MosaicED Brain Teaser!
What fasting blood sugar level is considered diagnostic of diabetes?
D->7.Symptoms of diabetes: hypo symptoms are felt when BGL <4 or if disease progresses <6. Polyuria, BGL >10 causes glycosuria causes polyuria, blood and albumin seen in diabetes, if creatinine is seen think nephropathy, polydipsia - secondary to polyuria, nocturia, blurred vision, weight loss, fatigue, fungal infections.
Fasting blood sugars: 4-5.5 normal, 5.6-7 prediabetic, >7 diabetic. Random blood sugars >11 diabetes suspect. HBA1c >48 mmol (>6.4) diabetic. Glucose tolerance test (fast then give 75g of glucose and wait two hours), 7.8-11.1 prediabetic, >11.1 diabetic.
- diabetic neuropathy - when checking for it big toe, 3rd and 5th metatarsal
- diabetic nephropathy
- diabetic retinopathy; non proliferative - cloudy on fundoscopy, proliferative - neovascularization
macrovascular; acute coronary syndrome, CVAs
autonomic; gastroparesis, postural hypotension, erectile dysfunction, mononeuritis - argyll-robertson pupil (pupils that accommodate but do not react to light), radial nerve - wrist drop, median nerve - hand of benediction (only shows when patients try to make a fist, looks exactly like ulnar claw), ulnar nerve - ulnar claw
Treatment: close control early in the disease can build a good glycaemic memory which will mean better controlled diabetes down the track. Type 1 needs insulin, education and a pump if they can afford it. They can have short acting, long acting and mixed.
Type 2 Diet and exercise are always the first line. Only begin pharmacological treatment which you see complications or a HBA1c >7.8, a reduction of 1% HBA1c = 25% risk reduction of microvascular complications. Aim for HBA1C <6.5, PP BSL <10, FBSL 4-7, HDL >1, LDL <2.5.
Always give diabetics statins irrespective of cholesterol and ACE inhibitors help renal function and improves mortality in DM. Drugs:
Biguanide - Metformin (diabex): hepatic glucose output reduction and increases insulin sensitivity. Side effects: lactic acidosis, GI symptoms (Nausea & vomiting). contraindicated in renal failure
Sulfonylureas - Glipizide, gliclazide. increases insulin production. can induce weight gain causes hypoglycemic episodes!
GLP 1 agonists (glucagon-like polypeptide 1 agonists) - Exenatide, enhances insulin secretion and decreases glucagon secretion, adjuvant for patients on metformin - good for weight loss
SGLT2 inhibitors; block reabsorption of glucose in kidneys, UTIs and thrush
Thiazolidinediones - pioglitazone, rosiglitazone; reverse insulin resistance, Don’t give - heart failure side effects
If they are having a DKA or an HHS: hydrate them, give them insulin (bring sugars down slowly as too rapid can cause cerebral oedema) and address electrolyte imbalance (K).
If they are hypo, give them glucagon
Remember: autonomic neuropathy is quite a late sign, it is unlikely that it is a presenting symptom, FBSL >7, RBSL >11, HBA1c >48 mmol, GTT >11.1.