A371 T1 L10 mindmap by LIM JIA MIN

Diabetes

2020-07-23 04:34:56 UTC

It is a group of metabolic disorders characterised by resistance to the action of insulin, insufficient insulin secretion, or both, leading to hyperglycaemia.

Type I Diabetes

190084601 — 2020-07-23 04:35:44 UTC

Type 1 is due to autoimmune beta cell destruction, usually leading to absolute insulin deficiency.

Type II Diabetes

190084601 — 2020-07-23 04:36:07 UTC

Type 2 is due to a progressive loss of adequate beta cell insulin secretion caused by insulin resistance

Pre-diabetes

190084601 — 2020-07-23 04:38:03 UTC

Pre-diabetes is defined by glycaemic levels that are higher than normal, but lower than diabetes thresholds.

Risk factors

2020-07-23 04:40:43 UTC

- Overweight
- BMI for more than 23kg/m^2
- Family history of diabetes
- High risk race/ethnicity
- Women who have delivered a baby 4kg or more
- Hypertension
- Dyslipidaemia
- History of cardiovascular disease
- Women with polycystic ovarian syndrome
Sign and symptoms
Symptoms
- Tiredness
- Increase thirst
- Extreme hunger
- Unexplained weight loss
- Numbness or tingling on hands or feets
- Blurry vision
Signs
- Fasting blood glucose of more than or equal to 7mmol/L
- 2 hours post challenge plasma glucose of more than 11.1 mmol/L
- Random blood glucose of more than 111mmol/L
- HbA1c of more than 6.5%

Type I

190084601 — 2020-07-23 04:42:31 UTC

1. The body’s immune system destroys insulin producing cells (beta cells) in pancreas à usually no pancreatic function
2. Onset at < 30 year old
3. Symptoms usually starts suddenly and exact cause is unknown; family history not a strong risk factor
4. Need regular insulin injections

Medications that are used to treat Type II diabetes

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1) Biguanides - metformin
- (Immediate release) initially 500 mg OD-TDS, may be increased up to 850 mg BD or TDS according to response; max 3 g / day

- (controlled release) initially 500 mg once daily, may be increased up to 2 g daily
side effects: nausea, vomiting, anorexia, diarrhoea

2) Sulphonylureas - gliclazide, glipizide, glibenclamide, tolbutamide
a) Gliclazide
- (Immediate release)

40- 320 mg daily in 1 or 2 doses (up to 160 mg per dose)

- (controlled release) initially 30mg OD, increase dose by 30mg OD at not less than 2-week intervals
b) Glipizide
- 2.5-40mg daily in 1 or 2 doses; doses >15mg daily should be divided
c) Glibenclamide
- 2.5-20mg daily in 1-2 doses (up to 10mg per dose)
d) Tolbutamide
- 0.5g - 2g daily in 2-3 doses
side effects: hypoglycaemia, weight gain, nausea, diarrhoea, headache, rash

3) Sodium-glucose cotransporter 2 inhibitors - dapagliflozin
Dose: 10 mg once daily
side effects: polyuria, thirst, nausea, genital infections (e.g. vulvovaginal candidiasis)

4) Dipeptidyl peptidase-4 (DPP-4) inhibitors - sitagliptin
dose: 100 mg once daily
side effects: Headache, musculoskeletal pain (may be severe), Nasopharyngitis, upper respiratory tract infection, peripheral oedema

Difference between Type I and II

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Type II

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1. The most common form of diabetes; Insulin present in low, “normal” or high amounts
2. Onset at > 40 years old
3. Occurs more likely in people with high blood pressure, high cholesterol and people who are obese; Positive family history; Symptoms develop slowly.
4. Can often be controlled with diet and exercise but sometimes may need medications- OHGA and/or insulin.

Management

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Lifestyle intervention
- Recommended to all persons with pre-diabetes
- Goal: BMI (< 23kg/m2) and/or 5-10% body weight loss.

