Primary Care-DIABETES Flashcards
What is the pathophysiology of type 1 diabetes?
-Autoimmune destruction of Beta cells in Islets of Langerhans of pancreas
-leading to lack of production of insulin
-Glucose cannot be taken up from blood or
converted to glycogen for storage
patient:
Insulin is a hormone produced by the body to allow the sugar in your blood to enter cells and be used for energy. If you imagen it like insulin is the key to the cells doors, allowing the sugar to enter. In type 1 diabetes this key isn’t produced and so the cell doors cant be opened, glucose cant enter and there is a build up of sugar in the blood
What is the pathophysiology of type 2 diabetes?
- Beta cells remain intact but may secrete less insulin
- Other cells also become insensitive to insulin (insulin resistance)
patient explanation: the key doesn’t quite fit the lock
What genes are responsible for type 1 diabetes?
HLA-DR3
HLA-DR4
How does type 1 diabetes present?
Rapid onset of clinical triad over days/weeks
- Polyuria
- Polydipsia
- Weight loss
What are some long-term complications of diabetes?
Retinopathy Neuropathy Nephropathy Erectile dysfunction Vascular disease - main cause of death
How does diabetic ketoacidosis present?
Nausea + vomiting
Severe confusion
Dehydrated - dry mucus membranes and reduced skin turgor
Ketotic breath
Cusmor breathing - deep sighing breaths to try breathe off CO2
Generalised GCS
What would you see in DKA bloods?
In DKA you would see:
- high creatinine,
- sodium, potassium and phosphate eleveted or normal
- low bicarb
- high glucose
- ketones
- low pH
What is the criteria for diagnosis of diabetes?
One abnormal reading if they have symptoms:
HbA1c > 48mmol/L (neg cannot rule out)
Fasting blood glucose >7mmol/l
Random blood glucose >11.1mmol/l
If asymptomatic: 2readings on 2 separate days either fasting >7mmol/l OR Hba1c
What is the gold standard test for diabetes?
Glucose tolerance test
Ask patient to fast overnight, then give 75g of glucose. Check plasma glucose after 2 HOURS
• ≥11.1mmol/L = diabetic
• ≥7.8 and <11.1mmol/L = impaired glucose tolerance
• <7.8mmol/L = non-diabetic
What is the pharmacological management of T2DM?
STEP 1 IF 48+
Metformin 500mg BD after food (can titrate up to 2g/day if not <48)
STEP 2 DUAL THERAPY IF 58+ (new aim of <53) Metformin PLUS (glicazide 40mg OD, sitagliptin, pioglitazone, empagiflozin (SGLT-2i)
STEP 3 if 58+ Insulin or TRIPLE THERAPY -metformin+stigaliptin+glicazide -metformin+pioglitazone+glicazide -metformin+(pioglitazone or glicazide) +empagiflovin
OR GLP -1 injections if BMI>35
What class of drug is metformin in? How does metformin work?
Biguanides
- Reduces rate of gluconeogenesis
- Increases insulin sensitivity to increase uptake of glucose by cells but doesn’t affect insulin output
What are some side effects of metformin?
- GI upset (reduce appetite, Nausea, diarrhoea and abdo pain)-reduce these by taking with food
- Weight loss
When is metformin contraindicated?
- Renal dysfunction (STOP if egfr <30 or creat >150)
- Stop if tissue hypoxia or before GA or contrast containing iodine (withhold for 48 hours)
How do glitazones work?
example of a glitazone?
- Increase insulin production and sensitivity to insulin
- pioglitazone
What are side effects of glitazones?
When are they contraindicated?
- Fluid-retention - increased risk of HF
- Fractures
- Weight gain
C/I in cardiovascular disease or osteoporosis/bladder cancer
Must stop if there is weight gain or oedema
What does acarbose do?
Decreases breakdown of starch to sugar
What are the side effects of acarbose?
Severe flatulence
Abdominal distention
Diarrhoea
What is the diagnostic criteria for DKA?
D -Diagnosis of diabetes or BG >11mmol/L
K -Ketones (blood ketone >3mmol/L or urine ++)
A -Acidosis on ABG (<7.3 or bicarb <15)
note: patients on SGLT2 inhibition’s (flozin) may be euglycemic
What is the management of DKA?
