Diabetes

Diabetes

1. 4.7 million people affected, 1000 diagnosed every day, 1 in 15 have diabetes in UK, someone diagnosed every 2 minutes, 2% of inpatients have diabetes, 90% of people have type 2 diabetes

2. Diagnosis

   • Fasting plasma glucose >7mmol/l
   • Random venous plasma glucose concentration >11.1mmol/l
   • If symptomatic 1 reading, if asymptomatic 2 readings are required
   • HbA1c of >48mmol/mol (6.5%) - if blood problems or pregnant this does not work
   • Two hour 75g OGTT >11.1mmol/l (this is mostly used for pregnant women)

3. Type 1: beta cells in pancreas are being attacked, It is possible to measure antibodies (GAD and IA2 Ab) or measure zinc transporter. C-peptide breaks off insulin, can measure but most often patients will still be making some insulin for honeymoon period so not accurate.

   • If there is weight loss, that is a strong signal that there is not enough insulin
   • In young patients type 1 more common despite BMI
   • For basal bolus insulin, measure their weight, HALF their weight in KG, half of that is then long acting and the other half is short acting.Eg. Young 80kg patients, 20g Levemir and 20g Actrapid.

4. Type 2 : Patients may be making more insulin but just not responding to increased levels.New evidence that this type is strongly associated with genes, with one parent risk is 30%, if both parents then risk is 80%.

   • Biguanides - Metformin (world wide well established)
   • Sulphonylureas - Gliclazide (SE weight gain and heart attacks so less often used)
   • Thazolidenediones - Pioglitazone (SE heart failure and osteoporosis)
   • GLP-1 receptor agonist help lose weight by making patients feel full for longer, does not give hypos as works on glucose and insulin there (SE pancreatitis CI alcohol dependent)
   • DPP IV inhibitors breaks down hunger home and satiety hormone, good for frail elderly lady, mild effect (SE pancreatitis, lower risk)
   • SGLT-2 inhibitors makes you pass glucose in urine, found to have a positive effect on the heart, weight loss (SE UTI, thrush and euglycaemic DKA)

5. MODY: Monogenetic diabetes, it is very rare and presents in 3% of diabetes presenting in <30yo. Beta cell is normal but potassium ATP channel cannot shut so insulin cannot get out of the beta cell. Give patient sulfonylurea which will shut the channel and let insulin out. This channel is present in the brain too so a child with MODY will have late development as well.

   • Mx: Sulfonylurea
   • There is an online MODY calculator - checks probability for MODY

6. Type 3c (Pancreatic diabetes): patients do not make insulin but are extremely sensitive to it so prone to hypoglycaemia, these patients also do not produce pancreatic enzymes to absorb food so need to give Creon as well

7. Steroid induced: patients have very high sugars during the day and drop like a stone at night, treatment given at morning and lunchtime and less/none at night, At high risk of HHS/Honk

8. Diabetes means melting of the flesh

9. DKA

   • Euglycaemic DKA occurs in pregnant women and SGLT-2 inhibitors
   • pH<7.3, bicarb<15, ketones>3, glucose>11
   • Mx: Normal saline over 1,2,2,4,4,6 hours (with K+ replacement); Fixed rate insulin 0.1 x weight (in kg); 10% glucose when BG falls below 14
   • Check BG hourly, check ketones hourly, check VBG hourly
   • Protect from hypoglycaemia and hypokalaemia

10. Hyperosmolar Hyperglycaemic State (HHS)

    • typically occurs in elderly
    • may occur over several days
    • Extreme dehydration (high Na+); serum osmolality >320-340 [2Na + urea + glucose]; BG usually >30; no ketones present!!!
    • Mx: normal saline alone first 1L/hour; add insulin if ketones or if BG not falling further (if so 0.05 x weight kg)
    • Aim to drop BG<5/hour
    • Calculate hourly serum osmolality