Type 1 Diabetes Flashcards
1
Q
What is the definition of T1DM?
A
absolute insulin deficiency causes persistent hyperglycaema (random plasma glucose >11 mmol/L)
2
Q
What causes type 1 diabetes?
A
absolute insulin deficiency usually resulting from autoimmune destruction of insulin-producing beta cell in the pancrea
3
Q
What is the role of genetics in T1DM?
A
it is a heritable polygenic disease; increased risk of 6-7% if sibling has it, 1-9% if parent has it
4
Q
What are thought to be 5 environmental factors associated with type 1 diabetes?
A
- Diet
- Vitamin D exposure
- Obesity
- Early-life exposure to viruses associated with islet inflammation (e.g. enteroviruses)
- Decreased gut-microbiome diversity
5
Q
What are 2 ages when the peak incidence of diagnosis of T1DM occurs?
A
6 months - 5 years and 10-14 years
6
Q
At what age is the prevalence of T1DM highest?
A
35-60 years
7
Q
What are 8 complications to T1DM?
A
- Microvascular: retinopathy, nephropathy, neuropathy
- Macrovascular: peripheral arterial disease, IHD, cerebrovascular disease
- Metabolic disease: DKA, hypoglycaemia
- Other autoimmune conditions
- Psychological complications e.g. anxiety, depression, diabetes-related emotional distress
- Infections and other skin complications
- Reduced quality of life
- Reduced life expectancy
8
Q
What are 7 autoimmune conditions which have increased incidence with T1DM?
A
- Graves’ disease
- Hashimoto’s thyroiditis
- Autoimmune gastritis
- Pernicious anaemia
- Coeliac disease
- Vitiligo
- Addison’s disease
9
Q
What are 5 examples of psychological complications of T1DM?
A
- Anxiety
- Depression
- Diabetes-related emotional distress
- Behavioural conduct disorders (children)
- Eating disorders - Diabulimia (omitting insulin to lose weight)
10
Q
What a specific example of a skin complication of T1DM?
A
necrobiosis lipoidica - inflammaory condition in which shiny, reddish-brown or yellowish patches develop in skin of people with diabetes
11
Q
How much does type 1 diabetes reduce life expectancy in the UK?
A
11-15 years
12
Q
What are 5 clinical features of type 1 diabetes in adults?
A
- Ketosis
- Rapid weight loss
- Age of onset <50 years
- BMI < 25
- Person and/or family history of autoimmune disease
13
Q
What should you do immediately (same day) if T1DM is diagnosed?
A
refer immediately to diabetes specialist team to confirm the diagnosis and provide immediate care
14
Q
What are the only 3 situations when C-peptide and/or diabetes specific autoantibody titres are measured to confirm the diagnosis of T1DM?
A
- If T1DM suspected but clinical presentation includes some atypical features (e.g. >50y, BMI >25, slow evolution of hyperglycaemia)
- T1DM has been diagnosed and treatment started but clinical suspicion that may have monogenic form of diabetes, and one or both tests may guide use of genetic testing
- Classification of diabetes is uncertain and conirming it would have implications for availability of treatment e.g. continuous subcutaneous insulin infusion (CSII or ‘insulin pump’
15
Q
What are 4 symptoms that should make you suspect T1DM in a child or young person presenting with hyperglycaemia (random plasma glucose >11 mol/L)?
A
- Polyuria
- Polydipsia
- Weight loss
- Excessive tiredness
16
Q
What should you do immediately if T1DM is suspecte din a child or young person?
A
refer immediately to multidisciplinary paediatric diabetes care team with competencies needed to confirm diagnosis and provide immediate care
17
Q
What are 5 features that should make you suspected type 2 rather than type 1 diabetes in a child or young adult?
A
- Strong family history of type 2 diabetes
- Obesity
- Black or Asian family origin
- No insulin requirement, or have an insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase
- Evidence of insulin resistance (e.g. acanthosis nigricans)
18
Q
What are 3 features that should make you suspect monogenic or mitochondrial diabetes in a child or young person?
