Case 5 - Diabetes Flashcards
What is T2DM?
Combination of insulin resistance and beta cell dysfunction
Ketosis resistant - only a small amount of insulin is needed to activate gluconeogenesis
What is the pathophysiology of T2DM?
Higher calorie intake than burn
Leads to increased liver fat
More VLDL made, take up by islets
High levels of fatty acids, dmage the beta cells
Reduced acute insulin response to food
Increased hepatic glucose output due to liver fat
Cycle of increased plasma glucose and insulin resistance
What are the goals of diabetic treatment?
Goals:
- Reduce SE as much as possible
- Normoglycaemia
- CV risk management
What is lifestyle management for T2DM?
Bp control
Increase exercise and weight loss
Improve diet
Improve lipid profile
What are the different drugs for T2DM?
Biguanides Thiazilidinediones Sulphonylureas Meglitinides DPP4-i GLP-1 agonists SGLT2 antagonists
What is the management plan for T2DM?
If HbA1c >48 diagnose with DM
SHoudl commence lifestyle changes and aim for HbA1c of <48
Make changes to regime at HbA1c of 58, aim for 53 unless on drug with SE of hypoglycaemia
Metformin - aim for 48
Metformin + SU/SGLT2-i/DPP-4i/pioglitazone - aim for 53
Metformin +
either SU + DPP4-i/pioglitazone
or SGLT2i and another
Aim for 53
Consider insulin
What are the symptoms of T2DM?
Polydipsia Polyuria Weight loss Polyphagia Tiredness/lethargy Balanitis Microvascular complications - like diabetic retinopathy
What would be checked at a DM r/v?
HbA1c should be checked every 6 months when on a stable therapy, more frequently in the newly diagnosed, new treatments, children and in pregnancy Weight Exercise Smoking Glucose control BP Lipids Urine ACR eGFR Early detection of complications
What are the RFs for T2DM?
Increased BMI Afro-carribean/South Asian Poor diet HTN Increasing age Lack of exercise FHx of T2DM
How do you diagnose T2DM?
Fasting glucose >6.9 (done at 2 separate occasions)
Random glucose >11.1
Post-glucose load >11.1
HbA1c >48
What is non-diabetic hyperglycaemia?
OGTT 7.8-11
HbA1c 42-47
At risk of getting T2DM, macrovascular complications and gestational diabetes
What are the complications of T2DM?
HHS
Diabetic retinopathy
Diabetic nephropathy
Diabetic foot complications
What is HHS?
Hyperglycaemiac hyperosmolar state
Like DKA, but there’s no metabolic acidosis
What is diabetic eye disease?
Screening takes place yearly
Progression proportional to BP and glucose
Can treat with GF treatment and then vitrectomy
M0-1 depending on whether it affects the macula
R0-3 depending on extent of retinopathy
What is diabetic nephropathy and how is it staged?
Renal HTN caused by DM
High glomerular pressure can cause damage to the GBM and gradually larger molecules become filtered through into the urine e.g. RBC and protein
1 - eGFR >90 2- eGFR 60-90 3- eGFR 30-59 4- eGFR 15-29 5- eGFR <15
What is diabetic foot disease?
As blood supply to the neurones is lost, so is sensation in the feet
Neuropathic pain may be worse at the night and eased by rest
More prone to ulcers as cannot feel if something is rubbing
Gangrene common
Penetrating infection can lead to osteomyelitis
Charcot arthropathy
Who is at risk of gestational diabetes and what can it cause?
At what BMs is it diagnosed?
Those who have had diabetes before FHx of DM Previous gestational DM Ethnic origin Previous macrosomic baby High BMI
Can cause:
- C-section
- macrosomia
- Birth trauma
- Induction of labour
- Perinatal death
Diagnose with fasting glucose of >5.6
Post-fasting glucose of >7.8
What is T1DM?
Autoimmune condition that leads to the destruction of beta cells so that the body cannot make insulin
Can be triggered by a childhood viral infection
What are the RFs for T1DM?
Low BMI<25 Age<50 FHx of autoimmune Caucasian Rapid weight loss
What investigations are done for T1DM?
Urine tests
Random glucose level
Anti-GAD Abs
FHx
Glucose: Random glucose >11 Post-glucose >11 Fasting >6.9 HbA1c>48
What are the symptoms of T1DM?
Polydipsia Polyuria Weight loss Weakness May present with ketoacidosis
What is the treatment for T1DM?
Insulin
Can be with long-acting, short-acting or bi-phasic insulin
Have BD long-acting insulin and then short-acting before meals, dose adjusted to glucose levels as per pin prick test
If this is not possible, have a BD mixed regime
Rotate injection sites
Avoid repeated injections at the same site
Can have insulin pump for those people who are having frequent hypos despite insulin treatment
Test glucose QDS
Need to up monitoring when ill (DNV), if frequency of hypos increases, and when exercising
Correction dose is worked out by the equipment check again an hour after the pump dose is adjusted, or 2 hours after injections
Should never skip insulin
What is DKA?
Diabetic Ketoacidosis is the triad of ketosis, acidaemia and hyperglycaemia
Occurs when there is high glucagon and insulin resistance/deficiency, so body thinks it is in a constant state of starvation, and attempts to compensate by breaking down fatty acids in ketosis
The production of fatty acids leads to metabolic acidosis
Can present with:
-Hyperventilation
-N and V
-Dehydration
-Decreased GCS due to hypotension
Vomiting leads to a worsening cycle of acidosis
Don’t stop basal insulin
Fluid resus
Airway protection
Careful fluids
What is severe hypoglycaemia?
Clammy
Hunger
Tremulous
Neuroglycopenia
More likely in those:
- Increased alcohol
- Extremes of age
- Pregnancy
- Neuropathy
- Renal impairment
- Recent hypo
- LT DM
Can be treated simply with glucose - lucozade/buccal/IM
Which drugs increases sensitivity to insulin?
Increases sensitivity to insulin:
Biguanides - metformin
-SEs = GI disturbances, weight loss
Thiazolidinediones - pioglitazone
Which drugs increases beta cell activity?
Increase beta cell activity: Sulphonylureas - gliclazide -SEs = hypoglycaemia, weight gain Meglitinides - faster and shorter acting than SUs -SEs = hypoglycaemia, weight gain
Which drugs increase GLP-1 activity?
Increase GLP-1 activity
DPP-4 inhibitors - linagliptin
Incretins/GLP-1 agonists - exanitide
-SEs = GI symptoms, weight loss
Other drugs for DM?
SGLT2 antagonists - dapagliflozin
-SEs = weight loss
