Endocrine e-book

Question 1

Diabetes mellitus is defined as

Answer 1

Diabetes mellitus is defined as a persistent state of hyperglycaemia due to the body’s inability to properly utilise glucose.
Glucose is an essential part of the diet- it is the fuel for all of the cells within the human body, and is essential for cells to be able to function.
In order for us to be able to utilise the glucose we ingest in our diets the glucose needs to be able to enter the cells. The entrance of glucose into the cells is facilitated by the hormone insulin which is produced by the pancreas.
In patients with diabetes the glucose is unable to enter the cells and therefore remains in the bloodstream where it cannot be used as energy

Question 2

2 types of DM

Answer 2

There are two main different types of diabetes mellitus- type 1 and type 2, which are defined by the reason for the glucose being unable to be utilised.
Type 1 diabetes is caused when the pancreas does not produce any insulin. This occurs when the β-cells in the pancreas are destroyed- this may be autoimmune T-cell mediated destruction or idiopathic.
Type 2 diabetes is caused by a relative insulin deficiency and/or insulin resistance.
Type 2 DM is commonly associated with obesity, physical inactivity, hypertension, dyslipidaemia and a tendency to develop thrombosis; therefore it increases cardiovascular
risk. It is associated with long term microvascular and macrovascular complications, together with reduced quality of life and life expectancy.
Type 1 is most commonly diagnosed in people under the age of 30 and especially in childhood. Type 2 usually develops in people over the age of 40. However, there is now an increasing incidence of type 2 in younger patients who are obese.

Question 3

Signs and symptoms

Answer 3

 Polyuria
 Nocturia
 Polydipsia
 Lethargy
 Unexplained weight loss

Question 4

Reasons behind the symptoms

Answer 4

Patients may experience polyuria, nocturia and polydipsia as a result of osmotic diuresis secondary to the hyperglycaemia.
Lethargy is a result of the body’s inability to utilise the glucose to provide energy.
Unexplained weight loss is caused by the breakdown of body protein and fat as alternative energy sources as the glucose is unavailable.
Whilst the symptoms are the same for both types of diabetes mellitus the intensity at which a patient may experience their symptoms can vary.

Question 5

Type 1 and 2 DM symptom variations

Answer 5

Type 1 DM- Symptoms are usually experienced at a more severe level and the onset is usually faster.

Type 2- DM- Symptoms are usually more ‘vague’ in their presentation and they may develop over a longer period of time and in some cases even years.

Question 6

Treatment of type 1 diabetes mellitus

Answer 6

As type 1 DM is caused by a destruction of the insulin producing cells in the pancreas the treatment requires the replacement of the insulin.
The aim of treatment is to achieve as optimal a level of blood glucose control as is feasible, while avoiding or reducing the frequency of hypoglycaemic episodes.
Good control of type I DM will reduce the risk of both short term and long term complications.

Question 7

There are different types of insulin available;

Answer 7

 Short acting
 Intermediate
 Long acting
 Ultralong acting

Question 8

There are some common insulin regimens that are used and these are

Answer 8

 Multiple daily injection basal-bolus insulin regimens
Short acting insulin or rapid acting insulin analogue bolus doses before meals with intermediate or long acting insulin once or twice daily as the basal insulin.
An advantage of a basal-bolus regimen is that it offers more flexibility over when meals are taken and also allows doses to be varied in response to different carbohydrate quantities in meals.
 Mixed (biphasic) regimen
Insulin injections given twice a day consisting of short acting insulin mixed with intermediate-acting insulin. In type I DM this may be suitable for patients who have a
consistent day to day routine. This type of regimen allows some flexibility for adjusting doses but not as much as a basal-bolus regimen.

