257. Diabetes

Question 1

What is diabetes?

Answer 1

Metabolic derangement derived from lack or reduced effectiveness of insulin.

Long term this leads to serious micro or macrovascular impacts

Question 2

What is type 1 DM?

Answer 2

Insulin deficiency from autoimmune destruction of insulin secreting pancreatic b cells.

Prone to ketacidosis and weight loss

Associated with HLA DR3 and DR4

Question 3

WHAT IS TYPE 2 diabetes mellitus?

Answer 3

Caused due to decreased insulin secretion and enhanced insulin resistance. Associated with a lack of exercise, calorie and increased alcohol intake.

Question 4

How is an impaired glucose tolerance test carried out?

Answer 4

Fasting plasma glucose <7mmol

Given them glucose then assess after 2 hours, >7.8mmol but <11mmol

Question 5

How is an impaired fasting glucose test carried out?

Answer 5

just get them to fast, should be between 6.1 and 7mmol

Question 6

What are some other causes of diabetes?

Answer 6

Iatrogenic: steroids, Anti HIV drugs, newer antipsychotics

Question 7

What is metabolic syndrome X?

Answer 7

Central obesity
BP>130/85
Triglycerides>1.7mmol
HDL<1.2
Fasting glucose >5.6

Question 8

According to WHO how do you diagnose diabetes?

Answer 8

Symptoms of hyperglyceamia (polyuria, fatigue, polydypsia, weight loss)

Raised venous glucose on two separate occasions (fasting>7mmol, random> 11mmol)

HbA1c>48mmol (cant use in type 1, pregnant, children)

Question 9

What are the various types of insulin?

Answer 9

Ultra fast acting: humalog, novorapid- for meals

Isophane insulin: variable metabolised after 4-12 hours

Pre mixed insulins: e.g. novomix, mix of long and short acting

Long acting recombinant insulin analogues: used at bedtime in Types 1 and 2, good if nocturnal hypos are an issue

Question 10

What are meant by sick days in diabetes?

What advice is given surrounding insulin?

Answer 10

Patients tend to eat less on days when they are acutely unwell e.g. with flu

Despite this they often need more insulin. They should check their blood glucose more often when they are unwell and if concerned phone GP or specialist nurse

If ketotic, dehydrated or vomiting, admit.

Question 11

What is the treatment ladder for type 2 diabetes?

Answer 11

1. Lifestyle chamges
2. Metformin
3. +DPP4/pioglitazone/sulphynurea/SGLT-2i
4. • 1 agents above that not already on
5. Insulin/GLP

Question 12

Discuss metformin:

• mechanism of action
• side effects
• contraindications

Answer 12

Biguanide.
Increases insulin sensitivity and improves weight
Nausea, diarrhoea, abdo pain

Avoid if EFGR 36ml/min

Question 13

Discuss DPP4 inhibtors:

• mechanism of action
• side effects
• contraindications

Answer 13

E.g. sitagliptin

Stops action of DPP4 an enzyme which destroys the hormone incretin

Question 14

Discuss Glitazone:

• mechanism of action
• side effects
• contraindications

Answer 14

Increases insulin sensitivity

Hypo, fractures, fluid retention, abnormal LFT’s

CCF, osteoperosis, stop if oedema

Question 15

Discuss Sulfonylurea:

• mechanism of action
• side effects
• contraindications

Answer 15

e.g. gliclazide
Increased insulin secretion
hypo, increases weight

Question 16

Discuss Selective sodium glucose co transporter 2 inhibitors (SGLTI):

• indications
• mechanism of action
• side effects
• contraindications

Answer 16

e.g. empagliflozin

blocks re-absorbtion of glucose in the kidneys and promotes excretion of excess glucose in urine

Question 17

Discuss Glucagon like peptide analogues:

• indications
• mechanism of action
• side effects
• contraindications

Answer 17

mimics incretin (augments insulin release)

Patients are either BMI>35 and psychological or other medical problems or BMI<35 where insulin would have complications with work

Question 18

When do you treat BP in diabetes?

Answer 18

When it is over 135/80mmhg

Treat with ACE-I

Question 19

What non diabetic medications are good to consider to treat complications?

Answer 19

Statins

Aspirin

Question 20

Nephropathy is an early complication of diabetes. How is it recognised early?

What is the best way to treat nephropathy in diabetes

Answer 20

Microalbuminuria is recognised when urine dipstick is -ve for protein but urine albumincreatinine ratio is >3mg/mmol

Treat is UA:CR>3 ACE-I, ARB, spironolactone may help

Question 21

What are the different levels of eye disease that occur with diabetes?

Answer 21

Background retinopathy

Pre-proliferative retinopathy

Proliferative retinopathy

Maculopathy

Question 22

Describe the pathogenesis of diabetic eye disease?

Answer 22

Capillary endothelial change
Vascular leak
Microaneurysms
Capillary occlusion
local hypoxia and ischeamia
new vessel formation
Ischaemic areas bleed fibrose and can detach from retina

Question 23

What are the signs of diabetic neuropathy?

Answer 23

Absent ankle jerks,
loss of sensation
deformity (pes cavus, charcots)
Swelling, instability or deformity

Question 24

What are the signs of ischaemic changes in a diabetic foot

Answer 24

Loss of pulses
Reduced doppler score
Foot ulceration

Question 25

How do you manage diabetic foot problems

Answer 25

Regular chiropody
Bed rest and therapautic shoes
bed rest and crutches for charcot’s
Bisphosphonates may help

Question 26

What antibiotics are typically started for diabetic foot infections?

Answer 26

Benzylpenicllin
Flucloxacillin
Metranidazole

Question 27

What other neuropthies may diabetics get?

Answer 27

Systemic sensory polyneuropathy (glove and stocking)

Mononeuritis multiplex

Amyotrophy- painful wasting of quads

Autonomic neuropathy- affects BP, Gastric motility, erectile dysfucntion, arryhtmias