DIABETES FOR FINALS
Dr Emma Hodgkins, FY1
DIABETES WORLDWIDE
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Globally 285 million people currently
have diabetes, which is estimated to
double by 2030.
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UK prevalence 4.5% (5.5% in England)
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Diabetes is currently the fifth most
common reason for death in the world.
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Around 1 in 8 people between 20 and
79 years old have their death
attributed to diabetes and it is
expected to rise.
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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
WHAT ARE THE DIAGNOSTIC CRITERIA
FOR DIABETES?
CRITERIA FOR DIAGNOSING DIABETES
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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
HBA1C
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Two large-scale studies - the UK
Prospective Diabetes Study (UKPDS)
and the Diabetes C ontrol and
Complications Trial (DCCT) demonstrated that improving 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%.
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Research has also shown that people
with type 2 diabetes who reduce their
HbA1c level by 1% are:
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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
New = [Old % - 2.15] x 11
Old % = [New ÷ 11] + 2.15
HOW DO YOU MANAGE DKA?
DKA
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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
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
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
Potassium Replacement
Serum K > 5.5
Nil
K 3.5-5.5
40mmol/L
K < 3.5
Seek Sr review
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
MANAGING HONK
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AKA Hyperosmotic Hyperglycaemic 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%
HOW DO YOU MANAGE HYPOGLYCAEMIA?
MANAGING HYPOS
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If Low GCS:
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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
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If GCS 15
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Oral glucose (120ml
lucuzade, HYPOSTOP/
Glucogel)
This only lasts 1h so give a
sandwich too!
Monitor finger prick
glucose 1-2 hrly until stable
WHAT ARE THE STAGES OF DIABETIC
RETINOPATHY?
DIABETIC RETINOPATHY (1)
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Commonest cause of blindness in under 65s
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Background
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Microaneurysms (Dots) Blot Haemorrhages, Hard Exudates
(lipid leaked from aneurysms)
Pre-proliferative
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Cotton-wool spots, Beading & looping
DIABETIC RETINOPATHY (2)
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Proliferative
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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
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HOW DOES DIABETIC NEPHROPATHY OCCUR?
DIABETIC NEPHROPATHY
Glycation of proteins
Thick BM
Hyperglycaemia
Cytokine adtivation
Mesangeal Proliferation
Inflammation
Nephron loss
Activation of RAAS
Glomerular Hypertension
Hyperfiltration of protein
Microalbuminaemia
Proteinuria
Tubular damage
THE DIABETIC FOOT
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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
WHAT IS YOUR LONG TERM MANAGEMENT
STRATEGY FOR DIABETES?
LONG TERM DIABETES MANAGEMENT
INSULIN REGIMES
DIABETES DRUGS
GLP ANALOGUES & DPP4 INHIBITORS
REFERENCES
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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_may
11.pdf DKA guideline
http://www.bsped.org.uk/professional/guidelines/docs/DKAGu
ideline.pdf Paeds DKA