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OSCEazy Slide template 2021-2022 We look forward to your teaching session! • At OSCEazy, we have been renowned for our colourful slide templates and a very clear slide structure that presents information systematically • In this slide set there are slides for introductions, content, pictures, summaries...you can use as many or as few of these slides as you need by deleting/duplicating the template slides you want • We always advice to use a variety of different slide structures to keep your session engaging and interesting to look at! • You can add/replace content/pictures/textboxes to these slides as needed and delete any sections (such as this slide) as required **PLEASE DO NOT SHARE THIS SLIDE TEMPLATE OR USE THIS TEMPLATE FOR USES OTHER THAN YOUR TEACHING SESSION** • We would be very grateful to hear your feedback on our slide template. Please fill in this form once you have made your slides: https://docs.google.com/forms/d/e/1FAIpQLSdfFpHXn3QtY05WvPCqD_lq28lZoYnBRuk3jqCu8ORVKhSgAg/viewf orm?usp=sf_linkPreclineazy TobyDIABETES - CASE 11 T1 Diabetes Management T2 Diabetes Management Complications ofHyperglycaemia Complications of T1 Diabetes (DKA) Complications of T2 Diabetes HONK • Autoimmune response causing damage to beta cells in pancreas Insufficient insulin production causing • Extremely high blood glucose • Cells unable to metabolise glucose Type 1 diabetes • Fat breakdown instead leading to high ketones Glucose should be kept between 4-11mmols Type 1 complications • Insufficient insulin • Extreme hyperglycaemia with no way to absorb glucose Diabetic • Body being ‘starved’ of energy source Ketoacidosis • Fats metabolised instead – Beta oxidation Signs and symptoms • Fat breakdown produces ketones Dehydration Nausea, ADIPOCYTES Liver Triglycerides Ketone Bodies (acidic) vomiting, ↑Lipolysis Acetyl CoA Mental status change Acetone breath Free fatty acids Free Fatty Acids Frequent urination Type 1 diabetes and hypokalaemia Insulin is needed to bring K+ into cells in exchange for Na+ in K+/Na+ ATPase. - High K+ serum levels - Low K+ intracellularly K+ is excreted in urine with increased urination - Overall decrease in body K+ DKA management 1. Isotonic saline 2. Insulin (and dextrose) infusion 3. K+ infusion TYPE 1 DIABETES Management After diagnosis and initial treatment • Insulin therapy • HbA1c monitoring • Monitoring blood glucose Education • Diet Low Glycaemic Index food • Care when drinking alcohol (causes hypoglycaemia) • Info on ‘Sick Day rules’ Insulin therapy FIRST LINE: Combine a long Insulin Pump Long acting acting with a rapid active - Continuously infuse insulin Examples: Levemir, Lantus before meals - Insulin release automatic based on - Taken before bed blood glucose levels - Used by T2 diabetes (10% of - Uses Rapid acting insulin cases) before bed Short acting Rapid Examples: Novorapid, Humalog Examples: Actrapid, Humulin S - Can be used after meals - Used for infusions in DKA - Acts in 15 minutes Glucose monitoring Free libre Used to continuously monitor blood glucose and alarm you of a hypo Can be connected to your phone You must still do finger prick tests when driving or expecting a hypo as these are more accurate. Sick day rules (T1D) When you are ill you need to change your routine When you are ill your body releases more glucose from your liver to fight Increase dose of inulin (if BM>11) infection Patients should continue to eat Patients may not eat if they are ill so they don’t take insulin Monitor ketones and inject bolus if present Higher risk of DKA Type 2 diabetic should stop metformin/sulfonylureas • Body becomes tolerant to insulin so it is required at higher doses to have the same effect • Reduced effectiveness of insulin causes Type 2 diabetes raised blood glucose leading to complications Glucose should be kept between 4-11mmols Type 2 complications • Very