Complications of Diabetes_Mellitus.pptx

Complications of Diabetes mellitus

1. Diabetes Mellitus Introduction W . G aven 9/2/2018 W. Gaven 1

2. Understand diabetes mellitus Distinguish between type 1 and 2 Manage problems in clinics Understand prescribing Recognise and treat emergencies Recognise long term complications Aims 9/2/2018 W. Gaven 2

3. What is Diabetes? 9/2/2018 W. Gaven 3

4. Absent/Reduced Action of insulin This defect leads to altered metabolism of glucose This leads to high blood sugar Diabetes Mellitus 9/2/2018 W. Gaven 4

5. Insulin and Metabolism of glucose 9/2/2018 W. Gaven 5

6. High blood sugar bad for the vessels Emergency and chronic problems Medications can also cause problems So what happens? 9/2/2018 W. Gaven 6

7. Lethargy Increased urination ( polyuria ) Increased thirst ( polydipsia ) Weight loss Increased prevalence of infections Symptoms 9/2/2018 W. Gaven 7

8. Symptoms 9/2/2018 W. Gaven 8

9. Random blood sugar > 11mmol/l-suggestive Fasting blood sugar ≥7 mmol /l Oral glucose tolerance test ≥ 11.1 mmol /l HBA1c >7% Can also present in diabetic emergency Diagnosis 9/2/2018 W. Gaven 9

10. The HgA1c is the gold standard for diabetes care . To help prevent diabetes complications, the HgA1c should be maintained at 7% or below according to the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) findings. 9/2/2018 W. Gaven 10

11. Which is which type? 9/2/2018 W. Gaven 11

12. How to tell which type? Type 1 Type 2 Younger onset (<30years) Ketoacidosis Weight loss Older age group Obese 9/2/2018 W. Gaven 12

13. Type 1 vs type 2 Type 1 Type 2 Destruction of insulin producing cells No circulating insulin Always need insulin Get DKA Body resistant to its insulin Can start with lifestyle measures Tablets used Insulin in last resort Don’t get DKA 9/2/2018 W. Gaven 13

14. 19 year old male Unwell Losing weight significantly past 3 weeks Sweating, vomiting, deep breathing Blood sugar 420 Which type of diabetes? 9/2/2018 W. Gaven 14

15. Autoimmune disease Young patients Can present with DKA Will need insulin replacement Lifestyle advice Type 1 diabetes 9/2/2018 W. Gaven 15

16. Diabetic diet 9/2/2018 W. Gaven 16

17. Destruction of B cells in islets of Langerhans Do not produce insulin Pathology 9/2/2018 W. Gaven 17

18. Insulin prescribed via rule of thirds Advise healthy diet Check eyes Check feet Check urine Check U+E Treating type 1 diabetes 9/2/2018 W. Gaven 18

19. Prescribed by rule of thirds Life long in type 1 Increase doses in illness and exercise Amount needed varies Insulin 9/2/2018 W. Gaven 19

20. Insulin types Soluble Lente insulin fast acting lasts an hour or so longer acting lasts at least 12 hours 9/2/2018 W. Gaven 20

21. Total insulin = 0.5-1 unit/kg/day Total insulin dose split into 2/3 and 1/3 2/3 of insulin in AM 1/3 of insulin in PM AM and PM dose split into 2/3 and 1/3 2/3 of insulin dose as LENTE 1/3 of insulin dose as SOLUBLE Do not split insulin dose if BIPHASIC Biphasic is 70%~2/3 lente & 30%~1/3 soluble Insulin prescription rule of thirds 9/2/2018 W. Gaven 21

22. Start 120kg man on 0.5 unit/kg/day Total insulin=120 x 0.5= 60 units 2/3 x 60= 40 units AM 1/3 x 20= 20 units PM AM insulin 2/3 x 40= 26 units LENTE 1/3 x40= 14 units SOLUBLE PM insulin 2/3 x 20= 13 units LENTE 1/3 x 20= 7 units SOLUBLE An example 9/2/2018 W. Gaven 22

23. Older patients Tend to be obese Cells desensitised to insulin Step wise approach to management Type 2 diabetes 9/2/2018 W. Gaven 23

24. Step wise approach 9/2/2018 W. Gaven 24

25. First advise diet and exercise Management of type 2 DM 9/2/2018 W. Gaven 25

26. Increases bodies sensitivity to insulin Hypoglycaemia less common Lactic acidosis side effect (stop if unwell) Avoid in renal failure Metformin 9/2/2018 W. Gaven 26

27. Increases islet secretion of insulin At risk of hypoglycaemia Glibenclamide 9/2/2018 W. Gaven 27

28. Initially lente 0.3U/kg with one oral med Then insulin rule of thirds as with type 1 Insulin in type 2 DM 9/2/2018 W. Gaven 28

29. FBS < 120 mg/dl BP < 140/80 Look for other complications (to be discussed later) Clinic aims 9/2/2018 W. Gaven 29

30. Essential to control BP ACE- i 1 st (captopril12.5 mg bd start) Because ACE- i protect the kidneys Then Ca blocker ( nifedipine 10 mg bd start) Then other BP meds Diabetics and BP 9/2/2018 W. Gaven 30

31. Type 1 diabetic fasting blood sugar 300mg/dl On insulin Lente 20 units am 10 units pm Soluble 10 units am 5 units pm Case 2 9/2/2018 W. Gaven 31

