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Y3 GP > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Define Diabetes ?

A

A metabolic disorder characterised by persistent hyperglycaemia resulting from defects in insulin secretion, insulin action or both.

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2
Q

What are the types of diabetes ?

A

Type 1
Type 2
Gestational

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3
Q

What are the differences between the types of diabetes ?

A

Type 1 - absolute insulin deficiency causes hyperglycaemia
Type 2 - insulin resistance and a relative deficiency resulting in hyperglycaemia
Gestational - develops during pregnancy and resolves after delivery. Increased risk of getting Type 2 in the future.

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4
Q

What are the causes of type 1 DM ?

A

Genetic factors - autoimmune destruction of the insulin producing beta cells in the pancreas.
Environmental factors - exposure to vitamin D or obesity triggers DM

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5
Q

What are some complications of T1DM ?

A

Nephropathy
Retinopathy
Neuropathy
Atherosclerosis
MI, stroke and peripheral arterial disease
DKA
Other autoimmune disorders
Skin and urinary infections

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6
Q

What is used to make a diagnosis of T1DM in adults ?

A

Diagnosis made on clinical grounds in adults presenting with hyperglycaemia ( random plasma glucose more than 11mmol/L ) with one of the following :
. Ketosis
. Rapid weight loss
. Age of onset younger than 50
. BMI lower than 25
. Family history of autoimmune disorders

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7
Q

How is a diagnosis of T1DM made in a child ?

A

A child or young person resenting with hyperglycaemia ( random plasma glucose over 11 mmol/L ) and some of the following :
. Polyuria
. Polydipsia
. Weight loss
. Excessive tiredness

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8
Q

When is a DKA suspected ?

A

A person with known DM or significant hyperglycaemia with the following features :
. Increased thirst and urinary frequency
. Weight loss
. Inability to tolerate fluids
. Persistent vomiting or diarrhoea
. Abdominal pain
. Visual disturbances
. Lethargy
. Fruity smell on breath
. Dehydration
. Shock

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9
Q

If a DKA is suspected what should be tested for ?

A

.Assess for precipitating factors such as infection, stress, poor medication adherence or other medical conditions
. Test for ketones

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10
Q

What is the target level for HbA1c for someone with T1DM ?

A

48 mmol/L or less than 6.5%
Other factors should be taken into consideration such as co-morbidities
Measure the HbA1c every 3-6 months

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11
Q

How often should a person with T1DM be self monitoring glucose levels ?

A

4 times a day ( before meals and before bed )

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12
Q

What is the optimal targets for glucose self monitoring in T1DM ?

A

Fasting 5 - 7 mmol/L
Plasma 4 - 7 mmol/L

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13
Q

What are lifestyle management is needed for someone with T1DM ?

A

Diet advice - carb counting
Maintain healthy BMI
Avoid drinking alcohol on an empty stomach
Encourage exercise but monitor glucose carefully while exercising
Avoid smoking

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14
Q

How is a DKA managed ?

A

Admit the person immediately for confirmation of diagnosis and emergency treatment with fluids and IV insulin

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15
Q

What categories of insulin therapy are there ?

A

Rapid and short acting - fast onset and are used to replicate the insulin produced by the body in response to glucose absorption from a meal

Intermediate or long acting - slow onset and mimic the effect of endogenous basal insulin.

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16
Q

What are some regimes for insulin therapy ?

A

Multiple daily injection basal bolus
Mixed biphasic regime
Continuous insulin infusion

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17
Q

What is the main adverse effect if insulin therapy ?

A

Hypoglycaemia ( blood glucose less than 3.5 mmol/L )

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18
Q

What are some symptoms of hypoglycaemia from insulin therapy ?

A

Hunger
Anxiety
Irritability
Palpitations
Sweating or tingling lips
Convulsions
Loss of consciousness or coma

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19
Q

What should be given for severe hypoglycaemia where someone has reduced consciousness ?

A

IM glucagon

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20
Q

What clinical features are common to all forms of DM ?

