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• Type 1 diabetes – a primary deficiency of insulin, β-
cell destruction leads to failure of insulin secretion.
May be due to an autoimmune reaction against the
body’s own β-cells. Typically younger onset, and
insulin dependent from the start.
• Type 2 diabetes – insulin resistance, where insulin
secretion is relatively unimpaired, but its metabolic
effects are inhibited. Tends to be seen more in an
older, overweight population (but not always!)
• Diabetes can be secondary to excess secretion of
diabetogenic hormones e.g. cortisol (Cushing’s
syndrome) or growth hormone (acromegaly).
Type 1 v Type 2 Diabetes
• Failure of pancreatic beta cells
• usually autoimmune
Cannot use glucose, therefore use fats
• Liver produces keto-acids, acetone, hydroxybutyrate and
Volatile and sweet-smelling hence mellitus
Acidosis - <pH7.2 (dangerous)
Normally produced with exercise – for brain
Also produced in fasting
Type I Diabetes
Non-insulin dependent diabetes
Cells resistant to insulin action
• cannot store glucose
• cannot utilise glucose
• blood insulin tends to be high
• more complex and variable than type I.
• Classically disease of >40 years
• 1.4 million in UK and increasing
• But also in young now
obesity and over weight
lack of exercise
high sugar and high fat (wrong types of lipids)
Type II Diabetes Mellitus
High food intake with weight loss
High blood glucose
Foot sores, lesions and sensory loss
or asymptomatic (no symptoms)
the silent killer
Early indicators of Diabetes
0 60 120 180 240
Time after ingestion, min
Glucose solution drunk
Glucose tolerance test in diabetes
Inability to reduce
glucose after a test meal
Treatment of Type 1
• Monitoring of blood glucose
– HBGM or bedside and HbA1c
• Insulin injections
• Education for self-management
• Short acting, Intermediate acting, Long acting (slow
onset, lasts for longer)
• Arranged to provide insulin cover throughout the day
and night. E.g. basal-bolus regimen (rapid-acting
insulin before meals, long-acting insulin once or
twice daily e.g. at night)
• Given subcutaneously by injection.
• Side effects: Hypoglycaemia in overdose, fat
hypertrophy at injection site.
• Rapid-acting - Apidra, Novorapid, Humalog
• Short-acting - Actrapid,
• Intermediate-acting - Isophane
• Long-acting - Lantus, Levemir
• Mixtures - Mixtard 30, Novomix30, HumalogMix 25 & 50
0 2 4 6 8 10 14 18 22
Hours after injectionInjection
0 2 4 6 8 10 14 18 22
Hours after injection
Lunch Evening meal
Levemir & Novorapid
Breakfast Lunch Evening meal
Sick Day Rules
• Never stop insulin (change dose)
• Give some easily digested CHO
• Offer plenty of sugar-free liquids
• Monitor B/G 2 hourly
• If vomiting or ketones in urine get medical help
• Encourage rest
Treatment of Type 2 DM
• Diet & exercise
• Education for self-management
Home/bedside monitoring & HbA1c
• Oral hypoglycaemic agents
• Incretin mimics
• Insulin usually long-acting or mixtures
Oral Hypoglycaemic agents (OHAs)
• Sulphonylureas – ↑ insulin secretion
• Glitazones – ↓ insulin resistance
• Biguanides – ↓ insulin resistance & hepatic glucose output
• Example: gliclazide (short acting)
• Action: secretagogue- stimulates B cells in endocrine
pancreas to secrete insulin
• Other effects: CAN CAUSE HYPOGLYCAEMIA. Care in
hepatic and renal failure.
• Side effects: weight gain, GI side effects, cholestatic
jaundice, hepatitis, hepatic failure
• When to use: if metformin is contra-indicated, not
tolerated or not effective on its own.
• Example: metformin
• Action: increases glucose uptake in muscle and reduces
• Other effects: an anorectic agent, it helps to prevent
weight gain. It does not normally cause hypoglycaemia
• Side effects: Nausea, vomiting, Diarrhoea – will often
resolve if given some time. Risk of lactic acidosis (e.g.
in renal failure). Can reduce vitamin B12 absorption.