poor glycaemic control Hyperglycaemic • Very high glucose in the blood hyperosmolar • Glucose pulls water into urine causing syndrome DEHYDRATION Signs and symptoms Severe Dehydration Management Complications IV Fluids (saline) Myocardial infarction Nausea, vomiting, Mental status change Consider Insulin Thrombotic Complications Consider PotassireplacementHyperglycaemic complications Seen in T1 and T2 diabetes Complications Microvascular Macrovascular complications Complications • Cerebral Vascular • Nephropathy disease • Cardiovascular disease • Retinopathy • Peripheral Vascular • Neuropathy disease Complications Microvascular Macrovascular complications Complications • Cerebral Vascular • Nephropathy disease • Cardiovascular disease • Retinopathy • Peripheral Vascular • Neuropathy disease Complications Microvascular complications • Glucose reabsorption overworks the kidney • Nephropathy • Glucose causes • Retinopathy sclerosis of the • Neuropathy basement membrane Complications • Glucose hardens blood Microvascular vessels causing narrowing complications • High blood pressure damages vessels • Nephropathy • This causes hypoxia • Retinopathy o Cotton wool spots • Neuropathy o Haemorrhages o New vessel formation Complications High blood pressure damages nerves • Autonomic neuropathy (gastroparesis, Microvascular Erectile dysfunction, postural hypotension) complications • Sensory neuropathy (glove and stock distribution - in feet can cause ulcers) • Mononeuropathy (single nerve e.g. • Nephropathy oculomotor nerve palsy) • Retinopathy • Neuropathy Microvascular complications Complication monitoring • Nephropathy - Retinopathy screen every 2 years • Retinopathy - Annual foot screen - Annual kidney function test • Neuropathy TYPE 2 DIABETES Management After diagnosis - Hypoglycaemic control – diet and drugs - Sometimes insulin - Monitor HbA1c every 3-6 months (aim <48mmol/mol) Education - Smoking cessation - Weight control - Exercise regimeMechanism of insulin releaseDrugsGliptin Examples: Sitagliptin, saxagliptin Mechanism:Inhibit DPP-IV and therefore increases insulin secretion and inhibit glucagonsecretion. Side effects: GI UpsetSulfonylureas Examples: Gliclazide Mechanism:InhibitsATPsensitivepotassium channelsleadingto beta celldepolarisation and henceinsulinrelease Side effects: Weightgain (increased appetite), HYPOGLYCAEMIA Contraindications: ObesityIncretin Mimetic Examples: Exenatide Mechanism: Incretinsare released fromGITafter mealsand stimulate insulinsecretionto handle post prandialglucoseincrease.Incretinsalso inhibitglucagonsecretion. Thesedrugsmimic their action. Side effects: GI Upset,WEIGHTLOSS(increase satiety) METFORMIN FIRST LINE MEDICAL THERAPY FOR TYPE 2 DIABETES MECHANISM: •reduces hepaticGLUCONEOGENESIS •acts systemically to increase insulin sensitivity •Reducesintestinal absorption of glucose • Side effects: GI UPSET, LACTIC ACIDOSIS • Contra: GFR<30 GLIT AZONES AKA THIAZOLIDINEDIONES Examples: Pioglitazone Mechanisincreasesinsulinsensitivityin peripheraltissues Side effects: WEIGHTGAIN, FLUID RETENTION HEARTFAILURE Contraindications: SGL T 2 INHIBITORES ExamplesDapagliflozins MechanismInhibit a sodium – glucose cotransporter in the kidneys leading to increased urinary excretionof glucose Side effects: WEIGHT LOSS,UTIs/Thrush ContraindicatiSEVERE CHRONIC KIDNEY DISEASE Hypoglycaemic DRUGS The release of insulin i s G lip DPP-IV BETA CELL GLUCOKINASE ↑GLUCOSE GLUT2 GLUCOSE GLUCOSE– 6 - PHOSPHATE GLP-1incretins) GLYCOLYSIS & KREB’S ↑ INSULIN INSULIN ATP i Sufonlue tform as M e Ca 2+ Ca 2+Ca 2+ K+ K+ Pogltones K+ + + + + + + + + Hypoglycaemia Blood glucose <3 mmol/l EXCESS ENDOGENOUS INSULIN: EXCESS EXOGENOUS INSULIN : ↑INSULIN, ↑C-PEPTIDE ↑INSULIN, ↓C-PEPTIDE e.g. insulinoma e.g. patient taken excessinsulin, not eating enough carbohydrates, sulfonylureas • Low blood glucose • Brain starves of glucose • Leads to symptoms of