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A - BNF COPY > Chapter 6: Type 1 Diabetes, Insulin & Hypoglycaemia > Flashcards

Chapter 6: Type 1 Diabetes, Insulin & Hypoglycaemia Flashcards

1
Q

Characterised by persistent hyperglycaemia, what are the two ways in which diabetes can manifest?

A
  1. Deficient insulin secretion

2. Resistance to actions of insulin

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2
Q

What are the 4 types of diabetes?

A
  1. Type 1
  2. Type 2
  3. Gestational
  4. Secondary
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3
Q

To which 3 conditions can diabetes be secondary?

A
  1. Pancreatic damage
  2. Hepatitis
  3. Endocrine disease
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4
Q

Which agency must be notified if someone has diabetes and is being treated with insulin?

A

DVLA

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5
Q

Which adverse event should drivers be particularly careful of?

A

Hypoglycaemia

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6
Q

What must diabetics always carry to ensure they are informed about their plasma glucose?

A
  1. Glucose meter

2. Test strips

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7
Q

Diabetics using insulin should check their plasma glucose how long before driving?

A

Two hours

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8
Q

While driving how often should diabetics using insulin test their plasma glucose?

A

Every two hours - more frequent if recent activity that may increase risk of hypo

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9
Q

While driving, plasma glucose of diabetic drivers should always be above what threshold?

A

5mmol/L

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10
Q

If plasma glucose falls slightly below 5mmol/L, what should diabetic drivers using insulin do?

A

Have a fast-acting carbohydrated

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11
Q

What are the 3 steps that diabetic drivers using insulin should take if their plasma glucose falls below 4mmol/L

A
  1. Stop driving
  2. Switch off the engine, remove keys and move from driver’s seat
  3. Consume source of sugar
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12
Q

How long should diabetic drivers using insulin wait before driving after stopping due to it falling below 4mmol/L?

A

45 minutes after it has returned to normal

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13
Q

Under which circumstances should diabetic drivers using insulin not drive?

A

If hypoglycaemia awareness has been lost

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14
Q

As well as insulin, which other diabetic medicines may it be necessary to inform the DVLA about? (3)

A
  1. Sulphonylureas
  2. Nateglinide
  3. Repaglinide
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15
Q

Which lifestyle activity can mask the signs of hypoglycaemia?

A

Alcohol

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16
Q

Is it advised for all diabetics to avoid drinking alcohol?

A

No, they must drink in moderation and with food

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17
Q

Which test is mainly used to diagnose impaired glucose control? It is useful for when patients do not have severe symptoms but glucose tolerance is impaired

A

Oral Glucose Tolerance Test

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18
Q

If symptoms are already present, should the OGTT be used to diagnose diabetes?

A

No

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19
Q

In which type of diabetes is OGTT especially useful in diagnosing?

A

Gestational diabetes

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20
Q

How is the OGTT conducted?

A

Plasma glucose is measured after fasting.
Patient drinks glucose drink.
Plasma glucose is measured 2 hours after

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21
Q

Which test is a good indicator for glycaemic control?

A

HbA1c

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22
Q

What does HbA1c measure?

A

The amount of glycated haemoglobin

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23
Q

HbA1c shows average glucose control over how long?

A

The last 2-3 months

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24
Q

Should a patient fast before their HbA1c test?

A

No

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25
Q

HbA1c is used in Type 1 and Type 2 monitoring and diagnosis of Type 2, in which situations should it not be used? (10)

A
  1. Type 1 diagnosis
  2. Children
  3. Pregnancy
  4. Up to 2 months post-partum
  5. Symptoms of diabetes less than 2 months
  6. High risk diabetes or critically ill
  7. Treatment with medication that causes hyperglyacemia
  8. Acute pancreatic damage
  9. End stage CKD
  10. HIV
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26
Q

In Type 1 Diabetes, how often should HbA1c be measured?

A

every 2-3months

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27
Q

In Type 2 Diabetes, how often should HbA1c be measured?

A

every 2-3months

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28
Q

In which patients is HbA1c monitoring invalid?

A
  1. Disturbed erythrocyte turnover

2. Lack of/abnormal haemoglobin

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29
Q

In patients which HbA1c monitoring is invalid, what can be used instead?

A
  1. Quality controlled blood glucose profiles
  2. Total glycated haemoglobin estimation
  3. Fructosamine estimation
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30
Q

What does fructosamine estimation measure?

A

Glycated concentration of ALL plasma proteins over 14-21 days

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31
Q

Can type 1 diabetes produce endogenous insulin?

A

No (little to none)

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32
Q

Why is there no insulin secretion in type 1 diabetes?

A

Destruction of insulin-producing pancreatic beta cells

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33
Q

What causes the destruction of pancreatic beta cells in type 1 diabetes?

A

Auto-immune basis

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34
Q

At what age does type 1 diabetes most commonly occur?

A

Before adulthood

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35
Q

What are the microvascular complications of diabetes? (3)

A
  1. Nephropathy
  2. Neuropathy
  3. Retinopathy
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36
Q

What are the macrovascular complications of diabetes? (3)

A
  1. Stroke
  2. Cardiovascular disease (MI)
  3. Peripheral arterial disease
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37
Q

What blood glucose reading would you expect an adult presenting with Type 1 Diabetes to have?