Question 9

Continuous Subcutaneous insulin infusions

Answer 9

The use of a continuous subcutaneous insulin infusion is a relatively recent addition to the treatment regimens that are available to patients with type I diabetes mellitus. Pumps are popular with patients as they reduce the need for multiple insulin injections daily.
A continuous subcutaneous insulin infusion allows the patient to receive a continuous basal infusion of rapid or short acting insulin via a portable infusion pump and the patient will also administer bolus doses at mealtimes.
There are strict criteria that patients must meet if they are to be considered for the use of such a device, the patients need to be highly motivated to manage their diabetes, they need to be able to monitor their blood glucose concentrations accurately and they must be under the supervision of a healthcare team who are experienced in the management of diabetes.
-People with type I DM may be offered Insulin pump therapy if despite being highly motivated to manage their condition they have struggled to keep blood glucose levels under control on a multiple daily injection regimen

Question 10

Side effects of insulins

Answer 10

These are some of the most common side effects that can be associated with the use of insulins;
 Local reactions at the injection site
 Hypoglycaemia (if too much insulin is administered)
 Rarely; hypersensitivity reactions.

Question 11

Treatment of type 2 diabetes mellitus

Answer 11

As type 2 DM is characterised by a resistance to the insulin that is naturally produced by the body and also insufficient production of insulin by the pancreas which occurs progressively over time treatment is initiated to allow the body to use the insulin that is produced naturally more effectively.
The first stage when a patient is diagnosed as having type 2 diabetes is to recommend nonpharmacological management.

Question 12

Treatment of type 2 diabetes mellitus - Non-pharmacological management

Answer 12

Patients should be offered lifestyle advice; this should include advice on restricting the amount of energy and carbohydrates that they ingest and increasing the amount of physical activity that the patient undertakes (this must be on an individual patient basis and take account of other patient factors). At this stage patients often refer to themselves as having ‘diet-controlled’ diabetes.

Question 13

Treatment of type 2 diabetes mellitus - diet

Answer 13

Weight loss is often the first thing that is suggested to patients with type 2 DM. If patients are overweight, losing weight can help to improve insulin sensitivity.
Patients should be encouraged to reduce calorie intake, however it is important that this is done in a way that is sustainable for them long term. Energy dense foods such as bread, rice, pasta and potato based foods are usually advised to be limited in a patients diet, particularly if they are not very active. Patients should also be advised to increase the amount of vegetables in their diet as vegetables provide a variety of nutrients while having a
relatively low calorie count, in addition to this vegetables contain soluble fibre which helps people to feel fuller for longer.
If patients are not overweight they should be encouraged to eat a balanced diet to help keep blood glucose levels under control.

Question 14

Treatment of type 2 diabetes mellitus - exercise

Answer 14

Increasing the amount of exercise that a person undertakes is beneficial in lowering blood glucose levels in two ways.
Firstly, when muscles are used they require glucose from the blood, liver and muscles.
When the exercise is finished the body replenishes its stores of glucose by taking in available glucose from the blood- thus lowering blood glucose levels.
Secondly, exercise utilizes the energy (calories) from food so if exercise levels are increased and calorie intake maintained (or reduced as part of a healthy diet) patients will lose weight which will help to manage the diabetes mellitus

Question 15

Treatment of type 2 diabetes mellitus - other advise

Answer 15

Patients should be encouraged to stop smoking and reduce alcohol intake to help diabetes control and general health.
If these lifestyle advice measures fail, patients should be commenced on oral antidiabetic agents; these should be used alongside the dietary and physical activity changes NOT instead of them

Question 16

There are many classes of oral antidiabetic drugs available

Answer 16

 Biguanides; e.g. Metformin
 Sulfonylureas; e.g. Gliclazide
 Inhibitor of intestinal alpha glucosidases; e.g. Acarbose
 DPP-4 inhibitors; e.g. Sitagliptin
 Thiazolidinediones; e.g. Pioglitazone
 GLP-1 mimetics; e.g. Exenatide
 Meglitinides; e.g Repaglinide
 SGLT2 inhibitors; e.g. Dapagliflozin

Question 17

The next step….

Answer 17

If patients’ blood glucose concentrations are not controlled by diet and oral antidiabetic agents, the next step is to use insulin. The insulin can be added into a patients’ regimen or may be a substitute for oral therapy.
If insulins are to be added into a patient’s regimen it will usually be a long acting insulin given at bedtime.
If insulin is going to be used as a substitute for oral therapy it will usually be a twice daily biphasic insulin.

