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pre reg afsha endocrine > T1D > Flashcards

T1D Flashcards

1
Q

what is T1D

A

absolute insulin deficiency due to destruction of beta-cells that produce insulin in pancreatic islet of Langerhans
little or no endogenous insulin secretory capacity

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2
Q

most commonly occurs

A

before adulthood

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3
Q

microvascular complications include

A
  • retinopathy
  • neuropathy
  • nephropathy
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4
Q

macrovascular complications include

A
  • premature CVD
  • peripheral arterial disease
  • MI, stroke
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5
Q

macrovascular complications are to do with the

A

heart

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6
Q

metabolic complications

A

DKA
hypoglycaemia

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7
Q

Typical features in adult pt presenting with T1D

A

Hyperglycaemia
Random BG conc >11mmol/L
Ketosis
Rapid weight loss
BMI <25kg/m2
Under 50
Personal/FHx autoimmune disease

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8
Q

target HbA1c for T1D

A

48mmol/mol (6.5%) or lower

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9
Q

In adults, T1D should be diagnosed on clinical ground if pt presents with hyperglycaemia and one or more of the following features (may not always be present):

A

Ketosis
Rapid weight loss
Age of onset <50 (but do not rule out if 50 or older)
BMI <25 (but do not rule out if 25 or more)
P/FHx autoimmune disease

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10
Q

What are the figures of BG conc patients should aim for at different times of the day?

A

Fasting BG of 5-7 on waking
4-7 before meals at other times of day
5-9 at least 90 mins after eating
At least 5 when driving as per DVLA

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11
Q

In a child, T1D suspected if they present with hyperglycaemia and characteristic features of

A

Polyuria
Polydipsia
Weight loss
Excessive tiredness

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12
Q

what type of monitoring to offer pt

A

Continuous glucose monitoring (CGM) should be offered to support pt to self-manage their diabetes
Pt using CGM will still need to take capillary BG measurements, but can do this less often
Pt unwilling to or unable to use CGM should be offered capillary BG monitoring and be advised to measure their BG conc at least 4x/day, including before each meal and before bed

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13
Q

when to consider metformin (unlicensed) as an addition to insulin

A

BMI 25 or more (23 or more for SA ethnicity) and wishing to improve BG control while minimising effective insulin dose

This is because pt who are overweight can develop insulin resistance!

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14
Q

all patients will require therapy with

A

insulin

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15
Q

Multiple daily injection basal-bolus insulin regimens

A

One or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue as the basal insulin
ALONGSIDE multiple bolus injections of short acting insulin before meals
Allows flexibility to tailor insulin therapy with the carbohydrate load of each meal

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16
Q

Mixed (biphasic) regimen

A

1,2 or 3 insulin injections per day of SA insulin mixed with intermediate acting insulin
May be mixed by pt at time of injection, or a premixed product may be used

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17
Q

Continuous SC insulin infusion (insulin pump)

A

Regular or continuous amount of insulin (usually rapid acting insulin analogue or soluble insulin) delivered by a programmed pump and insulin storage reservoir via SC needle or cannula

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18
Q

what is the recommended 1st line insulin regimen

A

multiple daily injection basal-bolus insulin regimens

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19
Q

give examples of 1st line basal insulin regimens

A
  • BD insulin detemir (Levemir) as long acting basal
  • OD insulin glargine (toujeo, Lantus) if above not tolerated or BD regimen not accepted
  • OD degludec (tresiba) If particular concern about nocturnal hypo
  • alternative for pt who need help with injection admin from carer or HCP: OD ultra long acting - degludec or glargine (tresiba, toujeo)
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20
Q

are non-basal-bolus insulin regimens recommended for adults with newly diagnosed T1D

A

no

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21
Q

….. insulin analogue is recommended as the mealtime insulin replacement, rather than soluble human insulin or animal insulin