DKA MANAGMENT
Place 2 wide bore cannulas and start fluid replacement through one (0.9% NaCl)
1) FLUIDS 0.9% NaCl (1,2,2,4)
-Consider initial bolus 500ml if hypotensive BP <90
-When BP over 90 start 1224 Regime:
1L over 1hr → 1L over 2hr → 1L over 2hr → 1L over 4hr
2) INSULIN THERAPY
- IV infusion of insulin ACTRAPID
- soluble insulin mixed with NaCl (e.g. 50U in 50ml)
- concentration of 1 unit/mL
- at fixed rate of 0.1units/kg/hr
3) POTASSIUM
-Add KCL after first bag if potassium <5.5mmol/L
(NB: must never give >10mmol K+ over 1 hr)
4) GLUCOSE
- once the blood glucose level falls to 14mmol/l, change the fluid to contain 10% glucose (generally 0.9% saline with glucose and potassium). DO NOT reduce the insulin.
5) TREAT CAUSE
- due to stress (infection/PE/poor compliance/wrong dose insulin)
What is the DKA equivalent for type 2 diabetes?
HHS = hyperosmotic hyperglycaemia state
What often precipitates HHS?
Underlying infection
How do you diagnose HHS?
Hyperosmotic hyperglycaemia state
1) HYPOVOLEMIA
- cause low Na (water follows glucose and is lost)
2) HYPERGLYCEMIA (>30mmol/L)
3) Normal ketones/no academia (ketones <3mmol/L)
With increased osmolality > 320mosmol/kg
-(glucose + urea + 2xNa)
What is the management of HHS? (4)
Hyperosmotic hyperglycaemia state
- Mainstay treatment = fluid resuscitation (don’t replace too fast)
- Consider IV insulin (half as much as in DKA so 0.05units/kg/hr)
- Correct electrolyte disturbances
- Prophylactic LMWH (HIGH RISK OF THROMBUS)
What are the benefits of metformin? (3)
- Protects the heart
- Weight neutral
- Doesn’t cause hypos
What kind of drug is gliclazide and what does it do?
Glicazide is a sulfonylurea
-It stimulates pancreatic insulin secretion - can cause hypoglycaemia
Side affects of glicazide?
side effects of glicazide:
-hypoglyceamia
-weight gain as it increases appetite
Glitpins good alternative if BMI >35
What are the effect of gliptins?
Example of a gliptin?
What are the side effects of gliptins?
- Gliptins are DPP-4 and affect INCRETINS (glp1) by slowing their degradation>insulin stimulated
- Sitagliptin
- Weight neutral (good if overweight) and there are much fewer side effects (good for low egfr)- but can cause pancreatitis
Example of a SGLT-2 INHIBITOR?
How do they work?
- Empaglifozin is a SGLT-2 inhibitor
- SGLT-2 inhibitors inhibit reabsorption of glucose in the kidney (pee it out)
- cardioprotective (could use in step 2 if heart problems)
Side effects of SGLT-2 inhibitors? (4)
- weight loss (wee it out)
- increase risk of UTI and thrush
- increased risk of DKA because of dehydration (stop if D and V)
- also can get mourners gangrene (necrotising fasciitis of the genitalia or perineum)
examples of GLP1 injectables?
action of GLP1 injectables?
who are they good for?
GLP1 agonist injectables end in glutide e.g. Liraglutide, semaglutide, dulaglutide (tsunami that makes you feel full)
-once daily injection that make you feel full, delay gastric emptying and make the beta cells make more insulin
GLP-1 agonists are reserved for overweight people instead of insulin in step 3, they are cardio protective (could use in step 2 if heart problems)
Which diabetes drugs cause hypos?
- insulin
- sulfonylureas
- glitazones
- GLP-1 analogues possibly when used with others
-metformin and SGLT-2 inhibitors don’t cause hypos
What advice do you need to give to those taking insulin and driving?
- need to inform the DVLA
- need to test BG within 2 hours of drive and 2 hours throughout journeys
- Keep above 5mmol ‘5 and drive’. DO NOT drive under 4mmol.