confusion, ataxia, fainting, irritable. Q U E S T I 1 N A Gliclazide A 55 year old woman is recently diagnosed with B Dapagliflozin diabetes. She have a past history of Systemic Lupus Erythematosus and chronic kidney injury (eGFR 35), C Exenatide and she has a BMI of 32. D Metformin Which of the following drugs is contraindicated? E Saxagliptin ANSWER ON THE ZOOM POLL Q U E S T I 1 N A Gliclazide A 55 year old woman is recently diagnosed with B Dapagliflozin diabetes. She have a past history of Systemic Lupus Erythematosus and chronic kidney injury (eGFR 35), C Exenatide and she has a BMI of 32. D Metformin Which of the following drugs is contraindicated? E Saxagliptin ANSWER ON THE ZOOM POLLChronic kidney injury ( eGFR 35 ), and she has a BMI of 32. Which of the following drugs is contraindicated? Sulfonylurea causing increased insulin release A Gliclazide (promoting lipogenesis, therefore, it is contraindicated in obesity) B Dapagliflozin Dapagliflozins cause excretion of glucose increasing risk of UTI Exenatide is a type of saxagliptin C Exenatide eGFR >30 D Metformin Gliptins also increases insulin release but improves E Saxagliptin satiety so patients eat less. ANSWER ON THE ZOOM POLL Chronic kidney injury (eGFR 35 ), and she has a BMI of 32. Which of the following drugs is contraindicated? A Gliclazide B Dapagliflozin - Metformin prevents conversion of lactate C Exenatide to glucose - Lactate builds up causes metabolic D Metformin acidosis - If GFR is too low, this will not resolve as E lactate cannot be excretes Saxagliptin Metformin contra eGFR < 30 ANSWER ON THE ZOOM POLL Q U E S T I 2 N A Insulin, calcium gluconate, fluids A 15 year old girl presents with polyurea, nausea B Insulin, Fluids, calcium gluconate and vomiting over the last 12 hours. A blood test shows her ketones are 3mmol/l and her K+ is 4. C Insulin, Fluids, Potassium She is treated for DKA. D Insulin, glucagon, fluids What treatment is given? E Insulin, Metformin, Acetylcysteine e ANSWER ON THE ZOOM POLL Q U E S T I 2 N A Insulin, calcium gluconate, fluids A 15 year old girl presents with polyurea, nausea B Insulin, Fluids, calcium gluconate and vomiting over the last 12 hours. A blood test shows her ketones are 3mmol/l and her K+ is 4. C Insulin, Fluids, Potassium She is treated for DKA. D Insulin, glucagon, fluids What treatment is given? E Insulin, Metformin, Acetylcysteine e ANSWER ON THE ZOOM POLL Her K+ is 4. She is treated for DKA. What treatment is given? Normal K+ is 3.5 -5.2 mmol/l A Insulin, calcium gluconate, fluids Calcium gluconate can be given to stabilise cardiac membranes is K+ is too high but this is not the case B Insulin, Fluids, calcium gluconate Correct. K+ will drop following insulin (Na+/K+ atpase ) C Insulin, Fluids, Potassium Glucagon has opposing affects to Insulin D Insulin, glucagon, fluids Acetylcysteine is used for paracetamol overdose E Insulin, Metformin, Acetylcysteine e ANSWER ON THE ZOOM POLL Q U E S T I 1 N A Increase Insulin B Decrease insulin A type I diabetic is very ill. He has read about diabetic sick rules. C stop insulin Which action should he take? D Half Metformin dose E Monitor ketones every 2 hours ANSWER ON THE ZOOM POLL Q U E S T I 3 N A Increase Insulin B Decrease insulin A type I diabetic is very ill. He has read about diabetic sick rules. C stop insulin Which action should he take? D Half Metformin dose E Monitor ketones every 2 hours ANSWER ON THE ZOOM POLL Q U E S T I 1 N When ill you need more energy so cells need to A Increase Insulin uptake more glucose. Therefore insulin has to increase, not decrease. B Decrease insulin C stop insulin Metformin is given to T2 diabetics D Half Metformin dose Blood glucose is easier to measure than ketones E Monitor ketones every 2 hours ANSWER ON THE ZOOM POLLDIABETIC DRUGS PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK! @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@gmail.com