A

Over 11mmol/L

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38
Q

What BMI would you expect an adult presenting with Type 1 Diabetes to have?

A

Less than 25kg/m2

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39
Q

How old would you expect an adult presenting with Type 1 Diabetes to be?

A

Less than 50

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40
Q

As well as hyperglycaemia, low BMI, and younger than 50, what other characteristics do adults presenting with T1DM have? (3)

A
  1. Rapid weight loss
  2. Ketosis
  3. (Family) history of autoimmune disease
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41
Q

Increasingly used in T2DM, what is the mainstay of treatment for T1DM?

A

Insulin

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42
Q

Using insulin regimens, what are the 3 aims of treating T1DM?

A
  1. Achieve blood glucose control
  2. Reduce frequency of hypoglycaemic episodes
  3. Minimise the risk of microvascular and macrovascular complications
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43
Q

What is the target HbA1c for T1DM?

A

Less than 48mmol/mol

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44
Q

How often must T1DM patients monitor their blood glucose daily?

A

at least 4 times daily - before each meal and before bed

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45
Q

What is the target fasting blood glucose for T1DM patients?

A

5-7mmol/L

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46
Q

What is the target random blood glucose for T1DM patients?

A

4-7mmol/L

47
Q

What is the target blood glucose for T1DM patients after eating?

A

5-9mmol/L

48
Q

As well as controlling blood glucose with insulin, which other cardiovascular risk factors must be actively managed in patients with diabetes?

A
  1. Hypertension

2. Blood lipids

49
Q

Unlicensed, which oral antidiabetic can be used alongside insulin in the management of T1DM?

A

Metformin

50
Q

Unlicensed, in which patients can Metformin be used alongside insulin in the management of T1DM?

A

BMI over 25 (over 23 S. Asian)

51
Q

What are the advantages of usince Metformin alongside insulin (unlicensed) in T1DM?

A
  1. Improve blood glucose

2. Minimise insulin dose

52
Q

Which other healthcare professional should be involved in manageing patients with diabetes to ensure they control their weight, lower cardiovascular risk and understand the hyperglycaemia effects of food?

A

Dietician

53
Q

What type of training must T1DM patients receive in order to tailor their insulin dose throughout the day?

A

Carbohydrate-counting training

54
Q

Can insulin be initiated by the GP?

A

No, specilist initiation and management

55
Q

What are the 3 main insulin REGIMENS?

A
  1. Multiple daily BASAL-BOLUS regimens
  2. Mixed (BIPHASIC) regimens
  3. Continuous subcutaneous insulin infusion
56
Q

A basal insulin injection is…

A

Long acting

57
Q

A bolus insulin injection is…

A

Short acting

58
Q

What does a mixed (biphasic) regimen injection contain?

A

Short acting + intermediate acting

59
Q

What is the first line recommended insulin regimen for patients with T1DM?

A

Basal-bolus

60
Q

Give 2 examples of long acting insulin injections

A
  1. Insulin detemir

2. Insulin glargine

61
Q

Are non basal-bolus insulin regimens recommended for patients newly diagnosed with T1DM? Examples: biphasic, basal-only, bolus-only

A

NO

62
Q

When should rapid acting insulin be administered?

A

Before meals

63
Q

What is the second line insulin regimen for patients with T1DM?

A

Biphasic

64
Q

Which insulin regimen should patients with disabling hyperglyceamia or high HbA1c above 69 mmol/mol be given? Specialist initiation only

A

Continuous subcutaneous insulin infusion

65
Q

What can persistent poor glucose control be due to?

A
  1. Adherence issues
  2. Poor injection technique
  3. Injection site issues
  4. Poor blood-glucose monitoring skills
  5. Lifestyle (diet/exercise/alcohol)
  6. Psychological issues
  7. Organic disease
66
Q

Give 5 examples of organic disease that may cause poor glucose control

A
  1. Renal disease
  2. Thyroid disorder
  3. Coeliac disease
  4. Addison’s disease
  5. Gastroparesis
67
Q

Under which circumstances might a patient require increased insulin? (3)

A
  1. Infection
  2. Stress
  3. Accidental/Surgical trauma
68
Q

Under which circumstances might a patient require decreased insulin? (3)

A
  1. Physical activity
  2. Intercurrent illness
  3. Reduced food intake
  4. Impaired renal function
  5. Endocrine disorders
69
Q

What are the early symptoms of hypoglycaemia? (8)

A
  1. Palour
  2. Tingling lips
  3. Sweating
  4. Palpitations
  5. Fatigue
  6. Hunger
  7. Shaking/Trembling
  8. Irritable
70
Q

What are the symptoms of more advanced hypoglycaemia? (8)

A
  1. Weakness
  2. Blurred vision
  3. Difficulty concentrating
  4. Slurred speech
  5. Confusion
  6. Sleepiness
  7. Seizures
  8. Coma
71
Q

What is an invetiable adverse effect of insulin?

