DM + lipid disorders Flashcards
Presentation of T2DM
Can be Asyx
- Polydipsia
- Polyuria
- Blurred vision
- Acanthosis nigricans
- Recurrent Infections – UTI, cellulitis
Ix + Dx for T2DM
- HbA1c = >48 mmol/mol (6.5%)
- Fasting glucose = >7.0 mmol/L
- Random glucose > 11.1 mmol/L + syx
- If Asyx: above criteria must be demonstrated twice
- C-peptide: may be used to distinguish between type 1 and 2. (low c-peptide indicates no insulin is being made thus type 1)
When should Hb1Ac not be used?
Should not be used to dx DM in the following groups:
- <18y
- Pregnant women or 2m postpartum
- Syx for <2m
- Acutely ill + hi DM risk
- Taking medications that causes hi BGL e.g. steriods
- Acute pancreatic damage
- End stage renal disease
- HIV
Interpret with caution in the following
- Abnormal hb
- Severe anaemia
- Recent blodd transfusion
Management of t2dm
Lifestyle + education
- Low glycaemic index carbohydrate
- Low fat diary
- Wt loss
- Smoking cessation
- Measure HbA1c 3-6month intervals
- Assess CV risk, BP control
- Foot care, eye care
Medical Mx
- Metformin (1st line)
- If metformin not tolerated/CI (1st line): Thiazolidinedione, DPP4i, Sulphonyureas. SGLT2i
- Dual therapy (2nd)
- Triple therapy (3rd)
- Insulin (3rd/4th) +/- metformin
Name a drug for: thiazolidinedione, sulphonyureas, DPP4i, GLP, SGLT2i.
What is the Hba1c target if on one and two drugs?
thiazolidinedione - pioglitazone sulphonyureas - gliclazide DPP4i - sitaGLIPTIN GLP - exenaTIDE SGLT2i - empaGLIFLOZIN
HbA1c target for one drug = 48mmol. If >58, start 2nd drug and new target of 53mmol.
What anti-diabetics cause hypoglycaemia and wt gain?
Hypo
- insulin, SU
Wt gain
- insulin, SU, thiazolidinedione
Which anti-diabetic causes the following SE:
- lactic acidosis
- inc CVD, MI risk
- UTI
- metformin
- SU
- SGLT2i
HHS - what is it? presentation? Dx? Mx?
- It is a medical emergency with high mortality + complications such as MI, stroke.
- Severe volume depletion resulting in raised serum osmolarity. Hyperglycaemia results in osmotic diuresis with associated Na + K loss.
- Causes: infection, surgery, impaired renal function
Presentation
- Fatigue, lethargy, N+V
- Altered consciousness
- Hyperviscosity of blood
- Dehydration
- Tachycardia, hypotension
Dx
- Hypovolaemia
- Severe hyperglycaemia (>30mmol/L) without ketonemia or acidosis
- Hyperosmolarity
Management
- Fluid (0.9% saline) over longer period of time compared to DKA
- Insulin 0.05U/kg/hr, continue long-acting insulin
- VTE prophylaxis
T1DM - pathology, syx, ix, mx
Type 4 hypersensitivity autoimmune destruction of beta cells so pancreas stops producing insulin.
Syx: Wt loss, Polyuria, Polydipsia. May present with DKA (often 1st presentation of T1DM)
Investigations Dx = requires two abnormal results - HbA1c = >48 mmol/mol (6.5%) - Fasting glucose = >7.0 mmol/L - Random glucose > 11.1 mmol/L + syx
Management
- Lifestyle + education
- Basal-bolus insulin
DKA - what is it, causes, presentation
DKA is triad of hyperglycaemia, ketonemia, acidaemia
Causes: infection, stress, non-adherence to insulin, steroids, diuretics, binge drinking, MI
Syx: Drowsiness, abdo pain, N+V, acetone breath, kussmaul breathing, wt loss
Mx + Ix of DKA
ABCDE
(1. ) IV fluids
(2. ) IV insulin 0.1U/kg/hr, long acting insulin continued + short acting stopped
(3. ) IV 5% dextrose (glucose)
(4. ) Correct electrolytes (K+) if needed:
- remember Insulin drives K into cells
- if K+ >5.5.mmol no need to add K to fluids
- if K+ in normal range, give K
- if K dangerously low, requires senior review
Investigations
- VBG: ketonemia (>3mmol), BGL >11mmol, HCO3 low, pH <7.3, ketones 2++, ECG
- Monitor BGL, electrolytes
Hypoglycaemia, causes, syx, mx
- BGL <3.5mmol/L
- causes: insulin/SU, inc exercise, missed meal, alcohol, Addisons, liver failure
Syx:
- BGL <3.3.mmol: sweating, shaking, hunger, anxiety, N+V, tingling lips
- BGL <2.8mmol: vision changes, confusion, dizziness, seizures
Mx
If pt conscious:
- 10-20g fast acting carb, preferably liquid (avoid chocolate, biscuits)
- Recheck BGL after 10-15mins
- If no response: repeat oral intake + BGL
- Longer-acting carb to maintain BGL and prevent hypo
If pt unconscious/unable to swallow:
- IM glucagon
- If no response within 10mins -> 999 + IV glucose
- If alcohol is cause: IV glucose
If in ED, pt unconscious
- IV 10% dextrose
- If struggling to cannulate proceed to IM glucagon
Hypercholesterolaemia: Syx, Ix, Dx
Syx
- Asyx
- Look for signs of xanthomas (tendons/skin/eyelids), arcus cornealis
Ix
Offer to:
- measure total cholesterol if Hx or FH of premature CHD /<60y
- DNA test in child with parent with FH
Lipid profile: total cholesterol, LDL, HDL, triglycerides
- Total cholesterol >7.5
- two LDL cholesterol should be taken for FH
- secondary hypercholesterolaemia should be excluded: TFT, HbA1c, UE, LFT
Dx
The Simon Broome or Dutch Lipid Clinic Network Criteria
- dx criteria for FH
- used in primary care
Hypercholesterolaemia Mx
Statin
- Primary prevention (QRISK >10%): Atorvastatin 20mg
- Secondary prevention: Atorvastatin 80mg
- Perform baseline bloods prior: LFT, CK, UE, HbA1c, TFT
- Measure after 3m, 12m statin Rx
Ezetimibe
- Alternative if active liver disease
Hypertriglyceridemia - what does it increase risk of?, Dx? Mx?
- Condition where presence of high amounts of triglycerides in the blood. Increases risk for pancreatitis, CVD
- Often caused or exacerbated by uncontrolled DM, obesity, and sedentary habits
- Chronically elevated serum triglycerides are component of NAFLD.
Dx: triglycerides >2.3
Management
- Lifestyle: diet, weight loss, exercise
- Fibrates, nicotininc acid, fish oil
