1(E) T2DM, HHS Flashcards by Grace Poole

What is T2DM

Insulin resistance which leads to hyper-secretion of insulin from pancreatic B islet cells causing dysfunction

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What is MODY

Maturity onset diabetes of the young. T2DM - onsets in young people

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When doe T2DM usually onset

Over 40

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In which ethnicity is T2DM more common

Asian

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Explain inheritance of T2DM

80% concordance in twins

Greater genetic heritability than T1DM

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What are 3 other causes of T2DM

Cushing’s disease
Prolonged steroid use
Pancreas: surgery removing 90%, pancreatitis, trauma

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What are 5 RF for T2DM

Obesity
Asian
HTN
Sedentary
Metabolic Syndrome
Dyslipidaemia
GDM

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What does T2DM usually develop from

pre-cursor phase: either impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

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What are classic symptoms of T2DM

Polyuria

Polydipsia

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What are 4 non-specific T2DM symptoms

Visual disturbance
Fatigue
Poor wound healing
Recurrent infections (UTI)

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What do WHO state is pre-diabetes

State of impaired glucose tolerance - insufficient to diagnose DM

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What causes impaired fasting glucose

Liver resistance to insulin

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What defines impaired fasting glucose

Fasting glucose of 6.1. - 7mmol/L

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What should patients with impaired fasting glucose be offered

Oral Glucose Tolerance Test (OGTT)

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What causes impaired glucose tolerance

Muscle resistance to insulin

Remember T for tone

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Are patients more likely to develop diabetes in impaired glucose tolerance or impaired fasting glucose

Impaired glucose tolerance test

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what defines impaired glucose tolerance

OGTT of 7.8 - 11.1 mmol/L

FG < 7

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What defines impaired fasting glucose

Fasting glucose < 7

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What defines impaired glucose tolerance

Fasting glucose < 7

OGTT - 7.8 - 11.1 mmol/L

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Explain diagnostic criteria for diabetes if symptomatic

Symptoms (polyuria, polydipsia, weight loss) and one of:

Random plasma glucose >11.1
Fasting glucose >7
OGTT >11.1

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Explain diagnostic criteria for diabetes if asymptomatic

Requires two of:

Random plasma glucose > 11.1
OGTT > 11.1
Fasting plasma glucose >7

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Explain oral glucose tolerance test

75g anhydrous glucose solution is given and blood sugar measured 2h later

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Explain HbA1c is diagnosis of T2DM

HbA1c is not included in diagnostic testing. A positive test supports diagnosis of T2DM. A negative test does not exclude it

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What HbA1c indicates diabetes

> 48mmol/mol (6.5%)

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If suspect HbA1c but less than 48 (6.5%) what should be done

treat as high-risk of developing diabetes and repeat test in 6 months or when develops symptoms

Who should HbA1C not be used

- Children - T1DM - Pancreatic surgery - Steroids - Symptoms <2 months - Acutely ill - Pregnancy

What fasting plasma glucose defines gestational DM

FPG: >5.6

What OGTT defines gestational diabetes mellitus

OGTT >7.8

What is first-line management for T2DM

Lifestyle advice

Using lifestyle management, what HbA1c target is aimed for

48mmol/mol

How often is HbA1c measured initially

Every 3-months

If HbA1c increases beyond 48mmol/mol, what is added

Metformin

What HbA1c is aimed for on metformin

Less than 58mmol/mol (7.5%)

If HbA1c increases beyond 58mmol/mol what is added

Dual therapy: - Metformin and DPP4-i - Metformin and pioglitazone - Metformin and sitagliptin - Metformin and SGLT-2i

If HbA1c increases beyond 58mmol/mol (7.5%) in dual therapy what is done

Triple therapy: - Metformin, DPP4I, SU - Metformin, pioglitazone, SU - Metformin, SU, pioglitazone, SGLT-2i

If HbA1c increases beyond 58 on triple therapy what is done

Insulin therapy

What are the two types of insulin based therapies

Basal-bolus regimen: - Long-acting before bed - Short-acting before meals Biphasic: - Novomix BD

When is biphasic regimen preferred

If regular lifestyle

What are two glucagon like peptide analogues

Exenatide | Liraglutide

What is the MOA of glucagon-like peptide analogues

Augment insulin release

When are glucagon like peptide analogues indicated

Triple therapy ineffective or not tolerated

What is the criteria for glucagon like peptides to be prescribed

1. BMI >35 and psychological complications of obesity | 2. BMI <35 and significant occupational CI to insulin or where weight loss would benefit other co-morbidities

What BP is aimed for in T2DM

<140/90. | Unless, end-organ damage then <130/80

What BP medication are all diabetics put on

ACEi

What dose of statin is given as primary prevention if QRISK score >10%, T1DM of GFR <60

20mg

What is HHS

Hyperosmolar Hyperglycaemic state | Emergency associated with T2DM

What did HHS used to be called

Hyperglycaemic non-ketotic coma

What is a mnemonic to remember criteria for diagnosing HHS

VAGO

What is the criteria to diagnose HHS

hypoVolaemia NO Acidosis or NO ketosis Glucose high Osmolality >320

What osmolality is required to diagnose hyperglycaemic hyperosmolar state

>320

How is plasma osmolality calculated

= 2Na+ + Glucose + Urea

Explain history of symptoms in HHS

Usually longer history compared to DKA. Symptoms present over one-week

What are 2 general symptoms of HHS

- Lethargy | - N+V

What are 4 neurological symptoms of HHS

- Headache - Papilloedema - Decrease consciousness - Weakness

Explain HHS

- Insulin deficiency causes hyperglycaemia - Glucose in circulation causes osmotic diuresis - Less water, means relative increase in electrolytes in serum causing increase osmolality and hyperviscosity of blood (can cause MI. stroke, PAD)

Why do HHS patients not appear shocked

Despite massive water loss, glucose in circulation maintains osmotic pressure and intravascular volume

In which patients is HHS seen

T2DM

What is criteria to diagnose HHS

- HypoVolaemic - No acidosis (pH >7.3) or ketosis (<3) - hyperglycaemia - osmolality >320

Why must HHS be differentiated from DKA

As treating HHS with insulin has adverse consequences

Where should HHS patients be managed

HDU

What are the 3 aims for managing HHS

- Correct osmolality - Replace fluid and electrolytes - Normalise BG

What is first-line management for HHS

0.9% NaCl over 48h [slow rehydration]

Why is fluid corrected slowly in HHS

Too rapid correction of hypernatraemia will cause cerebral pontine myelinolysis

When is K+ replaced

- Urine starts to flow | - Potassium 3.5-5.5

How is hyperglycaemia corrected in HHS

Fluid replacement

Why is insulin not used in HHS

insulin will cause glucose to enter cells - this will cause cardiovascular collapse as water moves out of intravascular space

When is insulin only given in HHS

if ketosis (mixed DKA, HHS picture)

What does HHS cause

Hyperviscosity

What are 3 potential complications of hyper viscosity

- MI - Stroke - PAD