1) Healthy eating
- Portion a healthy plate
- Avoid sweetened beverages and foods
- Eat less fat
- Limit alcohol intake
2) Increased physical activity
- Engage in exercises that require intensity and that accelerates the heart rate
- No more than 2 consecutive days without exercise
- More than or equals to 150 mins of moderate activity OR more than equals to 75 mins of intense activity every week
3) Stop smoking

Gestational diabetes

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Glucose intolerance with onset or first recognition during pregnancy

Steps in Glycemic Control for Type 2 diabetes

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Step 1 - Change in lifestyle: diet & exercise
Step 2 - Oral monotherapy ( Metformin )
Step 3 - Oral combination ( Metformin + Sulphonylureas + SGLT-2)
Step 4 - Oral + Insulin ( Metformin + Sulphonylureas + SGLT-2
Step 5 - Insulins

Complications (Uncontrolled diabetes)

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IF diabetes if not well controlled, blood vessels, nerves and other body organs may be damaged. This could cause complications such as:
1) Retinopathy (Loss of eyesight)
2) Nephropathy (Kidney damage)
3) Neuropathy (Nerve damage)
4) Heart disease, stroke
5) Poor blood flow
6) Foot problems and leg ulcers
7) Infections
8) Impotence in men

Pre-diabetes

2020-07-23 04:57:18 UTC

Metformin - Dose of 250mg BD and can increase up to 850mg BD

Non-pharmacological Management

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1) Lose weight if overweight
- Healthy BMI from 18.5 to 22.9kg/m2
2) Adopt a well-balanced diet which includes a variety of food
3) Eat an appropriate and consistent amount of carbohydrate or starchy food at each meal to help achieve a constant blood sugar level
4) Eat more fibre-rich food and lesser fatty or oily food especially saturated and trans fat
5) Reduce salt intake
6) Have regular meals at similar timing each day
7) Have an active lifestyle

What is hypoglycaemia?

190084601 — 2020-07-23 05:02:34 UTC

Occurs when blood glucose levels fall below 4 mmol/L (72mg/dL)

When your glucose (sugar) level is too low, your body doesn't have enough energy to carry out its activities.

Symptoms:
1. Shaking
2. Hunger
3. Sweating
4. Dizzeness

Causes of hypoglyaemia

190084601 — 2020-07-23 05:04:36 UTC

1. Doses of hypoglycaemic medications are too high.

2. Delayed meals and this shows the importance of taking the oral hypoglycaemic medications with or after meals.

3. Exercise.

4. Alcohol.

5. Many drugs affecting blood glucose levels but mostly are manageable so have to monitor blood glucose more frequently

Management of hypoglycemia

190084601 — 2020-07-23 05:06:20 UTC

When a patient is experiencing symptoms of hypoglycaemia, try to provide 15g of fast-acting carbohydrates and perform blood glucose monitoring about 15 minutes later.

If symptoms are severe or patient is losing consciousness:

1. Call 995 for an ambulance and seek urgent medical assistance.

2. Do not administer anything orally.

3. Patient will be give a glucagon injection in the hospital setting.

Monitoring of blood glucose level

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1) Self-monitoring of blood glucose level (SMBG)
- Recommended for patients with type I and II diabetes who are using insulin
- Use of glucometer for monitoring
Who are recommended to use?
- Those at increased risk of developing hypoglycemia
- Pregnant patients with pre-existing diabetes or GDM
- Experiencing acute illness
- Those who failed to achieve glycaemic targets
- Those who are undergoing fasting

2) Self-urine glucose monitoring
- Accuracy influenced by the high variability of the renal threshold for glucose

3) Glycated haemoglobin (HbA1c)
- Should be performed routinely in ALL patients with diabetes, at initial assessment and as part of follow-up
- Quantifies average blood glucose over the previous 2-3 months

4) Regular examination on eyes
- Done at diagnosis
- Yearly routine follow-up

5) Regular examination on feet
- Self-check must be done DAILY
- Annual foot examination with a doctor should be done
Self-check symptoms:
- Negative pinprick sensation, dry feet to check for peripheral neutopathy
- Presence of ulceration, callus with haemorrhage, ingrown toenails