Case 5 - Diabetes Flashcards
What are the different types of diabetes?
- Type 2
- Type 1
- MODY
- LADA
- Gestational
- Drug induced (steroids, anti-psychotics)
What is MODY?
Maturity onset diabetes of the young – Genetic defects of beta cell function or insulin action.
- Like T2DM but young
- Strong FH
What is LADA?
Some insults causes pancreas to stop producing adequate insulin by damaging beta cells.
- Think of this in older patient with T1DM presentation or not responding to anti-hyperglycaemic agents.
What is pre-diabetes?
Blood glucose levels are higher than normal but not high enough to be called diabetes.
What is type 1 diabetes?
Result of an autoimmune response that triggers the destruction of β cells in the pancreas and results in an absolute insulin deficiency.
What are the causes of type 1 diabetes?
- Genetic
- Autoimmune response with production of antibodies
- Viral: enterovirus
What anti bodies are associated with T1DM?
- ICA: Islet cell antibodies
- GAD: Glutamic acid decarboxylase
When is T1DM presented?
Childhood onset <20 years
What are the risk factors of diabetes?
- Black/Hispanic/Native -
- America/ South Asian origin are 6x more likely to develop diabetes – non-modifiable
- Family history of diabetes – non-modifiable
- High waist to hip ratio – modifiable
- Older age – non-modifiable
- Hypertension
- Dyslipidaemia
- Physical inactivity – modifiable
- Dyslipidaemia
What are the symptoms of T1DM and T2DM?
- Polyuria - Glucosuria leads to polyuria in diabetic patients;
- Polydipsia – due to excessive thirst
- Polyphagia – increase in appetite
- Fatigue
- Visual disturbances – blurred vision
- Calf cramps
- Poor wound healing
- Pruritus – due to poor circulation, dry skin or yeast infection
- Candida infections
- Weight loss: T1DM
- Weight gain: T2DM
What is type 2 diabetes?
- Insulin resistance and pancreatic β cell dysfunction resulting in relative insulin deficiency.
- Over time insulin sensitivity goes down leading to increased blood glucose.
How to diagnose diabetes?
- HBA1c
- OGTT
- C peptides
- Fasting plasma glucose
What is fasting glucose test?
- Test after min 8 hours fast
- DM: ≥ 126 mg/dL (≥ 7.0)
C-peptide test results
- Increased: T2DM
- Decreased: T1DM
What is oral glucose tolerance test?
- Give 75g oral glucose, wait 2 hours.
- Given to fasting patient.
- DM: ≥ 200 mg/dL (≥ 11.1)
What are the normal levels for the different diabetes test?
- HBA1c: <42mmol/mol
- Fasting glucose: < 100 mg/dL (< 5.6)
- OGTT: < 140 mg/dL (< 7.8)
What specific tests are done for T1DM?
- Anti-GAD
- ICS antibody
What is the treatment for T1DM?
Life long insulin
What is the conservative management for diabetes?
- Weight loss (T2)
- Increased physical activity
- Balanced diet (reduced carbohydrate intake)
- Smoking cessation
- Reduced hypertension
- High fibre diet
How are complications monitored?
- Yearly retinal screening
- Foot exam for ulcers + neuropathy
- Annual urine testing for kidney function
- Weight/BP/lipids
- Education on complications
What are the different types of insulin?
- Rapid-acting (10min-4h) - Novorapid
- Short-acting (30min-8h) - Actrapid
- Intermediate-acting (1h-16h) - Insulatard
- Long-acting (1h-24h) - Lantus
- Combination (intermediate: rapid-acting) - Humalog 25 (25:75), Humalog 50 (50:50), Novomix 30 (30:70)
What is T2DM anti-hyperglycaemic therapy algorithm?
1st - General measures
2nd - Metformin
3rd - Metformin + another drug
4th - Metformin + 2 other drugs OR metformin + insulin
Which DM meds work by increasing insulin sensitivity?
- Metformin
- Pioglitazone
Which DM meds work by increasing insulin secretion?
- DPP4 inhibitors (gliptin)
- GLP1 agonists (glutide)
- Meglitinides (glinide)
- Sulfonylurea (zide)
Which DM med works by increasing renal excretion of glucose?
SGLT2 inhibitors (flozin)
Which DM meds increase weight?
- Sulfonylurea
- Insulin
- Pioglitazone
Which DM meds reduce weight?
- GLP1 agonists
- SGLT2 inhibitors
Which DM meds have the highest risk of hypoglycaemia?
- Insulin
- Sulfonylurea
What type of drug is metformin?
- Biguanide
- Increases insulin sensitivity
- Decreases hepatic glucose production
What are the side effects of metformin?
- Diarrhoea
- Abdominal discomfort
- Lactic acidosis (don’t prescribe if they have impaired renal function, eGFR <36)
What type of drug is glicazide?
- Sulfonylurea
- Stimulates insulin release
What are the side effects of sulfonylurea?
- Weight gain
- Hypoglycaemia
What type of drug is sitagliptin?
