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YOU BETTER WERK > DIABETES > Flashcards

DIABETES Flashcards

1
Q

What is the difference between type 1 and type 2 diabetes?

A

Type 1: insulin deficiency due to immune mediate destruction of insulin producing pancreatic beta cells
Type 2: relative insulin deficiency caused by progressive loss of pancreatic beta cell insulin secretion on background of insulin resistance

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2
Q

What is the BSL range for “pre-diabetes”?

A

fasting: 6.1 - 6.9 mmol/L

random/OGTT: 7.8 - 11 mmol/L

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3
Q

What is the diagnostic HbA1c and BSL for diabetes?

A

Fasting BSL > 7
Random BSL >11
HbA1c > 6.5%

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4
Q

When should HbA1c be checked post partum?

A

Not within the first 3 months post partum as it will be falsely low due to lower BSL concentrations due to pregnancy (haemodilution).

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5
Q

Describe the procedure of an OGTT`

A
  • Fast overnight for 8-12 hours, avoid smoking or caffiene
  • take fasting blood sample before 75g glucose drink
  • drink must be consumed within 5 min
  • pt must remain seated and not eat or drink for the 2 hour duration of test
  • if non pregnant take blood test at 2 hours after consuming the drink, if pregnant take blood at 1 hour and 2 hours
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6
Q

Screening for T2DM

A
  • AUSDRISK: should be used every 3 years in > 40s or > 18 if ATSI
  • considers: age, sex, ethnicity, fhx, elevated BP, elevated BSL, smoking, diet, physical activity and obesity
  • if at high risk screening should be annual
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7
Q

What AUSDRISK score = high, intermediate or low risk

A 
Low = 5 and under
Intermediate = 6-11
High = > 12
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8
Q

What are the 5 goals of diabetes management?

A
  1. optimise quality of life
  2. manage hyperglycaemia
  3. avoid acute complications (DKA, HONK)
  4. avoid hypoglycaemia
  5. avoid chronic complications
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9
Q

What should be included in a diabetes management plan?

A
  • short and long term goals and treatment targets
  • dietary plan
  • physical activity and exercise plan
  • medication management plan
  • sick day management plan
  • schedule for screening and monitoring of complications
  • ways to reduce cardiovascular disease
  • plan for self management
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10
Q

What classifies as severe hyperglycaemia?

A

BSL > 20

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11
Q

Indications for referral to hospital in adults with hyperglycaemia

A
  • signs of ketosis
  • signs of dehydration
  • severe hyperglycaemia and vomiting
  • symptoms and signs of underlying infection
  • altered LOC, confusion or delirium
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12
Q

What are the 3 insulin regimens for Type 1 diabetes?

A
  1. multiple daily injections (basal + bolus), usually 4 injections daily
  2. continuous s/c insulin infusion via pump
  3. mixed insulin, usually 2 injections daily
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13
Q

What BSL and HbA1c targets should Type 1 diabetics have?

A

BSL 4-8

HbA1c < 7%

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14
Q

Examples of total daily insulin doses at different phases and ages.

A
  • during remission phase for all ages—less than 0.5 units/kg daily
  • beyond remission phase for pre-adolescent children—0.7 to 1 unit/kg daily
  • beyond remission phase during puberty—1.2 to 1.5 units/kg daily.
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15
Q

What is the aim of basal insulin in T1DM?

A
  • aim to lower rates of nocturnal hypoglycaemia

- aim to achieve fasting BSL 4-8

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16
Q

How often should children with T1DM check their BSL?

A

At least four times a day, before meals and at bedtime

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17
Q

What is LADA?

A

Latent autoimmune diabetes

  • T1DM subtype
  • associated with type 1 autoantibodies (GAD and IA-2 _ ZnT8)
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18
Q

What BSL targets should be given to adult patients with T1DM?

A

Fasting BSL 4-8

Post prandial BSL 6-10

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19
Q

What percentage of total daily insulin should basal insulin be?

