  • Neuropathy
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12
Q

What are the consequences of peripheral neuropathic microvascular complications in diabetes?

A

Numbness
pain
tingling feet and then hands

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13
Q

What are the clinical manifestations of autonomic neuropathy microvascular complications in diabetes?

A 
Abnormal sweating 
Gastroparesis 
Diarrhoea 
Postural dizziness 
Erectile dysfunction 
Incontinence (very late complication)
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14
Q

What are the clinical manifestations of radiculopathy neuropathy microvascular complications in diabetes?

A

Pain, weakness (wasting)

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15
Q

What are the clinical manifestations of mononeuritis neuropathy microvascular complications in diabetes?

A

Diplopia

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16
Q

What are the clinical manifestations of compression neuropathy microvascular complications in diabetes?

A

Pain, tingling, weakness (carpal tunnel, ulnar n, lat popliteal n (around fibula head - foot drop))

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17
Q

What are nights sweats indicative of?

A

Night sweats - chronic infection, endocarditis, malignancys

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18
Q

Which substances should be measures to monitor diabetes control?

A
  • Glucose control – Random glucose (venous / capillary) – Glycated haemoglobin ( HbA1c)\
  • Ketones
  • Lipids – TC and LDL / HDL / TG
  • Renal function
  • Urine protein
  • Whole host of other substances which could be measured – CRP, Homocysteine, Leptin, Adiponectin
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19
Q

What is diabetic control?

A
  • The extent to which metabolism differs from normal
  • Other metabolites disordered in diabetes – e.g. ketones are a measure of insulin deficiency
  • Many other substances are affected by diabetes?
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20
Q

What does a positive urine glucose test tell you?

A

Blood glucose has been above 10mmol/litre since last bladder voiding if you get glucose in urine
(Only useful for screening, not for monitoring?

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21
Q

What are the problems with urine glucose monitoring?

A
  • Urine glucose is retrospective
  • Renal threshold may differ between patients and even within people (eg. If they are ill or have renal dysfunction)
  • Fluid intake affects urine concentration
  • Cannot be used to diagnose diabetes
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22
Q

What are the possible problem whole blood monitoring of glucose levels?

A

• We can measure glucose in whole blood • Glucose concentration falls by about 0.5mmol over 3 hours due to glycolysis in RBC
• Inhibiting glycolysis (with fluoride oxalate)can reduce this
– There is still a 0.2-0.3 mmol/l drop in glucose over 2-3
• Plasma glucose is 10-15% higher than in whole blood (and cappilaries)
• Affected by hematocrit

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23
Q

What do measure is most commonly used to monitor glucose levels?

A

Plasma glucose?

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24
Q

Describe 2 measures of long-term blood glucose control

A

• Glycated haemoglobin (measure of mean glucose control over preceding 1-3 mo)
(50pc -control in last 30 days - rest - further back than that
If you have different types of haemoglobin eg.foetal - skews results )
• Serum fructosamine (mean glucose control over preceding 2 weeks)

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25
Q

What is meant by glycated haemoglobin?

A

Glucose attaches covalently but non-enzymatically to haemoglobin over lifetime of red cell

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26
Q

By how much are HBa1c and mean blood sugar usually different?

A

HBa1c is usually lower by 1.5

27
Q

4 facts about Hba1c

A
  • Linear relationship with mean blood glucose over life of RBC
  • Affected by conditions affecting red cell turnover turnover
  • Inaccurate in patients with Hb variants and Hb S or C carriers
  • 50% of the value determined by glucose control in the past month
28
Q

What are the potential interferences with HbA1c measurement depending on method?

A

• Hb variants can interfere, e.g. -HbF (elevated in diabetes) can elevate -HbS, HbC can lower
• Altered red cell survival: -Haemolytic anaemia lowers
• Chemically modified Hb -Carbamylation in uraemia can elevate
-Acetylation with large doses aspirin can elevate

• Reduced glycation process -Vitamin C can lower

29
Q

Is HBa1c more closely related to a single blood glucose in type 1 or type 2 diabetes?

A

Type 2 - less variation in glucose

30
Q

How can Fructosamine be used as another measure of long-term control in addition to HBa1c?

