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Endocrinology > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Prevalence of diabetes is increasing - true or false

A

True

both types are on the rise

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2
Q

What are the 4 classes of diabetes

A

Type 1
Type 2
Gestational
Other - MODY etc

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3
Q

What is type 1 diabetes

A

Diabetes caused by autoimmune B cell destruction

Leads to absolute insulin deficiency

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4
Q

What is type 2 diabetes

A

Diabetes caused by a progressive loss of B cell insulin secretion
Often has background of insulin resistance

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5
Q

What is gestational diabetes

A

Diabetes that is diagnosed in 2nd/3rd trimester when there was no evidence before pregnancy
Will go away after delivery

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6
Q

List some diabetic conditions that come under the ‘other’ classification

A

Neonatal diabetes
MODY
Disease of exocrine pancreas - CF
Drug/chemical induced - steroids or HIV treatment

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7
Q

Type 1 diabetes is an autoimmune condition - true or false

A

True

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8
Q

What is the initial treatment for type 1 diabetes

A

immediate and permanent requirement for insulin

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9
Q

What is the initial treatment for type 2 diabetes

A

Initially managed with diet and tablets

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10
Q

In which class of diabetes might you expect microvascular symptoms on diagnosis

A

Type 2 - 20% of patients

No signs in T1

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11
Q

When should you consider testing for diabetes in someone who is asymptomatic

A

Overweight or obese with associated risk factors
Those with prediabetes
Women who had GDM - should get tested every 3 years
Age 45 and over

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12
Q

List risk factors for T2DM

A 
Obesity 
Family history 
Gestational diabetes 
Age 
Ethnicity - Asian, African 
Medications - antipsychotics 
History of MI/stroke
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13
Q

What is idiopathic type 1 diabetes

A

People with low insulin and prone to DKA but no evidence of auto-immunity
Strongly inherited pattern

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14
Q

Which pancreatic conditions can cause type 4 diabetes

A

Chronic or Recurrent pancreatitis
Haemochromatosis
Cystic Fibrosis

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15
Q

Which endocrine conditions can cause type 4 diabetes

A

Cushing’s syndrome
Acromegaly
Phaechromocytoma
glucagonoma

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16
Q

What is the normal goal for HbA1c in diabetic

A

Under 48 mmol/mol or 6.5%

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17
Q

What are some of the consequences of peripheral neuropathy

A

Foot ulcers

Charcot foot - can progress to complete destruction of foot

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18
Q

What is the major consequence of retinopathy

A

Blindness

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19
Q

What is the most common autoimmune disease associated with diabetes

A

Coeliac disease

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20
Q

What percentage of beta-cells have to be lost before you get marked hyperglycaemia

A

80-90%

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21
Q

Can autoantibodies predict disease risk

A

Yes

The more types of antibody you have, the higher your risk

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22
Q

What are the symptoms pf diabetic ketoacidosis

A

thirst, vomiting, abdominal pain, altered consciousness and acidotic breathing

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23
Q

What is LADA

A

Latent Autoimmune Diabetes of Adulthood
Much slower disease onset and usually not overweight
Subset of T2

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24
Q

What can be seen on histology of islet cells in T1DM

A

Lymphocytes attacking the B cells

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25
Q

What can be seen on histology of islet cells in T2DM

A

Amyloid deposition

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26
Q

List the common autoantibodies in T1DM

A

IA-2
IA-2b
GAD

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27
Q

Does having an affected family member increase your risk of developing diabetes

A

YES
10% higher risk if dad affected
1-4% if mum is

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28
Q

What are the classic symptoms of Type 1 diabetes

A

Polyuria
Polydipsia - thirst
Weight loss
General malaise and fatigue

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29
Q

What can lead to variation in insulin delivery

A 
Accuracy of device 
Leaks from injection sites 
Injecting into muscle by mistake 
Lipohypertrophy 
Blood supply in the area
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30
Q

What is HbA1c a measure of

A

Glycated haemoglobin

Measure of average blood glucose level over past 6-8 weeks

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31
Q

Describe the pathophysiology of T2DM

A

Genetic and lifestyle lead to insulin resistance
At first there is B cell hyperplasia as they try to compensate
B cells eventually fail leading to impaired glucose tolerance and then diabetes

