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
