Diabetes Mellitus Flashcards
(173 cards)
1
Q
What is Diabetes Mellitus characterised by
A
Hyperglycaemia
2
Q
What is Type 1 diabetes
A
Insulin Deficiency
- pancreatic beta islet cells are destroyed cause insufficient insulin release
3
Q
What type 1 diabetes overall treatment
A
- Insulin
4
Q
What is type 2 diabetes
A
Insulin resistance
- reduced insulin secretion or peripheral resistance to insulin
5
Q
What type 2 diabetes overall treatment
A
- Insulin
- Diet
- Oral Anti-diabetic drugs
6
Q
Symptoms of Diabetes
A
- Polyphagia (hunger)
- Polydipsia (thirst)
- Polyuria (excessive urination)
- weight loss
- fatigue
- blurred vision
- poor wound healing
7
Q
Diabetes Complications: Macrovascular complication
A
cardiovascular disease
Primary Prevention: Statin in…
- Type 1 diabetes
- Type 2 diabetes with QRISK of above 10%
(low dose aspirin is not recommended)
8
Q
Diabetes Complications: Microvascular Complications
(Eyes)
A
Retinopathy
- treat hypertension
9
Q
Diabetes Complications: Microvascular Complications
(Kidneys)
A
Nephropathy
- treat hypertension (ACEi / ARB)
be careful with ACEi as they act with hypoglycaemia effect especially in renal impairment
10
Q
How often should Adults be reviewed
A
Annually
11
Q
How often should children be reviewed
A
start screening after 12 years old or after 5 years after diagnosis
12
Q
Diabetes Complications: Nerves
(Sensory Neuropathy) and treatment
A
Diabetic foot
For pain:
- Antidepressants (Duloxetine)
- Tricyclic Antidepressants (Amitriptyline and Nortriptyline)
- Anti-epileptic drugs (gabapentin, pregabalin and carbamazepine)
- Strong opioids
13
Q
Diabetes Complications: Nerves (Autonomic Neuropathy) and treatment
A
Diabetic Diarrhoea
- codeine or tetracycline
Gastroparesis: delayed gastric emptying
- erythromycin
Erectile Dysfunction
- Sildenafil
14
Q
Diabetes Complications: Nerves (Gustatory Neuropathy)
A
Sweating, Scalp, head and neck
- antimuscarinics / antiperspirant
15
Q
Diabetes Complications: Nerves (Neuropathic Postural Hypotension)
A
- fludrocortisone
- increase salt intake
16
Q
How should the dose of insulin change during pregnancy
A
increases during 2nd and 3rd trimester
17
Q
Pre-existing diabetes
(pregnancy planning)
A
reduce the risk of congenital malformations
- aim for HbA1C levels <48mmol (6.5%)
- folic acid 5mg daily to prevent birth defects
18
Q
What birth birth defects is diabetes most common for
A
neural tube defects (CNS system affecting)
19
Q
What length of Insulin treatment should be used for pre-existing diabetes and pregnancy
A
Long acting insulin
- Insulin Isophane
(e.g Humulin I, Insulatard) - long acting Insulin analogues (Lantus, Semglee, and Toujeo)
20
Q
What should women who have it difficult controlling glycemic levels even when using multiple daily injections
A
Continuous subcutaneous insulin infusion pump
21
Q
What is at risk of happening after birth with glycemic levels
A
reducing a lot (hypoglycaemic)
22
Q
What should happen to the dose of insulin after birth
A
reduce, to reduce hypoglycaemia
23
Q
Pregnancy and Pre existing diabetes counselling
A
- risk of hypoglycaemia (especially in 1st trimester)
- always carry fast acting glucose (glucose drink/gum/sweat)
- prescribe glucagon if needed for type 1 diabetes
24
Q
Pre existing type 2 diabetes and pregnancy
A
- stop all oral antidiabetic drugs except metformin
- use insulin instead
- either metformin alone or with insulin
25
pre existing type 2 diabetes an breastfeeding
- continue metformin
- or resume glibenclamide post birth
26
Gestational diabetes: fasting blood glucose <7mmol treatment
1st Line:
dietary and exercise
2nd Line:
Metformin or Insulin
3rd Line:
Combined
27
Gestational diabetes: fasting blood glucose >7mmol treatment
1st Line:
Insulin with or without insulin and dietary and exercise
28
Gestational diabetes: fasting blood glucose 6 to 6.9 mmol with hydramnios or macrosomia treatment
1st Line:
Insulin with or without metformin
29
What is Hydramnios
Hydramnios is a condition that occurs when too much amniotic fluid builds up during pregnancy.
