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Endocrinology > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is diabetes?

A

Altered glucose homeostasis which leads to persistent hyperglycaemia when left untreated and micro and macro-vascular damage

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2
Q

How is the response to OGTT different between normal patient and diabetic patients?

A

OGTT uses 75g anhydrous glucose

Normal= blood glucose returns to levels pre-OGTT after 2 hours

Diabetes= blood glucose rises about 11.1 and remains in hyperglycaemia state
I.e. treatment required for levels to remove to normal

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3
Q

What concentration of blood glucose is classified as the renal threshold? Why is it important

A

10mmol

Renal glycosuria= raised glucose levels result in glucose being detected in urine

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4
Q

Which type of diabetes is mostly commonly symptomatic? What are these symptoms?

A

Type 1

Polyuria
Polydipsia
Blurred vision
Weight loss

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5
Q

What diagnostic test is done when type 2 diabetic patient presents with symptoms? What result would be diagnostic?

A

Random plasma glucose

> =11.1 mmol/L

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6
Q

How is type 2 diabetes diagnosed in asymptomatic individual?

A

Fasted glucose (FPG) >= 7 mmol/L

2h post OGTT >= 11.1 mmol/L

HbA1c 48mmol/mol

Tests need to be repeated on a second day with same test being used

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7
Q

What are the 3 normal functions of insulin?

A

Stimulates glucose uptake from blood
Stimulates glycogen formation in liver
Inhibit glycolysis

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8
Q

What causes the high blood sugar in type 1 diabetes?

A

Absolute absence of insulin leads to lose of 3 normal functions meaning increased serum glucose concentration

Increased glucogenesis via fat and protein breakdown

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9
Q

Which antibodies are used to diagnose type 1 diabetes? How many antibodies are required for a diagnosis of type 1?

A

Islet cell antibodies

Antibodies to glutamic acid decarboxylase

Insulin antibodies

Tyrosine phosphatase antibodies

Insulinoma-associated protein 2 (IA-2)

IA-2 beta

Zinc transporter

Positive for 2 antibodies

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10
Q

What can be tested for to differentiate between type 1 and type2 DM?

A

Ketones and antibodies

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11
Q

Why should insulin never be completely stopped in type 1 diabetic patients?

A

Causes hyperglycaemia and ketosis

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12
Q

What is the hallmark of diabetes?

A

Insulin resistance

Beta-cell dysfunction

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13
Q

There is small amount of insulin present in blood of type 2 DM patients. What process does this inhibit which is not inhibited in type 1 patients?

A

Glycogensis

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14
Q

What occurs when insulin is stopped in type 2 diabetes patients?

A

MAY cause hyperglycaemia and hyperosmolar state

-dependent on degree of insulin deficiency of patient

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15
Q

What 2 states can induce insulin resistance?

A

Pregnancy

Obesity

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16
Q

What are the key factors which enable differentiation between type 1 and type 2 diabetes at presentation?

A

Type 1 :

  • symptomatic
  • dehydrated and not feeling well
  • ketones in blood and urine
  • normally young w/ low or normal BMI
  • not familial
  • no ethnic predilection
  • can have other autoimmune conditions

Type 2:

  • usually asymptomatic
  • absent ketones
  • central adiposity + over weight
  • associated with family history
  • increased risk with Asian or Hispanic ethnicity
  • associated with co-morbidities i.e. hypertension and IHD
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17
Q

What is the most common monogenic (associated with single gene) type of diabetes?

A

MODY (maturity onset diabetes of the young)

I.e. diabetes occurs <25yo w/ no antibodies and positive family history

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18
Q

Why can chronic pancreatitis and cystic fibrosis be associated with diabetes?

A

Can lead to destruction of pancreas which leads to B-cell destruction i.e. decreased or absent insulin production

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19
Q

Why can haemochromatosis lead to diabetes?

A

Iron is deposited in the pancreas which leads to destruction of the tissue and therefore augmented insulin production

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20
Q

Which endocrine disorder predispose someone to diabetes?

A

Acromegaly
Hyperthyroidism
Cushing’s syndrome
Rare endocrine tumours

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21
Q

Which drugs can be diabetogenic?

A

Antipsychotics

CVS= atenolol, propranolol, diazoxide, thiazides

Lipid lowering= niacin, statins

Corticosteroids= dose dependent

Oral contraceptive

Calcineurin inhibitors

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22
Q

What are the different methods used for monitoring diabetes patients?

