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Diabetes, Coma and Complications
Terms in this set (143)
Why do athletes use insulin?
How does the body make insulin (genes)
Pre-pro insulin --> pro insulin --> peptide insulin
How does the body use glucose (2)
Stored in liver (glycogen)
Burned in muscle
What ways can glucose enter the blood (2)
Liver de novo
Is there ever a time that insulin is not being secreted from the pancreas?
No.. releases a baseline volume which increases when there is an increase in glucose in the blood
Definition of diabetes:
Metabolic disorder caused by chronic hyperglycaemia resulting from defects of secreting insulin, insulin action or both
What 3 unrelated diabetic problems can induce diabetes?
Steroid induced diabetes
Anti-psychotics induced diabetes
(prevents insulin uptake in cells)
2 clinical methods of diagnosing diabetes
Oral-Glucose Tolerance Test
What is the oral-glucose tolerance test?
Give glucose and measure blood levels post 2 hours.
If diabetic, results will be 7+mmol/L
What is measuring HbA1C?
Glycosylated Hb (Glucose in blood)- higher in diabetics
What time-span does HbA1c measure glucose levels
2-3 month trends (not rapid changes in glucose)
When do you measure HbA1C in patients? (5)
All symptomatic young people
Symptoms suggesting type 1 diabetes
Short duration diabetes symptoms
High risk patients (acute illness)
Taking medications that can raise glucose (Steroids/Antipsychotics)
What is HbA1c not good at detecting
Recent problems with glucose control. (if insulin suddenly stops being released, will still measure lower HbA1c than actual
Why should you take a FBC with HbA1C too?
To exclude thalassaemia and uraemia as a differential diagnosis
What is thalassaemia?
Heamolysis of Hb / defect of Hb- hence why low levels of HbA1C
What is uraemia?
Urea competitively binding with Hb (Hb-Carbamylates)
Normal Fasting Glucose
Normal 2 hour glucose
Diabetes fasting glucose
Diabetes 2 hour glucose
2 hour IFG
2 hour glucose IGT
What concentration blood glucose displays macrovascular changes?
What concentration blood glucose displays microvascular changes?
What type of vascular disease do diabetes encounter?
Micro and Macrovascular disease
What is impaired fasting glucose?
Abnormally higher levels of glucose in blood when fasting (6.1-7)
What is impaired glucose tolerance?
cell resistance to glucose; Higher levels of blood glucose fasting and after 2 hours
What is the cause of 1) IFG and 2)IGT
2) insulin resistance
What is the chance of either IFG or IGT progressing to diabetes?
How can you treat IFG?
1 year glucose checks
What diseases can IGT cause?
How do you treat IGT?
Optimise treatment of cardiac risk factors
1 year glucose checks
What are the 2 causes of Insulin deficiency?
Type 1 DM (autoimmune)
Alcoholism/Cancer (destruction of pancreas)
What are the 3 causes of Insulin resistance? (3)
Obesity (type 2; unknown link)
Receptor Abnormalities (leprachaunism and insulin resistance syndromes A and B)
Excessive hormones (Cushings/Acromegaly)
Gestational Diabetes causes
Increased glucose in blood to deal with added load from foetus
How can you prevent progression of IGT to Diabetes?
Exercise and weight loss
Prevalence of Type 1 diabetes
What is more genetic- type 1 or 2?
Type 2 (4x more likely to get it if parent has it)
What is the silk worm theory?
Too sterile environment- bacterial endotoxin not exposed to child so immune system gets confused whether self vs non self and therefore attack itself
What is the pathogenesis of Type 1 diabetes? (3)
Exposure Antigen (silk worm theory)
Expression of antibodies
Symptoms of Type 1 diabetes (5)
Polyuria and bedwetting
What does exercise do to patients with Type 1 diabetes?
Possible slowing down of Beta cells in the Islets of Langerhans
What are plausible triggers for Type 1 DM?
Triggering factor antigens (DR3+ and DR4+)
Treatment of Type 1 DM?
