Type 1 DM, hypoglycemia, HHS & DKA Flashcards
what is the patho of T1DM?
Beta-cell destruction
pancreas failure to produce insulin
what is T2DM?
progressive insulin secretory defect
or decreased sensitivity of insulin receptors
what are the different classifications of diabetes?
prediabetes
T1DM
T2DM
gestational DM
other: monogenic diabetes syndromes, dz’s of the exocrine pancrease (CF), drug or chemical induced
what do beta cells produce?
what do alpha cells produce
insulin and amylin
glucagon
what pt’s is T1DM most common in the US?
non-white hispanic white children
increased risk if fam hx
what are modifiable risk factors of T2DM?
physical inactivity, high body fat or body wt., high BP, high cholesterol
Causes of T1DM
immune-mediated (type 1A)
Idiopathic T1DM (type 1B)
What factor is present in first-degree relatives of pt’s w/ T1DM?
persistent presence of 2 r more autoantibodies which is a predictor of clinical hyperglycemia and DM
what are circulating antibodies present at the time of dx in T1DM?
islet cells glutamic acid decarboxylase 65 (GAD65) insulin ICA-512 zinc transporter 8 (ZNT8)
what are some tests to dx T1DM?
C-peptide gada or anti-GAD Insulin Autoantibodies insulinoma-assoc.-2 autoantibodies ICA ZnT8Ab
what is the C-peptide test and when can it be checked?
Low levels of C-peptide and insulin usually point to T1DM in presence of exogenous insulin
antibody levels ____ w/increasing duration of dz.
decrease
T1DM: ___ levels of anti-insulin antibodies develop in almost all patients once they are
treated w/____
low
insulin
The A1C test measures the average blood glucose for the past ____.
2-3 months
diabetes is dx’d at an A1C of greater than or equal to….
6.5%
what test rather than A1C should be used to dx type 1
diabetes in symptomatic individuals?
blood glucose
in what situations is screening for T1DM w/an antibody panel recommended?
ONLY in setting of a clinical research study or in
a first-degree family member of a proband with type 1 diabetes
The ADA recommends children under the age of 19 dx’d with T1DM strive to maintain an A1C level
7.5%
what are lab levels consistent w/prediabetes?
FPG 100-125 or 2h plasma glucose 140-199 or A1C 5.7-6.4%
what are some essentials of dx for T1DM?
polyuria, polydipsia, and wt. loss assoc. w/ RBG of 200mg/dL or more
FBG of 126 or more on more than one occasion
Ketonemia, ketonuria, or both
Islet autoantibodies are frequently
present.
what are some essentials of dx for T2DM?
often >40 y/o and obese
Polyuria and polydipsia
Candidal vaginitis may be 1st sxs
FBG of 126 or more; 2 hr after 75g PO glucose, BG 200mg/dL or more
HbA1c >6.5%
assoc. w/HTN, dyslipidemia, and atherosclerosis
s/s of T1DM
hyperosmolality and
hyperketonemia, increased urination and thirst, diuresis -> loss of glucose, blurred vision d/t lens exposure to hyperosmolar fluids
Common sxs of T1DM
lethargy, stupor, Kussmaul breathing, N/V, abd pain, smell of acetone
insulin resistance is characteristic of T1 or T2?
Type 2
____ of pt’s do not meet targets for A1C, BP, or lipids
33-49%
what specialty should a PCP refer to if pt has T1DM?
endocrinologist
what is the tx for T1DM?
insulin
acetylsalicylic acid
when should you prescribe acetylsalicylic acid for DM pt’s?
pts w/incr CVD risk for primary prevention
females over 50y/o, males over 60y/o, or 1+: HTN, HLD, smoking, family history of premature disease, or
albumineria
what are transplantation options for DM pt’s?
Pancreas transplantation with or without kidney transplantation
Islet cell transplant
which pt’s cannot receive pancreatic islet auto-transplantation?
pt’s w/ T1DM
what is the MC T1DM complication?
peripheral neuropathy
T1DM complications lipoprotein abnormalities assoc. w/
slight elevation of
LDL cholesterol and serum
triglycerides
T2DM complications lipoprotein abnormalities assoc. w/
distinct “diabetic dyslipidemia” is
characteristic of the insulin resistance
syndrome
High serum triglyceride level >300
low HDL cholesterol
what are 2 major DM neuro/vascular complications?
diabetic foot ulcers
gangrene of the feet
what is 1 major DM ocular complication?
diabetic retinopathy
what are 4 major DM heart dz complications?