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32
Q

What are the 8 effects of T2DM

A 
Decreased incretin effect
Increased glucagon secretion 
Increased hepatic glucose production 
Neurotransmitter dysfunction 
Decreased insulin secretion 
Increased lipolysis 
Increased glucose reabsorption 
Decreased glucose uptake
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33
Q

Does glucose control have more affect on micro or macrovascular complications

A

Microvascular

CVD risk is better treated by statins and BP control

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34
Q

What is the first line drug for T2DM

A

Metformin

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35
Q

How does metformin work

A

Decreases hepatic gluconeogenesis
Increases peripheral uptake of glucose
Helps decrease HbA1c, decrease risk of cancer and CHD

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36
Q

Which factors can lead to failure to reach glycaemic targets

A 
Younger patients 
Obese 
Female 
On 2 or 3 drugs 
Poor drug and lifestyle  compliance
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37
Q

How do sulphonylureas work

A

Blocks the KATP channel in B cells to stimulate insulin secretion

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38
Q

List some of the adverse effects of sulphonylureas

A

Abnormal LFTs
Increased risk of CHD
Can cause hypo as not glucose sensitive - don’t switch off when glucose is low

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39
Q

The efficacy of sulphonylureas decreases at high doses - true or false

A

TRUE

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40
Q

How do SGLT-2 inhibitors work

A

Blocker SGLT2 channel so reduces glucose reabsorption in the kidney
Glucose is lost to the urine
Also causes weight loss

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41
Q

What is the main side effect of SGLT-2 inhibitors

A

UTI

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42
Q

How does glitazone work

A

Act on a nuclear receptor
Thought that they make fat cells smaller and more numerous – cells are less inflamed and healthier which can help diabetes

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43
Q

List the side effects of glitazone

A

Increased fracture risk
Hepatotoxicity
Fluid retention

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44
Q

Who should you screen for diabetes

A

High risk groups!
Annually - those with impaired glucose tolerance, fasting glucose and those with history of gestational diabetes
Opportunistically - non-Caucasian, family history of T2DM, obese and PCOS

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45
Q

What is required to diagnose diabetes in a symptomatic person

A

Classic symptoms plus one positive test:

  • random glucose >11.1
  • fasting >7
46
Q

What is required to diagnose diabetes in an asymptomatic person

A

At least 2 positive tests at least 4 weeks apart

At least one fasting

47
Q

List the macrovascular complications of diabetes

A

IHD

Stroke

48
Q

List the microvascular complications of diabetes and their end points

A

Neuropathy - amputation
Nephropathy - dialysis
Retinopathy - blindness

49
Q

Describe the relationship between HbA1c and microvascular complications

A

The higher the HbA1c the higher the complication risk

Better control = lower risk

50
Q

Describe peripheral neuropathy

A

Pain/loss of feeling in feet and hands

Can get numbness, tingling, sharp pain, loss of balance etc

51
Q

What are potential complications of peripheral neuropathy

A

Painless trauma - e.g. could have pin in foot and not notice
Foot ulcers
Charcot foot

52
Q

Describe autonomic neuropathy

A

Affects the nerves regulating heart rate, BP and control of internal organs
You get changes in bowel, bladder function, sexual response, sweating, heart rate, blood pressure

53
Q

Describe proximal neuropathy

A

Neuropathy in the lumbosacral plexus
Get pain in the thighs, hips or buttocks leading to weakness in the legs
Less common but affects elderly
Associated with weight loss

54
Q

Describe focal neuropathy

A

It’s a sudden weakness in one nerve or a group of nerves causing muscle weakness or pain
E.g. carpal tunnel, foot drop, bells palsy, eye problems

55
Q

What increases your risk of neuropathy

A 
Increased length of diabetes
  Poor glycaemic control
  Type 1 diabetes > Type 2 diabetes
  High Cholesterol/ Lipids
  Smoking
  Alcohol
  Inherited Traits (genes)
  Mechanical Injury
56
Q

How can you treat painful peripheral neuropathy

A

Remove the cause – get better footwear, regular podiatrist visit to manage callus
Amitriptyline
Topical capsaicin creams

57
Q

How often should diabetics be screened for foot disease

A

Annually

58
Q

What is diabetic nephropathy

A

Progressive kidney disease caused by damage to the capillaries in the glomeruli
You get nephrotic syndrome and scarring of the glomeruli

59
Q

What are the consequences of diabetic nephropathy

A

Hypertension develops
Relentless decline in renal function
Accelerated vascular disease

