T1DM, T2DM & Me

Question 1

what is T1DM

Answer 1

autoimmune destruction of the pancreas
beta cells are destroyed so less insulin is made
less insulin means cells can’t take up glucose and the body thinks it is starving so the liver produces more glucose resulting in hyperglycaemia

Question 2

what can cause T1DM

Answer 2

genetics + unknown trigger 
acromegaly 
cushing's 
autoimmune disease 
pheochromocytoma

Question 3

what are symptoms of T1DM

Answer 3

thirst - polydipsia
tiredness
toilet - polyuria
thinner - weight loss

Question 4

what are clinical signs of T1DM

Answer 4

polyuria
hyperglycaemia
glucosuria
sweet breath if in ketosis

Question 5

what tests could you do for T1DM

Answer 5

finger prick blood glucose test in clinic - if >11.1 send for same day investigations
fasting blood glucose >7 indicates diabetes
oral glucose tolerance test > 11.1
HbA1c represents past 2-3 months, below 6% glycated is normal

Question 6

how could you manage T1DM

Answer 6

patient education - STEP
2 weeks leave to understand management
inform about sick day rules
insulin regimes

Question 7

what is the twice daily insulin regime

Answer 7

rapid acting + intermediate acting insulin before breakfast and dinner

Question 8

what is the 3x daily insulin regime

Answer 8

rapid + intermediate before breakfast
rapid before tea
intermediate before bed

Question 9

what is the 4x daily insulin regime

Answer 9

short acting before breakfast lunch and dinner
intermediate before bed
long acting at a fixed time daily

Question 10

what is diabetic ketoacidosis

Answer 10

high levels of ketone acids in the blood

Question 11

how does diabetic ketoacidosis happen

Answer 11

no insulin = no glucose getting into the cells
body converts FFAs into ketone bodies in the liver as an alternate energy source
the ketone bodies cannot be taken up by the brain without insulin
ketones build up in the blood causing metabolic acidosis

Question 12

how does DKA present

Answer 12

sweet breath from acetone (breakdown product of ketones that escapes in lungs) 
nausea 
vomiting 
breathing abnormalities 
drowsiness 
coma 
death

Question 13

what investigations could you do in ketoacidosis

Answer 13

urine dipstick for glucose and ketones
arterial blood gas
ECG

Question 14

how would you treat ketoacidosis

Answer 14

IV saline to rehydrate
IV insulin
IV potassium
monitor closely - NEWS, GCS, blood glucose

Question 15

what is T2DM

Answer 15

tissues loose their sensitivity to insulin - could be because there is less receptors or some are damaged
more insulin is required to have the same effect
the beta cells have an increased demand so undergo hyperplasia but then burn themselves out and become atrophied so less insulin is produced resulting in hyperglycaemia

Question 16

what are risk factors for T2DM

Answer 16

genetics 
obesity 
poor diet/lifestyle 
60+
alcohol 
asian

Question 17

how does T2DM present

Answer 17

often asymptomatic until there are complications 
tiredness
thirst 
weight loss 
polyuria 
blurred vision 
thrush or other low grade infections

Question 18

what investigations could you do for T2DM

Answer 18

blood glucose
random glucose
oral glucose tolerance test
urine dipstick

Question 19

what are complications of diabetes mellitus

Answer 19

vascular disease - peripheral, coronary and cerebral 
retinopathy 
nephropathy 
neuropathy 
diabetic ulcers

Question 20

what is a hypoglycaemic attack

Answer 20

when blood sugars get dangerously low

4 is the floor but less than 3mmol/l is common threshold

Question 21

what causes a hypo

Answer 21

taking too much insulin in T1DM compared to glucose consumed
missed meals or overactivity in T1DM

Question 22

what can cause a hypo in non-diabetics

Answer 22

EXPLAIN
exogenous drugs 
pituitary insufficiency 
liver failure 
addison's disease 
islet cell tumours 
non-pancreatic tumours

Question 23

how does a hypoglycaemic attack present

Answer 23

sweating 
anxiety 
hunger 
tremor 
palpitations 
dizzy 
confusion 
drowsy 
visual disturbances 
coma 
seizures 
can be misdiagnosed as alcohol overdose

Question 24

how do you manage a hypo

Answer 24

15-20g quick acting carbohydrate snack - 200ml orange juice and check BG 15-20 mins later, repeat snack up to three times
glucose gel between teeth and gums if conscious but not cooperative
IV glucose if unconscious - 10% at 200ml/hour
can also give glucagon - won’t work if patient is malnourished
once glucose is over 4mmol/l give long acting carbohydrate - toast

Question 25

how do you treat T2DM

Answer 25

lifestyle advice - diet, exercise alcohol etc
screen for complications
start with metformin
if HbA1c is still 58 or above add on DDP4 inhibitor or pioglitazone or Sulphonylureas or SGLT-2 inhibitor
if its still above 58 add on SU (SGLT-2i for metformin + SU)
if that doesn’t work consider
insulin based therapy
triple therapy - metformin, SU and GLP1 mimetic

Question 26

what are HbA1c targets

Answer 26

48mmol/l for new T2DM

53 for patients who use more than just metformin