Mechanisms and consequences of hypoglycaemia, and pharmacology of insulin treatment options in type 1 diabetes Flashcards

1
Q

What are the key features of type 1 diabetes mellitus?

A
  • Autoimmune condition (β-cell damage) with genetic component
  • Profound insulin deficiency
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2
Q

What are the key features of type 2 diabetes mellitus?

A
  • Insulin resistance
  • Impaired insulin secretion and β-cell damage but initially continued insulin secretion progressive
  • Excessive hepatic glucose output
  • Increased counter-regulatory hormones including glucagon
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3
Q

Do T1DM or T2DM require insulin?

A

T1DM
Eventually T2DM will need insulin

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4
Q

Which type of diabetes is once-daily basal insulin used in?

A

Only type 2

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5
Q

Which type of diabetes is twice-daily mix insulin used in?

A

Both

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6
Q

Which type of diabetes is basal-bolus therapy used in?

A

Mostly in type 1
Sometimes in type 2

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7
Q

What are the advantages of basal insulin in type 2 diabetes?

A
  • Simple for the patient, adjusts insulin themselves, based on fasting glucose measurements
  • Carries on with oral therapy, combination therapy is common
  • Less risk of hypoglycaemia at night
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8
Q

What are the disadvantages of basal insulin in type 2 diabetes?

A
  • Doesn’t cover meals
  • Best used with long-acting insulin analogues which are considered expensive
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9
Q

What are the advantages of pre-mixed insulin?

A
  • Both basal and prandial (meal) components in a single insulin preparation
  • Can cover insulin requirements through most of the day
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10
Q

What are the disadvantages of pre-mixed insulin?

A
  • Not physiological
  • Requires consistent meal and exercise pattern
  • Cannot separately titrate individual insulin components
  • Increased risk for nocturnal hypoglycaemia
  • Increased risk for fasting hyperglycaemia if basal component does not last long enough
  • Often requires accepting higher HbA1c goal of <7.5% or ≤8% (<58 or ≤64 mmol/mol)
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11
Q

Which is considered the best treatment for T1DM?

A

Intensive basal-bolus insulin therapy

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12
Q

What HbA1c levels do many people start insulin at?

A

levels of ≥9%

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13
Q

What is level 1 hypoglycaemia?

A
  • Alert value
  • Plasma glucose <3.9 mmol/l (70 mg/dl) and no symptoms
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14
Q

What is level 2 hypoglycaemia?

A
  • Serious biochemical
  • Plasma glucose <3.0 mmol/l (55 mg/dl)
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15
Q

What is non severe hypoglycaemia?

A

Patient has symptoms but can self-treat and cognitive function is mildly impaired

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16
Q

What is level 3 hypoglycaemia?

A

Patient has impaired cognitive function sufficient to require external help to recover (severe)

17
Q

What effect does hypoglycaemia have on the brain?

A

Cognitive dysfunction, blackouts, seizures, comas, psychological effects

18
Q

What effect does hypoglycaemia have on the heart?

A

Increased risk of myocardial ischaemia, cardiac arrhythmias

19
Q

What effect does hypoglycaemia have on the musculoskeletal system?

A

Falls, accidents, driving accidents, fractures, dislocations

20
Q

What effect does hypoglycaemia have on the circulation?

A

Inflammation, blood coagulation abnormalities, haemodynamic changes, endothelial dysfunction

21
Q

What are the autonomic symptoms of hypoglycaemia?

A

*Trembling
*Palpitations
*Sweating
*Anxiety
*Hunger

22
Q

What are the neuroglycopenic symptoms of hypoglycaemia?

A

*Difficulty concentrating
*Confusion
*Weakness
*Drowsiness, dizziness
*Vision changes
*Difficulty speaking

23
Q

What are non-specific symptoms of hypoglycaemia?

A

*Nausea
*Headache

24
Q

What is the second symptom of hypoglycaemia?

A

Low blood glucose (<3.9 mmol/l) (70 mg/dl)
patients with poor glycaemic control with an elevated HbA1c may experience symptoms of hypoglycaemia at levels >3.9 mmol/l

25
Q

What is the third symptom of hypoglycaemia?

A

Response to treatment with carbohydrate

26
Q

What are causes of hypoglycaemia?

A
  • Long duration of diabetes
  • Tight glycaemic control with repeated episodes of non severe hypoglycaemia
  • Increasing age
  • Use of drugs (prescribed, alcohol)
  • Sleeping
  • Increased physical activity
27
Q

What risk factors should screening be based on for severe hypoglycaemia?

A
  • Low HbA1c: high pre-treatment HbA1c in T2DM
  • Long duration of diabetes
  • A history of previous hypoglycaemia
  • Impaired awareness of hypoglycaemia (IAH)
  • Recent episodes of severe hypoglycaemia
  • Daily insulin dosage >0.85 U/kg/day
  • Physically active (e.g. athlete)
  • Impaired renal and/or liver function
28
Q

What are the steps to treat hypoglycaemia?

A
  1. Recognise symptoms so they can be treated as soon as they occur
  2. Confirm the need for treatment if possible (blood glucose <3.9 mmol/l is the alert value)
  3. Treat with 15g fast-acting carbohydrate to relieve symptoms
  4. Retest in 15 minutes to ensure blood glucose >4.0 mmol/l and re-treat (see above) if needed
  5. Eat a long-acting carbohydrate to prevent recurrence of symptoms