A
  • Serum proteins also glycated (like Hb)
  • Fructosamine is essentially glycated albumin
  • Measure of long-term control over lifetime of serum albumin – about 2 weeks (useful when control changing quickly e.g. diabetic pregnancy)
  • Usually measured with colorimetric assay
  • Less used than HbA1c
  • Reference range ~200-285 micromol/l
31
Q

Name 3 ketone bodies

A
  • Acetone
  • 3-Hydroxybutyric acid (Beta-hydroxybutyric acid)
  • Acetoacetic acid
32
Q

What is the series of events in ketone body formation in diabetes?

A

Insulin lack → Adipose tissue triglyceride
→ fatty acids + glycerol →acetyl CoA → TCA cycle (if insulin)

But if no insulin acetyl CoA → acetoacetic acid
Then acetoacetic acid → 3 hydroxybutyrate or acetone

acetone

33
Q

What do you know about ketone testing using strips?

A
  • Strips and tablets based on Rothera’s test: nitroprusside/glycine turns purple with acetoacetic acid/acetone
  • 3-hydroxybutyric acid not detected
  • Most ketone strips/tablets insensitive measure of ketosis
34
Q

What Do you know about blood ketone testing using monitors?

A
  • Measures 3-hydroxybutyrate electrochemically
  • Based on strips with immobilized 3-hydroxybutyrate dehydrogenase
  • Not yet widely used
35
Q

What does high creatinine indicate?

A

Poor renal function

36
Q

What are the features of dislipidaemia common in type 2 diabetes?

A

• Fasting lipid profile as part of annual review

- Triglyceride - VLDL triglyceride - ↓HDL cholesterol

37
Q

When should LDL levels be measures?

A

Fasting because it will be lowered postprandially.

38
Q

What do you know about monitoring albumin in diabetes?

A

• Proteinuria -hallmark of diabetic kidney disease
• Dipstick proteinuria: albumin conc. in spot urine sample -depends on patient hydration and therefore inaccurate
• 24 hour urine albumin excretion best
(300perdl - threshold of measurement
Muscular, low body fat, unwell, high temperature - can be why - false readings)

39
Q

What is microalbuminuria and why is it useful?

A
  • Microalbuminuria: very small excretion of protein in urine, not detectable by standard dipstick but immunoassay
  • Earliest sign of diabeteic nephropthay
  • Predicts later development of diabetic nephropathy
  • Albumin: creatinine ratio (ACR) in spot clinic urine sample simple now commonly used, corrects for errors in time of collection
40
Q

What are the normal threshold values for microalbuminuria, normal ACR and protienuria?

A
  • Normal ACR < 2.5 (3.5 male) mg/mmol
  • Microalbuminuria 2.5-30 mg/mmol
  • Proteinuria > 30 mg/mmol
41
Q

What is continuous glucose monitoring and how does it work?

A
  • Subcutaneously implanted enzyme electrode
  • Glucose oxidase immobilized at electrode
  • Glucose proportional to current response
  • Measures glucose in the tissue • Lags behind blood glucose ( 5-15 mins
  • Provides “real time” glucose readings – Glucose concentration – Direction / rate of change
  • Alarms to warn of high or low blood sugars
  • “closed loop systems” in development
42
Q

What are 6 extra considerations when managing a DKA patient?

A
  • NG tube/ bicarbonate/ arterial lines
  • Where to look after patient?
  • What is the trigger?
  • Infection/ antibiotics?
  • Prophylactic heparin?- High osmolarity - DVT and PE risk increased
  • Always check feet
43
Q

What are 6 possible complications in DKA management?

A
  • Hypoglycaemia
  • Hypokalaemia
  • Arrhythmias
  • Cerebral oedema
  • Adult respiratory distress syndrome
  • Thromboembolism
44
Q

What are the features of HHS – Hyperosmolar Hyperglycaemic state?

A 
usually people with type 2 diabetes mellitus
Hyperglycaemia 
-Dehydration 
- Hyperosmolarity 
- Absent/ minimal ketosis 
- +/- without coma
45
Q

What is ketosis absent/minimal in HHS?

A

Minimal ketone body generation

  • why? Relative insulin deficiency ask opposed to absolute
  • enough to prevent that generation of free fatty acids which gives ketones
  • dehydration and hyperosmolarity limit lipolysis?
46
Q

What is the pathophysiology of HHS?

