Diabetes

Question 1

DIABETES MELLITUS

Answer 1

Diabetes mellitus is a chronic metabolic disorder of relative or absolute insulin deficiency characterized by disorders of carbohydrates, proteins and fat metabolism.

Diabetes is a heterogeneous group of disorders characterised by varying degrees of insulin hyposecretion and/or insulin insensitivity. It leads to hyperglycaemia.

Question 2

Classification of diabetes mellitus

Answer 2

It is classified into type 1, type 2 and gestational diabetes.

Other related conditions:
 Impaired glucose tolerance (IGT)
 Gestational diabetes mellitus (GDM)
 Malnutrition-related diabetes mellitus (MRDM).

Question 3

Insulin-dependent diabetes mellitus (Type 1 diabetes):

Answer 3

Insulin-dependent diabetes mellitus (Type 1 diabetes): occurs as a result of insulin hyposecretion due to autoimmune destruction of beta cells in the pancreas.
onset of the disease is sudden Type I require exogenous insulin to maintain life Ketosis and ketoacidosis is common.

Question 4

Non-insulin-dependent diabetes mellitus (Type 2 diabetes):

Answer 4

Non-insulin-dependent diabetes mellitus (Type 2 diabetes): It is further subdivided into two forms as non-obese and obese patients. It occurs as a result of decreased insulin secretion or due to insulin insensitivity.

Onset is gradual Tendency to develop later in life and Patients rarely develop ketoacidosis.

Question 5

Gestational diabetes:

Answer 5

Gestational diabetes: this is glucose intolerance of variable degree with onset or first recognition during pregnancy. Occurs as a result of the antagonism effect of placental hormones such as human placental lactogen, estrogen and cortisol. After delivery, patient returns to normal.

Question 6

Clinical manifestations

Answer 6

 Polyuria and polydipsia as a consequence of osmotic diuresis secondary to sustained hyperglycaemia
 Blurred vision due to change in refraction as a result of hyperosmolar state
 Weight loss despite normal or increased appetite.

Question 7

Investigations

Answer 7

 Fasting blood glucose level greater than 6.7 mmol/L or a random value of more than 10 mmol/L
 Glucose tolerance test: in clinical practice used only in patients who have borderline results
 Urine testing not suitable due to the wide inter-individual variation in renal threshold

Question 8

Risk factors

Answer 8

 Family history
 Obesity
 Age: 45 years and older
 Impaired fasting glucose
 Hypertension
 Hyperlipidaemia
 Gestational diabetes.

Question 9

Goals of treatment in diabetes mellitus

Answer 9

The primary goals of DM management are to:
 Reduce the risk for microvascular and macrovascular disease complications,
 To ameliorate immediate signs and symptoms,
 To reduce mortality, &
 To improve quality of life.

Question 10

The risk of macrovascular complications include;

Answer 10

The risk of macrovascular complications include cardiovascular disease (coronary heart disease -MI, CVA and stroke) and peripheral vascular disease (PVD). PVD is also responsible for much of the morbidity associated with diabetic foot problems.

Question 11

The risk of microvascular complications include:

Answer 11

 Diabetic retinopathy is the leading cause of blindness.
 Nephropathy: In diabetic renal disease, the kidneys become enlarged and the
glomerular filtration rate (GFR) initially increases. However, if the nephropathy progresses, the GFR starts to decline & is indicated by the detection of microalbuminuria (small amounts of albumin present in urine). If higher amounts of albumin are detected, this is termed proteinuria (or macroalbuminuria) and signifies more severe renal damage.
 Peripheral neuropathy is the progressive loss of peripheral nerve fibres resulting in nerve dysfunction resulting in a complete loss of feeling.

Question 12

Management

Answer 12

1. Carbohydrate and total calorie restriction, increased fibre intake, decreased fat intake and increased physical activity to cause weight loss and produce normoglycaemia.
2. In patients with type 2 diabetes oral hypoglycaemic agents may be required. Some
   patients with type 2 diabetes will eventually require insulin therapy.
3. All patients with type 1 diabetes require a diet containing controlled amounts of
   carbohydrate and insulin therapy.

Question 13

Insulin Pharmacology:

Answer 13

Insulin Pharmacology: Insulin is an anabolic and anti-catabolic hormone. It plays major roles in protein, carbohydrate, and fat metabolism. Endogenously produced insulin is cleaved from the larger proinsulin peptide in the β cell to the active peptide of insulin and C-peptide, which can be used as a marker for endogenous insulin production. All commercially available insulin preparations contain only the active insulin peptide.
NOTE:
 Insulin is a polypeptide hormone which can be destroyed if administered orally.
 It is given by subcutaneous injection. Patient is advised to use a different site for each
injection to minimise fat hypertrophy at injection sites.
 Product should be stored in a refrigerator.
 Dose may need to be reviewed in relation to change in diet or increased exercise.
 Side-effects: local reactions and fat hypertrophy at injection site, increase in body
weight, hypoglycaemia.