30
What is fetal macrosomia
A baby who is diagnosed as having fetal macrosomia weighs more than 8 pounds
31
Gestational diabetes: intolerance to metformin and do not want insulin treatment
Glibenclamide
32
Which type of diabetes is Diabetic ketoacidosis DKA more common
Type 1
33
What is Diabetic ketoacidosis DKA
- when the body lacks insulin
- which means it can't use sugar for energy and instead breaks down fat for energy
-releasing chemicals called ketones.
- Too many ketones build up in the blood, making it acidic, a process known as acidosis.
34
What can DKA cause
- bad breath
- high blood ketones
- diabetic coma
- mental confusion
- convulsions
35
What is the DKA Treatment
- Soluble insulin
- Fluids to rehydrate your body
- potassium (do not give if kidneys cant produce urine)
36
DKA treatment points
- continue on long acting insulin
- add glucose to infusion when below 14 mmol
- continue until patients can eat and drink and blood pH is above 7.3
37
When should you notify the DVLA
about Diabetes and Driving
- if using insulin
- if have a group 2 drivers license (larger vehicles)
- visual, renal or limb complications
- 2 episodes of severe hypoglycaemia in past 12 months (1 if group 2 license)
38
When should one check blood glucose levels before driving
- no more than 2 hours before
- then every 2 hours during the journey
39
How many times a day should those on insulin and group 2 license record their insulin
2 times
40
if glucose level is 5mmol/L before driving
take a carbohydrate before driving
41
if glucose is <4mmol/L before driving
do not drive
42
What must drivers on insulin always carry
fast acting glucose (tablet)
43
How long should one wait after taking a fast acting glucose tablet to continue driving
45 mins after glucose levels return to normal
44
What is Insulin
polypetide hormone responsible for metabolism of carbs, fat and protein
45
What is Bolus Insulin
- quick acting
- taken just before meals
46
What is Basal Insulin
- longer acting
- usually for all day steady levels and night
47
Examples of Short acting soluble insulin
- human soluble (actrapid, humulin s)
- animal soluble
(hypurin)
48
Examples of Rapid Acting analogues
- Lispro (Humalog)
- Aspart (Novorapid)
- Glulisine (Apridra)
49
Examples of Intermediate acting insulin
- Isophane (Humulin I)
50
Examples of Long acting analogue
- Glargine (Lantus)
- Detemir OD/BD (Levemir)
- Degludec (Tresiba)
51
When to take short acting soluble insulin
- take within 15 to 30 mins before a meal
- consume meal within 30 mins to avoid hypoglycaemia
52
When to take rapid acting analogue insulin
- take immediately before or after meal
53
When to take intermediate acting insulin
- take BD with soluble insulin
54
When to take Long acting analogue insulin
- take OD at the same time each day to cover 24 hour period
55
Which circumstances and how is short acting soluble insulin used
- diabetic emergencies and surgeries
- via S/C, I/M, I/V
56
Which Bolus insulin has a lower risk of hypoglycaemia before lunch?
Rapid acting insulin analogues
57
Which insulin is an alternative to soluble insulin in emergencies
rapid acting insulin analogues
58
What happens if you give IV basal insulin (long acting analogue and intermediate)
can cause thrombosis
59
What happens if you mix long acting insulin analogues with soluble insulin
it can bind in the syringe
60
What can increase the amount of insulin needed
- infections / intercurrent illness
- stress
- acidental / surgical trauma
- puberty
- pregnancy (2nd and 3rd trimester)
61
What can decrease the amount of insulin needed
- endocrine disorders (Addison's disease, hypopituitarism)
- coeliac disease (gluten intolerance)
62
How to administer insulin
S/C injection to...
- buttock
- upper arm
- upper abdomen
- upper thigh
63
When would you use I/V insulin
for urgent treatment
- DKA
- surgery
- serious illness
64
What are the insulin injection regimens
- Multiple injection Regimen
- Biphasic Mixtures Regimen
- Long/ Intermediate acting regimen
- continuous subcutaneous infusion
65
What is the Multiple injection insulin Regimen
short/rapid acting insulin before meals
+
Intermediate/long acting insulin ONCE/TWICE daily
66
What is the Biphasic Mixtures insulin Regimen
- Short/Rapid acting insulin pre-mixed with long/intermediate insulin
- OD / BD before meal
(not for acutely ill patients as doses can change)
(it is for patients who have difficulty with the multiple injection regimen)
67
What is the Long/ Intermediate acting insulin regimen
- OD/BD with or without short insulin before meals
- long acting not for type 2 unless in certain criteria
68
What is the Continuous subcutaneous infusion insulin regimen
- type 1 diabetes in certain criteria
69
Type 1 diabetes 1st Line treatment
- start treatment with multiple injection regimens
70
Type 1 diabetes 1st Line treatment
- start with isophane insulin OD/BD
- plus short acting (soluble) insulin as biphasic or multiple injection regimen
71
What is a continuous subcutaneous infusion pump
- a device that delivers basal (long acting) insulin and patient activated bolus (short acting) insulin doses at meal time.
