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Diabetes 1

Medical Treatment
Biguanides e.g. metformin
Reduces blood sugar levels: slows absorptionof glucose fromgut to blood,
reduces glycolysis, increases sensitivity of myocytes to insulin
Maintains weightloss
S/E: transientnausea anddiarrhoea
Avoidif poor renal functionor anycause of lactic acidosis
Slowto act and require buildingup slowing to reduce adverse effects
Glitazone
Bindandactivate PPARs
Decrease insulinresistance
S/E water retentionleadingto oedema
ContraindicatedinHF
Sulphonylureas e.g. glimepiride &gliclazide
Increase insulinsecretionbybeta cells
(flogginga deadhorse)
Speeds upthe process of beta cell failure
Quickto act
S/E: hypos
Causes weightgain
Alpha glucosidase inhibitors e.g. acarbose
Inhibits enzyme involved in breakdowncarbohydrates
Slows absorptionof glucose into blood
S/E: wind(significant), abdo distension/ pain, diarrhoea
Canincrease risk of hypos whenused withsulphonyureas
DPP-4Inhibitors e.g. sitagliptin
Blocks an enzyme involved in stimulating glycolysis / gluconeogenesis
andrestrictionof insulinproduction
Incretinmimetics e.g. exenetide
Subcutinjections
Insulin
Normal action: Increasedbloodsugar
after a meal >pancreas releases insulin
Stimulates muscle cells to take upglucose
Inhibits glycolysis
Inhibits break downof fatstores into lipids
Sub-cutInsulins
Ultrafast - inject atstart of meal e.g. Humalog
Soluble insulin- inject 15 - 30 mins before meal e.g. HumulinS
Intermediate e.g. HumulinI
Longactinge.g. Ultratard
Longactinganalogues e.g. Lantus
Pre mixedinsulins e.g. NovoMix30 or HumulinM3
Sub-cutInsulinRegimens
BD regime - pre mixed insulins bypeninjector; useful for those with regular lifestyle
QDS regime - before meals ultra fast/ soluble insulinwithbed time long acting;
useful for flexible lifestyles
OD regime - long acting analgue; useful for type 2 DMs for initial insulinregime
DAFNE - dose adjustmentfor normal eating
Autonomyandindependence
Intensive
Improved glycaemic control along withincreased QoL
StartinginsulininType 2DM
Indicated whencontrol withoral agents is suboptimal: HbA1c >7.5% onmaximumoral therapy
Continue metforminto limitweightgain
TargetHbA1c <7.5%
J an2008 Pfizer ceasedproductionof inhaledinsulin
InsulinPumpTherapy
Continuous S/C insulininfusion
Adults andchildren>12Type 1DM
Need to have had disabling hypos frommulti daily injection(physical, anxiety or impact onQoL)
or HbA1c remains highdespite MDI +/- longacting analgoues
Require sustainedimprovementto continue
Costaround2750+consumables
Gestational
Includes gestational IGT and gestational DM
Same diagnostic criteria
Glucose tolerance changes duringpregnancy
Those who develop GDMor GIGT are at anincreasedrisk of developing diabetes
Type 2
Epidemiology
Typicallyolder
Higher prevalence inAsians, menandthe elderly
Genetics
No HLA association
80%concordance inidentical twins
Aetiology Insulinresistance and reducedinsulinsecretion
Causes of insulinresistance: obesity,
preganancy, renal failure, Asians,
acromegaly, CF, TB drugs, Cushing's,
metabolic syndrome
Associatedwithobesity, lack of exercise andcalorie excess
Presentation
Oftenasymptomatic
Presents withmicro / macro vascular complications
Type 1
Epidemiology
Typicallyjuvenile onset
Canoccur atanyage
Genetics
HLA Linked
30%cocordance inidentical twins (indicating env. influence)
4 genes important; 1 esp. that determines ilset sensitivityto damage e.g. from
viruses / cows' milk inducedantibodies
Linkedto other autoimmune conditions
Aetiology
Autoimmune beta cell destruction
Presentation
Polydipsia, polyuria, weightloss, DKA
Secondarycauses
Druginduced: steroids, thiazides
Pancreatic: surgery, trauma, cancer, destruction (haemochromatosis, CF)
Endocrine: Cushing's, hyperthyroidism
Diagnosis
DM(either)
Fasting glucose >7 or Randomglucose >11.1 &symptoms of hyperglycaemia
Raised glucose on2 separate occasions: fasting >7or random>11.1 or 2hr OGTT >11.1
ImpairedGlucose Tolerance (IGT)
Fasting glucose <7&2hr OGTT >7.9 butless than<11.1
Higher risk of progressionto DM
Lifestyle advice anddiet; regular review
ImpairedFastingGlucose (IFG)
Fastingglucose >6.1butless than<7
Lower risk of progressionto DM
Lifestyle advice anddiet; regular review
Diabetes.mmap - 07/09/2010 -