A

Capillary blood glucose i.e. self-monitored capillary blood glucose (SMBG)

Urine testing

HbA1c

Fructosamine

23
Q

Which patients use SMBG?

A

All type 1 patients

Type 2 patients on insulin

24
Q

Why is urine testing not reliable for monitoring diabetes patients?

A

A lowered renal threshold for glucose can lead to the urine testing positive for glucose without hyperglycaemia being present
I.e. renal glycosuria can occur in pregnancy and in renal tubular disorders

25
Q

What does a HbA1c test measure and what does it indicate? What is the target value to be below?

A

It measures the amount of glucose which is bound to Hb, which forms an irreversible ketoamine

Indicates the MBG over previous 8-12 weeks

48 mmol/mol
I.e. >= 48mmol/mol is value for diabetes diagnosis
(42-47 mmol/mol= pre-diabetes)

26
Q

What is a HbA1c test dependent on?

A

RBC life span

27
Q

What does a fructosamine test measure? Why does it show a shorter period of glucose control than HbA1c? Why is use of fructosamine indicated?

A

Non-enzymatic glyceration with serum proteins i.e. albumin

Albumin has quicker turn over compared with RBC i.e 28 vs 120 days
I.e Fructosamine= shows previous 1-2 weeks of glucose control

When patient has haemoglobinopathy which would make HbA1c unreliable

28
Q

What are the main components of the pharmacological therapy for diabetes?

A

Aspirin= secondary prevention being at increased risk of CHD

Glycaemic control

  • type 2= oral hyperglycaemic agents (OHA) before insulin
  • type 1= insulin

BP control

Lipids management

Eye screening

Foot care

29
Q

Type 2 diabetes is a progressive condition where 50% of beta cell function can be lost on presentation. How does this affect the treatment of type 2 diabetes?

A

Start with oral hypoglycaemia agents (OHA) and may need to progress to insulin

1st line= metaformin

30
Q

Which drugs tend to be used earlier on in diabetes and which are used later on in the disease progression and why?

A

Early:

  • metformin
  • DPP IV inhibitors i.e. gliptin
  • Thiazolidinediones i.e. glitazones

Later:

  • SU i.e when insulin secretion starts to decrease
  • GLP1-RA i.e. when weight gain important feature of diabetes
  • insulin i.e when patients are symptomatic despite being on highest doses of OHA
31
Q

What class of diabetes drugs are commonly used as secondary drugs alongside the main treatment and why?

A

SGLT-2 inhibitors

Due to associated weight loss and are insulin independent so can be used alongside other methods without effect

32
Q

What are the 2 main types of insulin? Give examples and what function they have in managing T1DM? What other types of insulin are there?

A

Rapid acting= Novorapid/Humalog
-given 30mins prior to meal and has effect up to 5 hrs to accommodate for rise in serum glucose after eating

Long acting =Lantus/Toujeo (Glargine) + Levemir (Detemir)
-flattens curve of action when taken before bed and works over 24 hrs as recombinant insulin analogue

Intermediate acting
Pre-mixed= mixture of rapid and intermediate

33
Q

What is the difference between human and analog insulin?

A

Analog= insulin molecule has been modified to be either longer lasting or quicker acting

34
Q

What are the different ways insulin can be given throughout the day?

A

Once or twice daily basal insulin of intermediate or long acting insulin

Once or twice premixed insulin

Pre-meal rapid-acting insulin with once daily basal insulin= commonly used in type 2 DM

Mealtime rapid-acting insulin only= used in gestational diabetes

35
Q

What is the normal insulin routine for a type 1 diabetic?

A

Basal insulin (long acting) taken once a day or split between morning and evening

Bolus insulin given with meals
-titrate depending on the carbohydrate content of meals and daily activity

36
Q

How do insulin pumps work?

A

Can provide continuous SC infusion of short-acting insulin to form the base line insulin

Bolus insulin can be given by pressing button

37
Q

What is the MOA of biguanides? Give an example of a drug in this class. When are these drugs indicated?

A

Activates AMP-activated protein kinase to decreased gluconeogenesis in the liver

Increased glucose uptake in muscles

Eg= metformin

Use= obese type 2 DM or in combination therapy

38
Q

What is the MOA of alpha-glucosidase inhibitors? Give an example of a drug in this class. When are these drugs indicated?