Question 18

Gestational Diabetes

Answer 18

This is simply diabetes that occurs in women during pregnancy due to the body’s inability to produce enough insulin to cope with the higher than normal levels of glucose in their body that occur as a result of the pregnancy.
This is most likely to be seen in the second trimester of a pregnancy.

Question 19

Risk factors for gestational diabetes

Answer 19

 Obesity
 Family history of diabetes mellitus
 Unexplained stillbirth or death of a neonate in a previous pregnancy
 Very large infant in a previous pregnancy (4.5kg/10lb or more)
 Previous history of gestational diabetes
 Family origin is South Asian, Black Caribbean or Middle Eastern.

Question 20

Gestational Diabetes Treatment

Answer 20

Often gestational diabetes can be controlled with changes to the diet; the woman will require referral to a dietitian.
It is possible that the woman may need oral antidiabetic agents or insulin, this is dependent on how high the glucose levels have been and for how long they have been high.

Question 21

Gestational Diabetes - Long term management

Answer 21

Gestational diabetes usually goes away once the baby has been born and there is not usually a need to continue with any medications that have been started during the
pregnancy. The mother should have her blood glucose concentration checked prior to discharge to ensure that they have returned to normal and she should also have a fasting blood test about six weeks after discharge.

Question 22

Monitoring of diabetes mellitus

Answer 22

There are two forms of monitoring that are essential in ensuring good control of a patients’ diabetes mellitus;
 Self-monitoring
 Monitoring by the healthcare team

Question 23

Self-monitoring -

Type 1 diabetes mellitus

Answer 23

Self-monitoring of blood glucose levels is an essential element of the management of diabetes, it allows patients to adjust the doses of insulin that they need to administer.
The frequency of self-monitoring is dependent on several factors;
 Characteristics of an individual’s blood glucose control
 Insulin regimen
 Personal preference in using the results to achieve the desired lifestyle.

Targets for short term glycaemic control (in adults);
 Pre-prandial 4.0-7.0 mmol/L
 Post-prandial less than 9.0 mmol/L

Question 24

Self-monitoring - Type 2 diabetes mellitus

Answer 24

There is less need for self-monitoring if the patient is either controlling their diabetes with lifestyle measures or oral hypoglycaemic agents; if a high result is seen from blood glucose monitoring the patient cannot adjust their doses as the change in dose will take too long to show an effect in blood glucose levels.
If patients are controlling their diabetes with insulin they will need to monitor more frequently.

Question 25

ketones

Answer 25

Ketones- only need to monitor in type 1 diabetes mellitus.
There is not a requirement to routinely monitor ketones but it is important that patients are made aware of when they need to monitor them; e.g. when the patient has a concurrent illness, particularly if there blood glucose is above 17mmol/L.

Question 26

Monitoring with the healthcare team

Answer 26

Patients should have a full diabetes review with a healthcare professional specialising in diabetes at least annually.
At this check up patients will have a review of their medication and general health and specifically with regards to their diabetes the following will be measured;
 HbA1c
 Blood pressure
 Blood lipids

Question 27

HbA1c

Answer 27

Glycosylated haemoglobin, this is a measure of how well controlled the diabetes mellitus has been controlled over the preceding 3 months.

Question 28

Blood pressure

Answer 28

Patients with diabetes mellitus need tighter blood pressure control due to the risks of complications associated with the disease.

Question 29

Blood lipids

Answer 29

Patients with diabetes mellitus are at greater risk of cardiovascular events and so it is important that there cholesterol levels are monitored regularly and treatment commenced where necessary.

Question 30

Hypoglycaemia

Answer 30

Low blood glucose levels; specifically less than 4mmol/L.

Levels of glucose in the body are too low to provide enough energy for the body to function.

Question 31

Hypoglycaemia - Symptoms

Answer 31

 Feeling ‘shaky’
 Sweating
 Hunger
 Tiredness
 Pallor
 Blurred vision
 Headaches
 Irritability

Question 32

Hypoglycaemia - causes

Answer 32

 Too much insulin
 Delayed/ missed meal or snack
 Not eating sufficient carbohydrates
 Excess physical activity
 Drinking large amounts of alcohol

Question 33

Hypoglycaemia - management

Answer 33

The management depends on the severity and whether the patient is conscious or unconscious.