A
- Diabetes in first year of life
- Rarely or never develop ketone bodies in the blood (ketonaemia) during episodes of hyperglycaemia
- Associated features e.g. optic atrophy, retinitis pigmentosa, deafness, or features of another systemic illness or syndrome
19
Q
What are 12 features that should make you suspicious of DKA?
A
- finger prick blood glucose >11mmol/L
- increased thirst and urinary frequency
- weight loss
- inability to tolerate fluids
- persistent vomiting and/or diarrhoea
- abdominal pain
- visual disturbance
- lethargy and/or confusion
- fruity smell of acetone on the breath
- acidotic breathing - deep sighing (Kussmaul) respiration
- dehydration, which can be classified as mild, moderate or severe
- shock - from severe dehydration
20
Q
What defines mild dehydration in DKA?
A
only just clinically detectable
21
Q
What defines moderate dehydration in DKA?
A
dry skin and mucous membranes, reduced skin turgor
22
Q
What defines severe dehydration in DKA?
A
sunken eyes and prolonged capillary refill time
23
Q
What are 3 signs of shock in DKA?
A
- Tachycardia, poor peripheral perfusion, and (late sign) hypotension
- Lethargy, drowsiness, decreased level of consciousness
- Reduced urine output
24
Q
What are 5 precipitating factors of DKA to assess for?
A
- Infection e.g. pneumonia or UTI
- Physiological stress e.g. trauma, surgery
- Non-adherence to insulin treatment regimen or intentional insulin omission to lose weight (diabulimia)
- Other medical conditions (hypothyroidism or pancreatitis)
- Drug treatment (corticosteroids, diuretics, sympathomimetic drugs such as salbutamol)
25
What are 3 types of drugs which could trigger DKA?
1. Corticosteroids
2. Diuretics
3. Sympathomimetic drugs e.g. salbutamol
26
What should you always test for in suspected DKA?
ketones
27
What causes raised ketones in DKA?
produced by liver when there is a lack of glucose (starvation ketones) and as an alternative energy source when there is a relative insulin deficiency
28
What are the cut-offs for high ketones for urine and blood ketones?
urine: 2+
blood: above 3mmol/L
29
How should you test for ketones in a child or young person?
blood ketones (in adult, urine or blood)
30
What are 7 symptoms of mild hypoglycaemia?
1. Hunger
2. Anxiety or irritability
3. Sweating
4. Tingling lips
5. Irritability
6. Palpitations
7. Tremor
31
What are 8 signs of established hypoglycaemia?
1. Weakness and lethargy
2. Impaired vision
3. Incoordination
4. Reduced orientation
5. Irrational behaviour
6. Emotional lability
7. Deterioration of cognitive function (if \<3mmol/L)
32
What is the clinical defintion of hypoglycaemia?
\< 3.5 mmol/L
33
What are 4 signs of severe hypoglycaemia?
1. Convulsions
2. Inability to swallow
3. Loss of consciousness
4. Coma
34
For adults with diabetes what type of care plan is important to have in place?
individual care plan - set up by diabetes specialist team
35
How often should an individual care plan be reviewed?
annually
36
What is an example of a structured education programme to offer for adults diagnosed with T1DM?
DAFNE (dose-adjustment for normal eating) programme
37
What is an example of an online resource for adults with T1DM?
Diabetes UK website www.diabetes.org.uk
38
What are 12 aspects of the individualised care plan for adults with T1DM?
1. Diabetes education - sites and timescales
2. Insulin therapy - injections, regimens, dose adjustment
3. Self-monitoring of blood glucose
4. Treatment targets
5. Hypoglycaemia - risks, symptoms, treatment
6. Management of special situations e.g. driving, fasting, physical activity
7. Managemetn of diabetes during period of illness
8. Cardiovascular risk factors (monitoring and management)
9. Complications
10. Means and frequency of communicating with specialist team
11. Frequency and content of follow up consultations
12. Contraception and pregnancy planning advice (when appropriate)
39
Who should initiate and manage insulin therapy for adults with T1DM?
healthcare profesionals with relevant experise and training
40
What is the target HbA1c for adults with T1DM?
