Diabetes Flashcards
How does a new diagnosis of T1DM often present
in DKA, may occur over a longer period of time
Features of DKA
abdominal pain
polyuria, polydipsia, dehydration
Kussmaul respiration (deep hyperventilation)
acetone-smelling breath (‘pear drops’ smell)
Investigations to perform in T1DM
urine dip - glucose and ketones
fasting glucose and random glucose
C-peptide levels are typically low in patients with T1DM
diabetes-specific autoantibodies are useful to distinguish between type 1 and type 2 diabetes
Antibodies present in T1DM
- anti-GAD (encourages the destruction of pancreatic cells which produce insulin)
- Islet cell antibodies (ISA) - act on beta cells (primary source of insulin)
- insulin autoantibodies (IAA)
- Insulinoma-associated-2 autoantibodies (IA-2A)
First two mentioned are commonest
Diagnostic criteria for T1DM
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
Signs of T1DM
ketosis
rapid weight loss
age of onset below 50 years
BMI below 25 kg/m²
personal and/or family history of autoimmune disease
Why is C peptide low in T1DM
C peptide is also produced by the beta cells of the pancreas (same with insulin), hence, the destruction of these cells will not only demonstrate a high BM but a low level c peptide
Once diagnoses T1DM, what blood test should be monitored?
HBA1C every 3-6 months
Target is less than 48 mmol
Recommended monitoring daily for T1DM
4 times daily glucose and before and after meal times. Increase if hypos,, unwell, pregnancy, sport, breastfeeding.
Blood glucose targets in AM and PM
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
Should metformin be considered in T1DM
If BMI >25
What is the recommended regime in T1DM re insulin
offer multiple daily injection basal–bolus insulin regimens with rapid acting at meal times
Parameter for a diagnosis of pre-diabetes
fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk
OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
Mx of prediabetes
lifestyle modification: weight loss, increased exercise, change in diet
at least yearly follow-up with blood tests is recommended
NICE recommend metformin for adults at high risk ‘whose blood glucose measure (fasting plasma glucose or HbA1c) shows they are still progressing towards type 2 diabetes, despite their participation in an intensive lifestyle-change programme’
Diabetes T2 and HTN target range
< 140/90 mmHg
T1DM and HTN target range
Intervention levels for recommending blood pressure management should be 135/85 mmHg unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg
Albuminuria is a sign fo what
KD
What is metabolic syndrome
Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure (hypertension) and obesity. Anything that increases cardiovascular risk.
Mx of choice white male with diabetes (age not relevant!) T1/T2DM
ACE inhibitors/or angiotensin-II receptor antagonist
Irrespective of age as deemed renoprotective
Mx of choice in afrocaribean with diabetes
A2RBs
you review a patient 6 months after starting metformin. His HbA1c is 51 mmol/mol (6.8%). He has no CVD risk factors. How do you titrate his medications?
increase metformin and titrate
If metformin is causing GI upset, what should you do
swap to modified release
If metformin is contraindicated and patient has CVD risks, what therapy would you choose to manage T2DM
SGLT-2
If metformin is contraindicated and patient has NO CVD risks, what therapy would you choose to manage T2DM
DPP‑4 inhibitor or pioglitazone or a sulfonylurea
If metformin is contraindicated and patient is already on a DPP-4 inhibitor and HBA1C >58 with no CVD RFs, what medication should you consider adding?
pioglitazone or a sulfonylurea
When to consider adding a second/third line agent.
If Hba1c >58
What are the options for triple therapy for T2DM
metformin + DPP-4 inhibitor + sulfonylurea
metformin + pioglitazone + sulfonylurea
metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
Note SGLT-2 only in CVD risk and D+P never a combination
Can also consider insulin at this point
When to consider a GLP-1 in T2DM
BMI ≥ 35 kg/m² and specific psychological or other medical problems associated with obesity or
BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities
only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
Do you continue metformin alongside a GLP-1
Yes
What is the recommended insulin in T2DM
human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need
you review an established type 2 diabetic on maximum dose metformin. Her HbA1c is 55 mmol/mol. What do you do?
Nothing as not at the 58mmol threshold for escalation
a type 2 diabetic is found to have an HbA1c of 62 mmol/mol (7.8%) at annual review. They are currently on maximum dose metformin. What do you do?
DPP‑4 inhibitor or pioglitazone or a sulfonylurea
in T2DM when should you offer a statin and what would you give ?
only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg on
SGLT-2 examples
flozins e.g. empagliflozin
Sitagliptin is an example of what
DPP-4
exenatide is an example of what
GLP-1
sulfonylurea examples
Glimperamide, gliclazide
IDE
Diagnostic thresholds for gestational diabetes on bloods
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Screening test of choice for gestational diabetes
OGTT
Should do this on anyone who has previously had GD early on and at the 24 week mark. Do it at the 24 week mark for anyone with RFs such as FHx.
If from fasting glucose, BM is >5.6 but below 7, how do you manage the pregnant patient
Diagnose GD and offer dietary and lifestyle adviceI
If after a dx of GD and mx with diet and lifestyle, BM still not satisfactory e.g. fasting >5.6, what do you do?
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin
A pregnancy lady has a fasting BM of 8.5…what do you do?
start insulin
any fasting BM>7 in a pregnant lady should be managed with insulin in the first instance
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, what do you do to mx the pregnant lady?
start insulin
How should you manage a pregnant lady with pre-existing diabetes?
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
A 25-year-old Asian woman who is 26 weeks pregnant has an oral glucose tolerance test (OGTT). This was requested due to a combination of her ethnicity and a background of obesity. A recent ultrasound shows that the fetus is large for dates. How do you manage her is her BM comes back high?
insulin as macrosomnia present in Hx
A 71-year-old woman with type 2 diabetes attends her annual health review. She has a background of heart failure and stage 3 chronic kidney disease. It is noted that her HbA1c has risen from 57mmol/mol (7.4%) to 60mmol/mol (7.6%) over the last 12 months. She recently discontinued a trial of an SGLT2 inhibitor after developing euglycaemic diabetic ketoacidosis. Her current medications include metformin, losartan and bisoprolol.
Sitagliptin is correct. Her HbA1c is above the target range for metformin monotherapy (58mmol/mol, or 7.5%), and as she is on the maximum dose of metformin NICE guidelines recommend adding a second agent. As she has a background of heart failure and CKD4, the most appropriate option would be a DDP-4 inhibitor such as sitagliptin (prescribed at a reduced dose due to CKD4).
Sulfonylureas should be avoided in significant renal impairment
Maternal complications from diabetes when pregnant
polyhydramnios - 25%, possibly due to fetal polyuria
preterm labour - 15%, associated with polyhydramnios
Neonatal complications from diabetes when pregnant
macrosomia (although diabetes may also cause small for gestational age babies)
hypoglycaemia (secondary to beta cell hyperplasia)
respiratory distress syndrome: surfactant production is delayed
polycythaemia: therefore more neonatal jaundice
malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy)
stillbirth
hypomagnesaemia
hypocalcaemia
shoulder dystocia (may cause Erb’s palsy)