A

~40-50% of total daily insulin

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20
Q

Name 3 long acting insulins and their onset/peak and duration

A

Detemir 100 units/ml: onset 90min, duration 16-24hrs
> levemir

Glargin 100 units/ml: onset 1-2 hours, duration up to 24H
> lantus

Glargin 300 units/ml: onset 1-6 hrs, duration 24-36hrs
> toujeo

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21
Q

Name 4 rapid acting insulins

A
  1. Aspart 100units/ml (Novorapid)
    > onset 10-15min, peak 60-90min, duration 3-5 hrs
  2. Glulisine 100 units/ml (Apidra)
    > onset 10-15 min, peak 60-90 min, duration 3-5 hrs
  3. Lispro 100 units/ml (Humalog)
    > onset 10-15min, peak 1-2 hours, duration 3-5 hrs
  4. Lispro 200unit/ml (Humalog U200)
    > onset 10-15min, peak 1-2 hours, duration 3-5 hrs
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22
Q

What is the general onset, peak and duration of rapid acting insulins?

A

Novorapid, apidra, humalog

Onset - 10-15min
Peak - 1-2 hrs
Duration - 3-5 hrs

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23
Q

Name 1 short acting insulin.

A

Neutral 100 unit/ml (Actrapid, Humulin)

> onset 30min, peak 2-3 hours, duration 6-7 hrs

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24
Q

What is the total daily insulin requirement for a healthy adult?

A

0.5-0.8 units/kg

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25
Q

What is the typical initial total daily insulin dose for a type 1 diabetics?

A

0.3-0.4 units/kg

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26
Q

What is the most common insulin regimen for type 1 diabetes?

A 
Basal = 40% daily or BD, long acting insulin 
Bolus = 60% in divided doses 15 min prior to meals, rapid or short acting insulin
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27
Q

Describe how to adjust basal insulin.

A

Dose of basal insulin should be adjusted by 10-20% every 3-7 days until fasting BSL targets (4-8) are achieved. Should always stabilise basal insulin first before adjusting bolus doses.

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28
Q

Describe how to adjust bolus insulin.

A

Provided patient is having fixed carbohydrate intake bolus insulin doses can be adjusted by 10-20% every 3-7 days to achieve:
> 2 hour post prandial bsl

    • most patients will have an insulin:carbohydrate
      i. e. 1:10, if eating 60g of carbs will need 6 units of insulin
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29
Q

Correction/supplemental insulin doses

A
  1. This is calculated by drop in BSL concentration from a 1 unit bolus
  2. If patient is on a stable insulin dose you can calculate from total daily insulin
    > sensitivity factor = 100/total daily insulin dose

Example = total daily insulin dose 50U, needing to drop BSL from 14 to 6 (8mmol/L drop).
> sensitivity factor = 100/50 = 2, therefore 1 unit of insulin will drop BSL by 2
> hence correction dose needed will be 4 units

Given in combination to usual dose of bolus to cover carbohydrate content of meal

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30
Q

How to avoid hypoglycaemia with exercise in T1DM.

A
  • eat 15-30g of carb for every 30 min of moderate exercise
  • reduce insulin dose in relation to anticipated intensity and duration
  • if aerobic exercise expected to last more than 30 min a decreased insulin dose is preferred to increased carb intake
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31
Q

When should ketones be tested for in T1DM?

A
  • during acute illness or stress
  • when BSLs are consistently > 15
  • with symptoms of DKA, nausea/vomiting/abdo pain
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32
Q

What classified as mild ketosis?

A

ketones 0.6-1.5mmol/L

> 1.5 indicates potential for developing DKA

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33
Q

How often should HbA1c be reviewed in T1DM?

A

Every 3-4 months

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34
Q

How often should retinopathy be screened for in T1DM?

A
  • start screening 2-5 years after diagnosis (after 11)
  • assess every 12 months if ATSI, known retinopathy, high HbA1c levels

Otherwise assess every 2 years if previous eye examination was normal

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35
Q

How often should a foot examination/peripheral neuropathy be screened for in T1DM?

A

If high risks screening every 3-4 months

Otherwise at least annually

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36
Q

Other autoimmune screening in T1DM.

A

Thyroid: every 2 years
Coeliac: screen at 2 and 5 years after diagnosis

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37
Q

How often should lipids be screened for in T1DM?

A
  • every 5 years if normal results
38
Q

Describe effects of alcohol and hypoglycaemia.

A

ETOH inhibits glucose production by the liver and increases risk of hypoglycaemia in T1DM

39
Q

T1DM and driving

A
  • bsl should always be checked prior to driving to ensure it is > 5
  • bsl should be checked Q2H while driving
  • patients should always have glucose containing foods available while driving
40
Q

Metformin role in pre-diabetes.

