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Diabetes Lubna Sheikh

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Type 1: the body's failure to produce sufficient insulin Type 2: resistance to the insulin, often initially with normal or increased levels of circulating insulin Gestational diabetes: occurs in pregnancy Secondary diabetes: 1-2% of patients with diabetes Causes include: cystic fibrosis, chronic pancreatitis, cushings, thyrotoxicosis, steroids. What is it?

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Type 1 15% of those that have diabetes Juvenile onset, but can occur at any age HLA DR3 and DR4 and islet cell antibodies Always need insulin therapy At risk of ketoacidosis Caucasian of Northern European ancestry Type 2 85% Usually diagnosed

Fasting glucose > 7 mmol/L and a glucose tolerance test OR Random glucose > 11mmol/L (usually on 2 separate occasions) Diagnosis

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Emergency: Diabetic ketoacidosis (DKA) Hyperglycaemic Hyperosmolar Non Ketotic state (HONK) Hypoglycaemia Long term Macrovascular Stroke, MI, Peripheral vascular disease Microvascular Neuropathy, nephropathy, retinopathy Complications

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Self-management Education Coping Diet Smoking Regular monitoring New Symptoms Of cardiovascular, cerebrovascular, renal, ophthalmological or neurological complications of diabetes? Erectile dysfunction Screen for depression Pregnancy and pre-pregnancy Are they pregnant or planning on having any children? Blood results HbA1c Home glucose monitoring results. Non-fasting lipid profile. Estimated glomerular filtration rate Side effects of medication Diabetic Review

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Conservative Lifestyle weight loss, dietitian input, low refined sugar in diet, exercise regime Smoking cessation help and advice Foot care Eye checks Medical Type 1: Insulin regimes Type 2: Metformin, Sulphonylureas, Glitazones, DDP4 inhibitors, Insulins Control BP, cholesterol and other risk factors Surgical Islet cell transplants Complications e.g. amputation Management

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Medical Management Metformin Increases insulin sensitivity Normally first line treatment Side effects: epigastric pain, anorexia and diarrhoea. Metformin should not be used in cases of severe liver or kidney disease as lactic acidosis has been known to occur. Sulphonylureas Promote insulin secretion in response to glucose Should be avoided during pregnancy They encourage weight gain and therefore should not be first line treatment in obese patients. They interact with warfarin Main side effect: Hypoglycaemia

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OnsetPeakDurationExample Short-acting30 minutes2-4 hours8 hoursActrapid Humulin S Intermediate1-2 hours4-12 hours16-24 hoursInsulatard Humulin I Long-acting1-2 hours4-12 hours20-35 hoursHuman Ultratard Humulin Zn Insulin

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Insulin Regimens

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A 52 year old man presents to his GP as he has been feeling lethargic and tired for the last few months. He has over the last 2 weeks also become very thirsty and is drinking more than normal. He reports no other significant symptoms. He suffers from hypertension which is managed with ramipril and has no known allergies. He works as a librarian and is overweight. He drinks socially and smokes 5 cigarettes a day. Clinical scenario 1

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How would you investigate this man? What might urinalysis show? How would you manage this gentleman? What are the micro and macrovascular complications of diabetes?

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A 7-year-old male patient presented to the emergency department at 2 AM with vomiting and abdominal pain. He had a 2-week history of polyuria and polydipsia, accompanied by a 20-pound weight loss and blurred vision. His medical history was unremarkable. BP on admission was 120/75. Clinical Scenario 2

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What signs might you see in this patient? What causes the blurred vision? How would you manage this patient?

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Rehydrate give 1L Hartmanns solution per hour for two hours, then reduce. Insulin give 6 units, then 6 further units per hour adjust according to sliding scale Potassium give with caution while monitoring cardiac rhythm Acidosis if the pH is less than 7.30 get urgent advice; give IV HCO 3 if pH < 7.0. Stomach aspiration to help remove excess potassium K+ is transported into cells from the blood in co-transport with glucose in cases of a lack of insulin, this process does not occur. RIPAS