Chronic disease - Diabetes mellitus Flashcards
Metabolic Syndrome/ Insulin Resistance Syndrome/ Syndrome X
Diagnostic criteria
T2DM
Risk factors
Unmodifiable:
- Age >45
- Family history
- Genetic predisposition to obesity/ beta-cell function/ insulin resistance
- Hx of GDM or Macrosomia
- PCOS
Modifiable:
- Obesity or Overweight
- Metabolic Syndrome
- Pre-DM conditions: Impaired Fasting Glucose, Impaired Glucose Tolerance
- Lack of Exercise
- Environmental e.g. Stress, Over-nutrition
- Impaired liver function e.g. Cirrhosis, Chronic hepatitis
- Long term systemic steroid use
Clinical presentation of T2DM
T2DM
Diagnosis
HbA1c
confounding factors
False positively high HbA1C level
Repeated glycation/ More old blood
* CKD/ ESRF: ↓ EPO, ↓ RBC count
* Iron deficiency anaemia, Thalassaemia
* Polycythaemia, Post-splenectomy
Abnormal proportion
* HbF > Normal (0.5%) e.g. HPFH
* HbH disease (α Thalassaemia intermedia)
Analytical error
* Increased serum TG/ Bilirubin, Uraemia (End-stage renal failure)
* Alcoholism, Lead/ Opiate poisoning, High dose chronic salicylate (Aspirin)
False negatively low HbA1C level
Shortened glycation/ More new blood
* Shortened RBC life span e.g. Haemolytic anaemia, Blood loss/ transfusion, Hypersplenism
* Pregnancy (>20w): Foetomaternal transfusion → High proportion of young RBC in circulation
* Blood transfusion
Abnormal proportion e.g. HbC, HbD, HbS diseases
Ingestion of large amount of Vitamin C/E (compete with glucose, inhibit Hb Glycation)
Serum fructosamine
Indication
Confounding factors
Glycosylated serum proteins that is tested in DM: Correction of serum albumin level required if < 3.0 mmol/L
Fructosamine correlates with blood glucose concentration over the prior 2 – 3 weeks
Reflects glycemic control over a shorter period of time compared with HbA1c
More consistent measurement, reduced analytical time and lower cost than HbA1c
Monitoring T2DM
At F/U:
- Glycaemic control assessment: HBGM (Morning FPG +/- PPG), Clinic FPG, HbA1c
- Complication screening: Urinalysis for ketones and proteinuria, Visual acuity and fundoscopy, Foot risk, Neurothesiometer and neurological exam for neuropathy
- Macrovascular complication screening if indicated: Cardiovascular and cerebrovascular assessments
- Risk Stratification: Complications screening and other comorbidities e.g. JADE programme
Risk stratification program for diabetic complications
Risk stratification program for diabetic neuropathy
DM control targets
Treatment goals
Fasting PG = 5 – 7 mmol/L
Post-prandial PG < 7.8 mmol/L
Hba1c
* ≤ 6.5 – 7% for most patients
* ≤ 7.5 – 8.0% for elderly and those with multiple morbidities
Blood pressure ≤ 140/90 (≤ 130/80 in young or selected high-risk patient)
* ACEI/ ARB/ CCB are more preferred
Lipid (LDL-based)
* < 2.6 mmol/L for moderate risk groups
* < 1.8 mmol/L for high risk groups
DM control ladder
Ladder of Glycaemic Control
1. Lifestyle modification (Diet + Exercise + Optimise body weight)
2. Lifestyle modification + Oral Hypoglycaemic agents
3. Lifestyle modification + Insulin
ADA/EASD Guideline (2015) on Anti-hyperglycaemic Therapy in T2DM
1. Monotherapy: Metformin
2. HbA1c > 7.5%: Dual therapy (Metformin + Another drug or Insulin)
3. HbA1c > 9%: Triple Therapy (Metformin + 2 Other drug or Insulin)
4. Combination Injectable Therapy
DM Dietary advice
DM drug classes
Incretin-Mimetics
Examples
MoA
S/E
DPP4 inhibitors
Examples
MoA
S/E
a-glucosidase inhibitor
Examples
MoA
S/E
Insulin secretagogues
Examples
MoA
S/E
Insulin sensitizers
Examples
MoA
S/E
SGLT2i
Examples
MoA
S/E
DM drugs with following S/E profiles important
- Weight loss
- No weight gain
- Weight gain
- Hypoglycemia
- No hypoglycemia
- Cardioprotective
Insulin therapy
Indications
Source
Route
Injectable insulin
Preparation and effect
Injectable insulin
Preparation, onset, peak time, duration of action
Insulin therapy
Regimens
Complications of Insulin therapy
Comparative advantages to regular human insulin, bolus and basal insulin
Insulin doseage calculations
DKA
Precipitating factors
Clinical manifestations
Diagnostic criteria
DKA
Treatment
HHS
Clinical presentation
Precipitating factors
Diagnosis
Treatment
Chronic DM complications
DM Nephropathy
Diagnosis
DM nephropathy
Management and advice
Diabetic retinopathy
Time to development
Risk factors
Complications
Diabetic retinopathy
Stages
Diabetic retinopathy
Treatment
Minimum routine follow-up:
Yearly if DR is present (OR)
Every 2 years if DR is NOT present
Diabetic neuropathy
Clinical manifestations
Assessment
DM diet advice - Chinese food
DM diet advice - Takeout and western diet
