Please enable JavaScript.

Coggle requires JavaScript to display documents.

DM (Complications of established diabetes (• Diabetic retinopathy:…

- - - - Pituitary insufficiency.
      - Liver failure, plus some rare inherited enzyme defects.
      - Addison’s disease.
      - Islet cell tumours (insulinoma) and immune hypoglycaemia (eg anti-insulin receptor antibodies in Hodgkin’s disease).
      - Non-pancreatic neoplasms, eg fibrosarcomas and haemangiopericytomas.
  - - - ogtt
    - - If episodes are often, advise many small high-starch meals. If post-prandial ↓glucose, give slowly absorbed carbohydrate (high fibre). In diabetics, rationalize insulin therapy
- - - - • 0.9% saline is the replacement fluid of choice.
        
        • Typical fluid deficit is 100mL/kg, so for an average 70kg man = 7 litres.
        
        • Give eg 1L in 1h (faster if systolic bp <90mmHg) then: 1L over 2h, 1L over 2h, 1L over 4h, 1L over 4 h, 1L over 8h. This regimen may not be appropriate for all: reassess frequently, especially if young, elderly, pregnant, or comorbidities.
        
        • Bicarbonate may increase risk of cerebral oedema and is not recommended.
    - - • Typical deficit = 3–5mmol/kg, plasma K+ falls with treatment as K+ enters cells.
        • Don’t add K+ to the 1st bag. Thereafter add K+ according to most recent vbg result
- - - - Abscess or deep infection; spreading anaerobic infection; gangrene/rest pain; suppurative arthritis.
- - - - If this doesn’t work, options are: ↑diet, diazoxide, dextrose ivi, enteral feeding, everolimus.
- - - - A biguanide. ↑ insulin sensitivity and helps weight. se: nausea; diarrhoea (try modified-release version); abdominal pain; not hypoglycaemia. Avoid if egfr ≲36mL/min (due to risk lactic acidosis).
    - - (Eg sitagliptin.) Block the action of dpp-4, an enzyme which destroys the hormone incretin.
    - - ↑ insulin sensitivity; se: hypoglycaemia, fractures, fluid retention, ↑lft (do lft every 8wks for 1yr, stop if alt up >3-fold). ci: past or present ccf; osteoporosis; monitor weight, and stop if ↑ or oedema.
    - - ↑ insulin secretion; eg gliclazide 40mg/d. se: hypoglycaemia (monitor glucose); it ↑ weight.
    - - Selective sodium–glucose co-transporter-2 inhibitor. Blocks the reabsorption of glucose in the kidneys and promotes excretion of excess glucose in the urine (eg empagliflozin, shown to reduce mortality from cardiovascular disease in patients with type 2 dm, when compared to placebo)
  - - - monotherapy - metformin
        
        if HbA1c rises to 58mmol/mol consider dual therapy with:
        
        if HbA1c rises to 58mmol/mol consider dual therapy with:
        
        metformin + DPP4 inhibitor +su
        
        metformin + pioglitazone + su
        
        metformin +su /pioglitazone + SGLT-2i
        
        insulin-based therapy
        
        triple therapy not tolerated: metformin, SU and GLP1 mimetic
        
        insulin - use a structured programme
        
        metformin and SGLT-2i (glifazon)
        
        metformin and sulphonylurea (su)
        
        metformin and pioglitazone
        
        metformin + DPP4 inhibitor (Eg sitagliptin)
  - - - 1 Ultra-fast acting (Humalog®; Novorapid®); inject at start of meal, or just after (unless sugar-laden)—helps match what is actually eaten (vs what is planned).
      - 2 Isophane insulin (variable peak at 4–12h): favoured by nice (it’s cheap!).
      - 3 Pre-mixed insulins (eg NovoMix® 30 = 30% short-acting and 70% long-acting).
      - 4 Long-acting recombinant human insulin analogues (insulin glargine) are used at bedtime in type 1 or 2 dm. There is no awkward peak, so good if nocturnal hypoglycaemia is an issue. Caution if considering pregnancy. Insulin detemir is similar and has a role in intensive insulin regimens for overweight type 2 dm.
      - Plan the regimen to suit the lifestyle, not vice versa. Disposable pens: dial dose; insert needle 90° to skin. Vary injection site (outer thigh/abdomen); change needle daily.
      - Subcutaneous insulin dosing during intercurrent illnesses (eg influenza)
        
        Endocrinology Advise patients to avoid stopping insulin during acute illness.
        
        • Illness often increases insulin requirements despite reduced food intake.
        
        • Maintain calorie intake, eg using milk.
        
        • Check blood glucose ≥ 4 times a day and look for ketonuria. Increase insulin doses if glucose rising. Advise to get help from a specialist diabetes nurse or gp if concerned (esp. if glucose levels are rising or ketonuria). One option is 2-hourly ultra fast-acting insulin (eg 6–8u) preceded by a fingerprick glucose check.
        
        • Admit if vomiting, dehydrated, ketotic (Endocrinologyp[link]), a child, or pregnant.
      - Insulin pumps (continous subcutaneous insulin)
        
        Consider when attempts to reach Hba1c with multiple daily injections have resulted in disabling hypoglycaemia or person has been unable to achieve target Hba1c despite careful management.
- - - - If conscious, orientated, and able to swallow, give 15–20g of quick-acting carbohydrate snack (eg 200mL orange juice) and recheck blood glucose after 10–15mins (repeat snack up to 3 times). If conscious but uncooperative, squirt glucose gel between teeth and gums. In unconscious patients, or those not responding to these measures, start glucose ivi (eg 10% at 200mL/h if conscious; 10% at 200mL/15mins if unconscious), or give glucagon 1mg iv/im (will not work in malnourished patients). Expect prompt recovery. Once blood glucose >4.0mmol/L and patient has recovered, give long-acting carbohydrate (eg slice of toast).