diabetes 1 Flashcards
(27 cards)
diabetes definition and types
persistent hyperglycaemia
type 1 - deficient insulin secretion
type 2 - resistance to insulin
gestational - pregnancy
secondary - due to meds - antipsychotics, bb, glucocorticoids, statins
main symptoms of diabetes
frequent urinating, more at night
thirsty
lethargy
unintentional weight loss
genital itch, thrush
longer healing time for cuts
blurred vision
assessing fitness to drive - imp points
all drivers taking insulin + sulphonylurea should inform DVLA
should be assessed on awareness of hypoglycaemia
- capable of bringing vehicle to a safe controlled stop
group 1 vs 2 - drivers
group 1:
adequate awareness of hypoglycaemia
no more than 1 ep of severe hypoglycaemia whilst awake in prev 12 months
group 2:
full awareness of hypoglycaemia
no ep of severe hypoglycaemia in prev 12 months
must report all eps of severe hypoglycaemia including during sleep
must use a blood glucose meter that stores 6 weeks of readings
if any visual complications - inform DVLA and stop driving
DVLA advice for drivers
drivers taking insulin should always carry glucose meter and blood-glucose strips
check blood-glucose conc. no more than 2 hours before and every 2 hours whilst driving
blood-glucose conc. should always be > 5mmol/L while driving
if it falls < 5 - take a snack
if < 4 - DO NOT DRIVE
ensure supply of fast-acting carbs in vehicle
hypoglycaemia whilst driving - imp points
hypoglycaemia - < 4 mmol/L
drivers should:
safely stop vehicle
switch off engine, remove keys
move from drivers seat
eat/drink suitable sugar source
wait until 45 mins after blood-glucose has returned to normal before driving > 5
drivers MUST NOT drive if hypoglycaemia awareness was lost (if they weren’t able to stop in a controlled manner) and inform DVLA
T1DM features, glucose targets - imp points
insulin deficiency - destroyed beta cells in islet of langerhans
most common - before adulthood
features:
hyperglycaemia (>11 mmol/l)
ketosis
rapid weight loss
bmi < 25
age < 50
family history of autoimmune
BM monitoring done at least 4x a day (before each meal and before bed)
BM targets:
5-7 on waking (fasting)
4-7 fasting BM before meals
5-9 90 mins after meals
> 5 whilst driving
types of insulin regimens
first line - basal bolus:
basal - long acting (once or twice a day)
bolus - short/rapid acting before meals
1st line basal determir - BD
2nd line basal determir OD or glargine - OD
biphasic mixtures
- short acting mixed with intermediate - injected 1-3 times daily
contininuous subcut insulin infusion (pump)
- given when disabling hypoglycaemia or uncontrolled hyperglycaemia
when would you change insulin requirements?
increase insulin:
infection
stress
trauma
medications - levothyroxine
decrease insulin:
physical activity
reduced food intake
intercurrent illness
impaired renal function
certain disorders - hypothyroidism, coeliac disease, addison’s disease
insulin administration - imp points
inactivated by GI enzymes - given subcut
inject at site with plenty of subcutaneous fat:
- abdomen (fastest absorption)
- outer thighs (slower)/butt (slowest)
rotate site of injection
- lipohypertrophy can occur if injected at same site multiple times- leads to erractic absorption
- alternate b/w right and left side on weekly basis
types of insulin (short-acting) - imp points
soluble insulin:
human+bovine/porcine
inject 15-30 mins before meal
onset 30-60mins, peak action 1-4 hours
duration - upto 8 hours
rapid acting:
lispro, aspart, glulisine (no LAG)
inject immediately before or with meal
onset < 15 mins
duration 2-5 hours
types of insulin (intermediate and long acting) - imp points
intermediate:
biphasic isophane - biphasic aspart/lispro (isophane insulin mixed with SA)
onset 1-2 hours, peak 3-12 hours
duration 11-24 hours
long acting:
determir, degludec, glargine (DDG)
inject OD (determir BD)
onset 2-4 days to reach steady state
duration 24 hours
