Treatment algorithm for T2DM
Duodenal jejunal bypass if BMI >41
Otherwise:
1) Metformin If HbA1c >58:
2) + DPP4 inhibitor/ pioglitazone/ sulfonylurea
3) Metformin + DPP4 + SU
4) Metformin + pioglitzaone + SU
5) GLP-1 agonist (liraglutide) or SGLT2 inhibitors (-flozins)
6) + insulin
What should the Hba1c target be?
<48mmol
What should the target be if there is a hypo risk + how is this achieved?
Monotherapy to keep Hba1c at 53mmol
When to add a 2nd + 3rd drug?
Hba1c >53, 58mmol
When to diagnose T1DM?
Fasting glucose >7
Glucose tolerance >11.1
Urine dip ++ glucose
What is the mechanism behind DKA?
Metabolic acidosis, hyperglycaemia, ketonamia
Lack of insulin = reduced production of pyruvate
Acetyl coA increases so ketones increase
Genetic link with diabetes
T1DM - HLA D4/3 lniked
T2DM - stronger family link but no HLA association
T2DM RF
CVD risk factors - HTN, high cholesterol
Age >45
Obesity Fam Hx
Ethnicity - Asian + Hispanic
Gestational DM or baby >4.5kg
PCOS - leads to insulin resistance
Diagnosis of T2DM
Symptomatic + 1 positive test result
Asymptomatic + 2 positive test results
Positive tests: fasting >7, random >11.1, OGTT >11.1
HbA1c >48 = diagnostic
Microvascular complications of DM
Retinopathy Nephropathy Neuropathy
Macrovascular complications of DM
IHD Stroke PVD
General complications of DM
Immunocompromised - due to bacteria thriving in hyperglycaemic environment
Poor healing
Annual monitoring for DM
ABCDEFG
Advice
BP
Cholesterol
Diabetic control - HbA1c, albumin:creatinine ratio
Eyes - fundoscopy
Feet - diabetic foot exam
Glycaemic control (drugs)
What is ACR?
Albumin: creatinine ratio/ PCR first wee in the morning
Should be low <30 - high result indicates nephropathy
What are the stages of diabetic retinopathy?
Background = dot+blot haemorrhages, microaneurysms, hard exudates
Maculopathy = decreasing visual acuity, haemorrhages around macular
Pre-proliferative = cotton wool spots
Proliferative = new vessel formation
Difference between microaneurysms + haemorrhages
Microaneurysms = along the line of blood vessels Haemorrhages = random bleeds (flame + splinter)
What are cotton wool spots + hard exudates?
Soft exudate = ischaemia of retina
Hard exudates = lipid deposition
Types of insulin
Short, medium + long acting
Types of insulin regime
BD biphasic: premixed insulins BD
QDS regimen (basal bolus): before meals short acting insulin + long acting at bedtime
ON regime: OD long acting before bed
DAFNE regime: calculate carbs + adjust insulin
What is the sick day rule?
Don’t stop, maintain calorie intake, check BM QDS
Mechanism of metformin + CI
Biguanide
Increases sensitivity to insulin
Doesn’t increase amount of insulin therefore no hypos
Helps with weight loss
CI with high creatinine
SE of metformin
Nausea + diarrhoea - less so with modified release
Doesn’t cause hypos
Mechanism + SE of SU, name of SU
eg Gliclazide, Glimeparide
Increases insulin secretion
Causes weight gain
Can get hypos
Need to monitor BM + inform DVLA
Mechanism, names of + SE of DPP4 inhibitors
eg Sitagliptin
Blocks action of DPP4 - augments insulin + lowers blood glucose
Mechanism, names of + SE of Glitazone
eg Pioglitazone
Increases insulin sensitivity
CI in HF - due to fluid retention
Can get hypos
SE: deranged LFTs, fluid retention
Mechanism, names of + SE of SLGT-1
eg Gliflozins
Blocks reabsorption of glucose in kidneys
What are the diabetic emergencies?
