Diabetes Flashcards
what is diabetes? definition….
Diabetes mellitus (DM) is a metabolic disorder of multiple aetiology characterised by–>
chronic hyperglycaemia with
disturbances of carbohydrate, fat and protein metabolism
resulting from defects of insulin secretion, insulin action, or a combination of both.
Epidemiology of Diabetes type 2 in ireland?
Over 90% of adults with diabetes have type 2 DM (T2DM).
10% of those with diabetes have type 1 diabetes - usually juvenile-onset, but it may occur at any age. It may be associated with other autoimmune diseases. It is characterised by insulin deficiency.
type2——– It affects approximately 5% of Irish
adults, however the true prevalence is probably underestimated.
In many countries, the prevalence of T2DM is rising steadily, due to the ageing population and increased rates of obesity:
in Ireland its prevalence is predicted to increase by 37% over the 10-year period from 2005-2015
Genetic of type 1? (HLA subtypes)
Associated with HLA DR3 and DR4 and islet cell antibodies around the time of diagnosis.
Criteria for diagnosis of type 2?
T2DM is characterised by a long pre-clinical phase;
Any one of the following criteria is diagnostic:
- HbA1c ≥ 48mmol/mol (equivalent to ≥ 6.5%)* (WHO guidelines)
or - Fasting plasma glucose ≥7 mmol/L*
or - Two hour plasma glucose ≥11.1 mmol/L during an oral glucose tolerance test*
or - Symptoms of hyperglycaemia and random plasma glucose ≥11.1 mmol/L
- in the absence of unequivocal hyperglycaemia, results should be confirmed by repeat testing
when do patients present with type 2?
Many patients are asymptomatic until well
after long term, microvascular and macrovascular complications have occurred.1
risk factors for type 1 and type 2
give 2 for type 1, and 6 for type 2?
type 1—-combination of a genetic predisposition and an autoimmune process that results in gradual destruction of the beta cells of the pancreas (Possible triggers for the process may include viruses, dietary factors, environmental toxins, and emotional or physical stress. )
type 2—–Obesity, especially central (truncal) obesity.
Lack of physical activity.
Ethnicity: people of South Asian, African, African-Caribbean, Polynesian, Middle-Eastern and American-Indian descent are at greater risk of type 2 diabetes, compared with the white population.
History of gestational diabetes.
Impaired glucose tolerance.
Impaired fasting glucose.
Drug therapy - eg, combined use of a thiazide diuretic with a beta-blocker.
Low-fibre, high-glycaemic index diet.
Metabolic syndrome.
Polycystic ovarian syndrome.
Family history (2.4-fold increased risk for type 2 diabetes).
Adults who had low birth weight for gestational age.
presentation of diabetes?
acute?
Presentation
• Acute –mostly type 1, rarely type 2—
Ketoacidosis
hyperosmolar non-ketotic coma
• Asymptomatic ———Incidental finding or through risk stratification
presentation of diabetes?
subacute—
• Subacute —Weight loss, polydipsia, polyuria, lethargy, irritability, infections
(candidiasis, skin infection, recurrent infections slow to clear), genital itching, blurred vision, tingling in hands/feet
presentation of diabetes?
with complications?
categories: skin neuropathy nephropathy eye
• With complications —
Skin changes (pruritis, xanthomas, neuropathic or ischemic ulcers) neuropathy (autonomic, erectile dysfunction, diabetic diarrhoea) mononeuropathies (cranial nerves 3 and 6) nephropathy (proteinuria, inc BP, decreased renal function), arterial (hypertension) or eye disease (blurred vision, glaucoma)
Pharmacological management of diabetes?
name the 7 main drug classes?
biguanides sulfonylureas thiazolidinediones Glinides DPP4 inhibitors alphaglucosidase inhibitors Gliflozins eg...Dapaglif (also...SGLT2 inhibitor)
Biguanides
give an example MOA, side affects, beneficial effects, contraindications
metformin (glucophage)—-1st line treatment for type 2DM
MOA–>inhibits gluconeogenesis
unwanted: Gi side affects, Gastrointestinal adverse effects can be minimised by slowly
increasing the dose over several weeks.
Renal dysfunction is considered a contraindication to its use as it may increase the risk of lactic acidosis- rare
beneficial; beneficial effect on cardiovascular
morbidity
when might you come across lactic acidosis in diabetics?
and what are the symptoms?
if renal dysfunction,
uncontrolled diabetes over long time, prolonged fasting or alcohol intake, dehydration & severe diarrhoea,
symptoms?
The onset of lactic acidosis can be subtle and the symptoms can be
non-specific such as vomiting, bellyache (abdominal pain) with
muscle cramps, a general feeling of not being well with severe
tiredness, and difficulty in breathing. Further symptoms are
reduced body temperature and heart beat
sulfonylureas?
give an example MOA, side affects, beneficial effects, contraindications
why might they be used instead of biganuaides?
eg Glibenclamide
they all end in —-ide
MOA: insulin secretagogue
side: weight gain, hypoglycaemia
beneficial: rapidly effective
contra:
Why? : if any contraindications to biganuaides, eg renal function…..
what are TZD’s?
thiazolidinenediones…aka glitazones…
give an example MOA, side affects, beneficial effects, contraindications
of TZD’s?
pioglitazone
not ususally taken on their own, mostlyu in combination
MOA:increase the sensitivity of muscle, fat and liver to insulin
side: weight gain, fluid retention, CHF, bone fractures, bladder cancer association?
Beneficial:lower lipid profile
contra: in heart failure
what are incretins?
incretin hormones (glucagon-like peptide [GLP-1] and glucose-dependent
insulinotropic peptide [GIP]) are secreted at low basal levels in the fasting state, which increase rapidly and transiently
following food ingestion.
What are gliptins?
MOA:
Benefits:
concerns?
DPP-4 inhibitors (also known as gliptins)
act by prolonging the duration of incretin hormones
resulting in increased glucose mediated insulin secretion and reduced glucagon
benefits: DPP-4 inhibitors are not generally associated with hypoglycaemia and are weight neutral.
concerns?There is concern that DPP-4 inhibitors may interfere with immune function;an increase in upper
respiratory infections has been reported.There is also an association of pancreatitis with DPP-4 inhibitors
what are the parenteral therapies for diabetes?
GLP-1 agonist
insulin
what professionals should be involved in the management of type 2 DM
management
of patients with T2DM should be provided by an integrated multi-disciplinary team including, the patient with diabetes, the GP,
pharmacist, practice nurse, endocrinologist, diabetes specialist nurse, dietician, ophthalmologist and podiatrist
what are the aims of diabetes treatment?
The aims of treatment are to reduce blood glucose and to manage
the CV risk factors and long-term complications of T2DM
what is the first line therapy in controlling blood glucose in Diabetes?
(in addition to lifestyle intervention) Commence metformin if no contraindications or commence alternative oral hypoglycaemic agent authorised for monotherapy use and suitable for individual patient
review in 3-4 months
what is the second line therapy for lowering blood glucose?
(in addition to lifestyle intervention, dose optimisation and advice on adherence to medication)
Add sulphonylurea or thiazolidinedione (if hypoglycaemia a concern and no congestive heart failure)
or DPP-4 inhibitor (if hypoglycaemia and weight gain a concern)
or GLP-1 agonists (if hypoglycaemia a concern, weight loss desired and BMI >30kg/m2)
review in 3-4 months
