Diabetes Flashcards
Prevalence of diabetes is increasing - true or false
True
both types are on the rise
What are the 4 classes of diabetes
Type 1
Type 2
Gestational
Other - MODY etc
What is type 1 diabetes
Diabetes caused by autoimmune B cell destruction
Leads to absolute insulin deficiency
What is type 2 diabetes
Diabetes caused by a progressive loss of B cell insulin secretion
Often has background of insulin resistance
What is gestational diabetes
Diabetes that is diagnosed in 2nd/3rd trimester when there was no evidence before pregnancy
Will go away after delivery
List some diabetic conditions that come under the ‘other’ classification
Neonatal diabetes
MODY
Disease of exocrine pancreas - CF
Drug/chemical induced - steroids or HIV treatment
Type 1 diabetes is an autoimmune condition - true or false
True
What is the initial treatment for type 1 diabetes
immediate and permanent requirement for insulin
What is the initial treatment for type 2 diabetes
Initially managed with diet and tablets
In which class of diabetes might you expect microvascular symptoms on diagnosis
Type 2 - 20% of patients
No signs in T1
When should you consider testing for diabetes in someone who is asymptomatic
Overweight or obese with associated risk factors
Those with prediabetes
Women who had GDM - should get tested every 3 years
Age 45 and over
List risk factors for T2DM
Obesity Family history Gestational diabetes Age Ethnicity - Asian, African Medications - antipsychotics History of MI/stroke
What is idiopathic type 1 diabetes
People with low insulin and prone to DKA but no evidence of auto-immunity
Strongly inherited pattern
Which pancreatic conditions can cause type 4 diabetes
Chronic or Recurrent pancreatitis
Haemochromatosis
Cystic Fibrosis
Which endocrine conditions can cause type 4 diabetes
Cushing’s syndrome
Acromegaly
Phaechromocytoma
glucagonoma
What is the normal goal for HbA1c in diabetic
Under 48 mmol/mol or 6.5%
What are some of the consequences of peripheral neuropathy
Foot ulcers
Charcot foot - can progress to complete destruction of foot
What is the major consequence of retinopathy
Blindness
What is the most common autoimmune disease associated with diabetes
Coeliac disease
What percentage of beta-cells have to be lost before you get marked hyperglycaemia
80-90%
Can autoantibodies predict disease risk
Yes
The more types of antibody you have, the higher your risk
What are the symptoms pf diabetic ketoacidosis
thirst, vomiting, abdominal pain, altered consciousness and acidotic breathing
What is LADA
Latent Autoimmune Diabetes of Adulthood
Much slower disease onset and usually not overweight
Subset of T2
What can be seen on histology of islet cells in T1DM
Lymphocytes attacking the B cells
What can be seen on histology of islet cells in T2DM
Amyloid deposition
List the common autoantibodies in T1DM
IA-2
IA-2b
GAD
Does having an affected family member increase your risk of developing diabetes
YES
10% higher risk if dad affected
1-4% if mum is
What are the classic symptoms of Type 1 diabetes
Polyuria
Polydipsia - thirst
Weight loss
General malaise and fatigue
What can lead to variation in insulin delivery
Accuracy of device Leaks from injection sites Injecting into muscle by mistake Lipohypertrophy Blood supply in the area
What is HbA1c a measure of
Glycated haemoglobin
Measure of average blood glucose level over past 6-8 weeks
Describe the pathophysiology of T2DM
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
What are the 8 effects of T2DM
Decreased incretin effect Increased glucagon secretion Increased hepatic glucose production Neurotransmitter dysfunction Decreased insulin secretion Increased lipolysis Increased glucose reabsorption Decreased glucose uptake
Does glucose control have more affect on micro or macrovascular complications
Microvascular
CVD risk is better treated by statins and BP control
What is the first line drug for T2DM
Metformin
How does metformin work
Decreases hepatic gluconeogenesis
Increases peripheral uptake of glucose
Helps decrease HbA1c, decrease risk of cancer and CHD
Which factors can lead to failure to reach glycaemic targets
Younger patients Obese Female On 2 or 3 drugs Poor drug and lifestyle compliance
How do sulphonylureas work
Blocks the KATP channel in B cells to stimulate insulin secretion
List some of the adverse effects of sulphonylureas
Abnormal LFTs
Increased risk of CHD
Can cause hypo as not glucose sensitive - don’t switch off when glucose is low
The efficacy of sulphonylureas decreases at high doses - true or false
TRUE
How do SGLT-2 inhibitors work
Blocker SGLT2 channel so reduces glucose reabsorption in the kidney
Glucose is lost to the urine
Also causes weight loss
What is the main side effect of SGLT-2 inhibitors
UTI
How does glitazone work
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
List the side effects of glitazone
Increased fracture risk
Hepatotoxicity
Fluid retention
Who should you screen for diabetes
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
What is required to diagnose diabetes in a symptomatic person
Classic symptoms plus one positive test:
- random glucose >11.1
- fasting >7
What is required to diagnose diabetes in an asymptomatic person
At least 2 positive tests at least 4 weeks apart
At least one fasting
List the macrovascular complications of diabetes
IHD
Stroke
List the microvascular complications of diabetes and their end points
Neuropathy - amputation
Nephropathy - dialysis
Retinopathy - blindness
Describe the relationship between HbA1c and microvascular complications
