DM

and Glucose
26/07/22 5:28 AM

1. Glucose and Diabetes

1. Hypoglycaemia -Blood glucose < 4mmol/L or <72mg/dL, Important Cause- Alcohol
• Dx- Whipple's Triad
○ Low plasma glucose (usually <4)
○ Manifestations (sweating, confusion, tachycardia, hypotension, altered
mentation)
○ If blood glucose is corrected- rapid resolution of symptoms occur
• Rx
• Conscious/ Drowsy
○ 200mL Fruit Juice
○ Oral Glucose Gel
• Unconscious/Cannot Swallow- IV Glucose / 1mg Glucagon IM/SC (2 Tubes)
• Seizures- Glucagon
• Alcoholic- IV Glucose
• Unconscious + Alcohol- Set IV line then IV Glucose (cannot use Oral and Glucagon)
• Preparations of IV Glucose
• D10
○ 10 minutes- 150mL
○ 15 minutes- 200mL
○ Every 1-2 minutes- 50mL until patient conscious or 250mL given (5 times)
• D20
○ 10 minutes- 75mL
○ 15 minutes- 100mL
• Insulinoma- C-peptide Test
2. Hyperosmolar Hyperglycaemic State- High Glucose + High Serum Osmolality but Without DKA
• Rx- IVF 0.9% NS and Electrolyte Correction
3. DKA- Glucose >11 + Abdominal pain + Vomiting + Kussmaul breathing + Dehydration
• Dx- Glucose>11 + Ketonuria ++/Ketonemia + ABG- pH < 7.3 + HCO3<15
• Rx
• 0.9% NaCl initially > Insulin pump at 0.1unit/kg/hour > ABG or VBG> KCL
40mmol/L > D5/D10 when Glucose<12 > Don't use HCO3 (cerebral oedema)
○ 1 ltr IV fluid 0.9% over 1 hour (if systolic BP >90)
or
○ 1 ltr IV fluid 0.9% over 10-15 minutes (if systolic BP <90)
• DKA or Sepsis- Baby with Severe dehydration (dry mucous membranes, sunken eyes and
fontanelles, reduced skin turgor) + Hyponatremia + Hypokalemia
• Rx- IV Fluids (0.9% NaCl + KCl)
4. Diabetes (each word is important)
• Diagnosis
• 1 Abnormal Value + Symptoms
Or
• 2 Abnormal values Without Symptoms
○ Abnormal values (FBG and not RBS, Preferred over HbA1c because cheaper)
§ FBS >_ 7 mmol/L (126 mg/dL)
§ HbA1c >_ 48 mmol/L (>6.5%) (Normal- 42, Target in DM= <48)
• Pre-Diabetes (Impaired Glucose Tolerance)
○ Fasting- 5.5-6.9
○ 2 hour Post-Prandial/ OGTT- 7.8-11 (140-200)
○ HbA1c- 42-47
• Tiredness is not a symptom of DM alone
• In Asymptomatic People with 1 abnormal value> repeat test in 2 weeks to confirm
diagnosis
• Gestational DM/ Acromegaly- OGTT is DxOC
• Variants
• MODY (Maturity Onset Diabetes of Young)
○ DM <25 Y/O + FHx (2 generations) + Mild Hyperglycaemia
○ Rx- Refer to Endocrinology for Genetic Counselling + Lifestyle modifications
§ Sulphonylureas before Insulin
§ Rx- Refer to Endocrinologist
• LADA- Late Autoimmune Diabetes of Adults (30-50 YO)
○ DM1 Variant with Slow Progression + Autoimmune Disease
○ DM1 vs DM2- GAD Antibodies (Glutamic Acid Decarboxylase)
• Rx
• Target- <_ 48 (<6.5)
• Newly Diagnosed
○ First- Lifestyle Modifications
○ Still HbA1c>48?- Start 1 OHA (usually metformin)
○ Still High HbA1c?
§ <58- Lifestyle modifications
§ >58- LIFESTYLE MODIFICATIONS > Add another OHA
• Considering Medications
○ Impaired KFT- Insulin/ Gliptins (DDP4)
§ C/I- With Bad Kidneys, avoid MS (Metformin, Sulfonylurea)
○ Biguanides- Metformin (<30 eGFR, reduce dose if <45)
○ Sulphonylureas (risk of Hypoglycaemia)
○ Weight
§ Increase (SPR)- Sulphonylureas (e.g. Glibenclamide), Glitazones
(Pioglitazone), Repaglinide
§ Decreases- Biguanides (Metformin)
§ No effect- DDP4 (Gliptins)
○ Kidneys
§ Good- Insulin, Gliptins (DDP4)
§ Bad- Metformin, Sulphonylureas (With Bad Kidneys, avoid MS
(Metformin, Sulfonylurea)
§ SGLT-2 inhibitors (Gliflozin)- contraindicated if GFR<60
○ Heart failure- Gliptins (DDP 4 inhibitors- also in Pancreatitis) and Glitazones
(also in Bladder Cancer)
§ Preferred- SGLT2 Inhibitors (Dapagliflozin)
○ SGLT-2 inhibitors- contraindicated if GFR<60
• Mnemonics
○ With bad kidneys (GFR <30), do not use MS (Metformin, Sulphonylureas)
○ The heart has 4 chambers, so with Heart Failure (and Pancreatitis), do not use
DDP4 inhibitors (Gliptins)
○ The Pie (Pioglitazone) comes with the die (Risk of bladder cancer).
Pioglitazone is also contraindicated in Heart Failure
○ Hypoglycaemic that cause weight gain are SPR- Sulphonylureas, Pioglitazone,
Repaglinide
○ The rest cause weight loss except DDP4 inhibitors (Gliptins) which have no
effect on the weight
○ SPR without the P (SR) have risk of hypoglycaemia: Sulphonylureas and
Repaglinide
• Euglycemic DKA- Occurs in SGLT-2 (Gliflozin)- All features of DKA but Blood Glucose is not
elevated (<11), Ix- Capillary Ketones>Urinary Ketones, ABG, Rx- IV Fluids
• Autonomic Neuropathy- Both Sympathetic and Parasympathetic branches (ANS)
• Causes- Diabetes, Alcohol, Aging
• Features- Sweating, Incontinence, Diarrhoea or Constipation, Impotence, Postural
hypotension
• Suspect it in DM patient with Persistent Diarrhoea
• Metformin (Biguanide) can cause Diarrhoea as well
• Stop DAMN drugs in any patients with Diarrhoea or Vomiting
• Pre-Op Mx
• T2DM (on OHAs)
□ Minor Surgery- Continue
□ Major Surgery (1 meal skip)- Continue
□ Longer Surgery (>1 meal skip)/ Uncontrolled DM- Switch to Insulin
□ Emergency Surgery- R/O DKA
® Omit- Sulphonylureas (cause hypoglycaemia)
® Longer surgery- Consider omitting Metformin
® Safe to Use- Rest all
• T1DM (on Insulin)
□ Minor Surgery- Omit Dose (morning if AM surgery, lunchtime if PM surgery)
□ Major- Switch to VRIII (Variable Rate Intravenous Insulin Infusion Ratio)
® Before Sx- 80% of total once daily in VRIII (long-acting) + Continue Other
Insulin
® Intra-op- 80% of total once daily in VRIII (long-acting) + Stop Other
Insulin
® Target during Sx- 6-10 (max 12)
® KCl + Glucose + NaCl also given
□ Emergency- Switch to VRIII
• For Major Sx
□ In all cases, restart the previous regimen when per mouth diet is re-
established + Check Blood glucose 4 hourly