(not normal insulin pen)
72
What is type of diabetes is recommended for continuous subcutaneous infusion pump
Type 1
73
Which patients groups in type 1 diabetes are recommended for the continuous subcutaneous infusion pump
- glycaemic control >8.5% despite optimised MIR
- children under 12 where MIR is impractical
- suffers recurrent unpredictable hypoglycaemia
74
Side effects of insulin injection: Hypoglycaemia
Hypoglycaemia
- do not miss meals
- do not miss insulin injection
- do not do strenuous exercise before administration as can increase absorption
75
Side effects of insulin injection: Lipodystrophy
Lipodystrophy (build of of fat, protein and tissue
- rotate injection sites
76
Side effects of insulin injection: Local Injection site reactions
check injection technique
77
Multiple Injection Regimen food counselling
- must match insulin according to carbohydrate intake
78
Biphasic regimen food counselling
- must regulate and distribute carbohydrates intake throughout the day to match regimen
79
How to ensure safe insulin use
- Must always supply PIL to patient
- insulin passport
80
Which medication interacts with insulin to enhance hypoglycaemic effect
- ACE inhibitors
- Beta-blockers (masks symptoms of hypoglycaemia)
- Alcohol
81
Which medication interacts with insulin to antagonise hypoglycaemia effect
- corticosteroids
- oral contraceptives
- loop/thiazide diuretics
82
What is the Diabetes Acronym
SICK
S Sugar
I Insulin
C Carbohydrates
K Ketones
83
SICK acronym: S
Sugar
- Check blood glucose levels every 3 to 4 hours even at night
- still monitor even after feeling better
- if remains uncontrolled see GP
- Monitoring not usually needed for type 2 unless on insulin
84
SICK acronym: I
Insulin
- never stop taking insulin
85
SICK acronym: C
Carbohydrates
- maintain normal meal pattern
- can replace meals with carb drinks or snacks
- 3L per day of fluid
- seek help if drowsy or cant keep fluids down
- seek help if persistent vomiting or diarrhoea
86
SICK acronym: K
Ketones
- check ketone levels every 3 to 4 hours even at night
- if urine ketone 2+ see GP
- if blood ketone levels are >3mmol/L see GP
87
Anti-diabetic medication cautions: Metformin
- stop metformin if dehydrated
- because dehydration can cause increased risk of lactic acidosis
88
Anti-diabetic medication cautions: Gliflozins
- consider stopping gliflozins if dehydrated as they cause volume depletion
89
Signs of Dehydration
Signs of Dehydration
- fever
- vomiting
- diarrhoea
90
What does the dose need to have when prescribing insulin
Units
91
Insulin syringe caution
- do not give IV syringe for SC injection.
- as IV is in ml and not units
92
Insulin Injection technique caution
check it is SC not IV
93
Insulin fridge cautions
- store in 2 to 8 C
- once opened store at room temperature and use within 28 days
- if left outside the fridge at 15 to 30 C for more than 48 hours, must discard
- if frozen must discard
94
Insulin dose conversions: Beef to human
reduce dose by 10%
95
Insulin dose conversions: Pork to human
no dose change
96
Metformin mode of action
decreases liver gluconeogenesis and increases peripheral use
(1st line in type 2)
97
What type of medication is metformin
Biguanide
98
Site effects of Metformin
--- Lactic acidosis
- avoid in renal impairment
- avoid in Tissue hypoxia (low oxygen levels in tissue)
--- Gastro-intestinal disturbances
- nausea, vomiting, Diarrhoea
--- Weight loss
--- taste disturbances
--- reduced vitamin B12 absorption
99
Contra-indications of Metformin
- renal impairment risk
- general anaesthesia
- iodine containing media
100
Sulphenylurea mode of action
augments insulin secretion
101
Examples of long acting Sulphenylurea
Short acting