A
  • metformin has greatest benefits in reducing progression to diabetes in adults < 60 with BMI > 35
  • should consider if lifestyle modifications are unsuccessful
41
Q

What are the glycaemic targets in T2DM?

A
  • < 7% generally
  • however can be more aggressive in newly diagnosed patients
    • <6% if lifestyle modifictaion +/- metformin
    • <6.5% if 2 antihyperglycaemics
42
Q

Physical activity recommendations in T2DM

A
  • 150 -300min per week of moderate intensity exercise

- interrupt sitting every 30 minutes

43
Q

Indications for bariatric surgery

A
  • T2DM + BMI > 40 or with BMI 35-40 in context of suboptimal glycaemic control despite optimal lifestyle modifications and medical treatment
44
Q

Dietary advice for T2DM

A
  • aim for 5-10% weight loss
  • suggest low GI food: wholegrain bread, pasta, fruits and dairy provides
  • reduce sugar!
45
Q

Factors influencing choice of antihyperglycaemic agent in T2DM

A

Patient factors

  • degree of hyperglycaemia
  • risk of hypoglycaemia
  • weight
  • comorbidities

Drug factors

  • efficacy
  • potential nonglycaemic effects (i.e. CVD benefit)
  • risk of hypoglycaemia
  • effect on patient weight
  • contraindications
46
Q

Anti-hyperglycaemic class: Biguanide

Advantages and Disadvantages

A

Metformin

  • MOA: suppresses glucose production by liver and increases insulin sensitivity

Advantages: unlikely to cause hypoglycaemia, assist with weight loss, improved cardiovasc outcomes, low cost

Disadvantages: GIT side effects, B12 deficiency, lactic acidosis (rare)

Renal: adjust dose in renal impairment

47
Q

Anti-hyperglycaemic class: Sulfonylureas

Advantages and Disadvantages

A

Gliclazide, glipizide, glibenclamide

MOA: act at the pancreas to stimulate insulin secretion

Advantages: low cost

Disadvantage: can cause weight gain and hypoglycaemia, especially in older patients

Renal: avoid in patients with renal impairment!

48
Q

Anti-hyperglycaemic class: DPP4I

Advantages and Disadvantages

A

“Gliptins” - sitagliptin, linagliptin, saxagliptin

MOA: inhibits breaks down of GLP1 leading to increase insulin secretion and reduce glucagon

Advantages: hypoglycaemia unlikely, no weight gain, improves post prandial glucose control, safe in patients with CVD (except saxagliptin)

Disadvantage: avoid in heart failure, avoid in pts with hx of pancreatitis, can cause MSK pain

Renal: reduce dose with renal impairment

49
Q

Anti-hyperglycaemic class: GLP1 RA

Advantages and Disadvantages

A

“Tides” - guaglutide, exenatide, liraglutide

MOA: increases insulin secretion and reduced glucagon secretion by inhibiting action of DPP4 by binding GPL1

Advantages: hypoglycaemia unlikely, weight loss, improves post prandial bsl, reduces CVD events, slows progression of CKD

Disadvantages: avoid in patients with hx of pancreatitis or family hx of thyroid ca or MEN, GIT side effects

Renal: avoid in severe renal impairment

50
Q

Anti-hyperglycaemic class: SGLT2 I

Advantages and Disadvantages

A

“Flozins”

MOA: increases glucose excretion in urine

Advantages: hypoglycaemia unlikely, weight loss, reduces CVD risk, reduces BP, slows progression of CKD

Disadvantages: avoid in fasting pts due to risk of euglycaemic DKA, can cause urinary infections, reversible increase in creatinine

Renal: reduced glycaemic efficacy with renal impairment

51
Q

What medication is suggested for T2DM patients with HbA1c < 8.5% at diagnosis?

A

Metformin immediately OR after 2-3 months if targets not achieved with lifestyle modification

Second drug: sulfonulurea, DPP4 or SGLT2 inhibitor
If CVD risk factors: consider SGLT2 inhibitor of GLP 1

If target not achieved in 3 months add or substitute a third drug: sulfonylurea, DPP4, SGLT2I or GLP1 RA

52
Q

What medication is suggested for T2DM patients with HbA1c > 8.5% at diagnosis?