T2DM - imp points
insulin resistance + lack of insulin
develops later in life
prediabetes:
hba1c 42-47 mmol/L
can try and prevent diabetes with lifestyle advice
diabetes - hba1c 48 mmol/L OR fasting BM of 7mmol/L or more
T2DM treatment (low CVD risk)
assess HBA1C, kidney and cardiovascular function
1 metformin
aim for individually agreed threshold
2 Add in pioglitazone, SU or SGLT2i, DPP4-i
aim for individually agreed threshold
3 triple therapy
aim for individually agreed threshold
T2DM treatment (high CVD risk)
High CVD risk - established atherosclerotic CVD, HF or QRISK2 > 10%
1 - metformin
once metformin controlled add SGLT-i
if metformin not tolerated - SGLT-i alone
aim for individually agreed threshold
2 - dual/triple therapy
aim for individually agreed threshold
T2DM treatment (metformin resistant)
if can’t tolerate metformin due to SEs use MR preparations
1 high risk CVD - SGLT2i
low risk CVD - pio, SU or SGLT-2, DPP4
2 triple therapy
if hba1c still not controlled - insulin therapy
what are the agreed thresholds
1 pre-diabetes 42-47 mmol/L
2 managed by lifestyle advice +/- single drug
- drug not associated with hypoglycaemia (48 mmol/L 6.5%)
- drug associated with hypo e.g. SU or insulin (53 mmol/L 7.0%)
3 hba1c still not controlled on single drug (risen to 58 mmol/L 7.5%)
- aim for hba1c of 53 mmol/L (7.0%)
metformin - imp points
metformin (biguanide)
- decreases glucuneogenesis + increases peripheral utilisation of glucose
SEs:
lactic acidosis - avoid if eGFR < 30ml/min
GI side effects e.g. n&v, diarrhoea - use MR or increase dose slowly
MHRA - reduces vit B12
STOP in AKI
sulphonylureas - imp points
SU - increases insulin secretion
short acting:
glicazide
tolbutamide
long acting:
glibenclamide
glimepiride
- associated with prolonged and fatal hypoglycaemia - avoid in elderly
SEs:
- high risk of hypoglycaemia - target is 7% instead of 6.5% for others
- avoid in acute porphyria
- avoid in hepatic and renal failure - increased hypoglycaemia
pioglitazones - imp points
pioglitazone - reduces peripheral insulin resistance
avoid in patients with history of HF
increased risk of bladder cancer
- review after 3-6 months
- stop if patient responds inadequately
- report haematuria, dysuria urinary urgency
increased risk of bone fractures
increased risk of liver toxicity
- report N&V, abdominal pain, fatigue, dark urine
increased risk of infection
dpp4-i imp points
inhibit DPP4 - inhibits breakdown of incretins - increases insulin secretion + decreases glucagon secretion
alogliptin, sitagliptin, linagliptin, saxagliptin, vildagliptin (hepatotoxic)
avoid in ketoacidosis
caution in HF
cause pancreatitis
- stop if symptoms of acute pancreatitis occur
- persistent severe abdominal pain
sglt-2i imp points
inhibit SGLT2 transporter in renal PCT
dapagliflozin
empagliflozin
canagliflozin
MHRA warning:
- DKA
- monitor ketones if interrupted for surgery/illness
- fournier’s gangrene (necrotising fasciitis of genitalia or perineum)
- canagliflozin ONLY - risk of lower limb amputation - toes
makes you urinate a lot - volume depletion - correct hypovolaemia before starting
increased risk of UTIs
monitor renal function
GLP-1 agonist - imp points
increase insulin secretion, decrease glucagon secretion and slow gastric emptying
dulaglutide
liraglutide
exenatide
lixisenatide
semaglutide
tirzepatide
MHRA warning:
- risk of DKA when concomitant insulin reduced rapidly
- reminder of SEs and potential to misuse
- risk of pulmonary aspiration during anaesthesia or deep sedation
acute pancreatitis - report persistent severe abdominal pain
dehydration - risk of dehydration due to GI SEs - weight loss, delayed gastric emptying, n&V
other antidiabetics - imp points
acarbose
- delays digestion and absorption of starch and sucrose
- high risk of GI SEs - may require reduce dose
meglitides (nateglinide or repaglinide)
- stimulate insulin secretion
- stress exposure - stop and replace with insulin