48 mmol/mol
41
What is a condition that may mean the target HbA1c in adults with T1DM is higher?
CKD
42
How often should HbA1c be measured in adults?
every 3-6 months
43
What are 3 things needed to self monitor blood glucose?
blood glucose monitor, lancets, testing strips
44
What are 5 situations when adults with T1DM should test the blood glucose levels?
1. Before breakfast
2. 2 hours after meals
3. During periods of illness
4. Before driving
5. If feeling hypoglycaemic
45
What is an alternative to taking individual blood glucose readings throughout the day?
continuous glucose monitoring: tiny electrode inserted under skin, provide reading every 1-5 minutes
provides retrospective and real-time info
46
When is continuous glucose monitoring recommended for adults with T1DM?
not routinely, but special circumstances e.g. more than 1 episode a year of severe hypoglycaemia with no obvious cause
47
How many times a day should adults with T1DM be recommended to monitor BG levels?
at least 4 times a day, including before meals and before bed
48
What are 8 situations when more frequent monitoring of blood glucose may be needed for T1DM?
1. Target HbA1c not achieved
2. Frequecy of hypos increases
3. Legal requirement to do so e.g. before driving
4. During periods of illness
5. Before, during and after sport
6. When planning pregnancy, during pregnancy, while breastfeeding
7. If need to know BG levels \>4x a day e.g. impaired awareness of hypos
8. If necessary due to lifestyle e.g. drive for long period of time, high-risk activity or occupation, travel frequently across time zones
49
What is the optimal target for an adult with T1DM for fasting plasma glucose?
5-7 mmol on waking
50
What is the optimal target for an adult with T1DM for plasma glucose before meals/ other times?
4-7mmol/L
51
What is the target plasma glucose for adults who test after meals and within what time frame?
5-9 mmol/L at least 90 minutes after eating
52
What determines the adult target plasma glucose levels for bedtime?
take into account timing of last meal and related insulin dose, be consistent with recommended fasting level on waking
53
What are 5 situations when NICE recommends real-time continuous glucose monitoring is considered for adults with T1DM?
1. Extreme fear of hypos
2. \>1 episode a year of severe hypos with no obvious cause
3. Complete loss of awareness of hypoglycaemia
4. Persistent hyperglycaemia (HbA1c of 75 mmol/mol or higher) depsite testing at least 10 times a day
5. Frequent (more than 2 episodeS) of asymptomatic hypoglycaemia
54
What dietary advice is recommnded for adults with T1DM?
carbohydrate counting training
dietary information to prevent CVD - low in fat, salt, sugar, 5 fruit and veg
55
What is the risk of drinking alcohol in T1DM?
may exacerbate or prolong hypoglycaemic effect of insulin
56
What is the advice for alcohol intake for pregnancy women?
don't drink at all (this is in all cases not just T1DM)
57
What is the risk of exercising with T1DM?
may lower blood glucose levels (can also worsen hyperglycaemia and ketonaemia)
58
What are 3 situations when you should **always** arrange hospital admission for adults with T1DM for a period of illness?
1. If immediate risk of DKA
2. if moderate ketonuria (2+ on dipstick) or ketonaemia (1.5-2.9 mmol) with or without hyperlgycaemia and cannot eat and drink
3. Person doesn't improve rapidly with insulin treatment
59
What are 7 situations when you should _consider_ admission for illness in an adult with T1DM?
1. Underlying condition unclear
2. Person dehydrated or at risk of dehydration
3. Vomiting persists beyond 2 hours
4. Person and family/ carers unable to keep blood glucose above 3.5
5. Person on continuous subcutaenous insulin pump therapy
6. Person and family/carers exhausted e.g. repeated night-time waking
7. Language problems make it difficult to communicate with person and/or carers
60
What are 2 ways that intercurrent illness can affect T1DM?
1. Some e.g. fever can raise blood glucose levels
2. If diarrhoea and vomiting (e.g. gastroenteritis) can low BG levels, causing hypos
61
What are 6 things to make sure a patient has in intercurrent illness, if they can be managed in this setting?