- Gliclazide
- Tolbutamide
Used in elderly and renal impairment
102
Examples of long acting Sulphenylurea
Long acting
- Glibenclamide
- Glimepiride
103
Examples of Sulphenylurea in pregnancy
Pregnancy
- Glibenclamide (only 2nd and 3rd tri)
104
Side effects of Sulphenylurea
- hyponatraemia 9low sodium) (glipizide, glimepiride)
- hypoglycaemai (must treat in hospital)
- weight gain
- jaundice
- skin rashes
105
Sulphenylurea Patient counselling
- recognise symptoms of Hypo (glycaemia, natraemia)
- always carry surgary snack, do not miss meals
106
What medications interact with Sulphenylureas to increase hypo risk
- warfarin
- ACE inhibitors
107
What medications interact with Sulphenylureas to reduce renal excretion
NSAIDs
108
Thiazolinedione mode of action
reduces peripheral resistance
109
Examples of Thiazolinedione
Pioglitazone
110
NICE alert for Thiazolinediones
Continue if HbA1C reduced by 0.5% within 6 months
111
Side effects of Thiazolinediones: Heart
Heart failure
- increased incidence when combined with insulin
(Thiazolinediones are contraindicated in history of heart failure)
112
Side effects of Thiazolinediones: Cancer
Bladder Cancer
Thiazolinediones contra-indicated in history of bladder cancer or uninvestigated macroscopic haematuria
113
Patient counselling for Thiazolinediones
- report signs of liver toxicity (nausea, vomiting, abdominal pain, fatigue, dark urine)
- stop if jaundice occurs
- report signs of haematuria, dysuria an urgency
114
SGLT-2 Inhibitors mode of action (Gliflozins)
Inhibits sodium-glucose co-transport 2 in renal proximal tubule to reduce glucose reabsorption and increase renal excretion of it
115
Examples of SGLT-2 Inhibitors (Gliflozins)
- Dapagliflozin
- Empagliflozin
- Canagliflozin
116
Side effects of SGLT-2 Inhibitors
- life threatening atypical diabetic ketoacidosis (only moderately high glycaemic levels)
- Volume depletion (extracellular fluid loss)
117
Patient counselling with SGLT-2 Inhibitors
- stop and test for ketones if DKA suspected
- report symptoms of DKA
- report side effects of volume depletion
118
Patient counselling with SGLT-2 Inhibitors: Specifically Canagliflozin
increased risk of lower limb amputation (usually toes)
- report skin ulceration, discolouration and new pain
119
Symptoms of volume depletion
- postural hypotension
- dizziness
- constipation
- thirst
- fatigue
- UTIs
- genital infection
120
Symptoms of DKA
- nausea
- rapid weight loss
- fast/deep breathing
- metallic taste in mouth
- unusual fatigue
- confusion
121
DPP-4 Inhibitors (Gliptins) mode of action
DPP-4 breaks down hormone incretin. Incretin is made by the gut in response to food to increase insulin secretion and lower glucagon secretion
122
Examples of DPP-4 Inhibitors (Gliptins)
- Alogliptin
- Linagliptin
- Vidagliptin
- Saxagliptin
- Sitagliptin
123
Side effects of DPP-4 Inhibitors (Gliptins)
- Pancreatitis (report persistent severe abdominal pain)
- Vidagliptin can cause liver toxicity
124
Gliides mode of action
stimulates insulin secretion
125
Examples of Gliides
- Nateglinide
- Repaglinide
126
Side effects of Gliides
- hypersensitivity reactions
- urticaria (rash)
- Pruritus (severe itching)
127
Side effects of Gliides: Specifically Nateglinide
- abdominal pain
- constipation
- diarrhoea
- nausea
- vomiting
128
Side effects of Gliides: Specifically Repaglinide
visual disturbances
129
Gliides patient counselling
- be careful of hypoglycaemia when driving
- take these medications 30mins before main meal
- they are rapid onset and short duration of action
130
Alpha-glucosidase inhibitors mode of action
inhibits carbohydrate digestion by competitively inhibiting the alpha glucosidase enzyme in the small intestine lumen.
