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Y3 Medicine > 21 - Diabetes > Flashcards

21 - Diabetes Flashcards

1
Q

What is the diagnostic criteria for diabetes?

A

Symptoms plus one abnormal result or two abnormal results at different times:

- Fasting glucose >7

- OGTT 2hrs after 75g glucose >11.1

- HbA1C >6.5%

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2
Q

What is the pathophysiology of type 1 diabetes?

A

Autoimmune destruction of beta-cells so there is an absolute insulin deficiency.

Can be associated with other autoimmune conditions

Prone to ketoacidosis

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3
Q

What are some other causes of diabetes apart from type 1 and type 2?

A

- Pancreatic related: pancrreatitis, pancreatic cancer

- Drugs: steroids, new antipsychotics, ARV for HIV

- Endocrine causes: cushing’s, acromegaly, hyperthyroidism

- Gestational diabetes

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4
Q

How can you distinguish between type 1 and type 2 diabetes?

A
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5
Q

How is type 1 and type 2 diabetes managed in general terms?

A
  • Life style advice e.g exercise to improve insulin sensitivity, healthy eating
  • Assess cardiovascular risk and consider a high intensity statin
  • Control BP
  • Give foot care
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6
Q

How is type 2 diabetes managed if diet and lifestyle changes do not improve glycaemic control?

A

1st Line: metformin

2nd line if HbA1c >7.5%: dual therapy

3rd line if HbA1c >7.5%: triple therapy, insulin or GLP1 analogue

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7
Q

How do the following oral diabetic drus work and give some examples?

  • Biguanides
  • Sulfonylurea
  • DPP4i
  • Glitazones/Thiazolidinedones
  • GLP1 analogues
  • SGLT2i
A

- Biguanides (Metformin): decreases hepatic gluconeogenesis and increase insulin sensitivity

- Sulfonylurea (Gliclazide/Tolbutamide): increases insulin secretion by binding to ATP-K+ channels to allow the cells to depolarise

- DPP4i (Sitagliptin/Saxagliptin): inhibits DPP4i enzyme that normally breaks down incretins (GLP-1, GIP)

- Glitazones (Pioglitazone): increase insulin sensitivity by binding to PPAR-y receptor

- GLP-1 analgoues (Liraglutide/Exenatide): work like GLP1, not broken down by DPP4

- SGLT2i (Dapa/Empagliflozin): block reabsorption of glucose in PCT of kidneys so more excretion in urine. Helps BP, weight, cardiovascular disease

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8
Q

What are the side effects of the following diabetic drugs:

  • Biguanides
  • Sulfonylurea
  • DPP4i
  • Glitazones
  • GLP1 analogues
  • SGLT2i
A

Metformin: GI side effects (give modified release), abdominal pain, lactic acidosis if low eGFR

Sulfonylurea: weight gain, hypoglycaemia

DPP4i: GI symptoms e.g D+V+N, pancreatitis

Glitazones: hypoglycaemia, fractures, fluid retention, deranged LFTs so monitor every 8 weeks for a year, weight gain, visual impairment

GLP1 analogues: GI discomfort, pancreatitis, sweating

SGLT2i: UTIs, thrush, polyuria, stop if eGFR<45

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9
Q

What effect does the incretin GLP-1 have on the body?

A
  • Increase insulin secretion
  • Decrease hepatic gluconeogenesis
  • Delays gastric emptying
  • Decreased food intake by increased sateity
  • Increased uptake of glucose in muscles
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10
Q

Which diabetic drugs cause weight gain, weight loss or weight neutral?

A

Weight gain: Sulfonylureas, Thiazolidinediones, Insulin

Weight neutral: DPP4i

Weight loss: Metformin, GLP1 analogues, SGLT2i

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11
Q

What diabetic drugs increase insulin secretion?

A
  • Sulfonylureas
  • GLP-1 analogues
  • DPP4 inhibitors
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12
Q

What diabetic drugs increase insulin sensitivity?

A
  • Metformin
  • Glitazones
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13
Q

What are some contraindications for glitazones?

A
  • History of bladder cancer
  • History of heart failure
  • Active liver disease
  • Pregnant women
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14
Q

When starting GLP-1 analogues, what parameters have to change to continue using the drug?

A

If 3% weight loss or 1% Hba1c reduction does not occur within 6 months these must be stopped

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15
Q

What is some lifestyle advice you should give to people starting on insulin therapy?

A
  • Carb counting
  • Checking BMs
  • Adjust insulin when exercising
  • Avoid binge drinking
  • Education on how to treat hypos
  • Store insulin in fridge and remove before injecting
  • Change needle every time
  • Rotate injection sites
  • Dial dose
  • 90 degree injection
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16
Q

How do people self-administer insulin?

A
  • Subcut with pen, syringe or pump (Prime pen - dial the pen!!!!)
  • Into abdomen or legs
  • No pinch needed if 4-6mm needle
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17
Q

What are the different categories of insulin and give some examples for each?

