Type 1 Diabetes, Hypoglycemia, HHS, & DKA Flashcards
Immune-mediated Type 1 DM
- Scandinavia and northern europeans
- Beta cell autoimmunity
Idiopathic Type 1 DM
Type 1B
- Far fewer than type 1-A
- Asian or African origin
What is an almost certain predictor of clinical hyperglycemia and diabetes in Type 1 ?
presence of 2 or more autoantibodies
If you find auto-antibodies, who else needs to be screened?
- Siblings
2. Adults with atypical features of Type II diabetes
Name the 5 autoimmune markers for Type I diabetes
- ICA antibody
- Glutamic Acid decarboxylase (GAD54)**
- Insulin autoantibody
- Tyrosine phosphatase (IA-2)
- Zinc Transporter 8 (ZnT8) -enzyme specific to beta cells
What do low levels of C-peptide and insulin usually point to?
Type 1 diabetes
What is the most sensitive and specific diagnostic lab for type 1 diabetes?
Glutamic acid decarboxylase (GAD65)
What happens to antibody levels as disease duration increases?
antibody levels decline with time
What develops in almost all patients once they are treated with insulin?
anti-insulin antibodies
What is normal A1c?
<5.7%
What is prediabetes A1c?
5.7 - 6.4%
What should be used to diagnose Type 1 diabetes?
blood glucose is best for diagnosing Type 1 Diabetes in symptomatic patients
According to the American Diabetes Association, what should a type 1 diabetic strive to keep their A1c at?
<7.5
What are the classic presentation of Type 1 diabetes?
- Polyuria
- Polydipsia
- Polyphagia
- Weight loss
also:
-blurred vision
Type 1 diabetes: essentials of diagnosis
- Glucose 200mg/dL or more
- Fasting plasma glucose >126mg/dL x2 (separate occasions)
- Ketoemia, ketouria
- Autoantibodies
Clinical presentations that are more common in Type 1 Diabetes
- 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
What is the glycemic criteria for Glucose alert value (level 1)?
<70mg/dL
What is the glycemic criteria for clinically significant hypoglycemia (level 2)?
<54 mg/dL
Behavioral causes of hypoglycemia
- Insulin overdose
- EtOH abuse (glycogen depletion)
- Post exercise
Name important medication causes of hypoglycemia
- Beta blocker
- Beta-adrenergic blocking agents
- Sulfonylureas
- ACE inhibitors
- Fluoroquinolones
- Salicylates
- Pentamidine (pneumocystis jirovecii)
What blood test will be high if a patient has an insulinoma?
c-peptide
Name 2 important other/endrocrine etiologies of hypoglycemia
- Hypopituitarism
2. Addison disease
15:15 Rule
- Give 15 grams of carbohydrates (ex. juice, or glucose tablets)
- Repeat in 15 mins as needed.
What medication can be given in cases of hypoglycemic emergencies?
glucagon (if the person is unable to remain conscious)
Somogyi effect
Nocturnal hypoglycemia
-counter regulatory hormones that produce high blood glucose by 7am (prebreakfast hyperglycemia)
Treatment for Somogyi effect
eliminate intermediate insulin dose at dinnertime, and give lower dose at bedtime
or
increase food intake at bedtime
Which ion is the predominating factor in determining osmolality?
sodium (Na+)
What 3 ions contribute to serum osmolarity?
- Sodium
- Glucose
- Urea (BUN)
Hyperglycemic hyperosmolar state more commonly occurs in which type of diabetes?
Type II
Hyperglycemic Hyperosmolar State
- Type II DM
- Hyperglycemia (>600mg/dL)
- Serum osmolality ( >310 and 280 is normal)
- No acidosis, blood pH is >7.3
- Minimal ketouria/ketoemia
Hyperglycemic Hyperosmolar state: signs and symptoms
- Profound dehydration
- Non-ketotic
- polydipsia
- Polyuria
Hyperglycemic Hyperosmolar state: Lab results
- Plasma glucose: 800- 2400mg/dL!!!
2. Serum Urea nitrogen also very elevated!!
Hyperglycemic hyperosmolar state: Tx
- FLUIDS!!!!!
- insulin (IV)
(keep the glycemic levels between 250-300 to reduce risk of cerebral edema, once stable can give subcutaneously) - K+
- Phosphate
What is the most common precipitating factor of Diabetic Ketoacidosis?
infection**
others: steroids, -itis, EtOH, insuin deficiency, MI
In Diabetic ketoacidosis, what other labs with be elevated?
- glucagon
- cortisol
- GH
- epinephrine/norepinephrine
What are 2 important initial studies for DKA?
- UA
- Serum ketones
- CBC
- BMP (K+)**
- ABG= metabolic acidosis
- EKG
What are the main differences with DKA and HHS?
DKA: glucose >250, acidotic, ketouria and/or ketoemia
HHS: glucose >600, alkalotic, minimal to no ketones
DKA: signs and symptoms
- N/V/abdominal pain
- hyperventilation (kussmaul breathing)
- Fruity breath with acetones
- Possible altered mental status
- Hypovolemia (tachycardia and orthostasis)