A

Start metformin and a second drug immediately

53
Q

Suggested management if on triple antihyperglycaemic rx in T2DM and still not achieving glycaemic control.

A
  • if using triple therapy change one or more drugs to GLP1 receptor agonist OR insulin
  • if using a regimen with a GLP1R agonist change this to a basal insulin OR add a basal or mixed insulin regimen
  • if using a basal insulin consider adding SGLT2I or GLP1 RA
  • or may need to consider basal + multipole daily injections (basal- bolus) or BD mixed insulin regimen
54
Q

Initial insulin dosing in T2DM with suboptimal control

A

Long acting insulin 0.2 units/kg (up to 30units) S/C daily

55
Q

What is the pathophys behind hyperglycaemia in acute illness in diabetics?

A

Counter-regulatory hormones such as glucagon, cortisol and adrenaline

56
Q

Sick day plan for T1DM

A
  • check BSL + ketones every 1-4 hours
  • ketones > 0.6 + high BSL suggests need for supplemental insulin and increased fluids
  • in acute illness basal insulin requirement generally increases and supplemental/correction rapid acting insulin should be given every 2-4 hours in addition to usual meal time boluses to reduce hyperglycaemia and stop ketosis
57
Q

Sick day plan for T2DM

A
  • if unwell and BSL > 12 mmol/l without episodes of hypoglycaemia can increase basal insulin by 10-20% (110-120% of usual insulin dose)
  • may need to include short term rapid acting boluses doses with meals to manage acute hyperglycaemia
  • metformin may need to be withheld if dehydrated or reduced renal function
  • SGLT2 inhibitors should be withheld!
  • GLP1 RA can be temporarily withheld if nausea, vomiting or anorexia
  • DPP4I can be continued
  • sulfonylureas can be continued as tolerated
58
Q

With what renal function is metformin contraindicated?

A

Creat clearance < 40ml/min

CKD stage III or more

59
Q

Which antihyperglycaemic agent is associated with increased risk of UTI and DKA?

A

SGLT2 inhibitors

60
Q

What antihyperglycaemic agent is contraindicated in heart failure?

A

DPP4 inhibitor “gliptin”

61
Q

What is the cut off for HbA1c for major elective procedures?

A

<9%

62
Q

Suggested subcut insulin management day of procedure in T1DM.

A

Morning procedure: normal basal insulin, omit rapid acting insulin, hourly BSLs from waking

Afternoon procedure: normal basal insulin, given half usually rapid acting bolus, withhold lunch rapid insulin

63
Q

Pre-procedural insulin infusion

A

Run with 5% glucose at 100ml/hr
Run insulin units/hr based on patients total daily insulin dose and their BSL (measured hourly)
Run between 1-4units/hour if normal BSL

64
Q

Acute vs chronic (micro/macro) complications of diabetes (3 in each)

A

Acute: hypoglycaemia, HONK, DKA
Microvascular: kidney disease, retinopathy, neuropathy
Macrovascular: CAD, PVD, stroke

65
Q

Management of severe hypoglycaemia: adult

A
  • severe: unable to be self managed by patient
  • glucagon 1mg IM/SC
  • IV glucose: 10% 150-200ml (15-20g) over 15 min
    OR IV glucose 20% 75-100ml (15-20g) over 15 min

Once conscious need to give long acting complex carb

66
Q

Management of severe hypoglycaemia: child

A
  • glucagon: <25kg = 0.5mg IM/SC, >25kg = 1mg IM/SC
  • IV glucose 10%: 1-2 ml/kg over 20 min until BSL >4

DO not give 50% dextrose to children due to risk of hyperosmolality and death

67
Q

Products containing 15g of glucose

A 
15g tube of glucose gel
6-7 jelly beans or 4 large glucose jelly beans
3 teaspoons honey or sugar
125ml of fruit juice
150ml of soft drink
68
Q

Management of non-severe hypoglycaemia

A
  • when patient is able to self correct orally

Child: 5-10g glucose PO
Adult: 15g glucose PO
* if BLS < 3 in adults given at leat 20g glucose

Rule of 15s - 15g glucose, recheck in 15 min

69
Q

Which antihyperglycamic has greatest risk of hypoglycaemia?