Coronary atherosclerosis
Myocardial infarction
Peripheral vascular disease
Stroke
what is the glycemic criteria for hypoglycemia?
70mg/dL or less
causes of hypoglycemia?
behavioral: too much insulin or alcohol, post exercise
regulatory issues: loss of glucagon response, sympatho-adrenal responses
DM complications: gastroparesis, ESRD
Meds
Others: hypopituitarism, GI surg, insulinoma, etc.
sxs of hypoglycemia
shaky, diizzy, anxious, hungry, tachy, sweaty, HA, weak/tired, blurry vision
Medications assoc. w/hypoglycemia?
BB's sulfonylureas Gatifloxacin & levofloxacin ACE inhibitors Salicylates Quinine Pentamidine (used for?)
how can you prevent/tx hypoglycemia?
Glucose tablets or juice
Carbohydrates, 15 grams
Parenteral glucagon emergency kit (1 mg)
50 mL of 50% glucose solution by rapid intravenous infusion
what emergent tx can be used for hypoglycemia?
glucagon injection
what is the somogyi effect?
Nocturnal hypoglycemia leads to a surge of counter-regulatory hormones to produce high blood glucose levels by 7 am (prebreakfast hyperglycemia)
how can you tx somogyi effect?
eliminating the dose of intermediate insulin at dinnertime and giving it at a lower dosage at bedtime
or by increasing food
intake at bedtime
what are the 2 worst side effects of DM T1 or T2?
hyperglycemic hyperosmolar state and DKA
what is the calculation of serum osmolality?
= (2 x [Na+]) + (glucose/18) + (BUN/2.8)
hypertonic hyponatremia is caused by?
hyperglycemia
what can cause hyperosomolality in DM pt’s?
advanced renal failure (urea), alcohols
what are the classic findings in HHS?
MC in T2DM hyperglycemia >600mg/dL serum osmolality >310 blood pH >7.3 serum bicab >15 normal anion gap minimal *ketonuria/ketonemia
s/s of HHS
Profound dehydration - dx/tx are delayed until fluid deficit has
reached levels of 6–10 L
Non-ketotic, polydipsia, polyuria, possible neuro changes from nystagmus to coma
lab results consistent w/HHS?
BG: 800 - 2400 mg/dL
Serum urea nitrogen elevations >100
mg/dL typical
tx for HHS
Fluids!!!
restore UOP
hypovolemic sxs –> .9% NS
insulin (can be delayed)
K+ and Phosp
what do you want to reduce the risk of in HHS by maintaining glycemic levels?
cerebral edema
what is DKA?
a severe insulin deficiency
DKA is marked by elevations of…
elevations of glucagon, cortisol, growth hormone, epinephrine, and norepinephrine concentrations
DKA may be the 1st manifestation of what type of DM?
T1DM
DKA MCly occurs in…
pts already dx’d w/T1DM
how is DKA preventable?
by self-monitoring of blood glucose and blood
or urine ketone levels
what are the MC precipitating factors in DKA?
MC = infection (UTI’s and pneumonia’s)
Insulin deficiency Iatrogenic (glucocorticoids) Inflammation (pancreatitis) Ischemia (MI, CVA) Intoxication (etoh, drugs)
S/s of DKA
signs of hypovolemia (tachycardia, orthostasis),
N/V, abd, polydipsia, polyuria, enuresis, “fruity” acetone breath, Kussmaul breathing, AMS, coma
initial studies for DKA eval
ABC’s, mentation, volume status
CBC (leukocytosis) BMP EKG U/A +dipstick urine ketones? plasma osmo serum ketones ABG if bicarb is low amylase
production of ketoacids w/minor lactic acid and free fatty acid contributions causes…
metabolic acidosis
therapeutic goals
restore plasma volume and tissue perfusion, decr BG and somolality towards normal, correct acidosis, replenish, electrolyte losses, identify and tx precipitating factors
early sxs of DKA
N/V/abd pain and hyperventilation
As DKA worsens so does…
mental status
Is onset of DKA gradual or rapid?
rapid
Tx for DKA
ABC’s
Large IV’s
Fluids, fluids, fluids
frequent monitoring, esp. K+
when do you give insulin for DKA?
after addressing K+