2x daily injections
4x a day basal bolus
what are "new insulins"? (2)
What are the two types of Type 1 diabetes pancreas transplants?
Islet cells- infused islets from donor into the hepatic portal vein of recipient
Whole pancreas implanted in the duodenum
What does a transplant patient need lifelong?
Immunosupression drugs -- susceptible to infection
What is a pro of new insulins compared to injected insulin?
Binds onto a faster vector to get to the receptor quicker (works quicker)
What is the impression of Inhaled insulin? (3)
only done on small trials (10% dose absorbed)
Don't know long term safety
What is the impression of Insulin pumps (3)
Less insulin injections (continuous bolus of insulin which increases/reduces depending on glucose rich meals)
Costly and Time Consuming
When doing short duration surgery for Type 1 DM patients, when should you do it?
1st on the list; morning appointments
What should you monitor/do during short duration surgery for Type 1 DM patients? (4)
Half the normal morning dose insulin/ no pills
start medications when eating
When doing long duration surgery for Type 1 DM patients, when should you do it?
Morning appointments (first)
What should you monitor/do during long duration surgery for Type 1 DM patients? (4)
Insulin sliding scale
IV glucose and K+ (ATP sensitive K+ Channel)
Cover with Antibiotics
Start medications when eating
Incidence of Type 2 DM
Males= women (~40 years+)
1/1000 (50% undiagnosed)
If you don't exercise, what happens to insulin resistance
What are is the pathology of Type 2 DM?
Insulin Resistance (small baby theory)
What is the small baby theory?
If born smaller and grows into normal weight/big , you'll be more insulin resistant because your body was naturally made smaller
What is the 2 step model in diabetes?
Genetically predisposed --> IGT (resistance) --> diet, activity levels and obesity --> lack of insulin --> hyperglycaemia
How do you screen asymptomatic patients?
Random Plasma Glucose (7+)
What are metabolic symptoms of Type 2 DM? (2)
(less acute than type 1)
What are non metabolic symptoms of Type 2 DM?
Prutitis Vulvae/ Balanitis
Type of onset of symptoms in Type 2Diabetes
Treatment of Type 2 diabetes
Sulphonylureas (if thin - 1st line)
Metaformin (if overweight- 1st line)
Newer drugs: Thiazolidinediones
What is intertrigo
An inflammatory rash of the body folds
What are examples of Sulphonylureas?
Tolbuamide, Glibenclamide, Gliclazide
Why are thin people more sensitive to sulphonylureas?
They have a more genetic form of diabetes sensitive to this particular drug
How do sulphonylureas work? (2)
Stimulate release of insulin in pancreas (flogs the pancreas)
Increases muscle uptake of glucose
Problem of sulphonylureas;
Constant flogging can cause failure; treatment only lasts ~2-3 years
What are side effects of sulphonylureas? (5)
Nausea, anorexia , vomitting
What other diseases can Metaformin be preventative drug for?
How does Metaformin work
Increased sensitivity of cells to insulin
Why is metaformin indicated for Overweight Type 2?
Less mortality and weight gain
What are side effects of metaformin? (3)
Diarrhoea, Nausea, vomitting,
Vitamin B12 malabsorption
Example of a Thiazolidinedione
What is the mechanism of action of Thiazolidinediones (3)
Increase insulin sensitivity
Increases muscle uptake
Decreases endogenous secretion from liver
When do you take Thiazolidinediones?
With other drugs
What are side effects of Thiazolidinediones?
Fluid retention and Weight gain
Vitamin B12 deficiency
What 2 types of drugs affect absorption (controlling diabetes)
Lipase inhibitors (orlistat)
Alpha glucosidase inhibitors (acarbose)
What are the side effects of diabetic drugs which affect absorption?
how does lipase inhibitors work?
Decrease pancreatic and gastric lipase- less absorption therefore less exogenous glucose
Do you get hypos with Drugs that affect absorption
What is the incretin effect?
GLP-1, Glucagon and Gastric inhibitory Polypeptide secreted after eating.
