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Yr 3 endo > T1dm > Flashcards

T1dm Flashcards

1
Q

definition opf T1dm

A

metabolic hyperglycaemic condition

caused by absolute insufficiency of pancreatic insulin production

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2
Q

aetiology of T1dm

A

destruction of insulin producing B cells = insulin deficiency

autoimmune in 90%

genetically susceptable patinets and triggered by env (low concordance in identical twins)

polymorphisms of genes influence the risk - gene encoding preproinsulin and HLA-DQB and HLA-DR, PTPN22 and CTLA-4

gene 6q determines islet sensitivity to damage eg from viruses or cross-reactivity from cow’s milk induced Ab

pancreatic B cell autoantigens involved in initiation or progression of autoimmune islet injury - include: glutamic acid decarboxylase, insulin, insulinoma-associated protein 2 (IA-2) and cation efflux zinc transporter (ZnT8)

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3
Q

secondary dm

A
  • steroids
  • anti-HIV drugs
  • newer antipsychotics
  • protease inhibitors
  • pancreatic - pancreatitis, surgery, trauma, pancreatic destruction (eg haemochromatosis, CF), pancreatic ca
  • cushing’s disease
  • acromegaly
  • phaeo
  • hyperthyroidism
  • glucagonoma
  • pregnancy
  • congenital lipodystrophy, glycogen storage diseases
  • glycogen storage diseases
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4
Q

epidemiology of T1dm

A

one of the most common chronic diseases in childhood with a prevalence of 0.25% in the UK

usually adolescent, can effect any age

geographic variation

US and northern europe incidence - 8-17/100000 per yr

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5
Q

signs and sx of T1dm

A

juvenille onset < 30yrs

polyuria/nocturia - osmotic diuresis caused by glycosuria

polydipsia (thirst)

tiredness

weight loss

sx and signs of complications

signs of associated autoimmune conditions

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6
Q

sx and signs of diabetic ketoacidosis

A
  • nausea
  • vomiting
  • abdo pain
  • polyuria
  • polydipsia
  • drowsiness
  • confusion
  • coma
  • kussmaul breathing - deep and rapid
  • ketotic breath
  • signs of dehydration - dry mucous membranes, reduced tissue turgor
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7
Q

signs of T1dm complications

A

fundoscopy - dm retinopathy

examination of feet - neuropathy - 10g monofilament testing and vibration sensation, pulses - dorsalis pedis and posterior tibial pulses

BP

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8
Q

signs of associated autoimmune conditions

A

vitiligo

Addison’s disease

autoimmune thyroid disease

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9
Q

Ix for T1dm

A

blood glucose - fasting >7mmol/L or random >11mmol/L - 2 +ve results needed

HbA1c - overall glucose for 2-3mo

FBC - MCV, reticulocytes (increased erythrocyte turnover causes misleading HBa1c)

UE - nephropathy and hyperkalaemia from ACEi

lipid profile

urine albumin creatinine ratio - detect microalbuminuria

urine - glycosuria, high ketones, MSU (microscopy and culture)

CXR - exclude infection

ECG - acute ischemic changes

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10
Q

Ix for pts presenting with suspected DKA

A
  • FBC - high WCC even w/o infection
  • UE - high urea and creatinine from dehydration
  • LFT
  • CRP
  • glucose
  • amylase may be high
  • blood cultures
  • ABG - metabolic acidosis with high anion gap
  • blood/urinary ketones
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11
Q

Mx of diabetic ketoacidosis

A

consider HDU/ICU input

central line, arterial line and urinary catheter if server acidosis, hypotensive or oliguric

insulin

fluids

K replacement

monitor blood glucose capillary ketones and UO hourly, UEs 4 hourly VBG at 0. 2.4. 8. 12h and before stopping fixed rate insulin. Monitor phos and mg daily

broad spectrum AB if infection suspected

thromboprophylaxis

NBM for at least 6hr - gastroparesis is common

NG tube if GCS is reduced to prevent vomiting and aspiration

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12
Q

insulin mx in DKA

A

50U of soluble insulin in 50mL 0.9% saline

start at 0.1U/Kg/h until capillary ketones <0.3, venous pH >7.3 and venous bicarb >18mmol/L

if pt able to drink change to SC insulin

if not - insulin sliding scale

dont stop infusion until 1-2hr after regular SC insulin is restarted

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13
Q

fluid Mx in DKA

A

500mL 0.9% saline over 15-30min until systolic BP is >100mmHg

then 1L 2hrly x3 and 1L 3hrly x3

IV dextrose when glucose reaches 15mmol/L:

  • 1L 5% dextrose over 8hrs when blood glucose is 7-15mmol/L
  • 500mL 10% dextrose over 4h when blood glucose <7mmol/L
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14
Q