A

Polydipsia
Polyuria
Glycosuria

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21
Q

What are the characteristics of T2DM ?

A

Onset often after 40 years old
No HLA associations
No islet cell antibodies
Insulin resistance
Obesity
Not prone to ketoacidosis

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22
Q

What are some causes of T2DM ?

A

Lack of exercise
Obesity
HTN
Western diet
Genetic factors

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23
Q

What are some clinical features of T2DM ?

A

Polydipsia
Polyuria
Glycosuria
Nocturia

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24
Q

What is hyperglycaemic hyperosmolar state ?

A

A syndrome characterised by extreme elevations in serum glucose concentrations hyperosmolality and dehydration without significant ketosis.

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25
Q

What are the features that differentiate HHS from DKA ?

A

Hypovolaemia
Marked hyperglycaemia without significant hyperketonaemia
Osmolality

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26
Q

What are some precipitating factors for HHS ?

A

Intercurrent diseases such as :
. Acute MI
. Cushing’s syndrome
ACTH producing tumour
Infection
. Pneumonia
. UTI
. Cellulitis
. Sepsis
Medications
. CCB
. Loop diuretics
Substance abuse - alcohol and cocaine

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27
Q

What are the clinical features of HHS ?

A

Hyperglycaemia
Dehydration
Marked drowsiness
Usually old
Convulsions
Coma

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28
Q

What are some diagnostic criteria for HHS ?

A

Plasma glucose concentration
Arterial pH more than 7.3
Serum bicarbonate more than 15
Small ketonuria
Effective serum osmolality more than 320

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29
Q

What are some symptoms of HHS ?

A

Weakness
Visual disturbance
Leg cramps
Nausea and vomiting
Lethargy
Confusion
Dehydration
Low grade fever

30
Q

What are some investigations when suspecting HHS ?

A

Blood glucose
Serum osmolality
ABG
Urinalysis
Renal function tests and electrolytes
Creatinine levels

31
Q

What is the management of HHS ?

A

Seek expert advice
Insulin infusion

32
Q

What is there a high risk of in HHS and what should be given ?

A

Thromboembolism
Give subcut heparin

33
Q

What are some forms of diabetic nephropathy ?

A

Pyelonephritis
Glomerulonephritis
Atherosclerosis and HTN changes

34
Q

What are some features of diabetic nephropathy ?

A

Microscopic albuminuria is a sensitive early predictor of subsequent overt renal disease
Proteinuria
HTN
Nodular sclerosis

35
Q

What are some investigations of diabetic nephropathy ?

A

Measure urinary albumin : creatinine ratio
Measure serum creatinine annually

36
Q

What are some preventative measures of diabetic nephropathy ?

A

Well controlled blood glucose
Reduce over co-existing cardiac risk factors

37
Q

What are some causes of diabetic eye disease ?

A

Diabetic retinopathy
Diabetic cataract

38
Q

What is diabetic retinopathy ?

A

A chronic progressive potentially sight-threatening disease of the retinal micro vasculature associated with the prolonged hyperglycaemia and other conditions linked to DM such as HTN.

39
Q

What are the treatment principles of diabetic retinopathy ?

A

Maintain good blood glucose control
Maintain good blood pressure control
Check visual acuity
Laser photocoagulation, intravitreal steroids and surgical vitrectomy for sight threatening condition

40
Q

What are some complications of diabetic foot ?

A

Foot ulcers
Painful necrosis
Extensive spreading skin necrosis
Chronic ulceration

41
Q

What are some treatment options for painful diabetic neuropathy ?

A

Maintain good glycaemic control
Gabapentin
Phenytoin and carbamazepine
Pregabalin

42
Q

What are some management options for diabetic foot ?

A

Neuropathy - check sensation
X rays
Prevention with good glycaemic control and foot health
Check for infection
Necrotic tissue removal

43
Q

What is the polyol pathway ?

A

A 2 step metabolic pathway that converts glucose into fructose. The pathway plays a prominent role in the pathogenesis of complications in patients with end stage diabetes.

