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Diabetes for finals

Diabetes for finals . Dr Emma Hodgkins, FY1 . 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.

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Diabetes for finals

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  1. Diabetes for finals Dr Emma Hodgkins, FY1

  2. 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 Diabetes worldwide

  3. What are the diagnostic criteria for diabetes?

  4. 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 Criteria for diagnosing diabetes

  5. Two large-scale studies - the UK Prospective Diabetes Study (UKPDS) and the Diabetes C ontrol and Complications Trial (DCCT) - demonstrated thatimproving 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 HbA1c New = [Old % - 2.15] x 11 Old % = [New ÷ 11] + 2.15

  6. How do you manage DKA?

  7. 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 DKA

  8. Managing DKA (2) Fluid replacement 1L NaCl over 1 hr 1L NaCl with KCl over 2 hours, 1L NaCl with KCL over 2 hours 1L NaCl with KCl over 4 hours Add 10% glucose 125ml/hr if blood glucose falls below 14 mmol/L Potassium Replacement Serum K > 5.5 Nil K 3.5-5.5 40mmol/L K < 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 with 0.9% sodium chloride solution Aims of treatment: Rate of fall of ketones of at least 0.5 mmol/L/hr Blood glucose fall 3 mmol/L/hr Maintain serum potassium in normal range Avoid hypoglycaemia

  9. AKA HyperosmoticHyperglycaemic 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% Managing HONK

  10. How do you manage hypoglycaemia?

  11. 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 Managing Hypos • 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

  12. What are the stages of diabetic retinopathy?

  13. 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 (1)

  14. 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 Diabetic Retinopathy (2)

  15. How does diabetic nephropathy occur?

  16. Diabetic nephropathy Hyperglycaemia Mesangeal Proliferation Nephron loss Activation of RAAS Glomerular Hypertension Hyperfiltration of protein Microalbuminaemia Proteinuria Tubular damage Glycation of proteins Thick BM Cytokine adtivation Inflammation

  17. 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 The diabetic foot

  18. What is your long term management strategy for diabetes?

  19. Long Term diabetes management

  20. Insulin regimes

  21. Diabetes Drugs

  22. GLP analogues & DPP4 Inhibitors

  23. ABC of diabetes Oxford handbook of the foundation programme Oxford handbook of clinical medicine Dr Clarke- Medicine http://www.bsped.org.uk/clinical/docs/jbdsdkaguidelines_may11.pdf DKA guideline http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdfPaeds DKA References

  24. Thanks and Good Luck!!

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