DKA HHS Hypo
S+S of DKA
Drowsiness, vomiting, dehydration
Abdo pain Polyuria/ dipsia
Kussmaul hyperventilation = trying to blow off CO2 (trying to get a respiratory alkalosis to compensate)
ABG results for DKA
high O2, low CO2 (due to hyperventilation - normal if not)
pH = acidotic, base excess will be low, bicarb low <18
Causes of DKA
Infection, surgery, MI, pancreatitis, non-compliance (diabolemia)
Management of DKA
ABCDE approach
If hypotensive = fluid challenge (1L over an hour, then 1L over 2 hours, then 1L over 4 hrs)
Fixed rate insulin infusion 0.1 units/ kg/ hour (70kg = 7 units per hour)
Check VBG at 1h, 2h + 2hrly afterwards
When glucose <14, start 10% glucose fluids
Caution of hypokalaemia in DKA
Insulin pushes K+ into cells causing hypokalaemia
Check VBGs regularly, and give K+ if hypokalaemic
When do you stop insulin infusion in DKA?
When ketones <0.3, venous pH <7.3, HCO3 >18
What is a hypo?
BM <4 GCS <15
What is bronze diabetes?
Caused by haemochromatosis
likely to get liver cancer
How often are diabetics checked up?
Diet controlled - once a year
Tablet controlled - twice a year
Unstable/ symptomatic - 4 times a year (HbA1c takes 3 months to change)
What is HHS caused by?
Hyperglycaemia >40
High serum osmolality >320
Absence of significant acidosis
S+S of HHS
Confusion
Dehydration
Neuro dysfunction
Weakness
Seizures
Coma
Management of HHS
IV 0.9% NaCl
Aim for fall in glucose no more than 5mmol/ hr
Start IV insulin when blood glucose no longer falling with fluids
Treat underlying cause
Complications of HHS
Vascular complications eg MI, stroke, PAD can cause:
Seizures, cerebral oedema + central pontine myelinosis
Describe the pathology of central + nephrotic diabetes insipidus, how it is diagnosed + treated
Central diabetes insipidus = due to ADH deficiency
Nephrogenic diabetes insipidus = due to ADH insensitivity
DI – diagnose with water deprivation test – if plasma osmolarity increases + urine remains dilute = DI. Then give desmopressin – if urine becomes concentrated = CDI. If not, NDI
Treat CDI with desmopressin, NDI with thiazide diuretics
What investigation is used for chacot’s arthropathy + foot infection in diabetics?
Charcots = x ray, MRI if inconclusive
Infection = send soft tissue sample to microbio, consider x ray for osteomyelitis
What is the initial management of a diabetic foot ulcer?
Use SINBAD or Uni of Texas system to classify ulcer
Offer: offloading, control of foot infection + ischemia, wound debridement + dressings
What is the SINBAD classification?
Site
Ischemia
Neuropathy
Bacterial infection
Area
Depth
Management of charcot’s arthropathy
Non-removable offloading device
Take serial x rays until it resolves
Likely to resolve with sustained temperature difference of less than 2 degrees
Management of diabetic foot infection
?osteomyelitis - get an x ray
Take cultures + start abx
Osteomyelitis = abx for 6 weeks
What clinical factors suggest osteomyelitis?
Grossly visible bone
Ulcer larger than 2cm
Ulcer duration longer than 2 weeks
ESR >70
What bacteria cause diabetic foot infections?
Superficial = aerobic gram positive cocci
Deep/ chronic = polymicrobial
Smart goals for DM (ABCDES)
A1C <7%
BP – optimise
Cholesterol <2 (LDL)
Drugs: ACEi, statin + aspirin
Exercise + eating
Smoking cessation
Total insulin requirements for T1/2DM
T1 = 0.5 units/kg/day
T2 = 0.3 units/kg/day
Which DM med is best for CV disease?
SGLT2 inhibitor
Which DM meds are the most effective at lowering A1c?
GLP-1 + SGLT2
When to prescribe BP meds, statins + aspirin in DM?
ACEi if:
- Microvascular disease present
- Age >55
Statin if:
- Microvascular disease
- Age >40
- Age <40 AND diabetes >15 years or CV RF
Aspirin if:
- Pts with established CVD