GLP-1 have different roles in the body which causes uptake of glucose (5 roles)
What are incretin molecules? (3)
GIP (Gastric inhibitory polypeptide)
What is the role of GLP-1 on Alpha cells
Suppress glucagon secretion
What is the role of GLP-1 on Beta cells
Increase insulin secretion
What is the role of GLP-1 on the brain
Increases satiety and reduce appetite
What is the role of GLP-1 in the liver
Reduces hepatic glucose output
What is the role of GLP-1 in the stomach
Shows rate of gastric emptying
What inhibits GLP-1 effects?
What are the types of Incretin-based diabetic therapies
GLP-1 Receptor agonists
What type of drugs are DDP-4 inhibitors? (5)
What type of drugs are GLP-1 agonists?
What are the pros of GLP-1 agonists/analogues (4)
Resistant to DDP-4 degradation
Stomach, Alpha, Beta cell effects like GLP-1
What receptor in the kidneys is glucose reabsorbed through?
How do kidneys maintain sugar levels?
Normal co-transported through SGLT-2 transporters back into the blood
What do SGLT-2 inhibitors do?
Prevent reabsorption of glucose in PCT- glycosuria and a reduction of HbA1C
Example of SGLT-2 inhibitor
What other side effects do you get with SGLT-2 inhibitor?
What are the 2 insulin sensitiser drugs?
What are insulin releaser drugs ? (1)
Insulin replacement method:
What are Insulin independent mechanisms?
What are glucose excretion/calorific method drugs?
When do women experience gestational diabetes?
2-3rd trimester pregnancy
What are risk factors for gestational diabetes? (4)
35+ year olds
Previous history GD
Treatment of gestational diabetes (2)
85% Diet alone
15% diet and insulin
What is the prognosis with women with Gestational diabetes? (2)
50% will get diabetes within 5 years
15% will have GD in next pregnancy
What is the marker for Type 1 DM (antigen)
What are the onset of symptoms like in Type 1 and 2 DM?
Type 1- fast onset
Type 2- slow onset
What are acute complications of Diabetes? (2)
What are chronic complications of diabetes (2)
What are 3 microvascular complications (3)
What are 3 Macrovascular complications?
How do you treat Hypos? (conscious, drowzy, unconscious)
Conscious- oral glucose then long-lasting carbs
Drowzy- hypostop (gel)
Unconscious- S/C glucagon or IV 50% dextrose
What hormonal complications can cause diabetes?
What hormones decrease peripheral glucose uptake into liver (3)
Early Symptoms of Hypoglycaemia (5)
Shaky, pins and needles
Mild symptoms of Hypoglycaemia (3)
Advanced symptoms of hypoglycaemia (2)
What could happen in an unconscious hypoglycaemic patient?
What can cause a hypo
What is DKA?
Diabetic ketoacidosis in Type 1 DM
Symptoms of ketoacidosis?
Signs of ketoacidosis?
Impaired consciousness/coma (fast)
Blood sugar high (15+)
Urine ketones (2+)
Blood pH <7.2
What should you be wary about when measuring ketones in urine?
Some medications can show false positives
What are the causes of hyperglycaemia? (4)
Why do you get more ketones due to a lack of insulin?
Breakdown of fats produce ketones (good for brain but not for the rest of the body)
Treatment of hyperglycaemia
IV Saline and k+ (Treating hypotension and electrolytes)
IV dextrose (starvation treatment)
Treat underlying cause (infection, pregnancy etc)
Investigations for potential diabetic patients?
What is HONK
hyper-molar non ketoic hyperglycaemia
When is HONK most common
Type 2 diabetes
How do you diagnose HONK?
Blood glucose 30+
Blood pH 7.2+
Urine Ketone <1
low plasma osmolarity
Treatment of HONK
Iv saline and K+
Find underlying causes
Heparin (risk of clotting with HONK)
How long is the lag between chronic complications in type 1 diabetes?
How long is the lag between chronic complications in type 2 DM?
Less time lag
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