131
Example of Alpha-glucosidase inhibitors
Acarbose
132
Side effects of Alpha-glucosidase inhibitors
- flatulence (improves with time, but antacids do not help)
- Diarrhoea (withdraw or reduce dose)
133
Alpha-glucosidase inhibitors patient counselling
- chew with first mouthful
or
- swallow whole with liquid just before meal
- Carry glucose (not sucrose) to counteract hypoglycaemia
134
Glucagon-like peptide 1 receptor agonists (GLP-1 Agonists) mode of action
Binds to and activates GLP-1 receptors to increase insulin secretion suppress glucagon secretion, slowing gastric emptying
Prevents weight gain (S/C injection)
135
Examples of Glucagon-like peptide 1 receptor agonists (tide)
- Exenatide
- Albiglutide
- Dulaglutide
- Liraglutide
- Lixisenatide
136
Side effects of Glucagon-like peptide 1 receptor agonists
- Pancreatitis (stop medication if this occurs)
137
Missed Dose Advice: General - Glucagon-like peptide 1 receptor agonists
- Do not administer after meal
138
Missed Dose Advice GLP-1 Agonists: Lixisenatide
Inject within 1 hour of next meal
139
Missed Dose Advice GLP-1 Agonists: Exenatide
Continue with next schedule dose
140
Missed Dose Advice GLP-1 Agonists: Dulaglutide, Albiglutide
Inject within 3 days of next weekly dose
141
Pregnancy and Contraception: Glucagon-like peptide 1 receptor agonists
- use contraception
142
How many weeks after using MR Exenatide should one still be on contraception
12 weeks
143
Which Glucagon-like peptide 1 receptor agonists should you use contraception during usage
- Exenatide
- Lixisenatide
- Albiglutide
144
Type 2 Diabetes: 1st Line
Lifestyle and Diet control
145
Type 2 Diabetes: 2nd Line
Metformin
or if not tolerated use
DPP or Pioglitazone or Sulfonylurea
Ideal HbA1c target: 48
146
Type 2 Diabetes: 3rd Line
Dual Therapy
Ideal HbA1c target: 53
147
Type 2 Diabetes: 4th Line
Triple therapy
or...
Insulin Programme
Ideal HbA1c target: 53
148
What is the Insulin Programme
continue metformin
+
Insulin
149
Insulin Programme:
- Person prefers injecting before meals
- blood glucose rises markedly before meals
- Hypoglycaemia is a problem
If any of these apply which insulin should be used?
Rapid acting insulin Analogues
- Lispro (Humalog)
- Aspart (Novorapid)
- Glulisine (Apridra)
150
Insulin Programme:
- Person needs help injecting
- Lifestyle restricted y hypoglycaemic episodes
- Would otherwise need twice daily NPH insulin
If any of these apply which insulin should be used?
- Insulin Detemir (Levemir)
- Glargine (Lantus)
151
Insulin Programme:
- Person needs help injecting
- Lifestyle restricted y hypoglycaemic episodes
- Would otherwise need twice daily NPH insulin
If none of these apply which insulin would be used?
- NPH Insulin (Isophan)
- Short acting insulin
152
What Diabetes Diagnostic tests are there
- HbA1c blood test
- Oral glucose tolerance test
153
What is the HbA1c test
- recommended by who
- 48mmol/mol (6.5%) or above to diagnose diabetes
154
What is the Oral glucose tolerance test
- diagnosis of impaired glucose tolerance
- not needed for patients with severe hyperglycaemic symptoms
155
What are the 2 types of Diabetic monitoring
- Urinanalysis (Ketones, Protein (Albumin), Glucose)
- Blood Monitoring
Ketones, glucose
156
Blood glucose target preprandial (before dinner)
4-7mmol/L
157
Blood glucose target postprandial (after dinner)
>9mmol/L
158
HbA1c levels if Diabetic
48 to 59 mmol/L
(6.5 - 7.5%)
159
HbA1c levels if diabetic with high risk of arterial disease
>48mmol/L
(6.5%)
160
Hypertension targets in Diabetes with complications
140/80
161
Hypertension targets in Diabetes without complications
130/80
162
Cholesterol targets for normal people
<5mmol/L
163
Cholesterol targets for high risk patients e.g Diabetics
<4mmol/L
164
When would a statin be used in diabetes
- Type 1 diabetes
- Type 2 diabetes and 10% QRISK score
165
At which level does glycaemia level show hypoglycaemia
<4mmol/L
166
Hypoglycaemia symptoms
- hunger
- pale skin
- sweating
- chills
- dizziness
- blurred vision
- palpitations
- confusion
- coma
167
What is blunted hypoglycaemia
Over time, the brain adapts to the lower glucose levels, resetting the threshold for glucose sensing to lower values. As a consequence, individuals with impaired hypoglycemia awareness exhibit a blunted response to falling glucose levels,
168
Which medication can mask symptoms of hypoglycaemia and delays recovery
Beta-blockers
169
How to treat a hypoglycaemia medical emergency in the community
10-20g glucose/ sucrose
- coke
- lucozade
- sugar
- avoid chocolate/ biscuits as fat delays glucose absorption
170
What diabetic medication can cause hypoglycaemia that can last for hours?
Sulphonylurea
170
How to treat Sulphonylurea induced hypoglycaemia
Hospital
171
What to do if hypoglycaemia is unresponsive or is unconscious?
SC/IM glucagon
172
What to do if hypoglycaemia is unresponsive to glucagon after 10 minutes?
IV Glucose