1. Written 'sick day rules' and contact details of healthcare team
2. Easily digestible food and sugary drinks
3. Oral rehydration salt sachets
4. Additional supplies of inuslin
5. Glucose tablets or oral gel (to prevent hypoglycaemia)
6. Glucagon kit (if appropriate)
62
What are the 7 sick day rules of type 1 diabetes?
1. Never stop or omit insulin - may need to alter, seek advice from diabetes team
2. Check BG more fequently e.g. every 1-2h including through night
3. Consider checking blood or urine ketone levels regularly e.g. every 3-4h including through night, sometimes 1-2h depending on results
4. Maintain normal meal pattern if appetite reduced
5. Aim to drink at least 3L of fluid a day
6. Seek urgent medical advice if violently sick, drowsy, unable to keep fluids down
7. When feeling better, continue to monitor BG carefully until returns to normal
63
What are 7 things to assess annually to manage cardiovasuclar risk factors in adults with T1DM?
1. Lifestyle including smoking status
2. Waist circumference
3. Blood glucose control
4. Blood presure
5. Albuminuria
6. Full lipid profile
7. Family history of CVD
64
What are 5 baseline blood tests to ensure statin treatment is suitable when prescribing in adults with T1DM?
1. Non-fasting lipid profile
2. LFTs
3. Renal function
4. TFts - if hyperlipidaemia present
5. Creatine kinase - if persistent generalised unexplained muscle pain
65
What should be done at every review appointment for adults with T1DM? 5 things
1. HbA1c measurement
2. Measure height, weight, waist circumference, BMI
3. Assess for depression, anxiety, diabulimia
4. Smoking status
5. Monitor for neuropathy and associaed complciations e.g. erectile dysfunction, neuropathic pain, autonomic neuropathy, gastroparesis
66
What are 6 aspects of screening to perform once a year in T1DM?
1. Check injection sites, address problems
2. Assess for cardiovascular risk factors (smoking, BG control, waist circumference, BP, lipid profile, FH of CVD)
3. Eye disease screening
4. Kidney disease screening
5. Foot problem screening
6. Ensure screening for thyroid disease
67
When is eye disease screening recommended in T1DM?
on diagnosis, immediately refer (perform no later than 3 months from referral)
## Footnote
**repeated annually for T1 diabetes who are 12 years and over**
68
How is screening for diabetic kidney disease carried out?
ask adult to bring in first urine sample of day (early morning urine) once a year
send for assessment of ACR
check serum creatinine at same time to calculate eGFR
69
What should be offered for erectile dysfunction (form of neuropathy) if PDE-5 inhibitor treatment is contraindicated or unsuccessful?
refer man to service offering further assessment and other medical, surgical, or psychological management of erectile dysfunction
70
What are 4 forms of neuropathy to assess for in T1DM?
1. Chronic painful neurpathy
2. Erectile dysfunction
3. Autonomic neuropathy
4. Acute painful neuropathy of rapid improvement of blood glucose control
71
What are 4 signs of autonomic neuropathy in T1DM?
1. Unexplained diarrhoea
2. Bladder emptying problems
3. Gastroparesis-induced vomiting
4. Excessive sweating
72
What are 4 aspects of the management of acute painful neuropathy of rapid improvement of blood glucose control?
1. Reassure it is self-limiting and improves symptomatically over time
2. Specific treatments aim to make symptoms tolerable until condition resolves and may not relieve pain immediately, may need to be taken regularly for several weeks
3. Advise use of simple analgesics (paracetamol and NSAIDs) and local measures e.g. bed cradle - stops sheets and blankets touching and rubbing body
4. Do not relax blood glucose diabetes control if this is identified
73
When assessing for diabetic foot problems, who soon should a patient at moderate risk of developing a problem be seen by the foot protection service?
within 6-8 weeks
74
When assessing for diabetic foot problems, who soon should a patient at high risk of developing a problem be seen by the foot protection service?
within 2-4 weeks
75
For active diabetic foot problems, how soon should the person be referred to the multidiscplinary foot care service or foot protection service?
within 1 working day, for triage within 1 further working day
76
If at low risk of diabetic foot problems, how frequently should screening be carried out?
annually
77
If at moderate risk of diabetic foot problems, how frequently should screening be carried out?
every 3-6 months
78
If at high risk of diabetic foot problems but **no immediate concern**, how frequently should screening be carried out?
every 1-2 months
79
If at high risk of diabetic foot problems and **there is immediate concern**, how frequently should screening be carried out?
every 1-2 weeks
80
What immunisations are offered to children and young people with T1DM?