Conscious patient: 15-20g of fast acting carbohydrate. They may then need a snack of 15-20g of slower acting
carbohydrate to prevent levels dropping low again.
Blood glucose should be retested after 15-20 minutes and treatment repeated if levels are less than 4mmol/L.

Unconscious patient:
 Patient should be placed in recovery position
 If they have a glucagon injection this should be administered
 If there is no glucagon available; phone for an ambulance
 If patient has not recovered 10 minutes after the glucagon is administered; phone for an ambulance

DO NOT ADMINISTER ANYTHING ORALLY TO AN
UNCONSCIOUS PATIENT

Question 34

Hyperglycaemia

Answer 34

High blood glucose levels; specifically >7.5mmol/L before a meal, >8.5mmol/L 2 hours after a meal

Question 35

Hyperglycaemia - Symptoms

Answer 35

 Excessive thirst
 Passing more urine than usual
 Headaches
 Tiredness/ lethargy

Question 36

Hyperglycaemia - causes

Answer 36

 Missing doses of medications
 Eating more carbohydrates than the body or medication can cope with
 Stress
 Concurrent infections
 Over treating a hypoglycaemic episode

Question 37

Hyperglycaemia - management

Answer 37

The management that is required will depend on the cause of the hyperglycaemia.
If a patient is regularly having episodes of hyperglycaemia they will require a review of their medications and/ or their lifestyle with the healthcare team.
If the levels are only raised for a short time then the patient will not require emergency treatment, however if the level stays elevated the patient will need to;
 Drink plenty of sugar free fluids
 If they are usually on insulin they may need to take extra
 If they are also unwell, especially if they are vomiting they will need to speak to their healthcare team for further advice.
If the blood glucose is above 15mmol/L the patient should test their blood or urine for presence of ketones

Question 38

Which insulin would you give first line in type 2 diabetes

Answer 38

NPH insulin (isophane insulin)

Question 39

Short acting insulin examples

Answer 39

The short acting insulins can be either soluble insulin or rapid acting human insulin analogues.

These have a short duration and relatively rapid onset of action, this mimics the insulin normally produced by the body when glucose is ingested and absorbed during a meal.

Soluble insulins, for example Actrapid, are usually injected 15 to 30 minutes prior to meals. They have a rapid onset of action of about 30 to 60 minutes, a peak action of between 1 and 4 hours and duration of action of up to 9 hours. All of these timings are based on subcutaneous injections of the soluble insulin.

The rapid acting human insulin analogues, for example Novorapid, have a faster onset of action and a shorter duration of action than the soluble insulins. These rapid acting insulins only last long enough for the meal that is being eaten- the peak action is between 0 and 3 hours and they last between 2 and 5 hours. For these reasons they should be injected just before, with or just after a meal.

Question 40

Intermediate and long acting insulin examples

Answer 40

The intermediate and long acting insulins have an onset of action of 1-2 hours, a peak onset of action of 3-12 hours and a duration of action of between 11 and 24 hours (when given by subcutaneous injections).

Examples of intermediate acting insulins include Novomix 30 and Humalog Mix 25.

Examples of long acting insulins include Insulin Detemir (Levemir) and Insulin Glargine (Lantus).

Question 41

Ultra-long acting insulin examples

Answer 41

There is a newer class of insulin- the ultralong acting insulin, for example Insulin degludec (Tresiba), this has a duration of action of up to 42 hours. They should however still be administered once daily and preferably at the same time of day.

Question 42

Aim of insulin treatment

Answer 42

The aim of treatment is to maintain blood glucose levels within an acceptable range- this can be dependent on the individual patient and will be discussed with the patient and all members of the healthcare team looking after them. As the durations of actions of the different insulins is subject to variation between patients it is often the case that in order to achieve good control of their diabetes they will require a combination of insulins.