A

Hypoglycaemia

72
Q

When can impaired hypoglycaemia awareness occur? (2)

A
  1. Ability to recognise symptoms is lost

2. Symptoms are blunted / no longer present

73
Q

Which questionnaire can be used to assess hypoglycaemia awareness?

A

Gold/Clarke score

74
Q

What may reduce warning signs of hypoglyacemia?

A

Increased frequency of hypoglycaemia episodes

75
Q

Impaired awareness of symptoms at which plasma glucose reading is considered significant?

A

less than 3mmol/L

76
Q

Which class of drug can blunt awareness of hypoglycaemia by reducing the warning sign: tremor?

A

Beta blockers

77
Q

Provided by the GP or community pharmacy, which container is used when disposing of insulin pens and needles?

A

Yellow sharps bin

78
Q

How is the yellow sharps bin full of insulin pens and needles disposed of?

A

Taken from the patient by the local authority

79
Q

What are the two functions of insulin?

A
  1. Increase glucose uptake by adipose tissue and muscles

2. Suppress hepatic glucose release

80
Q

Which insulin regimen best mimics the normal profile of the body releasing endogenous insulin?

A

Basal-bolus

81
Q

Insulins from which source are no longer initiated in patients with diabetes?

A

Animals

82
Q

How common is insulin allergy?

A

Rare

83
Q

Through which route is insulin usually administered?

A

Subcutaneous

84
Q

With plenty of subcutaneous fat, to which areas of the body is insulin injected? (3)

A
  1. Abdomen
  2. Outer thighs
  3. Buttocks
85
Q

Which factors can change rate of absorption? (6)

A
  1. Local tissue reactions
  2. Injection site
  3. Depth of injection
  4. Changes in insulin sensitivity
  5. Blood flow
  6. Amount injected
86
Q

What can increase the amount of blood flow at the injection site?

A

Exercise

87
Q

Causing erratic absorption of insulin, what can occur if injections are repeatedly administered to the same site?

A

Lipohypertrophy

88
Q

What does short-acting insulin replicate?

A

The insulin released by the body in response to a meal

89
Q

What are the 3 short-acting insulins?

A
  1. Insulin glulisine
  2. Insulin aspart
  3. Insulin lispro
90
Q

How long does short-acting insulin take to act?

A

15mins

91
Q

How long before meals should short-acting insulin be administered

A

Immediately

92
Q

Why should post-meal injections be avoided? (2)

A
  1. Poorer glucose control

2. Hypoglycemia

93
Q

What is the intermediate-acting insulin called?

A

Isophane insulin

94
Q

What does intermediate-acting insulin mimic?

A

Endogenous basal insulin continuously secreted in response to glucose production by liver

95
Q

How long does intermediate-acting insulin take to work?

A

1-2hours

96
Q

How long does intermediate-acting insulin last?

A

11-24hours

97
Q

What are the 2 regimen options for intermediate-acting insulins?

A
  1. One or more daily injections of intermediate insulin + short-acting insulins at meal times
  2. Mixed (biphasic) insulin injections
98
Q

What are the 3 long-acting insulins?

A
  1. Insulin detemir
  2. Insulin glargine
  3. Insulin degludec
99
Q

Which long-acting insulin can be administered either once or twice daily? The other two can only be administered once daily

A

Insulin detemir

100
Q

Mimimicing endogenous insulin, what is the duration of action of long-acting insulin?

A

36 hours

101
Q

How long does it take for long-acting insulin to reach steady state?

A

2-4 days

102
Q

What is the NHS improvement important safety alert regarding insulin devices?

A

Risk of severe harm and death due to withdrawing insulin from pen devices - Insulin should not be extracted from pen devices

103
Q

What is the recommended plasma glucose level in children with T1DM most of the time?

A

Between 4 and 10mmol/L

104
Q

When prescribing and dispensing insulin, which word should NOT be abbreviated?

A

“unit”

105
Q

When handing out insulin to a patient, what must you do?

A

Show them the contained to confirm the expected version is dispensed

106
Q

What is the initial treatment of hypoglycaemia?

A

10-20g glucose by mouth

107
Q

After the initial treatment of hypoglycaemia, what can be given to prevent levels falling again?

A

A carbohydrate snack

108
Q

When is hypoglycaemia an emergency?

A

If it cause unconsciousness

109
Q

In hypoglycaemia, if sugar cannot be given by mouth, what can be administered by injection?

A

Glucagon - increases the plasma-glucose concentration by mobilising glucagon stored in the liver

110
Q

True of false: Glucagon can be issued to close relatives of patients taking insulin to treat hypoglyacemia

A

TRUE

111
Q

In hypoglycaemia, what is the alternative treatment to glucagon?

A

Glucose 20% IV Infusion into a large vein

112
Q

In hyperglycaemia, glucose 20% can be administered as an alternative to glucagon. Why can’t glucose 50% be given? (2)

A
  1. High risk of extravasation

2. Difficult to administer

113
Q

Glucagon is not appropriate for use in chronic hypoglycaemia. Which drug can be administered by mouth to treat hypoglycaemia due to excess endogenous insulin secretion ?

A

Diazoxide

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