A

rapid acing

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22
Q

when to inject rapid acting insulin

A
  • inject before meals
  • routine use after meals should be discourages
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23
Q

if a multiple daily injection basal-bolus regimen is not possible, consider ……. regimen if preferred

A

BD biphasic insulin regimen

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24
Q

In pt using BD human mixed insulin regimen and have hypoglycaemia that affects their QoL, trial a

A

BD anagolue mixed insulin regimen

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25
Q

Continuous SC insulin infusion (insulin pump) therapy should only be offered to pt who

A
  • suffer disabling hypoglycaemia while attempting to achieve their HbA1c level
  • or who have had high HbA1c levels (69 mmol/mol (8.5%) or above) with multiple daily injection therapy (including the use of LA insulin analogues if appropriate) despite high level of care
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26
Q

factors that can increase the required insulin dose

A

Infection, stress, accidental or surgical trauma

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27
Q

factors that can decrease insulin requirements, therefore increase susceptibility to hypo episodes

A

physical activity, intercurrent illness, reduced food intake, impaired renal function, some endocrine disorders (e.g. thyroid, addisons disease, coeliac)

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28
Q

assess pt awareness of hypo annually using .. (2)

A

Gold score or the Clarke score

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29
Q

what can reduce warning signs of hypo

A

Increase in the frequency of hypoglycaemic episodes

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30
Q

Impaired awareness of symptoms below the following BGC….. is associated with a significantly increased risk of severe hypoglycaemia

A

3mmol/litre

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31
Q

this class of drugs can blunt hypo awareness by reducing warning signs e.g. tremor

A

beta blockers

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32
Q

can patients experience loss of awareness of hypo after transfer from animal to human insulin

A

conflicting evidence
Clinical studies do not confirm that human insulin decreases hypo awareness

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33
Q

Suspect DKA in a pt with known diabetes or significant hyperglycaemia (finger prick BGC >11mmol/L) and the following clinical features

A
  • increased thirst and urinary freq
  • weight loss
  • inability to tolerate fluids
  • persistent vomiting and/or diarrhoea
  • abdominal pain
  • visual disturbance
  • lethargy/confusion
  • fruity breath smell
  • acidotic breathing (seep sighing, Kussmaul, respiration)
  • dehydration
  • shock (resulting from severe dehydration)
34
Q

what values suggest high ketones in the blood and urine

A

2+ in urine
above 3mmol/L in blood

35
Q

what to do if DKA suspected

A
  • assess for precipitating factors e.g. non adherence, infection, physiological stress, other medical conditions, drug treatment
  • test for ketones, even if plasma glucose levels are near normal
  • in child test for blood ketones if not possible, arrange immediate madden to hospital
36
Q

when are ketones produced

A

produced by liver when there is a lack of gucose

37
Q

is hyperglycaemia always present in DKA

A

no

38
Q

do low blood ketone levels (<3mmol/l urine) exclude DKA

A

no

39
Q

is tingling lips a sign of hypoglycaemia

A

yes

40
Q

mild hypoglycaemia signs

A
  • hunger
  • anxiety
  • irritability
  • tingling lips
  • sweating
  • palpitations
  • tremor
41
Q

non-mild hypoglycaemia signs (as BGC falls lower)

A

Weakness and lethargy
Impaired vision
Incoordination
Reduced orientation
Confusion
Irraitonla behaviour
Emotional lability
Deterioration of cognitive function (when BGL <3mmol/L)

42
Q

Severe hypoglycaemia may result in (4)

A

Consulvions
Unable to swallow
Loss of consiousness
Coma

43
Q

Target HbA1c for adults with T1D

A

48mmol/mol (6.5%) or lowe

44
Q

Target HbA1c for adults for T1D & CKD not treated with dialysis

A

<6.5 to <8%

This means <48 and <64

45
Q

how often to measure HbA1c levels in most pt

A

every 3-6 months

46
Q

how does continuous glucose monitoring work

A

way of measuring glucose levels continuously throughout day and night via a tiny electrode inserted under skin
They provide continuous measurements (every 1-5mins) of glucose conc in the interstitial fluid which correlate with blood glucose levels
Provides info to detect hypo and hyper episodes, predicts impending hypo and detects wide fluctuations in glucose levels