* annual immunisation against influenza (if aged over 6 months)
* immunisation against pneumococal infection
81
How many times a year should children and young peole attend the paediatric diabetes clinic?
4 times a year - regular contact associated with optimal blood glucose control
82
When may initial management of T1DM be managed as an inpatient? 3 situations
1. children younger than 2 years of age
2. children and young people with social or emotional factors that would make home-based inappropriate
3. childrne/ young people who live far from the hospital
83
What are 6 things that should be taken into account when tailoring a child's/young person's programme of education for T1DM?
1. Emotional wellbeing
2. Age and maturity
3. Cultural considerations
4. Existing knowledge
5. Current and future social circumstances
6. Life goals
84
What is the target HbA1c for children and young people?
48 or lower
85
What is the target plasma glucose levels for young people of driving age when driving?
at least 5 mmol/L
86
What should you explain to patients about the link between blood glucose levels and HbA1c?
achieving and maintaining blood glucose levels towards the lower end of the target optimal range will help achieve lowest attainable HbA1c
87
What are 6 situations to offer real-time continuous glucose monitoring to children and young people?
1. Frequent severe hypoglycaemia
2. Imapired awareness of hypos associated with adverse consequences (e.g. seizures or anxiety)
3. Inability to recognise or communicate about hypos
4. Neonates, infants and pre-school children
5. Children and young people undertaking high levels of physical activity
6. Children and young people who have comorbidities e.g. anorexia nervosa or who are receiving treatment e.g. steroids that can make BG control difficult
88
What are 2 types of continuous glucose monitoring?
intermittent (real time or retrospective) and ongoing real-time
89
What are 4 general rules about exercise in children with T1DM?
* can take part in all forms provided appropriate attention given to diet and changes in insulin
* changes in daily exercise patterns may require insulin dose and/or carbohydrate intake to be altered
* eat additional carbs before, should be available throughout and afterwards
* encourage to monitor BG before and after
90
What is the recommended exercise for toddlers (1-2 years)?
at least 180 min a day in variety of physical activities at any intensity
91
What is the recommended exercise for children 3-4 years?
Spend at least 180 minutes per day in a variety of physical activities spread throughout the day, including active and outdoor play. The 180 minutes should include at least 60 minutes of moderate-to-vigorous intensity physical activity.
92
What is the recommended exercise for children aged 5-18?
Engage in moderate-to-vigorous intensity physical activity for an average of at least 60 minutes per day across the week.
93
What are 5 things to monitor at every review appointment for a child or young person with T1DM?
1. Measure HbA1c
2. Review injection sites, address problems
3. Measure height and weight and plot on an appropriate growth chart. Calculate BMI
4. Check smoking status
5. Assess for psychological problems: depression, anxiety, eating disorders, alcohol/substance misuse, relationship probs
94
What should you advise children/ their carers about dental care with T1DM?
regular dental examination e.g. every 3-6 months
95
What eye screening should be performed in children and young people?
should have eye examination by optometrist every 2 years until age of 12 years - then eligible for annual diabetes eye screening
96
What monitoring for renal complications of T1DM should be offered in children?
monitor ACR in children aged 12 and older annually
use early morning urine sample
97
What monitoring should be offered for thyroid diseases in children with T1DM?
perform at diagnosis and annually thereafter until transfer to adult services
98
What monitoring for hypertension in T1DM should be performed in children?
monitor annually in children 12 and older
99
What are 4 key associated conditions with T1DM in children should you be aware of?