- DPP4 inhibitors (incretin)
- Increase insulin secretion
What are the side effects of DPP4 inhibitors?
- GI disturbances
- URTI symptoms
- Pancreatitis
What type of drug is liraglutide?
- GLP1 agonist
- Increase insulin secretion
What are the side effects of GLP1 agonists?
- GI disturbances
- Weight loss
- Dizziness
What type of drug is empagliflozin?
- SGLT2 inhibitors
- Stops glucose reabsorption
What are the side effects of SGLT2 inhibitors?
- Weight loss
- Glucosuria (risk of UTI)
What are the acute complications of diabetes?
- Hyperosmolar hyperglycaemic state
- Diabetic ketoacidosis
- Hypoglycaemia
What are microvascular complications?
- Retinopathy
- Nephropathy
- Neuropathy: peripheral and autonomic
What are the macrovascular complications?
- Stroke
- MI
- Peripheral vascular disease
- Coronary heart disease
- Diabetic cardiomyopathy
How are eyes affected in retinopathy?
- Loss of central vision: due to capillary leakage into retina causing intra-retinal haemorrhage. Seen as hard exudates
- Total blindness: Retinal ischaemia leads to new but poor quality (non-functional) vessels forming. Occurs due to capillary occlusion.
How to minimise blindness?
- Blood glucose and BP control
- Annual retinal screening
- Vitrectomy
How to minimise end stage kidney disease?
- Bood glucose control
- Early detection of nephropathy (albumin:creatnine)
- BP control: ACEi
- Dialysis + transplantation
Which genes are associated with T1DM?
HLA D3/4
What are neuropathic pain symptoms?
Burning, cold, tingling, stabbing, toothache, walking on glass, contact sensitivity, allodynia, numbness, restlessness, worse at night, eased by exercise or counter irritation.
What is a neuropathic foot ulcer?
Loss of protective sensation and abnormal foot function (putting pressure in affected areas, making them worse).
How is a neuropathic foot ulcer presented?
- Callus present near metatarsal heads causing toes to be retracted
- Blistering due to toes
What are the features of Charcot neuropathy?
Pes cavus, claw toes, loss of transverse arch, rocker-bottom deformity
How can diabetes in pregnancy affect foetus + mother?
1st trimester - congenital abnormalities
2nd/3rd trimester - accelerated growth and lead to cardiomypothay, difficult birth, neonatal mortality
What is DKA?
- Absolute insulin deficiency (T1DM)
- Increased glucagon, catecholamine, cortisol and G: leading to excess glucose
- Fats are broken down into ketones: leads to H+ release causing hyperventilation and CO2 retention. Causes metabolic acidosis.
What are the potential triggers of DKA?
- Infection
- Lack of adherence to medication
- Alcohol
- Steroids
- Injury/surgery
- Pregnancy
- Menstruation
- Diabulemia
What are the symptoms of DKA?
- Gradual drowsiness
- Vomiting
- Dehydration
- Abdominal pain - ketoacidosis leads to irritation of the peritoneum.
- Polyuria/dipsia
- Lethargy
- Ketotic breath – fruity breath
- Kussmasul breathing
How to diagnose DKA?
- Acidaemia: pH <7.3 or HCO3- <15mmol/L)
- Hyperglycaemia: >11mmol/L or known DM
- Ketonaemia: ≥3mmol/L or ketonuria ++ on dipstick
How to investigate DKA?
- Blood glucose
- Ketone levels
- pH, U+Es, HCO3-
- Urine dip
How to manage DKA?
- Fluids: IV 0.9% saline with potassium
- Add potassium to second bag onwards depending on serum K+
- Insulin e.g. 0.1unit/kg/h fixed rate - Glucose when glucose <14mmol/L after insulin to prevent hypoglycaemia
What is HHS?
- Small amounts of insulin being secreted
- Associated with T2DM: develops slowly (days to weeks)
- Develops as a result of illness/dehydration
- Don’t get ketosis or acidosis like you do in DKA
What are the symptoms of HHS?
- Polyuria
- Polydipsia
- Leg cramps
- Nausea and vomiting
- Neurological abnormalities
- Altered mental status
- Lethargy
- Coma/ decreased conscious level
- Dehydration
How to treat HHS?
- Rehydration
- Prophylactic LMWH
- Fixed rate insulin infusion
- Monitor/replace K+
What is the cause of hypoglycaemia?
- In diabetics due to drugs
- Causes of blood glucose levels to reach <3.3 mmol/L (<60 mg/dL).
What are the symptoms of hypoglycaemia?
- Adrenergic (sweating, tremor, hunger) THEN
- Neruoglycopenia (blurred vsion, confusion, parasthesia)
What is hypoglycaemia unawareness?
After several episodes or very low hypoglycaemia, body gets used to adrenergic symptoms and doesn’t display them.
How to treat hypoglycaemia?
- Able to Cooperate - 30ml Lucozade and 15 g slower acting carbohydrate
- Unable to Cooperate but Conscious - 1.5/2 tubes of glucose gel onto buccal membrane
- Comatose, Fitting - Glucagon (SC, IM, IV)
