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Diabetes Flashcards

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1
Q

Why does blood glucose rise is patients with diabetes despite fasting

A

Dawn phenomena GH and cortisol are released and they raise glucose ready for the morning in those without diabetes the body responds by increasing insulin to inc glucose uptake in the cells this doesn’t happen in T1 and T 2 diabetes

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2
Q

What is HbA1c

A 
Glycated  haemoglobin it is measured to identify the 3 month average plasma glucose concentration 
Target number is 48 
Normal is below 42
Prediabetes is 42-48 
Diabetes 48 above
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3
Q

What is c peptide

A

It’s a connecting expertise 31 amino aci polypeptide that connect insulin A chain to its B chain
If the level is low it means you arent secreting enough insulin
If too high there is a kidney problem or an insulinoma

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4
Q

Diagnostic criteria WHO

A

Hyperglycaemia after an overnight fast randomly or overnight glucose tolerance test
If symptoms are present there is no need for a confirmation test
Symptomatic patients require a repeat of the same clinical biochemical test
If random both need to be over 11.1
Fasting over 7
OGTT 11.1 at 120mins
HbA1c >48

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5
Q

What colour tube is the blood test taken in

A

Venous sample in a fluoride tube with a grey top
HbA1c is EDTA purple top
Capillary readings are not suitable for diagnostic purposes

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6
Q

What are the typical symptoms

A 
Thirst 
Unexplained polyuria
Unexplained weight loss 
DKA
HHS
one biochem test needed to confirm 
No confirmatory that is only in asymptotic patients
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7
Q

Risk factors for type 1 diabetes

A 
HIA DR3/DR4 association
Autoimmune endocrinooathies -addisons or hasimotots thyroiditis 
Geography northern hemisphere
10% of diabetes patients 
Immune mediated destruction of beta cells 
It is 
ABSOLUTE 
PERMANENT 
DEFICIENCY OF INSULIN
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8
Q

Type 2 risk factors for diabetes

A 
Obesity 
FHx
Ethnicity
Age >40
Previous GDM, PCOS
metabolic syndrome 
INSULIN RESISTANCE 
RELATIVE INSULIN DEFICIENCY
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9
Q

How to measure risk factors to T2D

A

qdscore.org

Then tests can be done appropriately

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10
Q

Ehh so to determine the type of Diabetes depending on the signs and symptoms

A

Ketosis
Rapid weight loss
Age of onset under 50
BMI under 25
Personal or fhx of other autoimmune diseases
Poor response to oral hypoglycaemic drugs within 6months of diagnosis
If unsure antiGAD ab , c peptide to determine if any endogenous insulin production
DHx anti psychotics , steroids , anti retrovirals can cause metabolic syndrome including weight inc risk for diabetes development
Exocrine pancreatic failure
Look for in exam signs of obesity related autoimmune or genetic factors
- acanthosis nigricans
Cushing, acromegaly , Prader willi syndrome

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11
Q

What is the other type of type one diabetes

A

LADA
Latent onsets autoimmune diabetes in adults
Type one diabetes in adulthood

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12
Q

What is the other type of type two diabetes

A

MODY
Maturity onset diabetes of the young
Defect in HNI
Respond to sulfonylureas

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13
Q

What are the implications to the patient

A

I live 1020 years less
Complications microvascular and macrovascular
Such as Poor healing going blind ulcers leg amputations
Hypos
quarter are depressed
And insurance difficulties
DVLA year reviews

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14
Q

What is the immediate management

A

If type one diabetes need to give insulin
need to educate them on the complications how to administer the insulin and carbohydrate count
The type to diabetes depending on the severity
You can treat with diet alone , metformin, is first line then follow the algorithm for second line additional treatments
Losing weight is always helpful in T2D

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15
Q

What is metabolic syndrome

A

Central Obese >30bmi
Plus 2
Hypertension>130/85
Diabetes fasting glucose >5.6mmol/l or T2DM
High cholesterol - HDL <1.03 men and <1.29 women, Triglycerides >1.7mmol/l

Causes weight, genetics, insulin resistance

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16
Q

What is metformin

A

It is a Biguanide

And it increases insulin sensitivity

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17
Q

What is a sulfonylurea

A

Inc secretion of glucose

Gliclazide

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18
Q

What is a gliptin

A

Block DPP 4 which stop incretin from being destroyed

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19
Q

What can the complications be

A

Injection site there can be infection which you treat lipo hypertrophy so you need to change the injection site
vascular disease can be micro or macro = PVD, MI stroke
Nephropathy - microalbumiuria , urine dipstick or an UA:CR if above 3 put them on ACEin even if BP normal as has kidney protecting actions
Diabetic retinopathy- blindness is preventable with good glycemic control
Earlier cataracts
Needs to be annual screening
Diabetic foot/ neuropathy - glove and stocking
Glove and stocking distribution
Neuropathic deformity - charcots foot
Ischaemia - absent pulses
Foot ulcers - painless, punched out, pressure points

