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WelcometoAberdeenUniversity EndocrinologySociety ● Welcome to the next event of our Endocrinology Masterclass Series! ● This is an online revision workshop and is an interactive sessions so please make sure you have SOCRATIVE Student app downloaded. ● uoaendodiabetes@gmail.com please send us an email on: ● Please like and share on: ○ Twitter - Aberdeen University Endocrinology Society ○ Facebook - Aberdeen University Endocrinology Society ○ Instagram - @auendosoc ○ Youtube - Aberdeen University Endocrinology Society Pleasefillout thispre-eventform post-event form is needed for us to send you a certificate! AlexMergo Year 4 Medical Student Revision facilitator, content developer The Endocrinology MasterclassSeries: Natthaya Eiamampai Year 4 Medical Student Revision facilitator, content developer Pancreatic pathology and Diabetes Orla Vennard Content developerdent The contents of this presentation have been validated by a registered endocrinologist Outline ● Hormones of the pancreas and basic physiology ● Pathology of the pancreas ● Diabetes ○ Type 1 diabetes ○ Type 2 diabetes ● Revision questions ● This session will last approximately 1 hour ● SOCRATIVE room name: ENDOSOC20 Disclaimer: Information is taught to the best of our knowledge and this should not replace teaching by the medical schoolPhysiologyRoleof Insulin & GlucagonType I DiabetesMellitus(T1DM)T1DMPresentation Adults typically present with In children and young people < 18 years of age: hyperglycemia and usually ≥1 of: ● Hyperglycaemia (random plasma ● Ketosis ● Rapid weight loss glucose ≥11.1 mmol/L) ● Polyuria (excessive urine) ● Age <50 years ● Polydipsia (excessive thirst) ● BMI <25 kg/m² ● Personal and/or family history of ● Unintentional weight loss autoimmune disease. ● Excessive tiredness ● Other symptoms e.g. blurred vision. Many patients present with diabetic ketoacidosis (acute complication of T1DM).T1DMDiagnosis andFurther Testing Diagnosis of T1DM can be made by: ● fasting glucose ≥ 7.0 mmol/l ● random glucose ≥ 11.1 mmol/l (or after 75g OGTT) Other blood tests that should be ordered include: ● baseline bloods – FBC, U&Es ● HbA1c – to understand how long they have been a diabetic prior to the presentation ● TFTs and TPO – ?autoimmune thyroid disease ● anti-TTG – ?coeliac disease ● antibodies associated with T1DM – insulin autoantibodies (IAA), antibodies to glutamic acid decarboxylase (anti-GAD), islet cell antibodies (ICA, against cytoplasmic proteins in the beta cell) and insulinoma-associated-2 autoantibodies (IA-2A)T1DMManagement: Blood Glucose Monitoring Patients should monitor their own blood sugars at least 4 times a day (e.g. three times before meals and once before bed). Blood glucose monitoring is recommended more frequently in some situations: ● Physical activities ● Pregnancy ● Those with hypoglycaemic episodes.T1DMManagement: Blood Glucose Targets Long-term control of T1DM is monitored by HbA1c levels. HbA1c is formed when glucose in blood binds to haemoglobin in RBCs. Because HbA1c circulates for the entirety of a RBC’s lifespan, HbA1c level reflects the blood glucose levels over the preceding 2-3 months. ● Higher glucose = higher HbA1c levels ● Target of HbA1c <48 mmol/L (6.5%)* * may not be possible in all the patientsT1DMManagement: Blood Glucose Targets Fasting glucose OGTT at 2 hrs HbA1c [mmol/l] [mmol/l] [mmol/mol] Gestational diabetes* ≥5.6 ≥7.8 Normal range ≤6.0 ≤7.8 ≤41 (5.9%) Prediabetes 6.1-6.9 7.8-11.1 42-47 (6.0-6.4%) Diabetes mellitus ≥7.0 ≥11.1 ≥48 (6.5%)T1DMManagement: Insulin ● Exogenous insulin – can be injected subcutaneously ○ traditionally comes as a parenteral preparation ● Numerous types: ○ Rapid-acting e.g. Novorapid, Humalog ○ Long-acting insulin e.g. Lanuts, Levemir ○ Mixed e.g. Humulin M3, Novomix 30, Humalog Mix 25T1DMManagement: HypoglycaemiaManagement Hypoglycaemia is generally defined as BG <4 mmol/L. There are multiple situations which can make a patient develop hypoglycaemia. Patients may experience: mood changes, hunger, headaches, sweating, dizziness, blurred vision, extreme fatigue and paleness, trembling, heart palpitations. In severe cases they may also experience: confusion, aggression, drowsiness, blackout, collapse, epileptic seizure. Mild hypos can be self-managed with 15–20 g rapid-acting carbohydrate in the form of ONE of these: ● 4-5 jelly babies ● 200 ml orange juice ● 4-6 glucose tabletsT1DMManagement: HypoglycaemiaManagement BG <4 mmol/L community hospital conscious & able to unconscious OR swallow unable to swallow 10-20g oral glucose in liquid, gel or tablet form OR GlucoGel / Dextrogel SC / IM glucagon IV 20% glucoseT1DMManagement: Monitoring for Complications Retinopathy annual screening monofilament