32. Check patient well Check compliance Increase insulin by a small amount i.e... 24 units lente am 12 pm Soluble 12 am and 6 pm Case 2 Plan 9/2/2018 W. Gaven 32

33. Diabetic ketoacidosis (DKA) Hyperosmolar non ketotic coma (HONK) Hypoglycaemia/ hypoglycaemic coma Diabetic Emergencies 9/2/2018 W. Gaven 33

34. Occurs in type 1 patients Insulin absence leads to increased blood sugar an ketones formed Acidotic state- patient v.ill Diabetic Ketoacidosis (DKA) 9/2/2018 W. Gaven 34

35. New diabetes Didn’t take insulin Infection e.g pneumonia, UTI Trauma/ Surgery Emotional stress Causes of DKA 9/2/2018 W. Gaven 35

36. Ill-looking Vomiting Abdominal pain Polyuria (urinating lots) Polydipsia (drinking lots) Coma Dehydration Acidotic breathing Ketotic breath (Quite pleasant) Diabetic Ketoacidosis (DKA) 9/2/2018 W. Gaven 36

37. High blood sugar (usually) Ketones in urine Acidosis pH < 7.3 In practice no ABG, in Malawi diagnosis made on clinical symptoms, blood sugar and ketones in urine +/- acidotic breathing DKA diagnosis 9/2/2018 W. Gaven 37

38. Main priority IV fluid start adding pottassium Give fluid fast 9/2/2018 W. Gaven 38

39. Give IV soluble Then start perfuser of insulin When blood sugar <15 mmol /l give dextrose instead of saline Insulin 9/2/2018 W. Gaven 39

40. Tranfer to HDU Regular monitoring of vital signs and blood sugar Keep on treatment until ketones negative in urine look for signs of cause and treat (? antibiotics) Generally 9/2/2018 W. Gaven 40

41. Occurs in type 2 diabetes Excess of GLUCOSE causes dehydration Often elderly patients not drinking enough Patients very unwell Hyperosmolar non- Ketotic Coma (HONK) 9/2/2018 W. Gaven 41

42. Confused to comatose patients Often have added complications i.e infection/ thrombus HONK symptoms 9/2/2018 W. Gaven 42

43. Patient very dehydrated Very high blood sugar No ketones in urine Can have mild acidosis HONK investigation 9/2/2018 W. Gaven 43

44. Mainly dehydrated Need more fluids than DKA IV fluids Give insulin stat and via a perfuser Monitor on HDU HONK treatment 9/2/2018 W. Gaven 44

45. DKA vs HONK DKA HONK Type 1 patients Ketones in urine Usually recover Acidosis can be severe Fluids priority Type 2 patients Usually elderly/ frail No ketones in urine Mild acidosis Fluids priority 9/2/2018 W. Gaven 45

46. Blood sugar below 2.5 mmol /L Very common in diabetics Often early symptoms lost Hypolycaemia 9/2/2018 W. Gaven 46

47. Sweating Tremor Tachycardia Anxiety Hunger Though may be none Symptoms of Hypo’s 9/2/2018 W. Gaven 47

48. Dizziness Headache Blurred vision Confusion Decreased mental ability In worst instance loss of consciousness and coma Later symptoms 9/2/2018 W. Gaven 48

49. Excess insulin (? Deliberate OD) Change in insulin requirements Renal failure concentrates drugs Sepsis Stress- trauma Exercise Missing meals Hypo causes 9/2/2018 W. Gaven 49

50. Urgent bolus 50% dextrose Recheck blood sugar Conscious should recover within an hour Dextrose 10% infusion Continually monitor blood sugar Treat underlying cause Managing hypoglycaemia 9/2/2018 W. Gaven 50

51. Vascular problems Eye problems Kidney disease Nerve disease Diabetic foot Long term Complications 9/2/2018 W. Gaven 51

52. Stroke Heart disease Leg claudication Impotence Increased big and small vessel disease 9/2/2018 W. Gaven 52

53. Dots and blots New vessels and scarring Can cause blindness Eye problems- Retinopathy 9/2/2018 W. Gaven 53

54. Laser surgery Prevents worsening Retinopathy can be treated 9/2/2018 W. Gaven 54

55. Very common 50% Initially asymptomatic Urinary protein clue Check U+E Kidney problems 9/2/2018 W. Gaven 55

56. ACE inhibitors ( captorpil start 12.5 mg bd ) Control BP (<140/ 80) Can progress to end stage renal failure ? Dialysis – haemo / peritoneal Kidney treatment 9/2/2018 W. Gaven 56

57. Most parts of nervous system Peripheral neuropathy Mononeuropathy (wrist drop) Raadiculopathy (like zoster in back nerves) Autonomic neuropathy(GI main target, orthostatic hypotension, erectile dysfunction) Nerve disease 9/2/2018 W. Gaven 57

58. Diabetic foot ulcer 9/2/2018 W. Gaven 58

59. Common Contributed by vascular and neurological problems Need x-rays – deeper infection Good shoes- comfy not tight fitting Keep feet clean and dry In serious cases amputation/ debridement Diabetic foot ulcer 9/2/2018 W. Gaven 59

60. Absence/ ineffective insulin Type 1/ Type 2 Insulin vs tablet therapies Emergencies- DKA, HONK, Hypo Long term complications + management Summary 9/2/2018 W. Gaven 60