44
Q

Why does the sorbitol / polyol pathway become upregulated ?

A

When glucose levels become very high such as in diabetics the pathway is increased to cope with the high levels

45
Q

What is the polyol or sorbitol pathway ?

A

First step - glucose is converted to sorbitol via aldose reductase. This step utilises a H+ which is donated by NADPH. This is a rate limiting reaction
The second step - conversion of sorbitol into fructose via the enzyme sorbitol dehydrogenase. This step donates H+ to NAD + creating NADH. This step is reversible.

46
Q

What is an issue about the sorbitol pathway ?

A

Not all tissues have the enzyme sorbitol dehydrogenase such as retina, kidneys and Schwann cells.
This causes sorbitol to accumulate to toxic levels and cause the complications of diabetes.

47
Q

What diet would you advice for someone with T2DM ?

A

Encourage high fibre,
low glycaemic index sources of carbohydrates
Low fat dairy products
Low amounts of trans-fatty acids, high sugary drinks and high salt foods

48
Q

What advice would you give on physical activity in T2DM ?

A

Minimise time spent sedentary
Advise regular exercise

49
Q

What advice would you give for drinking alcohol with T2DM ?

A

Advise to stick to recommended amounts
Eat a snack before and after drinking alcohol

50
Q

What is the second line treatment for diabetes if Metformin is not tolerated due to symptoms ?

A

Modified release metformin

51
Q

What is the mechanism of action of Metformin ?

A

Reduces hepatic gluconeogenesis and increases insulin sensitivity and therefore glucose uptake intracellularly.

52
Q

What are some adverse effects of metformin ?

A

GI upset - nausea, vomiting, diarrhoea and abdominal pain
Lactic acidosis - rare

53
Q

What is a contraindication of Metformin ?

A

Low kidney function - GFR lower than 30

54
Q

What is an example of sulfonylurea ?

A

Gliclazide

55
Q

What is a positive of sulfonylureas ?

A

Bring down HbA1c quickly

56
Q

What is a negative of sulfonylureas ?

A

Very high risk of hypoglycaemia

57
Q

What shouldn’t be given if someone is on a sulfonylurea ?

A

Beta blocker as it masks the symptoms of hypoglycaemia

58
Q

What is a contraindication of sulfonylurea ?

A

Ketoacidosis
Severe renal impairment

59
Q

What are some adverse effects of sulfonylureas ?

A

GI upset - abdo pain, nausea, vomiting, diarrhoea
Hepatic impairment
Skin - rash, pruritus and urticaria

60
Q

What are some examples of DPP4 inhibitors ?

A

Linogliptin
Sitagliptin

61
Q

How do DPP4 inhibitors work ?

A

Block the DPP4 enzyme which normally decreases incretin. This means incretin increases which causes increased release on insulin and decreases glucagon secretion.

62
Q

What are some positives of DPP4 inhibitors ?

A

Weight loss or weight neutral
Linogliptin can be used even with a GFR lower than 15
Little risk of hypoglycaemia

63
Q

what are negatives of DPP4 inhibitors ?

A

Risk of pancreatitis

64
Q

What are some positives of GLP1 agonists ?

A

Causes weight loss
Decreases appetite
No risk of hypoglycaemia

65
Q

What are negatives of GLP 1 agonists ?

A

Risk of pancreatitis

66
Q

What are some examples of GLP1 agonist ?

A

Exenatide

67
Q

What is an example of a glitazone ?

A

Pioglitazone

68
Q

What are some negatives of glitazones ?

A

Increased risk of HF and bladder cancer

69
Q

What is the mechanism of action of an SGLT-2 inhibitor ?

A

Increases renal secretion of glucose causing glycosuria

70
Q

What are some positives of SGLT 2 inhibitors ?

A

No risk of hypoglycaemia
Causes weight loss
Reduces risk of HF

71
Q

What are the negatives of SGLT 2 inhibitors ?

A

Risk of thrush
Risk of UTI

Y3 GP (12 decks)

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