K replacement for DKA

A

start in the second fluid bag if passing urine

adjust amount of K accoriding to the plasma K

  • if >5.5mmol/l = none
  • iof 2.5-5.5 mmol/L = 40mmol/L
  • if <2.5mmol/L = 60-80mmol/L
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15
Q

glycaemic control in T1dm

A

advice and pt education - nurse specialists and dieticiants

self adjust doses based on exercise, glucose, calorie intake and carb counting

avoid binge drinking - danger of delayed hyperglycaemia

SC insulin - short acting (Lispro, aspart, glulisine) 3x daily before meals and one long acting (isophane, glargine, getemir) once daily. Rotate injection sites

insulin pumps may give better control - but expensive and cumbersome and DKA may occur if pump malfunctions - give if attempts to reach HbA1c = hypoglycaemia or person unable to meet target

DAFNE (dose adjustment for normal eating) - calculate carb intake and adjust dose accordingly

monitor - sx, regular finger prick tests, monitor HbA1c (target <7%) every 3-6mo

screening and Mx of complications and cardiovascular risk

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16
Q

treatment of hypoglycaemia in T1dm

A

if low consciousness - 50mL of 50% glucose IV or 1mg glucagon IM

if conscious and cooperative - 50g oral glucose eg luczade, milk, sugar, 3 dextrose tablets - then starchy snack

shouldnt drive for 45mins

17
Q

complications of t1dm

A

DKA

microvascular - retinopathy, nephropathy, neuropathy

macrovascular - PVD, IHD, stroke, TIA, MI, renovascular disease, limb ischemia

suseptible to infections - especially on feet

complication of insulin:

  • weight gain,
  • fat hypertrophy at insulin injection sites
  • hypoglycaemia caused by missing a meal or insulin OD
18
Q

DKA presentation

A

low insuin and high counter-regulatory hormones = hepatic gluconeogenesis and low peripheral glucose utilisation

renal reabsorptive capacity of glucose is exceeded = glycosuria, osmotic diuresis and dehydration

increased lipolysis = ketogenesis and metabolic acidosis

ppte by infection, errors in mx, new dx, other medical disease or no cause identified

19
Q

hypoglycaemia sx

A

neuroglycopenic and adrenergic signs:

  • personality chnage
  • fits
  • confusion
  • coma
  • pallor
  • sweating
  • tremor
  • tachycardia
  • palpitations
  • dizzyness
  • hunger
  • focal neurological sx

may be masked by autonomic neuropathy, B blockers and brain adapting to recurrent episodes

20
Q

prognosis of T1dm

A

depends on early dx, good glycaemic control and compliance with screening and treatment

vascular disease and renal failure are major causes of increased morbidity and mortality

21
Q

latent autoimmune diabetes of adults (LADA)

A

form of t1dm

slower progression to insulin dependance later in life

22
Q

dx criteria for dm

A

sx of hyperglycaemia and raised venous glucose detected once

or - raised benous glucose twice ot oral glucose tolerance test 2h value >11.1mmol/L

HbA1c >48mmol/mol - avoid in pregnancy, children, T1dm , haemoglobinopathies

23
Q

differentiating T1 and T2dm

A

T1

  • before puberty
  • HLAD3 and D4
  • autoimmune B cell destruction
  • polydipsia, polyuria, weight loss, ketosis, persistent hyperglycaemia despite diet and med, islet cell Ab, autoAb, anti-glutamic acid decarboxylase Ab, ketonuria

T2

  • older
  • no HLA
  • insulin resistence/B cell dysfunction
  • present with complications
24
Q

general Mx of dm

A

education and lifestyle - exercise to increase insulin sensitivity, healthy eating - low sat fats, low sugarm increase starch carbohydrate, moderate protein

bariatric surgery

global vascular risk - statin, control BP

foot care

DVLA

25
Q

SC insulin

A

short, medium and long acting - 100u/L

  1. ultra-fast acting - inject at start of meal or just after
  2. isophane insulin - variable peak at 4-12hr
  3. pre-mixed insulin - eg NovoMix 30 = 30% short acting and 70% long acting
  4. long acting recombinant human insulin analogues (insulin glargine) used at bedtime . insulin determir - for intensive insulin regiemes for overweight T2dm
26
Q

common insulin regiemes

A

disposable pens

BD biphasic regimen - twice daily premixed insulin - T1 regular lifestyle or T2

QDS regimen - before meals ultrafast insulin and bedtime long acting analogue - flexible lifestyle

once daily before bed long acting insulin - good initial insulin regimen when switching from tablets in T2

27
Q

SC insulin dosing during intercurrent illness

A

avoid stopping insulin

illness increases insulin requirement

maintain calorie intake eg using milk

check BM and ketonuria - increase insulin if glucose rising - ultrafast acting

admit if vomiting, dehydrated, ketotic, a child or pregnant

28
Q

controlling BP in T1dm

A

treat if BP >135/85 unless albuminuria or >=2 features of metabolic syndrome - then 130/80

ACEi or ARB

Yr 3 endo (29 decks)

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