A

- Rapid acting (5-15 min onset): Insulin Lispro (Humulog), Insulin Aspart (Novorapid)

- Short acting (30-60 min onset): Actrapid, Humulin S

- Intermediate Acting (2-4hr onset): Isophane Inulin (NPH)

- Long acting (2-4hr onset): Insulin glargine, Insulin Detemir

- Mixed: Novomix with 30% short acting, 70% long acting

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18
Q

When is long acting recombinant insulin good?

A

No peak so good if nocturnal hypoglycaemia

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19
Q

What are some common insulin regimes?

A

- Once daily: 1 long acting at bed time

- BD Biphasic: Twice daily pre-mixed insulin (short and intermediate acting) by pen. Given morning and evening and need set routine with meals every day

- Basal Bolus/QDS: 1 long acting insulin and then rapid acting insulin injections before meals

CSII: uses libra

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20
Q

How do you choose which insulin regime is best for a patient?

A

Plan regime to suit the lifestyle of the patient!!!!

- Once daily is good for type 2 in conjunction with oral hypogylcaemics

- Basal bolus good for type 1 who want flexibility of when to have meals

- BD good for type 1 and type 2 who have set routine

- CSII: good for type 1 with issues controlling glucose despite monitoring and multiple injections daily

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21
Q

What is important to note when prescribing insulin?

A
  • Write UNITS in full
  • Always prescribe by brand name and do not switch
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22
Q

What is Humulin R?

A

5x more concentrated than standard insulin for patients who are severely insulin resistant so would need large volumes of standard e.g >300 units

Injected TDS before meals

Prescribed in marks not units so do not use 1ml insulin syringe

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23
Q
A
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24
Q

What education programme should type 1 diabetics be offered in conjunction with their insulin regime?

A

DAFNE to improve glycemic control by carb counting

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25
Q

How long after opening can insulin be used?

A
  • If unopened store in fridge, if open store at room temperature
  • Use within 30 days then discard
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26
Q

What advice should you give to patients on insulin about sick days e.g influenza illness?

A
  • Do not stop insulin to avoid DKA
  • May need to up insulin fasting acting insulin if hyperglycaemic
  • Maintain calorie intake e.g milkshakes
  • Check BMs every 2-4 hrs and through the night as well as checking ketonuria. Go to hospital if ketonuria
  • Go to hospital if vomiting, dehydrated or ketotic
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27
Q

How do you read a 1ml 100U syringe?

A
  • Every 0.1 ml is 10 units
  • 1ml is 100 units
28
Q

What is Tresiba?

A

Degludec (long acting insulin) that is available at higher concentrations

29
Q

What is important when wri

A
30
Q

What is stress hyperglycaemia?

A
  • Transient hyperglycaemia which normalises after discharge
  • No previous diabetes diagnosis

- BM >7.8 but HbA1c<6.5%

31
Q

What the issues with inpatient hyperglycaemia?

A
32
Q

What is the pathophysiology of stress hyperglycaemia?

A

During stress there is an increase in cortisol secretion which leads to insulin resistance, hepatic gluconeogenesis and reduced peripheral glucose utilisation

Also can be affect by steroids and dextrose given in hospital

33
Q

What is the difference between FRII and VRII?

A

Fixed: based on body weight, 0.1units/kg/hr, used for DKA/HHS

Variable: changes hourly based on BMs, used for NBM and will miss more than 1 meal/vomiting/ACS/tight glycaemic control needed e.g sepsis

  • Glucose target 6-10 and avoid wide swings!
  • Both need to continue any basal insulin
34
Q

What insulin is used in an IV insulin infusion?

A

Soluble insulin!!!!

35
Q

How do you set up insulin ready for infusion?

A

- 50 units in 49.5ml NaCl

  • Two practioners should check
  • Always set up fluids with glucose in going through the same cannula with Y connector!!!!!
36
Q

What fluids should you use with VRII?

A

ALWAYS NEED POTASSIUM AND GLUCOSE IN THE FLUID!!!!

37
Q

What monitoring should you do for a patient once they are started on VRII and when can it be stopped?

A
  • Check CBG hourly and consider if need to go up or down the scale
  • Aim for BM 6-10
  • Check ketones in type 1 DM
  • Continue until patient eating and back on their normal medication. Need to give s/c before stopping!!!
38
Q

What fluids should you use with FRII?

A
  • Add 10% glucose if BM<14
  • Otherwise just 0.9% NaCl with 40% KCl
39
Q

What monitoring should you do for a patient once they are on FRII and when can this be stopped?

A
  • Blood ketones
  • BMs
  • If cannot get blood ketones use venous pH and bicarbonate
  • Stop once patient is eating and DKA resolved. Need to give s/c insulin before stopping!!!!!
40
Q

What are the aims of diabetic treatment in end of life care?