• When to use: Is first line agent in obese type 2
Post-prandial glucose regulators
• Example: repaglinide
• Mode of action: stimulates insulin release rapidly
(take before meal)
• Side effects: GI upset and hypoglycaemia
• Example: Pioglitazone
(Rosiglitazone recently removed from use)
• Action: PPAR-gamma receptor agonists resulting
in reduced peripheral insulin resistance
• Side effects: GI upset, weight gain, oedema,
• When to use: can be combined with metformin
or sulphonylurea or insulin or used independently
• When NOT to use: ANY history of or current heart
failure. Previous or active bladder cancer
• Example: acarbose
• Action: alpha-glucosidase inhibitor – delays GI
absorption of carbohydrate
• Side effects: flatus, diarrhoea, abdominal distension
• Mood changes
• Lack of concentration
A wide variety of health care professionals are involved in managing
patients with diabetes – including:
1. Consultant Physicians / Diabetologists
2. General Practitioners
3. Diabetes nurse specialists
4. Practice nurses
6. Optometrists / Ophthalmologists
9. Other medical specialists (nephrologists, cardiologists, vascular
• Enquire if the patient is monitoring their condition. Do they attend their
various check-up appointments?
• Most patients are encouraged to measure their blood glucose at different
times of the day, by using a glucometer. It is also important for patients to
monitor their glucose levels during times of illness.
• Take time to review the patients self-monitored glucose levels. Observe
i) Hyperglycaemia is there a pattern to this? Particular time of the day?
ii) Hypoglycaemic episodes?
• Any symptoms of complications related to diabetes?
(e.g. Visual disturbance; numbness, infections / ulcers on their feet? Any
excertional chest pain? Any claudication symptoms in the legs?)
• Any sexual dysfunction? (e.g. erectile dysfunction in men?)
Lifestyle and health advice
• Smoking status: Does the patient need referred to a smoking cessation
• Level of alcohol consumption
• Diet: Eating a balanced diet and managing their weight, can enormously
benefit diabetic patients health . Taking steps to balance their diet will
help control: serum glucose, cholesterol and triglycerides levels & blood
• Level of exercise: Patients should be advised to exercise for half an hour -
five times per week. Physical activity has many health benefits for diabetic
patients including: i) improved diabetic control ii) prevention of some of
the complications of diabetes iii) prevention and treatment of high blood
pressure iv) improved cholesterol and HDL levels
• Vaccination: Has the patient received their annual influenza vaccination?
Have they had their pneumococcal vaccination?
• Regular annual eye examinations or screening (e.g. retinal
photography) is extremely important in detecting eye problems
associated with diabetes.
• Patients should make sure their eyes are checked at least once a
year - so any problems can be picked up and treated early.
Retinal photograph of a patient
with diabetic retinopathy
• Circulation: assessing the peripheral pulses
• General skin care of the feet
• Presence of any neuropathy of the feet (e.g. by fine touch or
microfilament or by degree of vibratory sense)
Diabetic foot ulcer
• Any signs of infection?
• If the patient is on insulin - their injection sites
should be examined.
• Is their any evidence of lipoatrophy or
Serum lipid control
• Controlling lipids can improve outcomes for diabetic
• Total serum cholesterol <4 mmol/l
• LDL <2 mmol/l
• Start all diabetics on a statin.
Blood glucose control
• Measuring serum glycated haemoglobin (HbA1c) levels can
provide an overview of a patients blood glucose levels over
the last 8 weeks.
• To show good diabetic control the HbA1c level should be
<6.5%, but <7.5% for those at risk of severe hypoglycaemia
• Diabetic nephropathy is the most common single cause of end
stage renal failure (ESRD) amongst adult patients starting on
renal replacement therapy.
• All diabetic patients should have annual urinary
albumin:creatinine ratio & microalbuminuria performed and
their serum creatinine measured.