60
Q

How do you screen for nephropathy

A

Urinary albumin creatinine ratio (ACR)

Should also do dipstick tests to check for infection and proteinuria

61
Q

What are the risk factors for nephropathy progression

A 
Hypertension
Cholesterol
Smoking
Poor glycaemic control
Albuminuria
62
Q

How can you treat diabetic nephropathy

A

BP maintenance - <130/80
Start ACEi in those with microalbuminuria or proteinuria
Manage glycaemic control

63
Q

What eye pathologies do people with diabetes get

A

Diabetic Retinopathy
Cataract
Glaucoma
Acute hyperglycaemia can lead to reversible visual blurring

64
Q

What is maculopathy

A

changes around the macular area of eye

Affects central vision

65
Q

What are the different stages of retinopathy

A

Mild non-proliferative - haemorrhage and microaneursyms
Moderate non-proliferative - addition of hard exudate
Severe non-proliferative - add IRMA and venous beading
Proliferative - new vessels form

66
Q

Why do new vessels form in retinopathy

A

Retina becomes ischaemic so new blood vessels form in an attempt to compensate
New vessels are delicate and commonly leak

67
Q

How can you treat retinopathy

A 
Improve glycaemic control and BP management 
Stop smoking 
Laser treatment 
Vitrectomy 
Anti-VEGF injections for maculopathy
68
Q

How common is erectile dysfunction in diabetics and what causes it

A

Occurs in 50% of diabetic men

Due to vascular complications and neuropathy

69
Q

how often should you screen diabetics for retinopathy

A

Annually

70
Q

What is diabetic ketoacidosis

A

DKA
Disordered metabolic state
Occurs in insulin deficiency with increase in counter-regulatory hormones such as glucagon
It is an emergency

71
Q

What biochemical picture would you expect to see in someone with DKA

A 
Ketonaemia >3mmol/L
Or significant ketones on urine test 
Blood glucose >11
Bicarb <15 mmol/L(pH of blood falls) 
Raised creatine, potassium and lactate 
Low Na
72
Q

What can lead to DKA

A

Occurs in the newly diagnosed or undiagnosed
Infection
Drug and alcohol use
Main contributor is poor glycaemic control (e.g. non-adherence)

73
Q

How do you manage DKA

A 
HDU and follow hospital protocol 
Fluid replacement 
Insulin 
Potassium 
Address risks and underlying causes if there is any (e.g. source infection)
74
Q

What is Kussmaul breathing

A

Hyperventilation caused by ketoacidosis

Involuntary attempt to remove carbon dioxide from the blood

75
Q

What are the features of HHS

A

Older patients
Marked hypovolemia and hyperglycaemia
Often much sicker than in DKA
Associated with CV disease, sepsis and steroids and thiazide diuretics

76
Q

What biochemical picture would you expect from HHS

A 
High glucose (higher than DKA) 
Renal impairment 
Na high 
Fewer ketones than in DKA 
Raised osmolarity
77
Q

How do you manage HHS

A

Fluids - give carefully as risk of overload
Insulin - may not need but give slowly if they do
Need to normalise osmolarity carefully

78
Q

What is the CPR of diabetic foot care

A

Check
Protect
Refer

79
Q

What is MODY

A

Maturity onset diabetes of the young
Type-2 like syndrome that comes on in younger people
Genetic cause - autosomal dominant

80
Q

Mutations in which genes can lead to MODY

A

Glucokinase

Transcription factors

81
Q

Describe the glucokinase mutation in MODY

A 
Affects first stage of glycolysis in beta cells 
Onset at birth
Stable hyperglycaemia
Diet treatment- does not need insulin 
Complications rare
82
Q

Describe the transcription factor mutations in MODY

A

Adolescence/young adult onset
Progressive hyperglycaemia
1/3 diet, 1/3 OHA, 1/3 Insulin
Complications frequent

83
Q

What is C peptide a measure of

A

Endogenous insulin production – tells you it’s their own insulin
Will disappear after 3 years in T1DM patients so can confirm its not MODY or similar

84
Q

Describe neonatal diabetes

A 
Diagnosed between 0-6 weeks 
May resolve (transient) or if permanent it needs lifelong insulin treatment
85
Q

What can be used to diagnose T1DM

A 
History - symptoms 
fasting glucose >7 
Random glucose >11.1 
GAD/IA2 antibodies 
C-peptide - after 3 years
86
Q