A
  • Avoid hypos, DKA, HHS
  • Avoid foot complications
  • Avoid dehydration
  • Reduce polypharmacy e.g stop statins, reduce doses due to steroids and weight loss, reduce complexity
41
Q

What BMs should you aim for in an end of life diabetic?

A
  • Pre-meal BM no less than 6
  • Pre-meal BM no higher than 15
  • HbA1c is irrelevant

Both to prevent symptoms of hyperglycaemia and hypoglycaemia

42
Q

What is the issue of people with diabetes taking steroids?

A
  • Risk of hyperglycaemia that can lead to HHS
43
Q

How should you manage patients with diabetes starting on steroids that have steroid induced hyperglycaemia?

A
44
Q

How should you manage patients with steroid induced diabetes (non-diabetic before steroids)?

A
  • If patient experiences hyperglycaemia >12 twice start on sulfonylurea or insulin/up the dose
  • Stop once steroids stopped
45
Q

Pregnant women are sometimes give steroids to induce lung maturity in their babies. If a pregnant patient has diabetes, what needs to be done to prevent dangerous hyperglycaemia from the steroids?

A

VRII

46
Q

If a patient develops hyperglycaemia whilst on steroids but they do not have a diabetes diagnosis, how should they be followed up?

A

Measure HbA1c after steroid cessation as at risk of diabetes

47
Q

What are some issues with nutrition for diabetic inpatients?

A
  • Meal times may not correspond with medication times for insulin
  • Availability and types of snacks so risk of hypos
  • Menu choices
  • Carbohydrate values need to be known for carb counting
48
Q

What are some causes of hypos in diabetics that are being enterally fed?

A
49
Q

How does gestational diabetes occur?

A

Release of hPL and oestrogen from the placenta which cause a level of insulin resistance, therefore the pancreas has to increase the insulin production.

If pancreas doesn’t have ability to produce more insulin this is diabetes

Also increased hepatic glucogeonesis

50
Q

What are CBG targets in pregnancy?

A
51
Q

What are the risks with gestational diabetes?

A
  • Miscarriage
  • Preterm labour
  • Pre-eclampsia
  • Congenital malformations
  • Macrosomia
  • Neonatal hypoglycaemia
  • Worsening diabetic complications e.g retinopathy, nephropathy
52
Q

What are some risk factors for developing gestational diabetes?

A
  • >25
  • Family history
  • Obese
  • Non-caucasian
  • Previous gestational DM
53
Q

What is some pre-conception advice you should give to someone who is at risk of gestational diabetes?

A
  • Discuss risks
  • Reduce weight
  • Good glucose control HbA1c <6.5%
  • Offer folic acid until 12 weeks
54
Q

How is GDM screened for?

A

OGTT at booking and 24-28 weeks

Fasting plasma glucose level of 5.6 or above,

or

2-hour plasma glucose level of 7.8

55
Q

What medications do you need to stop in type 2 diabetics that fall pregnant?

A
  • Stop all oral diabetic medications apart from metformin
  • Consider starting on insulin
56
Q

How do mothers with gestational diabetes deliver?

A

Induced or C-section at 38 weeks!!!!!

Tend to go for C-Section due to risk of shoulder dystocia

57
Q

What are the principles of management for gestational diabetes?

A
  • Education on dietary changes
  • Testing CBG
  • Metformin +/- Insulin
58
Q

What are some factors that can cause hypoglycaemia in a diabetic?

A
59
Q

What happens to a type 1 diabetics driving licence if they have a hypo?

A

If on insulin or at risk of hypos always have to tell DVLA

If more than one severe hypo episode whilst awake in 12 months then have to inform DVLA and stop driving for 3 months

60
Q

What are some causes of hypoglycaemia in a non-diabetic?

A
  • Reactive hypoglycaemia (non-diabetic)
  • Alcohol
  • Low cortisol
  • Insulinoma
  • Low GH levels
  • Eating less or exercising more
61
Q

Women who have GDM are at higher risk of developing T2DM. How should you monitor for this?

A

At their 6 week check do a fasting blood glucose.

50% will be -ve on this but still go on to develop T2DM

62
Q

How do you perform a safe discharge for an inpatient with diabetes?

A
63
Q

What are the dangers of giving insulin?

A
  • Hypoglycaemia
  • Reaction to insulin
  • Lipodystrophy
  • Weight gain
64
Q

When a type 2 diabetic starts on insulin what changes to their drugs do they need to make?

A
  • Continue metformin
  • Stop other oral hypoglycaemics
  • Can have GLP1 injections under specialist care
  • SGLT2i can be an option
  • ACEi and Statins
65
Q

What features support a diagnosis of DKA?

A
  • CBG > 11
  • Known diabetic diagnosis
  • Ketones +++

Cannot be pH or bicarb because this is an ABG not VBG!!!

Y3 Medicine (24 decks)

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