DIABETES FOR FINALS Dr Emma Hodgkins, FY1

DIABETES WORLDWIDE

Globally 285 million people currently have diabetes, which is estimated to double by 2030.

UK prevalence 4.5% (5.5% in England)

Diabetes is currently the fifth most common reason for death in the world.

Around 1 in 8 people between 20 and 79 years old have their death attributed to diabetes and it is expected to rise.

The life expectancy on average now is reduced by: More than 20 years for people with Type 1 diabetes Up to 10 years for people with Type 2 diabetes

WHAT ARE THE DIAGNOSTIC CRITERIA FOR DIABETES?

CRITERIA FOR DIAGNOSING DIABETES

Fasting Glucose > 7mmol/L Random glucose >11.1 mmol/mol 2h glucose >11.1 in an OGTT HbA1c > 6.5% (48 mmol/mol)

‘Pre-diabetes’ Impaired glucose tolerance = 2h glucose 7-11.1 Impaired fasting glucose = fasting 6.1-7.0

HBA1C

Two large-scale studies - the UK Prospective Diabetes Study (UKPDS) and the Diabetes C ontrol and Complications Trial (DCCT) - demonstrated that improving HbA1c by 1% (or 11 mmol/mol) for people with type 1 diabetes or type 2 diabetes cuts the risk of microvascular complications by 25%.

Research has also shown that people with type 2 diabetes who reduce their HbA1c level by 1% are: 19% less likely to suffer cataracts 16% less likely to suffer heart failure 43% less likely to suffer amputation or death

due to peripheral vascular disease New = [Old % - 2.15] x 11

Old % = [New ÷ 11] + 2.15

HOW DO YOU MANAGE DKA?

DKA

Diagnostic criteria: all three of the following must be present capillary blood glucose above 11 mmol/L capillary ketones above 3 mmol/L or urine

ketones ++ or more venous pH less than 7.3 and/or

bicarbonate less than 15 mmol/L

MANAGING DKA (2)Fluid replacement 1L NaCl over 1 hr1L NaCl with KCl over 2 hours, 1L NaCl with KCL over 2 hours1L NaCl with KCl over 4 hoursAdd 10% glucose 125ml/hr if blood glucose falls below 14 mmol/L

Potassium ReplacementSerum K > 5.5 NilK 3.5-5.540mmol/LK < 3.5 Seek Sr review

Insuin : Fixed rate insulin infusion(AFTER setting up IV fluids)

(0.1unit/kg/hr) 50 insulin (Actrapid® or Humulin S®) made up to 50ml with0.9% sodium chloride solution

Aims of treatment: Rate of fall of ketones of at least 0.5 mmol/L/hrBlood glucose fall 3 mmol/L/hr Maintain serum potassium in normal rangeAvoid hypoglycaemia

MANAGING HONK

AKA Hyperosmotic Hyperglycaemic state (HHS) Veinous access, bloods, blood cultures, blood gas 1L NaCl over 30 mins

Insulin therapy Aim to reduce glucose levels slowly, by

approximately 3 mmol/hour.Patients with HHS are often exquisitely sensitive to insulin and require much lower doses than in (DKA).

Mortality 10-20%

HOW DO YOU MANAGE HYPOGLYCAEMIA?

MANAGING HYPOS

If Low GCS: Protect Airway, 15L O2 IV access 50l 50% glucose STAT (100 of 20%, 200 of 10%) For large insulin OD give

1mg of glucagon SC/IM/IV Should respond in 10 min 1L 10% glucose over 4-8h Aim for BM > 5

If GCS 15 Oral glucose (120ml

lucuzade, HYPOSTOP/ Glucogel)

This only lasts 1h so give a sandwich too!

Monitor finger prick glucose 1-2 hrly until stable

WHAT ARE THE STAGES OF DIABETIC RETINOPATHY?

DIABETIC RETINOPATHY (1) Commonest cause of blindness in under 65s Background

Microaneurysms (Dots) Blot Haemorrhages, Hard Exudates (lipid leaked from aneurysms)

Pre-proliferative Cotton-wool spots, Beading & looping

DIABETIC RETINOPATHY (2) Proliferative

New vessels around the disc & peripherally New vessels on the iris (rubeosis)

End Stage Vitreous haemorrhage, scarring, retinal detachment

Urgent Referral: Fall in acuity, 1 cotton wool spot, 3 blots, New vessels

HOW DOES DIABETIC NEPHROPATHY OCCUR?

DIABETIC NEPHROPATHY

Hyperglycaemia

Mesangeal Proliferation

Nephron loss

Activation of RAAS

Glomerular Hypertension

Hyperfiltration of protein

MicroalbuminaemiaProteinuria

Tubular damage

Cytokine adtivation

Inflammation

Glycation of proteins

Thick BM

THE DIABETIC FOOT Combination of peripheral vascular disease &

neuropathy Lack of sensation to heat and trauma foot ulcers Impaired healing Charcot foot: osteoporosis, fracture and inflammation

– often presents as a hot swollen foot after minor trauma

Increased risk of osteomyelitis necrosis, gangrene & amputation

WHAT IS YOUR LONG TERM MANAGEMENT STRATEGY FOR DIABETES?

LONG TERM DIABETES MANAGEMENT

INSULIN REGIMES

DIABETES DRUGS

GLP ANALOGUES & DPP4 INHIBITORS

REFERENCES

ABC of diabetes Oxford handbook of the foundation programme Oxford handbook of clinical medicine Dr Clarke- Medicine http://www.bsped.org.uk/clinical/docs/jbdsdkaguideli

nes_may11.pdf DKA guideline

http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf Paeds DKA

Thanks and Good Luck!!