- Always have hypo treatment within reach
-sulfonureas are at risk of hypos so may need to inform
In stage 3 what is a good choice if weight loss is needed?
GlP-1 mimetics (liragutide/dulagutide) good for weight loss
-metformin +glicazide+ (liragutide/dulagutide)
Explain types of insulin used in type 1
1st line: BASAL BOLUS regim
- basal or background insulin is intermediate/long acting
- multiple bolus injections of short acting BEFORE meals
INSULIN PUMPS-continuous s/c infusion (specialist decision)
How do you inject insulin?
How to inject insulin
reusable will have cartalidge, others you’ll need to insert
STEP 1 wash and dry your hands
STEP 2 choose your sight (stomach under belly button, thighs and bum) make sure not the same as previous ones
STEP 3 attach needle and remove caps
STEP 4 prime- dial 2 units and press plunger until it comes out (removes air and regulates dose)
STEP 5 gently pinch skin and insert needle at 90° angle
STEP 6 press plunger, wait for her then count to 10 slowly
STEP 7 remove needle-sharps bin or needle clipper
What is a sign on the body of insulin resistance?
Acanthosis nigricans in armpit-seen in T2DM
If someone is on metformin and their Hba1c is increasing but still <58 what do you do?
- Just increase metformin
- Only introduce dual therapy if >58
What are the options for dual therapy for T2DM?
Metformin plus one of the following: Sulfonylurea (glicazide/glimepiride) or DPP4 (SitagliPtin) or Pioglitazone or SGLT2: (DapaGLifozin) or
What should be included in the annual NINE diabetic review?
DIABETIC REVIEW 1. Weight + BMI 2. Creatinine 3. Urinary ACR (<1) >3mg is concerning. >30 proteinuria 4. Cholesterol (non HDL<4 is healthy) 5. HbA1c (<48mmol/L) - biannual INSERT AIMS HERE (below) 6. BP (<140/90 if no complications OR <130/80 with complications) 7. Smoking status 8. Eye exam 9. Foot exam (pulses, ulcers, callus)
- MONITER AND MANAGE PROGRESSION OF THE DISEASE
• Monitor Hba1c- Aim for <53
○ >48mmol if on lifestyle advice or metformin
○ >53mmol if on a hypoglycaemic drug
• Check compliance
What educational courses are good for T1DM and T2DM?
- DAFNE course for type1 with follow up
* DESMOND course for type 2 with follow up
When would you give a statin?
What dose would you give?
What dose would you give if CVD?
- Give 20mg statin if Qrisk3 >10%
- Give 80mg if established CVD
What do you do if you notice a raised ACR for diabetic patient?
RAISED ACR
- if 1st ACR is > 3mg/mmol → do another early next morn
- if > 3, confirmed then give ACE-I or ARB ( even if BP normal- to protect kidneys and control HTN
What are the 2 things your looking at on the ANNUAL diabetic foot exam?
Diabetic Foot
- Neuropathy
- charcot foot/joint (neuropathic joint)
- neuropathic ulcers (plantar surface, not painful) - Ischaemia
- absent foot pulse (DP.a, PT.a)
- ↓ABPI
- intermittent claudication
Complications of diabetic feet?
Complications of diabetic feet
- Calluses
- Ulceration
- Charcot’s arthropathy (swelling, distortion, LOF, flat feet, loss sensation)
- Cellulitis
- Osteomyelitis
- Gangrene
4 stages of diabetic retinopathy?
How do you treat?
Diabetic retinopathy
- Background
- Microaneurysms (dots) and haemorrhages (dot and blot)
- Hard exudates (more severe) - Maculopathy
- odema/other changes covering 1/3 of the macula - Pre proliferative
- Soft exudates (cotton wool spots- ischemia of nerves) - Proliferative (effects vision)
- new vessel formation
Treat with laser phocoagulation
Sick day rules for diabetes?
Diabetes sick day rules:
If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis
-Continue normal regime but check frequently
What are your Hba1c goals in diabetes?
Aim for <53
○ >48mmol if on lifestyle advice or metformin
○ >53mmol if on a hypoglycaemic drug
