Flashcards in Diabetes management Deck (46):
Describe the difference between type 1 and type 2
type 1= autoimmune, absolute insulin deficiency; type 2= insulin resistance and varying degrees of insulin secretion
What are the limits for impaired fasting glucose?
How is diabetes mellitus diagnosed?
Fasting blood glucose of > 7 mmol/l; HbA1C> 48 mmol/mol2 hr and value > 11.1 mol/l in the OGTT
What would you look out for if you suspect type 1 diabetes?
antiGAD and islet cells auto antibodies
What are the principles of type 2 diabetes management?
weight loss, exercise, oral hypoglycemic agents, regular health checks (monitor Hb1ac), address other CV risk factors such as lipids, hypertension, smoking etc.
What are the benefits of exercise (in terms of glucostasis)?
Increases glucose intake into muscle, improved sensitisation of muscle to exercise can last 2-3 days
What is the first line of medical treatment in diabetes type 2?
Metformin (biguanides)--> inhibits hepatic glucose output, no weight gain
what can cause weight gain (T2 diabetes medication)
sulfonylureas. It stimulates B cell insulin release
What is acarbose?
inhibits breakdown of starches and disarccarides in the gut.
what are GLP1 analogues?
exenatide- slow gastric emptying and improve satiety
prolong GLP1 action-->improved B cell sensing, increase insulin secretion, decrease glucagon secretion
inhibits SGLT2 main glucose transporter in the renal tubule-->to promote glycosuria thus lowering blood glucose
management of DKA?
1. replace fluid (500-1000mls of saline)
2. insulin infusion (make sure potassium is within normal range. if not, delay insulin and start IV potassium first)
3. glucose if hypoglycaemia occurs
what is thiazolidinediones?
Thiazolidinediones causes insulin sensitisation.
The drug binds to PPAR’s (peroxisome proliferator-activated receptors). When PPAR’s are activated they cause transcription of a number of genes
These activated genes ultimately result in decreased insulin resistance
how do we manage peripheral neuropathy in diabetic patients?
Frequent visits to the podiatrist, neuropathic pain management with gabapentin/pregabalin etc.
how do we prevent diabetic complications in diabetics?
frequent visits to podiatrist, GP, optometrist and frequent assessment of BSLs and HBA1C. Medication compliance
what would we prescribe in a diabetic patient with hypertensions and microalbuminemia?
Ace inhibitor- to slow progression of nephropathy
how do we manage hyperosmolar hyperglycaemia?
1. fluid replacement
2. Insulin, + glucose later
3. Potassium replacement
hence similar to DKA
for sick day management- what are the recommendations for how often to check BSL?
ever 2-4 hrs
why do we have sick day management protocols?
Acute illness in a person with diabetes is usually associated with increased secretion of stress hormones such as glucagon, cortisol and adrenaline. These changes promote hyperglycaemia and consequent dehydration, and may lead to DKA in type 1 diabetes, or Hyperosmolar hyperglycaemia in type 2 diabetes.
what is the target HbA1c levels for a patient with T2 diabetes mellitus?
The general HbA1c % should be less than 7, however the HbA1c target should really be INDIVIDUALISED for the patient
how do we manage hypoglycaemia?
administer glucose and glucagon
what do we have to consider if a diabetic patient comes in with high BSLs?
whether the diabetic patient has an illness such as infection- as it can throw off blood glucose control a bit
a type 2 diabetic patient comes in with high blood sugars- approx 20.6, ketones in the urine, polyuria and polydipsia and glucouria. What are you worried about? What do you do?
hyperosmolar hyperglycaemia which can lead to a coma.
Do a blood gas and at anionic gap
why do we worry about diabetic patients on beta blockers?
beta blockers would blunt the sympathetic overdrive associated with hypoglycaemia, and so we might miss signs of hypoglycaemia
what are some short acting insulins?
aspart (novorapid), lispro (humalog), glulisine
what are some long acting insulins?
glargine (lantus), determir (levemir)
which sulfonylurea is recommended?
is DKA associated with hypokalemia or hyperkalemia?
what do you need to consider before commencing a patient on sulfonylureas who is already on metformin? If sulfonylureas was contraindicated, what other drug could you suggest?
need to determine their occupation/job as sulfonylureas put you at risk of developing hypoglycaemia. Possibly suggest DPP4 inhibitor or GLP 1 agonist
what do we mean by NPH insulin?
medium acting insulin. NPH= neutral protamine hagedoone
what are mixed insulins made up of? e.g. novomix,
medium acting NPH insulin and short acting insulins
what is the onset of action for short acting insulins?
what is the onset of action for long acting insulins?
main finding for the DCCT study?
first evidence that intensive glycaemic control reduces complications in T1 diabetes. Random controlled trial. Earlier intervention, better prognosis
what is the legacy effect from the DCCT trial?
quite a few years of good glucose control--> leads to reduction in CVD microvascular complications many years later
Tell me about the ACCORD trial
Group of long term T2 diabetes patients; split into intensive group and standard group. In the intensive group they tried to bring the HbA1c to 6.4%. 3.5 years later the trial was stopped bc mortality rate in intensive group was high due to severe hypoglycaemic events. So this has shaped our approach these days that we aggressively try to control HbA1c EARLY in the disease whereas we try to relax this in late diabetes.
what must the HbA1c target be balanced against?
risk of hypoglycaemia
what are some things a dietician can recommend to help with stabilising blood sugar levels
low GI foods
what is the basic principle of basal bolus insulin therapy?
what are some problems of this therapy?
mimics normal insulin production and control post prandial hyperglycaemia.
1. Subcutaneous --> systemic circulation --> liver
rather than endogenous insulin going straight into the portal vein and to the liver.
2. glucose levels naturally vary every day
3. onset of action of fast acting insulin is generally 10-30 mins rather than straightaway in endogenously produced insulin
aside from metformin, which hypoglycaemic agents help with losing weight?
GLP1 (e.g. exenatide) and DPP4 inhibitors
what two drugs increase insulin sensitivity?
metformin and glitazone
SE of pioglitazone
weight gain, fluid retention, bone loss. Hence sort of going out of favour despite having good efficacy for reducing HbA1c
if a Type 2 diabetes patient who was on metformin and sulfonylureas now requires insulin- what happens to the sulfonylureas?
If the patient is just going on basal insulin- then sulfonylureas is continued
if the patient is also going to have bolus insulin before meal times- sulfonylureas is removed from the treatment protocol
when is foxiga (SGLT1 inhibitors) not recommended?
in elderly individuals who are more likely to become dehydrated due to excess glucouria