A

Sulfonylureas due to stimulation of insulin secretion
- gliclazide, glipizide, glibenclamide

Especially prominent if only insulin

70
Q

Characteristics of DKA

A
  • dehydration
  • hyperglycaemia
  • polyuria, polydipsia, tachypnoea
  • acetone breath
  • nausea/vomiting/abdo pain
71
Q

Typical blood gas results in DKA

A

pH <7,3
bicarb <15
ketones > 1.5
BSL > 14 (but can be lower if taking SGLT2I)

72
Q

Describe management of mild ketosis

A

Ketones 0.6 - 1.5

Can be managed as per sick day management plan withe extra insulin

73
Q

What are the 4 main aims of management of DKA?

A
  1. correction of fluid loss with aggressive rehydration
  2. correction of hyperglycaemia and suppression of ketone production with insulin
    > with addition of glucose infusion once BSL drops
  3. correction of electrolytes - especially potassium
  4. investigation of precipitant/cause
74
Q

Which has a higher mortality HONK or DKA?

A

HONK!

75
Q

Definition of HONK

A
  • high serum osmolality: often >320
  • extreme hyperglycaemia > 30
  • severe dehydration
76
Q

How to calculate effective serum osmolality

A

2 x (Na + K) + BSL + urea concentration

Should be calculated hourly
Aim for reduction of 3mmol/kg/hours and can titrate fluids to these

77
Q

Aims of HONK management

A
  • slow and safe replacement of IV fluids and electrolytes
  • slowly and safely normalise BSL
  • treat underlying cause
  • wait to avoid rapid correction of effective serum osmolality
78
Q

What are the estimated fluid losses in HONK?

A

100-200ml/kg

Treat with 50% of estimated fluids loss within first 12 hours and then the remainder over 12-36 hours

79
Q

Use of insulin in HONK

A
  • if ketones are <1 can hold off on insulin until after some rehydration as this will reduce BSL
  • once BSL stops falling from rehydration reassess fluid intake, renal function and can start IV insulin infusion
  • start at 0.05units/kg/hour
  • aim to reduce BSL by 4-6 mmol/L with target of 10-15mmol/L

Less commonly but if ketone > 1 then start insulin concurrently with IV rehydration

80
Q

Define normal, micro and macro albuminuria

A

Women: 3.5, 3.5-35, > 35
Men: 2.5, 2.5-25, >25

81
Q

Stages of CKD by GFR

A 
I. >90
II 60-89
IIIa 45-59
IIIb 30 - 44
IV. 15-29
V < 15
82
Q

Which antihyperglycaemic medications slow progression of diabetic kidney disease?

A

SGLT2I

Liraglutide

83
Q

What cholesterol medication can slow progression of diabetic retinopathy?

A

Fenofibrate

Can slow progression irrespective of blood lipid level

84
Q

Management of painful diabetic neuropathy

A
  1. amitriptyline 25mg nocte

Need to exclude other causes i..e B12 deficiency and myeloma

85
Q

Charcot arthropathy

A
  • unilateral, red, hot swollen foot
  • destructive joint disorder caused by diabetes
  • associated with peripheral neuropathy
  • causes inflammation leading to bone fracture, dislocation, instability
  • if suspected need to place patient NWB
86
Q

Features of diabetic autonomic neuropathy

A
  • hypoglycaemia unawareness
  • erectile dysfunction
  • orthostatic hypotension
  • diabetic gastroparesis
  • diarrhoea
  • bladder atony and urinary retention
  • cardiac autonomic neuropathy
87
Q

Pharmacological management of orthostatic hypotension in diabetic autonomic neuropathy

A

Fludocortisone 100mcg daily, increasing according to response to max 300 mcg daily

88
Q

BP target in diabetes

A

<130/80 with albuminuria/proteinuria
Otherwise <140/90
First line management ACEI/ARB
Likely will require CCB or thiazide in addition for combination approach

89
Q

Diabetes and aspirin

A

Not recommended for primary prevention of CVD however advised if known atherosclerosis

90
Q

When should OGTT be repeated post partum in women with GDM?

A

At 6-12 weeks post partum but can be delayed until 4-6 months post partum if not practical

91
Q

What vaccinations are recommended for diabetics?

A

Influenza
Pneumococcus
DTPA

YOU BETTER WERK (15 decks)

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