Type 1 Diabetes, Hypoglycemia, HHS, & DKA

Question 1

Immune-mediated Type 1 DM

Answer 1

• Scandinavia and northern europeans

- Beta cell autoimmunity

Question 2

Idiopathic Type 1 DM

Answer 2

Type 1B

• Far fewer than type 1-A
• Asian or African origin

Question 3

What is an almost certain predictor of clinical hyperglycemia and diabetes in Type 1 ?

Answer 3

presence of 2 or more autoantibodies

Question 4

If you find auto-antibodies, who else needs to be screened?

Answer 4

1. Siblings

2. Adults with atypical features of Type II diabetes

Question 5

Name the 5 autoimmune markers for Type I diabetes

Answer 5

1. ICA antibody
2. Glutamic Acid decarboxylase (GAD54)**
3. Insulin autoantibody
4. Tyrosine phosphatase (IA-2)
5. Zinc Transporter 8 (ZnT8) -enzyme specific to beta cells

Question 6

What do low levels of C-peptide and insulin usually point to?

Answer 6

Type 1 diabetes

Question 7

What is the most sensitive and specific diagnostic lab for type 1 diabetes?

Answer 7

Glutamic acid decarboxylase (GAD65)

Question 8

What happens to antibody levels as disease duration increases?

Answer 8

antibody levels decline with time

Question 9

What develops in almost all patients once they are treated with insulin?

Answer 9

anti-insulin antibodies

Question 10

What is normal A1c?

Answer 10

<5.7%

Question 11

What is prediabetes A1c?

Answer 11

5.7 - 6.4%

Question 12

What should be used to diagnose Type 1 diabetes?

Answer 12

blood glucose is best for diagnosing Type 1 Diabetes in symptomatic patients

Question 13

According to the American Diabetes Association, what should a type 1 diabetic strive to keep their A1c at?

Answer 13

<7.5

Question 14

What are the classic presentation of Type 1 diabetes?

Answer 14

• Polyuria
• Polydipsia
• Polyphagia
• Weight loss

also:
-blurred vision

Question 15

Type 1 diabetes: essentials of diagnosis

Answer 15

1. Glucose 200mg/dL or more
2. Fasting plasma glucose >126mg/dL x2 (separate occasions)
3. Ketoemia, ketouria
4. Autoantibodies

Question 16

Clinical presentations that are more common in Type 1 Diabetes

Answer 16

• Lethargy
• Stupor
• Smell of acetone**
• Kussmaul breathing (hyperventilation)
• N/V/Abdominal pain
• Nocturnal Enuresis (bedwetting)*
• Abrupt onset
• No/Rare micro or macrovascular complications at dx

Question 17

What is the glycemic criteria for Glucose alert value (level 1)?

Answer 17

<70mg/dL

Question 18

What is the glycemic criteria for clinically significant hypoglycemia (level 2)?

Answer 18

<54 mg/dL

Question 19

Behavioral causes of hypoglycemia

Answer 19

1. Insulin overdose
2. EtOH abuse (glycogen depletion)
3. Post exercise

Question 20

Name important medication causes of hypoglycemia

Answer 20

1. Beta blocker
2. Beta-adrenergic blocking agents
3. Sulfonylureas
4. ACE inhibitors
5. Fluoroquinolones
6. Salicylates
7. Pentamidine (pneumocystis jirovecii)

Question 21

What blood test will be high if a patient has an insulinoma?

Answer 21

c-peptide

Question 22

Name 2 important other/endrocrine etiologies of hypoglycemia

Answer 22

1. Hypopituitarism

2. Addison disease

Question 23

15:15 Rule

Answer 23

• Give 15 grams of carbohydrates (ex. juice, or glucose tablets)
• Repeat in 15 mins as needed.

Question 24

What medication can be given in cases of hypoglycemic emergencies?

Answer 24

glucagon (if the person is unable to remain conscious)

Question 25

Somogyi effect

Answer 25

Nocturnal hypoglycemia | -counter regulatory hormones that produce high blood glucose by 7am (prebreakfast hyperglycemia)

Question 26

Treatment for Somogyi effect

Answer 26

eliminate intermediate insulin dose at dinnertime, and give lower dose at bedtime or increase food intake at bedtime

Question 27

Which ion is the predominating factor in determining osmolality?

Answer 27

sodium (Na+)

Question 28

What 3 ions contribute to serum osmolarity?

Answer 28

1. Sodium 2. Glucose 3. Urea (BUN)

Question 29

Hyperglycemic hyperosmolar state more commonly occurs in which type of diabetes?

Answer 29

Type II

Question 30

Hyperglycemic Hyperosmolar State

Answer 30

- Type II DM - Hyperglycemia (>600mg/dL) - Serum osmolality ( >310 and 280 is normal) - No acidosis, blood pH is >7.3 - Minimal ketouria/ketoemia

Question 31

Hyperglycemic Hyperosmolar state: signs and symptoms

Answer 31

- Profound dehydration - Non-ketotic - polydipsia - Polyuria

Question 32

Hyperglycemic Hyperosmolar state: Lab results

Answer 32

1. Plasma glucose: 800- 2400mg/dL!!! | 2. Serum Urea nitrogen also very elevated!!

Question 33

Hyperglycemic hyperosmolar state: Tx

Answer 33

1. FLUIDS!!!!! 2. insulin (IV) (keep the glycemic levels between 250-300 to reduce risk of cerebral edema, once stable can give subcutaneously) 3. K+ 4. Phosphate

Question 34

What is the most common precipitating factor of Diabetic Ketoacidosis?

Answer 34

infection** | others: steroids, -itis, EtOH, insuin deficiency, MI

Question 35

In Diabetic ketoacidosis, what other labs with be elevated?

Answer 35

- glucagon - cortisol - GH - epinephrine/norepinephrine

Question 36

What are 2 important initial studies for DKA?

Answer 36

- UA - Serum ketones - CBC - BMP (K+)** - ABG= metabolic acidosis - EKG

Question 37

What are the main differences with DKA and HHS?

Answer 37

DKA: glucose >250, acidotic, ketouria and/or ketoemia HHS: glucose >600, alkalotic, minimal to no ketones

Question 38

DKA: signs and symptoms

Answer 38

- N/V/abdominal pain - hyperventilation (kussmaul breathing) - Fruity breath with acetones - Possible altered mental status - Hypovolemia (tachycardia and orthostasis)