These are my own notes which helped me achieve 117/119 in the clinical aspect of the GPHC pre-registration exam.
The subheadings contained within this document are as follows:
- General points
- Diagnostic tests
- Type 1 Diabetes
- Insulin
- Basal bolus regimen
- Once daily regime...
General Points
Polypeptide hormone secreted = pancreatic beta cells
Insulin = increase glucose uptake = lower blood conc = prevent hyperglycaemia
and micro & macro and metabolic complications
Natural insulin secretion profile = Basal insulin (slow & steady secretion of
background insulin that controls glucose continuously released from liver)
& meal time bolus insulin (secreted in response to glucose absorbed from
food and drink)
What causes diabetes?
Insulin deficiency
Resistant to insulin
What are the different types of diabetes?
T1 & 2
Diabetes insipidus - key points (what is the main cause? symptom? what does
it effect? 2 types? what to give for the 2 types?)
When your body cannot control water properly - decrease amount of action
of ADH
Different from DM - does not affect blood glucose but water
Kidneys cannot hold enough water
Key symptoms = passing a lot of urine & dehydration - making you thirsty
Endocrine System 1
, Cranial = brain = produces less ADH
Nephrogenic = kidneys = resistant to effects of ADH - does not hold water
(nephrogenic diabetic insipidus)
Vasopressin & desmopressin = ADH used in cranial DI (desmopressin s/e
extreme dilution of water leads to = hyponatreamic convulsions
Carbamazepine, Thiazide D & oxytocin = used in nephrogenic/partial
pituiatary diabetes insidious
Which patient needs to notify DVLA? What must they tell them?
All drivers treated with insulin MUST inform DVLA
Drivers to notify DVLA = depending on their treatment, license type & if they
have diabetic complications (inc episodes of hypoglycaemia)
Drugs with greatest risk of hypoglycaemia (insulin, sulphonylurea,
meglitinides)
What DVLA advice do we give patients?
Avoid hypoglycaemia & know warning signs & actions to take
Carry a glucose meter & test strips when driving
Check blood glucose no more than 2 hours before driving & every 2 hours
while driving
Blood glucose should always be >5mmol/L while driving
Take snack if BG falls to below <5mmol/L (make sure fast acting carb in
car)
Do not drive if BG <5 do not drive if <4 than definitely not or if warning
signs developing
Already driving = stop vehicle in safe place, switch off engine, eat or
drink suitable source of sugar, wait until 45 mins after BG normal
before carrying on
Don’t drive if hypo awareness is lost & notify DVLA
Resume driving when medical reports show hypo awareness has been
regained
Advice on alcohol consumption?
Endocrine System 2
, Mask signs of hypo (confusion, hunger, rapid heartbeat)
Drink in moderation & with food
Diagnostic Tests
LEARN ALL THE BG RANGES
What is HbA1c? What is it used for?
Diagnosed T2 but NOT T1 - monitor glycaemic control in T1 & T2
Glycated Hb - forms when RBC are exposed to glucose
Tests reflects average plasma glucose = previous 2-3 months
Provides a good indication of glycemic control
Performed anytime of the day & does not require any special preparation
Expressed as mmol/mol (table in BNF conversion)
HbA1c involves what cells?
RBC - last in the body for about 3 months = HbA1c reflects control over 3
months
Hb
Glucose
When do you not use HbA1c?
Do not use for diagnosis in T1, diabetes in children, during pregnancy &
women up to 2 months postpartum
DO NOT USE = pts with symptoms of diabetes <2 months, high diabetes risk
& acutely ill, treatment with meds that can cause hyperglycaemia, pancreatic
damage, CKD, HIV
Lower values associated with lower risk of long term vascular complications
How often do you monitor T1 pts?
Patients should have individual targets
Endocrine System 3
, 3-6 months (more frequent if BG changes rapidly)
How often do you monitor T2 pts
Patients should have individualised targets
3-6 months until medication & HbA1c = stable & then monitor every 6
months
HbA1c & fasting blood glucose test diagnoses what?
T2 Diabetes
OGTT diagnoses what?
Gestational diabetes
Involves = BG conc after fasting = 8 hours & then 2 hours after drinking a
standard anhydrous glucose drink (polycat, OGTT oral)
Random blood glucose test diagnosed what?
Type 1 Diabetes
Type 1 Diabetes
Need to mange other CV risks as well (HTN, high lipids etc)
What is this type characterised by?
An absolute insulin deficiency due to LITTLE or NO insulin secretion
due = destruction of insulin producing beta cells in the pancreatic
islets of langerhans - INSULIN REPLACEMENT NEEDED
1. Insulin regime to achieve optimal blood glucose levels
2. Avoid or reduce hypoglycaemic episodes
3. Minimise risk of long term macro & microvascular complications
4. Prevent disability from complications by early detection & active
management of disease
5. Target of glycaemic control should be individualised
Optimal targets for Glucose self monitoring in adults? (dropdown)
Monitor BG at least 4 times a day (before each meal and before bed) - prevent it
falling below 4mmol/L (below 4 on the floor)
Target HbA1c T1 Diabetes =
≤48mmol/mol (6.5%) or lower
Fasting plasma glucose level on waking =
5-7mmol/L (wake at 7) (wake up at 5 to 7)
Plasma glucose before meals at other times of the day =
4-7mmol/L (BE4 meals)
Plasma glucose levels after meals =
5-9mmol/L (dine at 9) (dine at 5 to 9)
Plasma glucose conc when driving =
Endocrine System 5
, 5mmol/L at least (five to drive)
Random plasma glucose conc =
<11mmol/L
Maintained at what conc
4-9mmol/L most of the time
Insulin
What are the 3 types of insulin?
1. Human insulin (lab made) - produced by recombinant DNA tech & have
same amino acid sequence as endogenous human insulin
2. Human insulin analogue - produced same way as human insulin but
modified to be absorbed faster or longer duration
3. Animal insulin (bovine or porcine) - insulin from animal sources - not used
as much
Why is insulin given by injection?
Inactivated by GI enzymes - SC most ideal
Where should patients inject insulin?
Area with most S/C fat (abdomen = fastest absorption rate) or
Outer thigh/buttock (slower absorption compared to abdomen or inner thigh)
Advice for patients?
Injecting same small area repeatedly can cause lipohypertrophy (when
lumps of fat or scar tissue form under your skin)
Rotate sites to minimise risks - can cause erratic absorption of insulin &
contribute to poor glycaemic control if done in same area
Advise pts not to use affected areas for further injection or until the skin has
recovered
Check injection sites for signs of = infection, swelling, bruising &
lipohypertrophy before administration
What are the 3 groups of insulin preparations?
Endocrine System 6
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