A

relative insulin deficiency and increase in glucagon
- Increased gluconeogenesis & glycogenolysis
- Increased hepatic glucose output
• lipolysis and ketogenesis less
• circulating NEFA lower than in DK
• dehydration and hyperosmolarity limit lipolysis?

47
Q

What at the 4 criteria for diagnosis of DKA?

A
  • Serum glucose > 33mmol/l
  • Hyperosmolarity >320 mOsm/l
  • Absence of acidosis - (Might have meta if acidosis from pre-renal failure- dried out, old, diabetic nephropathy etc)
  • Small or no ketonuria
48
Q

In what types of diabetes do you get DKA and HHS?

A

DKA: type 1 (and type 2)
HHS: type 2

49
Q

What ages are patients with DKA and patients with HHS likely to be?

A

DKA: Any age esp. young
HHS: elderly

50
Q

How fast is the onset of DKA and Of HHS?

What are the mortalities of these conditions?

A

DKA: rapid onset (less than 24hrs), mortality - less than 5%
HHS: onset can take weeks, mortality - up to 50%

51
Q

What are the pH levels like in DKA and in HHS?

What are the bicarbonate levels like in these 2 conditions?

A

DKA: pH - less than 7.3, bicarbonate - low
HHS: pH - normal, bicarbonate - normal

52
Q

What are urine ketone levels like in DKA and in HHS?

A

DKA: high
HHS: normal/1+

53
Q

What are glucose levels like in DKA and in HHS?

A

DKA: Glucose >15mmol/L
HHS: Glucose >30mmol/L

54
Q

What are the precipitating factors of HHS?

A
  • Infection 40-60%
  • New onset DM 33%
  • Acute illness 10-15%
  • Non compliance 5-15%
55
Q

What would be a typical history for an HHS patient?

A
  • Often ill several weeks beforehand
  • Age >60
  • Polyuria, polydipsia, thirst
  • Drinking sugary drinks to quench thirst
  • Altered mental state
  • Abdominal symptoms - not to same extent as surgical abdomen in DKA
56
Q

What are 4 signs of HHS?

A
  • Osmotic - dehydration
  • Nausea and vomiting
  • Neurological- may mimic stroke resolution, resolution is expected
  • Impaired mental status - severe cases -10% with coma
57
Q

What are the 5 principles in the management of HHS?

A
  • Fluids
  • Insulin
  • Correct electrolytes
  • Precipitants
  • Anticoagulation
58
Q

How are fluids used in HHS treatment?

A 
• More cautious fluid replacement 
More gentle
-1l of saline in one hour
1L - 2 hourly for next 2 hours
Then 1L every 4
• Urine catheter essential 
• Low threshold for CVP
59
Q

What is the use of insulin in HHS therapy?

A

IV insulin as per DKA regimen but half infusion rate
More insulin sensitive
Rapid decrease in glucose causes a rapid fluid shift/ coma

60
Q

Other than fluids and insulin what is used in the management of HHS?

A
  • Potassium replacement
  • Full dose anticoagulation with LMW heparin
  • Proton pump inhibitor?
  • Broad spectrum antibiotic?
61
Q

What are 5 complications associated with HHS management?

A
  • High rate of arterial and venous thrombosis
  • Cerebral oedema
  • ARDS
  • Hypoglycaemia and hypokalaemia
  • Death
62
Q

What are the considerations after a hyperglycaemic emergency has been dealt with?

A
  • What caused it? • Can it be prevented in future? • Does the day to day diabetes mnx need changing? • Need to see DSN / Dr
  • Phone contact on discharge • Expedite outpatient follow up
63
Q

What are three principles for prevention of hyperglycaemic crisis?

A
  • Better education
  • Effective communication during acute illness
  • Sick day rules
64
Q

What are the diabetic sick day rules?

A

• NEVER STOP insulin, even if vomiting • CHECK CBG frequently, 3-4 hrly • CHECK urine for ketones • EXTRA short acting insulin if CBG>20 g • Small sugary drinks frequently if hypo, keep drinking even if not eating • GET MEDICAL HELP if -vomiting/diarrhoea -CBG >20 >3hrs -ketones persist -troublesome hypos

Endocrinolgy (8 decks)

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