47
Q

choice of the following 2 should be offered to all pt with T1D as self monitoring of BGC
and what alternative to offer them if they decline

A

real-time CGM (rtCGM) or intermittently scanned CGM (isCGM)
If the pt cannot use or does not want rtCGM or isCGM, offer capillary blood glucose monitoring

48
Q

if a pt has CGM system, is this all they need

A

no they also need to take capillary blood glucose measurements, but can do this less often

49
Q

why do pt still need to do capillary blood glucose measurements if they have a CGM system

A

capillary blood glucose measurements check accuracy of CGM device
it is a back up e.g. when BG levels are changing quickly or device stops working

50
Q

All pt with T1D will need the following to monitor capillary blood glucose

A

Blood glucose monitor
Lancets - fit into finger-pricking device
Testing strips - blood in collected for testing in the machine

51
Q

when to test with capillary blood glucose

A

before breakfast, 2 hr after meals, during periods of illness, before driving, if they feel hypoglycaemic

52
Q

Pt using capillary blood glucose monitoring alone - how often should they check:

A

routinely monitor BG levels and measure at least 4x/day including before meals and before bed

53
Q

Optimal targets for glucose self monitoring in adults with T1D at different times of they

A

Fasting on waking: 5-7 mmol/L
Before meals at other times of the day: 4-7mmol/L
At least 90 mins after eating: 5-9mmol/L

54
Q

why should drinking alcohol on empty stomach be avoided

A

absorbed faster so eat a snack that contains a carb (sandwich, crisps) before and after drinking

55
Q

why is it important for pt to wear some form of diabetes identification if they are drinking alcohol

A

reduced awareness of hypo that comes with drinking may be confused with alcohol intoxication

56
Q

if people do drink 14 units of alcohol a week, they should spread this

A

evenly over 3 days or more

57
Q

oral health and diabetes

A
  • higher risk of periodonctiis (gum disease)
  • management of this can improve BGC and reduce risk of hypo
  • have regular oral health reviews
58
Q

what is diabulimia and what are the consequences

A

missing insulin doses intentionally in order to lose weight
can cause DKA

59
Q

what puts pt at risk of DKA

A

periods of illness - not eating or drinking
vomiting and diarrhoea

60
Q

sick day rules

A
  • never stop insulin, dose may need altering
  • check BGC more frequently e.g. every 1-2 hours including during night and titrate insulin dose accordingly
  • consider checking blood and urine ketone levels regularly e.g. every 3-4h including through the night, sometimes every 1-2h depending on results
  • maintain normal meal pattern where possible if appetite reduced
  • normal meals can be replaced by carb containing drinks e.g. milk, milkshakes, fruit juice, sugar drinks
  • aim to drink 3L fluid to prevent dehydration daily
  • avoid carbonated drinks
  • urgent medical attention if violently sick, drowsy, unable to keep fluids down (IV fluids may be needed)
  • when better, continue monitoring BGC until they return to normal
61
Q

T1D and hypertensive. what are the targets for ACR <70

A

<140/90

62
Q

T1D and hypertensive. what are the targets for ACR 70 or more

A

<130/80

63
Q

T1D and hypertensive. what are the targets for pt 80 and over

A

regardless of ACR aim for 150/90

64
Q

1st line antihypertensive in T1D

A

renin-angiotensin system blocking drug (ACE or ARB)
low dose, titrate up to max tolerated by doubling dose every 1-2 weeks
after each upward titration, monitor renal function, serum K and BP

65
Q

it may be necessary to prescribe other drugs to improve BP (along with ACE/ARB). what could these be