Are the HLA genes associated with T1DM

A

YES
Cause around 50% of familial risk
Most diagnosed under 30 will have one of the genotypes

87
Q

What environmental factors may cause diabetes

A

Seasonality - timing of birth
Viral infection - measles can trigger
Maternal factors
Weight gain

88
Q

What is checked at diabetic annual review

A 
Weight 
BP 
HbA1c
Renal function 
Lipids 
Retinal screening 
Foot risk
89
Q

What is LADA

A

Latent onset diabetes of adulthood
Slowly progressing type 1 that presents in older patients
Auto-antibodies present
Usually not obese

90
Q

Is diabetes linked to CF

A

Yes

25% of those with CF will also be diabetic

91
Q

What conditions are involved in Wolfram syndrome

A 
Diabetes Insipidus
Diabetes Mellitus
Optic Atrophy
Deafness
Neurological anomalies
92
Q

What are the symptoms of Bardet-Biedl syndrome

A 
Obesity 
Polydactyly 
Hypogonadal 
Visual and hearing  impairment
Mental retardation 
Diabetes
93
Q

HHS mainly affects which class of diabetics

A

Type2

94
Q

What are the main nutritional considerations in T1DM

A

Consistency and timing of meals
CHO - carbs
Timing of insulin
Monitoring blood glucose regularly

95
Q

What are the main nutritional considerations in T2DM

A

Weight loss
Smaller meals and snacks
Physical activity
Monitoring blood glucose and medication

96
Q

What are the benefits of advanced carb counting

A

Can have wider variety of food
Learn to predict BG
Promotes self management

97
Q

What are the cons of advanced carb counting

A

Complex - needs education and support

Needs regular BG monitoring

98
Q

What are the usual causes of hypoglycaemia

A

Missed/delayed meal
Not enough carbs in meal
Too much insulin Exercise
Alcohol

99
Q

What are the risks of alcohol and diabetes

A

Hidden calories
Hypoglycaemia - alcohol increases activity of insulin
Hypo symptoms can be confused with drunkenness

100
Q

What can lead to insulin resistance in expecting mother

A

Placental hormones such as progesterone’s and hPL
Supposed to divert glucose etc to baby at expense of mother
In modern times more women are predisposed to diabetes (weight etc) so it can lead on to GDM

101
Q

When does GDM usually present

A

Last trimester

Placenta gets much bigger so greater hormone effect

102
Q

What complications can T1/T2 DM cause in pregnancy

A

Congenital Malformation
Prematurity
Intra-uterine growth retardation (IUGR)
Caused by high blood sugars so need great control in pregnancy

103
Q

What complications can GDM cause in pregnancy

A 
Same as T1/2 - malformation, prematurity and IUGR 
Also macrosomia (large baby which can cause delivery problems), polyhydramnios (excess fluid), intrauterine death
104
Q

What complications can occur in the new-born due to GDM

A

Respiratory distress - immature lungs
Hypoglycaemia - sugar level suddenly drops as not supplied my mother and baby will have developed high insulin in womb
Hypocalcaemia

105
Q

What CNS defects are higher risk in diabetic mothers

A

Anencephaly - absence of major portions of the skull, brain etc
Spina bifida
Risk 5x higher

106
Q

Can diabetes increase risk of caudal regression syndrome

A

YES
by 200x
Skeletal abnormality in lower limbs and CNS problems

107
Q

How do you manage T1 and T2 DM in pregnancy

A

Couselling - help with good sugar control
Regular monitoring
Folic acid 5mg - preferably before conception (much higher dose than unaffected women
Consider change from tablets to insulin
Stop contraindicated tablets before conception

108
Q

How is GDM treated

A

Good diabetic diet and lifestyle
Counselling
Good sugar control and regular monitoring
May use metformin and/or insulin

109
Q

Does GDM resolve?

A

Usually does after birth - check fasting glucose after 6 weeks
However, greatly increases risk of developing T2 - 50% will have it after 10 years

110
Q

How can you prevent diabetes after GDM

A

Keep a healthy weight
Healthy diet and exercise
May use tablets
Annual fasting glucose tests

111
Q

Which type of diabetes is more ‘genetic’

A

Type 2

112
Q

Which drug would be the usual second line drug for type 2 diabetes?

A

Glicazide - sulphonylurea

Endocrinology (13 decks)

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