A

Acts to reduce glucose absorption in the gut by inhibiting alpha-glucosidase

Eg= Acarbose

Use= obese type 2 DM either alone or in combo with metformin

39
Q

What is the MOA of sulphonylureas? Give an example of a drug in this class. Why are some longer acting that others?
When are these drugs indicated?

A

Bind to SU receptor on beta-cells which forms part of the kATP channel
Closes channel= decreased K+ efflux
Induces depolarisation which opens Ca2+ channels and leads to increased insulin secretion

Eg= Gliclazide/ Glibenclamide/ Glipizide/ Tolbutamide
Glibenclamide is longer acting due to metabolite being ACTIVE

Use= in combination to metformin if better control required

40
Q

Which class of drugs is contraindicated for obese patients?

A

SUR drugs due to them stimulating appetite

41
Q

What is the MOA of meglitinides? How do they differ from SU? Give an example of a drug in this class. When are these drugs indicated?

A

Similar MOA to SUs

  • bind to kATP channel to cause it to close
  • decreased K+ efflux
  • membrane depolarisation= Ca2+ channels open
  • augmentation of insulin release from beta-cells

Increased selectivity for kATP channels in beta cells

Eg= Nateglinide/ Repaglinide

Use= in combination with metformin

42
Q

What is the MOA of thiazolidinediones? Give an example of a drug in this class. When are these drugs indicated?

A

Acts to decreased serum FA by acting on adipose tissue to increase FA uptake and increase lipogenesis
Decreased serum FA induces increased glucose uptake and decreased gluconeogenesis

Eg= Rosiglitazone/Pioglitazone

Use= in combo with metformin or SU

43
Q

What is the MOA of GLP-1 agonists? Give an example of a drug in this class. When are these drugs indicated?

A

Mimic the action of incretins (GLP-1) (GI hormones that are transported to the pancreas to help regulate the secretion of insulin) to increase the secretion of insulin

Eg= Exenatide/ Liraglutide/ Lixisenatide

Use= when other methods of increasing insulin secretion fail i.e. SU or meglitinides

44
Q

What is the MOA of DPP-IV inhibitors? Give an example of a drug in this class. When are these drugs indicated?

A

Block the action of DPP-IV which normally acts to breakdown incretins i.e. increases incretins levels which increases insulin levels

Eg= Vildagliptin/ Sitagliptin (“liptin”)

45
Q

What is the MOA of SGLT-2 inhibitors? Give an example of a drug in this class. When are these drugs indicated?

A

Targets Na+/glucose transporter in PCT which leads to increase loss of glucose and sodium and consequently water i.e. INSULIN INDEPENDENT

Eg= Dapagliflozin/ Canagliflozin/ Empagliflozin

Use= can be used alone or in combination

46
Q

What are the possible adverse effects of using SGLT-2 inhibitors?

A

They can causes dehydration due to the increased loss of sodium causing increased loss of water
-can lead to decreased blood volume and decreased perfusion of tissues
I.e. can lead to worsened wound healing etc

47
Q

What is the basic outline of T1DM management?

A

Basal bolus regimen

Long-acting=before bed
-Glargine or Detemir

Short-acting= 30 mins before meals
-Novorapid or Humalog

NOTE: can use insulin pumps and metformin should be considered in patients with BMI>25 (rare)

48
Q

Why is basal bolus regimen for T1DM used now instead of BD mixing (mixing of short + long acting insulin)?

A

Promotes patient autonomy

  • patient able to decide how much to inject based on the calorie content of their meal
  • better mimic of basal insulin levels
49
Q

What is the difference between Lantus and Toujeo (both long acting insulins in Glargine class) ?

A

Toujeo= more concentrated

-used when diabetes needs better control because don’t need to inject as large a volume for the same effect

50
Q

What characteristics of long acting insulin’s meaning they are able to have action over 24hrs?

A

They are recombinant analogues of insulin which are stored at an acidic pH before being injecting

Means that they will only precipitate when they make contact with bodies pH

51
Q

What are the possible side effects of insulin?

A

Hypoglycaemia
Lipidermaosclerosis
-fat deposits which build up at the site of repetitive injection which can reduce the insulin efficacy due to insulin being deposited into these fat deposits

52
Q

In what scenarios can insulin be used which is not T1DM?

A

VRII sliding scale
Pregnancy when gestational diabetes cannot be control with diet alone
Hyperkalaemia= insulin acts to shift potassium into the intracellular compartment rapidly

53
Q

What are the different stages in T2DM management and what are the indications for progression between the stages?

A

1st line

Endocrinology (18 decks)

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