Question 14

Short-acting insulin

Answer 14

Short-acting insulin (e.g. insulin aspart and insulin lispro) has a rapid onset of action.

Question 15

Intermediate- and long-acting insulin

Answer 15

Intermediate- and long-acting insulin (e.g. isophane insulin, which is a suspension of insulin in protamine, or insulin zinc suspension, which includes addition of a suitable
zinc salt) has a slower onset of action but action is of longer duration.

Question 16

Mixtures of short-acting and intermediate-acting insulin

Answer 16

Mixtures of short-acting and intermediate-acting insulin (e.g. in the proportion of 30% to 70%, which is administered twice daily) may be used. A short-acting insulin may be
required before meals to avoid excessive post-prandial hyperglycaemia.

Question 17

Hypoglycaemia

Answer 17

Hypoglycaemia is defined as a blood glucose level of less than 4 mmol/l. Individuals with diabetes may experience hypoglycaemia due to the side effects of treatment with Insulin, Glitazones or Sulphonylureas

Question 18

Signs and symptoms of hypoglycaemia

Answer 18

Autonomic: Activating sympathetic or para-sympathetic nervous system
 Sweating
 Tremor/Shaking
 Anxiety/ Tingling
 Palpitations
 Hunger
 Blurred vision
Neuroglycopenic: Caused by glucose deprivation to the brain
 Confusion
 Lack of Concentration
 Drowsiness
 Atypical behaviour
 Speech Difficulty
 Diplopia
 Incoordination
Others Non Specific
 Weakness
 Dry Mouth
 Headaches

Question 19

Warning signs of hypoglycaemia may be minimised in patients who are taking ___________and those who are experiencing increased frequency of ____________ attacks.

Answer 19

Warning signs of hypoglycaemia may be minimised in patients who are taking beta blockers and those who are experiencing increased frequency of hypoglycaemic attacks.

Question 20

Management of hypoglycaemia

Answer 20

Patient should be advised to consume a rapidly absorbed carbohydrate (e.g. dextrose tablets or non-sugar-free sweets or soft drinks) immediately until symptoms subside. If patient is unconscious then patient requires administration of glucagon and glucose.

Question 21

Diabetic nephropathy / Management

Answer 21

Diabetic nephropathy
 Incidence increases in type 2 diabetes
 Presents with albuminuria, proteinuria and reduced glomerular filtration rate
 Hypertension and oedema develop
Management:
 ACE inhibitors +/- diuretic or calcium channel blockers
 Target blood pressure in diabetics is 120/80 mmHg.

Question 22

Retinopathy

Answer 22

Retinopathy
 Most common microvascular complication.
 Accumulation of sorbitol which cannot be metabolised by cells in the retina takes place
and this leads to oedema
 Damage to existing vessels and formation of new unstable vessels
 Precipitated with hypertension, hyperlipidaemia and pregnancy
 Signs: haemorrhage, spots, venous changes on retina.

Question 23

Peripheral neuropathy

Answer 23

Characterised by paresthesia and pain in the lower extremities, and decreased sensation which may contribute to foot injuries.
Management:
 Pain – paracetamol or NSAIDs are first line of treatment.

 Tricyclic antidepressants particularly amitriptyline and imipramine are used in patients where analgesics alone are not sufficient.
 Carbamazepine and gabapentin may also be considered.
 Other antiepileptic drugs, namely lamotrigine and topiramate, have been shown to be
effective.

Question 24

SPECIFIC MANAGEMENT
 OBESE

Answer 24

SPECIFIC MANAGEMENT
 OBESE
- Metformin is first line
- After 2month scale up by adding sulfonylureas as second line
- Third line give insulin exenatide or Glitazones.

Question 25

SPECIFIC MANAGEMENT

NON-OBESE

Answer 25

• Sulfonylureas or Meglitinide as first line
• Then metformin can be added as second line.
• Add insulin exenatide or Glitazones.

Question 26

SPECIFIC MANAGEMENT

ELDERLY

Answer 26

SPECIFIC MANAGEMENT

ELDERLY
- Sulfonylureas or Meglitinide (lower doses)
- Then switch to simple insulin doses.

Question 27

SPECIFIC MANAGEMENT

ELDERLY

Answer 27

ELDERLY
- Sulfonylureas or Meglitinide (lower doses)
- Then switch to simple insulin doses.

Question 28

SPECIFIC MANAGEMENT

ASIANS

Answer 28

ASIANS
- Glitazones are first line
- Metformin is added as second line
- Sulfonylureas or insulin are third line