Need to quickly review Diabetes – Diagnosis, Medication mnemonics, Pre-op management of diabetes and more? Have a quick read below:
Table of Contents
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Hypoglycaemia
- Blood glucose <4mmol/L or <72mg/dL
- Important Cause- Alcohol
Dx- Whipple’s Triad
- Low plasma glucose (usually <4)
- Manifestations (sweating, confusion, tachycardia, hypotension, altered mentation)
- If blood glucose is corrected- rapid resolution of symptoms occur
Rx
Conscious/ Drowsy
- 200mL Fruit Juice
- Oral Glucose Gel
Unconscious/Cannot Swallow
- IV Glucose / 1mg Glucagon IM/SC (2 Tubes)
Seizures
- Glucagon
Alcoholic
- IV Glucose
Unconscious + Alcohol
- Set IV line then IV Glucose (cannot use Oral and Glucagon)
Preparations of IV Glucose
D10
- 10 minutes- 150mL
- 15 minutes- 200mL
- Every 1-2 minutes- 50mL until patient conscious or 250mL given (5 times)
D20
- 10 minutes- 75mL
- 15 minutes- 100mL
Insulinoma
- Diagnosis by C-peptide Test
Hyperosmolar Hyperglycaemic State
- High Glucose + High Serum Osmolality but Without DKA
Rx
- IVF 0.9% NS and Electrolyte Correction
Diabetic Ketoacidosis
- Glucose >11 + Abdominal pain + Vomiting + Kussmaul breathing + Dehydration
Dx
- Glucose>11 + Ketonuria ++/Ketonemia + ABG- pH < 7.3 + HCO3<15
Rx
0.9% NaCl initially > Insulin pump at 0.1unit/kg/hour > ABG or VBG> KCL 40mmol/L > D5/D10 when Glucose<12 > Don't use HCO3 (cerebral oedema)
- 1 ltr IV fluid 0.9% over 1 hour (if systolic BP >90)
or
- 1 ltr IV fluid 0.9% over 10-15 minutes (if systolic BP <90)
DKA or Sepsis
- Baby with Severe dehydration (dry mucous membranes, sunken eyes and fontanelles, reduced skin turgor) + Hyponatremia + Hypokalemia
Rx
- IV Fluids (0.9% NaCl + KCl)
Diabetes Mellitus
Diagnosis
- 1 Abnormal Value + Symptoms
Or
- 2 Abnormal values Without Symptoms
Abnormal values (FBG and not RBS, Preferred over HbA1c because cheaper)
- FBS >_ 7 mmol/L (126 mg/dL)
- HbA1c >_ 48 mmol/L (>6.5%) (Normal- 42, Target in DM= <48)
Pre-Diabetes (Impaired Glucose Tolerance)
Fasting- 5.5-6.9 2 hour Post-Prandial/ OGTT- 7.8-11 (140-200) HbA1c- 42-47
- Tiredness is not a symptom of DM alone
- In Asymptomatic People with 1 abnormal value> repeat test in 2 weeks to confirm the diagnosis
Gestational DM/ Acromegaly
- OGTT is DxOC
Variants
MODY (Maturity Onset Diabetes of Young)
- DM <25 Y/O + FHx (2 generations) + Mild Hyperglycaemia
- Rx- Refer to Endocrinology for Genetic Counselling + Lifestyle modifications
- Sulphonylureas before Insulin
- Rx- Refer to Endocrinologist
LADA- Late Autoimmune Diabetes of Adults (30-50 YO)
- DM1 Variant with Slow Progression + Autoimmune Disease
DM1 vs DM2
- GAD Antibodies (Glutamic Acid Decarboxylase)
Diabetes Treatment
- Target- <_ 48 (<6.5)
- Newly Diagnosed
- First- Lifestyle Modifications
- Still HbA1c>48? – Start 1 OHA (usually metformin)
- Still High HbA1c?
- <58- Lifestyle modifications
- >58- LIFESTYLE MODIFICATIONS > Add another OHA
Diabetes Medications
- Impaired KFT- Insulin/ Gliptins (DDP4)
- C/I- With Bad Kidneys, avoid MS (Metformin, Sulfonylurea)
- Biguanides- Metformin (<30 eGFR, reduce dose if <45)
- Sulphonylureas (risk of Hypoglycaemia)
Weight
- Increase (SPR)- Sulphonylureas (e.g., Glibenclamide), Glitazones (Pioglitazone), Repaglinide
- Decreases- Biguanides (Metformin)
- No effect- DDP4 (Gliptins)
Kidneys
- Good- Insulin, Gliptins (DDP4)
- Bad- Metformin, Sulphonylureas (With Bad Kidneys, avoid MS (Metformin, Sulfonylurea)
- SGLT-2 inhibitors (Gliflozin)- contraindicated if GFR<60
Heart failure
- Gliptins (DDP 4 inhibitors- also in Pancreatitis) and Glitazones (also in Bladder Cancer)
- Preferred- SGLT2 Inhibitors (Dapagliflozin)
- SGLT-2 inhibitors- contraindicated if GFR<60
Mnemonics
- With bad kidneys (GFR <30), do not use MS (Metformin, Sulphonylureas)
- The heart has 4 chambers, so with Heart Failure (and Pancreatitis), do not use DDP4 inhibitors (Gliptins)
- The Pie (Pioglitazone) comes with the die (Risk of bladder cancer). Pioglitazone is also contraindicated in Heart Failure
- Hypoglycaemic that cause weight gain are SPR- Sulphonylureas, Pioglitazone, Repaglinide
- The rest cause weight loss except DDP4 inhibitors (Gliptins) which have no effect on the weight
- SPR without the P (SR) have the risk of hypoglycaemia: Sulphonylureas and Repaglinide
Euglycemic DKA
- Occurs in SGLT-2 (Gliflozin)- All features of DKA but Blood Glucose is not elevated (<11), Ix- Capillary Ketones>Urinary Ketones, ABG, Rx- IV Fluids
Autonomic Neuropathy
- Both Sympathetic and Parasympathetic branches (ANS)
- Causes- Diabetes, Alcohol, Aging
- Features- Sweating, Incontinence, Diarrhoea or Constipation, Impotence, Postural hypotension
- Suspect it in DM patients with Persistent Diarrhoea
- Metformin (Biguanide) can cause Diarrhoea as well
- Stop DAMN drugs in any patients with Diarrhoea or Vomiting
Pre-Op Mx for Diabetes
T2DM (on OHAs)
- Minor Surgery- Continue
- Major Surgery (1 meal skip)- Continue
- Longer Surgery (>1 meal skip)/ Uncontrolled DM- Switch to Insulin
- Emergency Surgery- R/O DKA
- Omit- Sulphonylureas (cause hypoglycaemia)
- Longer surgery- Consider omitting Metformin
- Safe to Use- Rest all
T1DM (on Insulin)
- Minor Surgery- Omit Dose (morning if AM surgery, lunchtime if PM surgery)
- Major- Switch to VRIII (Variable Rate Intravenous Insulin Infusion Ratio)
- Before Sx- 80% of total once daily in VRIII (long-acting) + Continue Other Insulin
- Intra-op- 80% of total once daily in VRIII (long-acting) + Stop Other Insulin
- Target during Sx- 6-10 (max 12)
- KCl + Glucose + NaCl also given
- Emergency- Switch to VRIII
- For Major Sx- In all cases, restart the previous regimen when per mouth diet is re-established + Check Blood glucose 4 hourly