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20
Q

Different types of retinopathy

A

Background - dots - microaneurysms and blots which are haemorrhages and hard exudates
Pre proliferative - signs of retinal ischaemia- cotton wool spots, haemorrhages, venous bleeding
Proliferative - new vessels
Maculooathy - dec visual acuity can happen at any stage it is when the signs affect the macula not trust the periphery.
Refer to specialist for all these
May need laser therapy at the peripheries and may need anti VEGF if new vessels start to form in proliferative retinopathy

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21
Q

What regime is usually used in T1F

A

Basal bonus regime
Due to the absolute insulin deficiency require a dose to replace the basal dose
Lantus levemir all day and then before eating a rapid acting insulin such as Humalog and nova rapid

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22
Q

What are hypos

A

When the blood sugar falls below 4

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23
Q

How to manage a hypo

A

Test the blood cap blood and then take rapid release glucose such as dextrose tablet, jelly babies, lucozade
The retest 15 mins later if returning to normal ensure you stake a starchy food such as a biscuit or a sandwich to help prevent it happening again.

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24
Q

How is hypo awareness rated

A

GOOD score
That they rate themselves 1-7
1 always aware
7 not aware ever

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25
Causes if hypo
Missed insulin dose Triggered by exercise , alcohol, injection in lipodystroohic site preventing absorption Overcorrection if high glucose Insulin stacking repeated insulin to correct high dose Snack without rapid acting
26
How does hyperglycaemia promote atherosclerosis
Inc inflammation by sowing blood flow Inc oxidative stress protein kinase c activation alters growth factor expression Non enzymatic glycosylation of proteins and lipids
27
Who is treated in an antenatal diabetes clinic
Those with existing diabetes or those with gestational diabetes Existing - Conception planning prev feral malformation Stop statin and ACE Ensure 48 HbA1c Folic acid 5 mg dose before and up to 12 was pregnancy Eye screening x2 Aspirin from 12 weeks to prev pre eclampsia
28
What is gestational diabetes
Hormones in pregnancy inc insulin resistance - progesterone - growth hormone - human placental lactogen
29
When does screening occur and who is screened
``` 24-28;weeks High BMI FHx Prev GDM Prev still birth Black or Asian Macrosomia Polyhydraminos ```
30
Which test is used to screen for GDM
Diagnostic OGTT 75g
31
What are the diagnostic criteria for GDM
Different to normal Fasting is >5.6 2hr >7.8
32
Treatment given
Told to blood glucose monitor Carb control Inc growth more treatment , metformin , insulin Growth scan 6-13 weeks after delivery post natal fasting glucose to see if normal glucose tolerance occurs
33
What obstetric complications are we trying to avoid
``` Mother Preeclampsia Diabetic eye disease Baby Fetal malformation Macrosomia Early delivery Polyhydraminos Birth trauma Neonatal jaundice and hypoglycaemia Still birth and neonatal death ```
34
What abnormalities are being looked for in a diabetic eye clinic
Dots -microaneurysm Boots- haemorrhages Exudate - lipoprotein leak from the capillaries - cotton wool spots Background retinopathy - observed signs but not in the macular so not sight threatening Maculooathy signs in the macular therefore sight threatening
35
What is released in the eye when these diabetes has caused damage to the vessels
VEGF | Causes friable new vessel to form which then leak and bleed into the vitreous humour causing vision loss
36
What convictions can be caused by VEGF
``` Rubeosis iridisis Or neovasculatisation of the the iris It is sight threatening and is bleeding into the anterior chamber Glucaoma Cataract ```
37
What treatment is given for retinopathy
Anti VEGF | Monoclonal antibody that neutralise VEGF
38
What can be seen in the foot in a diabetic foot clinic
Hammer toe or hallux valgus Can be chased by reduced sensation of the foot also a prime site for a neuropathic ulcer to develop Sweat less due to autonomic neuropathy - dry foot Ulcer Reduced sensation PVD Charcot foot
39
Types of ulcer in diabetic foot disease
Neuropathic - no feeling, punched out, blood supply present so healing possible -ischaemic No blood, no healing can be necrotic or septic and require amputation
40
How to test sensation in a diabetic foot
Mono filament testing | On the big toes and then at three points on the ball of the foot
41
What tests are done to see if there is PVD
Puleses Doppler ABPI
42
What is Charcots foot
``` Disorganisation of the the foot bone and joint There is underlying neuropathy as the patient cannot feel the ongoing trauma occurring that is happening by walking on it Mid foot is the common place Pes cavus collapsed arch of the foot Inc temperature due to inflammation Can see mid foot dislocation and fracture Can cause foot ulcers No sensation Treated by boot DH Walker Total contact cast Amputations ```