A
  • cardioselective BB (BNAMA: bisop, nebiv, ateno, metop, acebut but to lesser degree) - do not avoid these where indicated on pt on insulin
  • low dose thiazides can be combined with BB
  • when CCBs are used, only use long acting preps
66
Q

which CCBs can be used in T1D for hypertension

A

long acting ones e.g. amlodipine, nifedipine which are given OD

67
Q

do you need to use a risk assessment tool to assess CVD risk in pt with T1D

A

no

68
Q

what primary prevention for T1D pt who do not have established CVD (e.g. Hx MI, angina, stroke, TIA, PAD) and who do you give it o

A

atorvastatin 20mg if pt is >40, diabetes >10y, established nephropathy, other CVD RF e.g. obesity and hypertension

for all other pt, consider atorv 20mg for primary prevention

69
Q

secondary prevention for T1D + established CVD (e.g. Hx MI, angina, stroke, TIA, PAD etc)

A

atorvastatin 80mg

70
Q

what to carry out at yearly review

A
  • check injection sites and address any problems
  • assess for CV RF e.g. smoking, waist, BG control, full lipid profile, FHx CVD
  • ensure pt screened for eye disease, kidney disease, foot problems
  • ensure pt screened for thyroid disease
71
Q

HCP should be alert for the possibility of development of other autoimmune diseases (3)

A
  • coeliac (should be screened for at diagnosis, if pt has BMI or unexplained weight loss)
  • Addisons disease
  • pernicious anaemia
72
Q

NHS diabetes eye screening is offered once a year to anyone with diabetes who is aged

A

12 and over

73
Q

on diagnosis, immediately refer adults with T1D to local eye screening service. screening should be performed…

A

ASAP and no later than 3months from referral

74
Q

how often should all adults with T1D be screened for diabetic nephropathy

A

yearly

75
Q

what does an annual screening for diabetic nephropathy consist of

A
  • ask pt to bring in 1st urine sample of day (early morning urine)
  • send this for estimation of ACR
  • check serum creatine at same time to calculate eGFR
  • diagnosed CKD if eGFR is persistently <60 and/or ACR is persistently >3mg/mmol
76
Q

What treatment to give to adults with T1D who have confirmed nephropathy (3)

A

ACEi or ARB if no contraindications
Avoid high protein diet
Offer lipid modification therapy w/o a formal risk assessment

77
Q

how often should patients have screening for diabetic foot problems

A
  • have feet checked at diagnosis and at least annually thereafter, or sooner if any foot problems arise
78
Q

Examples of limb threatening and life threatening diabetic foot problems include

A

Ulceration with fever or any signs of sepsis
Alteration with limb ischaemia
Clinical concern that there is deep seated soft tissue or bone infection with or without ulceration
Gangrene with without ulceration

79
Q

Children with T1D and/or their family/carers are advised to have the following immunisations recommended by DoH (2)

A

Annual flu vaccine if >6 months
Pnuemoccal infection

80
Q

Advise children and young people who are using capillary blood glucose monitoring to measure their blood glucose levels to routinely perform at least….

A

5 capital blood glucose tests per day

81
Q

Depending on patients risk of developing a diabetic foot problem, carry out re assessments at the following intervals

A

Annually for people at low risk as part of their annual diabetes review
Frequently for example every three to six months for people at moderate risk
More frequently for example every one to two months for people who are at high risk, if there is immediate concern

82
Q

when is more frequent monitoring (up to 10 times a day or more) needed for pt who use capillary blood glucose monitoring?

A
  • freq of hypo episodes increases
  • legal requirements e.g. driving
  • periods of illnesses
  • before, during, after sport
  • planning pregnancy, P and BF
  • target HbA1c not reached
  • impaired awareness of hypo
  • lifestyle e.g. drive long periods, high risk activity or occupation, travel freq

pre reg afsha endocrine (29 decks)

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