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Diabetes

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Diabetes

  1. 1. • 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). Diabetes
  2. 2. Type 1 v Type 2 Diabetes
  3. 3. • Failure of pancreatic beta cells • Hypoinsulinemia • Juvenile • usually autoimmune Cannot use glucose, therefore use fats • Liver produces keto-acids, acetone, hydroxybutyrate and acetoacetate Volatile and sweet-smelling hence mellitus Acidosis - <pH7.2 (dangerous) Normally produced with exercise – for brain Also produced in fasting Type I Diabetes
  4. 4. Non-insulin dependent diabetes Cells resistant to insulin action • cannot store glucose • cannot utilise glucose • hyperglycaemia • 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 Risk factors obesity and over weight lack of exercise hereditary hypertension high sugar and high fat (wrong types of lipids) Type II Diabetes Mellitus
  5. 5. Thirst Diuresis High food intake with weight loss High blood glucose Retinal vessels Fatigue + Visual loss Foot sores, lesions and sensory loss Hypertension or asymptomatic (no symptoms) the silent killer Early indicators of Diabetes Type 1 Type 2
  6. 6. 0 60 120 180 240 Time after ingestion, min 0 2 4 6 8 10 Bloodglucose,mM Glucose solution drunk Glucose tolerance test in diabetes Normal Renal threshold Inability to reduce glucose after a test meal Diabetic
  7. 7. Treatment of Type 1 • Diet • Monitoring of blood glucose – HBGM or bedside and HbA1c • Insulin injections • Education for self-management • Exercise
  8. 8. Insulin • 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.
  9. 9. Insulin
  10. 10. Insulin • Rapid-acting - Apidra, Novorapid, Humalog • Short-acting - Actrapid, • Intermediate-acting - Isophane • Long-acting - Lantus, Levemir • Mixtures - Mixtard 30, Novomix30, HumalogMix 25 & 50
  11. 11. NovoRapid 0 2 4 6 8 10 14 18 22 Hours after injectionInjection with meal
  12. 12. Levemir Breakfast Injection 10.00pm 0 2 4 6 8 10 14 18 22 Hours after injection Lunch Evening meal
  13. 13. Levemir & Novorapid Breakfast Lunch Evening meal
  14. 14. 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
  15. 15. Treatment of Type 2 DM • Diet & exercise • Education for self-management • Monitoring Home/bedside monitoring & HbA1c • Oral hypoglycaemic agents • Incretin mimics • Insulin usually long-acting or mixtures
  16. 16. Oral Hypoglycaemic agents (OHAs) • Sulphonylureas – ↑ insulin secretion • Glitazones – ↓ insulin resistance • Biguanides – ↓ insulin resistance & hepatic glucose output
  17. 17. Sulphonylureas • 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.
  18. 18. GLIBENCLAMIDE
  19. 19. Biguanide • Example: metformin • Action: increases glucose uptake in muscle and reduces gluconeogenesis. • 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 diabetics.
  20. 20. METFORMIN
  21. 21. Post-prandial glucose regulators • Example: repaglinide • Mode of action: stimulates insulin release rapidly (take before meal) • Side effects: GI upset and hypoglycaemia
  22. 22. REPAGLINIDE
  23. 23. Thiazolidinediones (glitazones) • 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, dizziness • 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
  24. 24. PIOGLITAZONE
  25. 25. Alpha-glucosidase inhibitors • Example: acarbose • Action: alpha-glucosidase inhibitor – delays GI absorption of carbohydrate • Side effects: flatus, diarrhoea, abdominal distension
  26. 26. ACARBOSE
  27. 27. GLUCAGON
  28. 28. Hypoglycaemia • Sweating • Palpitations • Hungry • Shaking • Mood changes • Lack of concentration • Paleness
  29. 29. 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 5. Dietitians 6. Optometrists / Ophthalmologists 7. Podiatrists 8. Psychologists 9. Other medical specialists (nephrologists, cardiologists, vascular surgeons etc) 10. Pharmacists Diabetes management
  30. 30. Diabetes monitoring • 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 for any i) Hyperglycaemia is there a pattern to this? Particular time of the day? During illness? 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?)
  31. 31. Lifestyle and health advice • Smoking status: Does the patient need referred to a smoking cessation program? • 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 pressure • 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?
  32. 32. Eye assessment • 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
  33. 33. Feet assessment • 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
  34. 34. Skin assessment • Any signs of infection? • If the patient is on insulin - their injection sites should be examined. • Is their any evidence of lipoatrophy or lipohypertrophy?
  35. 35. Serum lipid control • Controlling lipids can improve outcomes for diabetic patients. • Total serum cholesterol <4 mmol/l • LDL <2 mmol/l • Start all diabetics on a statin.
  36. 36. 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
  37. 37. Renal function • 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.

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