43
What happens in anrenal diabetes clinic
``` Diagnosed with renal impairment Control progression diabetic nephropathy Management of CKD May need dialysis Transplant ```
44
Who uses insulin pumps
T1D | HbA1c above 69
45
What does an insulin pump help with
Reduces hypos In glycaemic control Needs close monitoring as interruptions in pump can cause DKA due to fast acting insulin being released all the time
46
What education programmes are out there for diabetics
DESMOND T2D lifestyle choices | DAFNE T1D carb count and insulin dose
47
Impaired glucose tolerance test should be
Fasting plasma glucose <7mmol/L | OGTT to exclude DM 2 hours post glucose >7.8mmol/l but <11.1mmol/l
48
Impaired fasting glucose results should be
Fasting plasma glucose >6.1mmol/l but <7mmol/l
49
Other causes of DM
Steroids Anti-HIV med Newer antipsychotics Pancreatic:pancreatitis surgery, trauma, pancreatitis destruction - haemochromatosis, CF; pancreatic cancer Cushing disease, acromegaly, phaeochromocytoma, hyperthyroidism, pregnancy
50
What are GLP analogues
Glucagon like peptide analogue Work as incretin mimetics They are gut peptides that work by augmenting insulin release Sub cut BMI>35 and other psychological/medical problems or insulin would not suit lifestyle or weightloss would help other comorbidities In order to continue them patients needs to show a significant response cos they so expensive They need to show a HbA1c dec of 11 and a weight loss of 3% by 6 months
51
What causes charcot foot
There is a lack of sensation so paincannot be sensed so there is continued mechanical stress which leads to the deformity due to repeated joint injury It can heal if weight bearing stopped.
52
Diagnostic criteria for DKA
Acidaemia pH <7.3 of HCO3- <15 Hyperglycaemia glucose >11.1 or known DM Ketonaemia >3 or 2+on dipstick
53
What is the first step in mx of DKA
2 large bore cannula Fluid resus 1l 0.9% saline over an hour Unless BP systolic <90 then 500ml blous over 15 min if no improvement - another and senior help and if no improvement another and ICU
54
What tests are done in DKA
Glu VBG for pH bicarbonate and K+ Lab glucose and ketone and bedside
55
insulin delivery in DKA
Fixed rate insulin - no matter what the glucose is insulin is delivered at a the same rate 50 units in 50ml of saline 0.1unit/k/hr Important to continue the long acting basal insulin fo the patient a their normal doses and times
56
What are the aims bicarb and ketones in DKA
Aim is to get ketones dropping by 0.5mmol/l/h | And Bicarbonate inc by 3mmol/l/h
57
What to do if ketone and bicarbonate aims are not met in DKA
Inc the insulin to 1unit/l/h until achieved
58
When do you check the ketones and glucose in DKA
Check capillary hourly
59
What is the regimen for checking pH, K+ and HCO3- in DKA
2, 4, 8, 12, 24 hr
60
How to assess for K+ in DKA
Typical deficit is 3-5mmol /kg Falls with treatment as plasma enters the cells Don’t add K+ to the first bag, add K+ according to the most recent VBG result >5.5 don’t add any KCl to IV fluids 3.5-5.5 add 40mmol <3.5 seek help from HDU/ICU fro higher doses
61
What to consider is urine not passed in an hour | DKA
Catheter | Urine output aim 0.5ml/kg/hr
62
What to do if vomiting /drowsy DKA
NG tube
63
What to give in DKA due to statis
LMWH
64
What glucose amount should you start adding glucose in DKA
<14 Start 10% glucose at 125ml/hr To prevent hypoglycaemia
65
When due to continue fixed rate insulin till DKA
<0.6 mmol/l ketones >.3 pH venous >15 venous bicarbonate
66
Who is hhs seen in
Unwell T2DM
67
What is the diagnostic criteria HHS
Markers dehydration Glucose >30 No switch to ketone metabolism so ketonaemia stays <3 and pH<7.3 Osmolality >320
68
Tx HHS
Rehydrate 0.9% saline over IVI >48hr Replace K+ when urine starts to flow Only use insulin if glucose not falling with rehydration by 5mmol/l/h or if ketonaemia Start slowly 0.05 units/kg/hr Keep blood glucose 10-15 for 24 hrs to avoid cerebral oedema Look for cause MI, sepsis,GI infarct
69
Hypoglycaemia mx
Conscious - fast acting glucose - 200ml orange juice or dextrose tablet Conscious uncooperative squirt glucose gel into mouth/gums In unconscious- IV glucose 10% 200ml/hr conscious or in 15min if unconscious Or give glucagon 1mg/IV/IM will not work on malnourished patients Recovered one BG >4 Give long acting car such as a slice of toast
70
Diagnosis of hypoglycaemia
BG <3mmol
71
Cause of hypo
Insulin SU tx Inc activity missed meal. Accidental, non-accidental OD
72
Symptoms of hypo
Sweating anxiety hunger tremor palpation dizzy | seizure coma, drowsy, confuse,
73
Causes of hypo in non-diabetics
EXPLAIN Ex - endogenous insulin , family member insulin, body builders help stamina, alcohol binge no food, aspirin poisoning, ACE-I, B-blockers, insulin-like GF P = pituitary insufficiency L.= liver failure A = Addison’s disease I = islet cell tumour, immune hypoglycaemia N = non-pancreatic neoplasm

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