assessment of neuropathy (every 15 months) and Diabetic foot vascular assessment +/- dopplers, full examination including footwear Nephropathy renal function (eGFR) and albumin:creatinine ratio (ACR) Cardiovascular risk primary/secondary prevention strategy with optimisation of factors lifestyle (weight, smoking), blood pressure, lipids etcDiabeticketoacidosisDiabetic ketoacidosis(DKA) DKA is characterised by a biochemical triad of hyperglycaemia, ketonaemia and acidosis. ○ Hyperglycaemia: > 11.0 mmol/L or known DM ○ Ketonaemia: ≥ 3 mmol/L or significant ketonuria (> 2+ on dipstick) ○ Acidosis: bicarbonate < 15.0 mmol/L and/or venous pH < 7.3DKA presentation Symptoms (usually acute) Signs ● Polyuria ● Dry mucous membranes ● Polydipsia ● Sunken eyes ● Tachycardia ● Weight loss ● Hypotension ● Weakness ● Ketotic breath ● Nausea/vomiting ● Kussmaul resp. ● Abdo pain ● Altered mental state ● Breathlessness ● Hypothermia ● Pseudohyponatremia Risk factors: Known T1DM, inadequate insulin, infection, other precipitators.DKA diagnosis Investigations Diagnosis ● Capillary blood glucose ● Capillary blood ketones or ● Hyperglycaemia (BG>11mmol/L) urine ketones ● Ketosis (Blood ketones ● Capillary or venous pH and >3mmol/L) bicarbonate ● Acidosis (pH <7.3)DKA management Correct dehydration evenly over 48 hours: intravenous fluids Give fixed rate insulin infusion (allows cells to start using glucose for energy, switching off the need for ketones) Also ● Treat underlying cause ● Add potassium to IV fluids and monitor serum potassium ● Monitor for signs of cerebral oedema ● Monitor glucose, ketones and pHDKA management 1. IV fluids If patient is alert and stable, and ○ initially 0.9% sodium chloride tolerates oral intake without 2. IV insulin vomiting – use oral glucose and subcut insulin ○ Start infusion at 0.1 unit/kg/hr ○ Once BG <14 mmol/L – add 10% dextrose at 125 mls/hr alongside saline 3. Electrolyte imbalance correction ○ Monitor serum potassium – may need to be added to replacement fluids ○ If rate of potassium infusion >20 mmol/hr, consider cardiac monitoring 4. Long acting insulin should be continued and short acting insulin stoppedType II DiabetesMellitus (T2DM)T2DM aetiology Not entirely known Combination of: 1) reduced tissue sensitivity to insulin (insulin resistance) and 2) inability to secrete very high levels of insulinT2DM riskfactors Risk factoresT2DM presentation Symptoms Signs ● Asymptomatic (common) - ● Usually not ketotic detected on screening ● Usually overweight but not ● Fatigue always ● Blurred Vision ● Low grade infections, thrush / ● Polyuria, polydipsia balanitis. ● Unintentional weight loss if ● Skin infections marked hyperglycemia ● Glucose on urine dipstickT2DM diagnosis ONE diagnostic lab glucose + symptoms Or TWO diagnostic lab glucose without symptoms. Diagnostic glucose levels (venous plasma) ● fasting glucose 7.0 mmol/l ● Random glucose 11.1 mmol/l ● OGTT 2h after 75g CHO 11.1 mmol/l ● Diagnostic HbA1c ≥ 48 mmol/mol. (different criteria for gestational diabetes)Pre-diabetes ● Impaired fasting glucose 6.1-7 mmol/l ● Impaired glucose tolerance 2h glucose ≥7.8 and <11mmol/l ● HbA1c 42-47mmol/mol; above normal range but not quite in the diagnostic criteria for diabetesT2DM management ● Patient education! ● Lifestyle advice ● Optimise risk factors ● Pharmacotherapy ● Monitoring for complications - Diabetic retinopathy - Kidney disease - Diabetic footT2DM management: lifestyle ● Weight loss: ○ diet/exercise ○ GLP1 analogues and SGLT2 inhibitors, orlistat ○ bariatric surgery ● Reduce alcohol consumption ● Smoking cessationT2DMmanagement: Complications Microvascular Macrovascular ● Eye: retinopathy, ● Brain: stroke, TIA cataracts, glaucoma ● Coronary heart disease ● Kidney: nephropathy ● Diabetic foot: PVD, ● Peripheries: gangrene neuropathyT2DMmanagement: PharmacotherapySummaryof T2DM medicationTreatment targets Largely based on serial measurements of HbA1c. ● Poor glycaemic control: HbA1c every 3 months. ● Stable disease: HbA1c every 6 months. ○ Management with lifestyle modifications only: aim HbA1c < 48 mmol/mol ○ Management with lifestyle + 1 antidiabetic agent: aim HbA1c < 48 mmol/mol ○ Management with a drug associated with hypoglycaemia (e.g. SU): aim HbA1c < 53 mmol/mol These targets may not be suitable for every patient - individualised treatment!Sick Day Rules Things to do: - Encourage eating and drinking, if they are unable to eat then offer sugary drinks to maintain fluids and carbohydrate intake - Increase frequency of BG monitoring - If patient is on oral hypoglycemia medication, they should continue to take as normal - If patient is on insulin, they must continue due to risk of DKAReferences ● Zero to Finals, T1DM ● Quesmed ● Passmedicine ● Osmosis