1. Juvenile cataracts
2. Necrobiosis lipoidica - shiny, red-brown, yellowish patches on shins
3. Coeliac disease
4. Addison's disease
100
When should you arrange further monitoring following on from renal screening in children with T1DM?
if ACR \>30, arrange further investigations
101
What foot screening is available for children with T1DM?
if \<12 years, give basic foot care advice
if aged 12-17, ensure paediatric care team or transitional care team assesses feet as part of annual assessment
102
What are 2 examples of rapid acting insulins?
1. Humalog (insulin lispro)
2. Novorapid (insulin aspart)
103
What is the onset of action of rapid-acting insulins and the duration of action?
* 15 minutes
* duration 2-5 h
104
What are 2 examples of short-acting insulins?
1. Actrapid
2. Humulin S
105
What is the onset and duration of action of short-acting insulins?
* 30-60min
* duration up to 8 h
106
What is another name for intermediate acting insulins?
isophane insulins
107
What are 3 examples of intermediate acting insulins?
1. Humulin I
2. Insuman Basal
3. Insulatard
108
What is the onset, time of maximal effect and duration of action of intermediate insulin?
* 1-2h
* 3-12h maximal effects
* 11-24h duration
109
What are 3 examples of long-acting insulins?
1. Lantus (insulin glargine)
2. Levemir (insulin detemir)
3. Tresiba (insulin degludec)
110
What is the duration of action of long-acting insulins?
up to 24h
111
What are 3 types of new insulin products launched in recent years?
1. High strength insulins e.g. Tresiba, Humalog, Toujeo
2. Insulin in fixed combo with liraglutide e.g. Xultophy
3. Biosimilar insulin e.g. Abasaglar and Lantus
112
What are the 3 options for insulin regimens for T1DM?
1. Multiple daily injection basal-bolus
2. Mixed (biphasic) regimen
3. Continuous subcutaneous insulin infusion (CSII) (insulin pump) therapy
113
What is the mixed (biphasic) regimen of insulin?
one, two or three insulin injections per day of short-acting or rapid-acting insulin mixed with intermediate acting insulin
can be manually mixed or premixed
114
How does continuous subcutaneous insulin infusion work?
* programmable pump and insulin storage reservoir that gives regular or continuous amount of insulin (usually rapid-acting or short-acting insulin) by a subcutaneous needle or cannula
* need intermediate or long acting insulin to provide basal cover
* can programme to deliver different basal rates of insulin at different times of day and night
115
What is the firs tline insulin regimen for adults with type 1 diabetes?
* multiple daily injection **basal-bolus insulin** regimens
* offer twice daily insulin detemir as long-acting basal insulin theray
* offer rapid-acting insulin injected before meals for mealtime insulin replacement
116
What are 2 situations when insulin pump therapy is recommended for adults with T1DM?
1. attempts to achieve target HbA1c levels with multiple daily injection therapy result in disabling hypoglycaemia
2. hbA1c levels have remained high - 69 or above - during multiple daily injection therapy (including, if appropriate, use of long-acting insulin analogues), despite high level of care
117
What is the insulin regimen offered to children and young people with T1DM from diagnosis?
multiple daily injection basal-bolus insulin reigmens
rapid acting insulin analogue before eating
118
What is recommended for second line in children/young people after basal-bolus regimens?
insulin pump therapy
119
What should you advise about insulin prior to injection? 3 things
1. Leave at room tempearture at least 30 min before injecting
2. Check expiry date
3. If cloudy insulin, invert or rotate (not shake) pen at least 10 times in palm of hands and invert 10 times to mix the insulin
120
At what angle to the skin should insulin be injected?
90 degrees
121
How long should the insulin needle be left in the skin when injected?
5-10s to ensure entire dose injected and avoid leakage of dose
122
What should be done after insulin injections?
apply gentle pressure over site for several seconds (don't rub)
123
How should insulin be stored?
if not currently being used store in fridge, 2-8 degrees C
can store at room temperature once in use for 28 days
protect from sunlight and excessive heat
124
What are 11 causes of recurrent hypoglycaemia?
1. inappropriate insulin regimens
2. lifestyle issues e.g. meal and activity pattern, alcohol
3. injection technique and skills
4. injection site problems
5. impaired hypo awareness
6. changes in insulin sensitivity - insulin-sensitive will require smaller amounts to lower BG levels
7. previous physical activity
8. drug iteractions
9. lack of appropriate knowledge and skills for self-management
10. possible organic causes e.g. hyperthyroidism, coeliac disease, Addison's
11. psychological problems - anxiety, depression
125
What is a training programme for adults with recurrent episodes of hypoglycaemia?
Blood Glucose Awareness Training (BGAT)
126
What can be considered for adults with recurrent severe hypoglycaemia that has not responded to other treatment?
refer to centre that assesses people for islet and/or pancreas transplantation
127
What is the management of a hypo when the patient is able to swall?
* 10-20g fast-acting carbohydrate, preferably in liquid form as easier to take (or 0.3g/kg for young people)
* this is: 3-6 glucose tablets, 90-180ml of fizzy drink or squash, 50-100ml lucozade energy
* recheck BG after 10-15min
* if no response, repeat oral intake
* re-test BG after 15 min
* if normoglycaemia restored, increase carbohydrate intake of next meal if due; otherwise immediately eat long-acting starchy carbohydrate
128
Why should you avoid chocolates and biscuits in hypos?
lower sugar content and high fat content may delay stomach emptying
129
What are 4 steps of management of hypoglycaemia if the patient is unconscious and unable to swallow?
1. IM glucagon should be administered immediately
2. emergency transfer to hospital if glucagon not available or family not trained to administer, or alcohol is cause
3. if person doesn't response in 10 min, emergency transfer to hospital for IV glucose
4. if respond to glucose treatment within 10 min and sufficiently awake, eat some oral carbohydrate
130
What are 2 types of scores which can be used to quantify awareness of hypoglycaemia?
Gold or Clarke score
131
What is the management of reduced hypo awareness?
* ensure person has had appropriate education
* review insulin regimens and doses and prioritise strategies to avoid hypoglycaemia
* refer to diabetes specialist team for consideration of continuous subcutaneous insulin infusion or continuous glucose monitoring if:
* person continues to have impaired awareness
* impaired awareness is associated with recurrent severe hypos
132
What are 5 types of injection site problems?
1. Painful injection
2. bleeding and bruising
3. Redness, swelling and itching at site of injection
4. Lipohypertrophy (need to rotate sites)
5. Insulin leakage
133
What are 3 less common adverse effects of insulin therapy?
1. Altered vision - reassure usually temporary
2. Acute painful neuropathy resulting frmo rapid improvement of blood glucose control - self-limiting, may need bed cradle
3. Insulin oedema - should resolve 3-4 days after reducing insulin dose
134
What are 4 key pieces of advice on driving for T1DM patients?
1. Should have supply of a fast-acting carbohydrate in vehicle, avoid driving if meal is delayed
2. Check blood glucose level just before start journey and every 2 hours during journey. if low, stop in safe place, move from drivers seat, eat or drink something sugary, wait until 45 min after BG has returned to normal
3. take regular meals, snacks, rest periods on long journeys
4. take care during changes of insulin regimens, lifestyle, exercise and travel
135
What must patients with T1DM do re DVLA?
their repsonsibility to inform them of their conditions
136
What are 6 conditions for T1DM patients to be able to drive cars (group 1 entitlement)?
1. must have adequate awareness of hypos - otherwise, must not drive
2. no more than 1 episode of severe hypoglycaemia while awake in preceding 12 months, most recent episode occurred more than 3 months ago
3. Practises appropriate glucose monitoring - testing no more than 2h before start of journey and every 2h of journey
4. Must not be regarded as likely source of danger to public while driving
5. meets visual standards for acuity and visual fields
6. under regular review
137
How do the regulations change for being able to drive with T1DM for lorries/buses (group 2 entitlement)? 4 differences
1. must have no episodes of severe hypoglycaemia in past 12 months
2. may be licensed if they use one or more blood glucose meters with memory functions to ensure 3 months of reading that will be available for assessment
3. demonstrate understanding of risks of hypos
4. has no disqualifying complications (visual, renal, limb) - if any present, may need to stop driving