The higher the HbA1c the higher the complication risk
Better control = lower risk
Describe peripheral neuropathy
Pain/loss of feeling in feet and hands
Can get numbness, tingling, sharp pain, loss of balance etc
What are potential complications of peripheral neuropathy
Painless trauma - e.g. could have pin in foot and not notice
Foot ulcers
Charcot foot
Describe autonomic neuropathy
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
Describe proximal neuropathy
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
Describe focal neuropathy
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
What increases your risk of neuropathy
Increased length of diabetes Poor glycaemic control Type 1 diabetes > Type 2 diabetes High Cholesterol/ Lipids Smoking Alcohol Inherited Traits (genes) Mechanical Injury
How can you treat painful peripheral neuropathy
Remove the cause – get better footwear, regular podiatrist visit to manage callus
Amitriptyline
Topical capsaicin creams
How often should diabetics be screened for foot disease
Annually
What is diabetic nephropathy
Progressive kidney disease caused by damage to the capillaries in the glomeruli
You get nephrotic syndrome and scarring of the glomeruli
What are the consequences of diabetic nephropathy
Hypertension develops
Relentless decline in renal function
Accelerated vascular disease
How do you screen for nephropathy
Urinary albumin creatinine ratio (ACR)
Should also do dipstick tests to check for infection and proteinuria
What are the risk factors for nephropathy progression
Hypertension Cholesterol Smoking Poor glycaemic control Albuminuria
How can you treat diabetic nephropathy
BP maintenance - <130/80
Start ACEi in those with microalbuminuria or proteinuria
Manage glycaemic control
What eye pathologies do people with diabetes get
Diabetic Retinopathy
Cataract
Glaucoma
Acute hyperglycaemia can lead to reversible visual blurring
What is maculopathy
changes around the macular area of eye
Affects central vision
What are the different stages of retinopathy
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
Why do new vessels form in retinopathy
Retina becomes ischaemic so new blood vessels form in an attempt to compensate
New vessels are delicate and commonly leak
How can you treat retinopathy
Improve glycaemic control and BP management Stop smoking Laser treatment Vitrectomy Anti-VEGF injections for maculopathy
How common is erectile dysfunction in diabetics and what causes it
Occurs in 50% of diabetic men
Due to vascular complications and neuropathy
how often should you screen diabetics for retinopathy
Annually
What is diabetic ketoacidosis
DKA
Disordered metabolic state
Occurs in insulin deficiency with increase in counter-regulatory hormones such as glucagon
It is an emergency
What biochemical picture would you expect to see in someone with DKA
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
What can lead to DKA
Occurs in the newly diagnosed or undiagnosed
Infection
Drug and alcohol use
Main contributor is poor glycaemic control (e.g. non-adherence)
How do you manage DKA
HDU and follow hospital protocol Fluid replacement Insulin Potassium Address risks and underlying causes if there is any (e.g. source infection)
What is Kussmaul breathing
Hyperventilation caused by ketoacidosis
Involuntary attempt to remove carbon dioxide from the blood
What are the features of HHS
Older patients
Marked hypovolemia and hyperglycaemia
Often much sicker than in DKA
Associated with CV disease, sepsis and steroids and thiazide diuretics
What biochemical picture would you expect from HHS
High glucose (higher than DKA) Renal impairment Na high Fewer ketones than in DKA Raised osmolarity
How do you manage HHS
Fluids - give carefully as risk of overload
Insulin - may not need but give slowly if they do
Need to normalise osmolarity carefully
What is the CPR of diabetic foot care
Check
Protect
Refer
What is MODY
Maturity onset diabetes of the young
Type-2 like syndrome that comes on in younger people
Genetic cause - autosomal dominant
Mutations in which genes can lead to MODY
Glucokinase
Transcription factors
Describe the glucokinase mutation in MODY
Affects first stage of glycolysis in beta cells Onset at birth Stable hyperglycaemia Diet treatment- does not need insulin Complications rare
Describe the transcription factor mutations in MODY
Adolescence/young adult onset
Progressive hyperglycaemia
1/3 diet, 1/3 OHA, 1/3 Insulin
Complications frequent
What is C peptide a measure of
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
Describe neonatal diabetes
Diagnosed between 0-6 weeks May resolve (transient) or if permanent it needs lifelong insulin treatment
What can be used to diagnose T1DM
History - symptoms fasting glucose >7 Random glucose >11.1 GAD/IA2 antibodies C-peptide - after 3 years
Are the HLA genes associated with T1DM
YES
Cause around 50% of familial risk
Most diagnosed under 30 will have one of the genotypes
What environmental factors may cause diabetes
Seasonality - timing of birth
Viral infection - measles can trigger
Maternal factors
Weight gain
What is checked at diabetic annual review
Weight BP HbA1c Renal function Lipids Retinal screening Foot risk
What is LADA
Latent onset diabetes of adulthood
Slowly progressing type 1 that presents in older patients
Auto-antibodies present
Usually not obese
Is diabetes linked to CF
Yes
25% of those with CF will also be diabetic
What conditions are involved in Wolfram syndrome
Diabetes Insipidus Diabetes Mellitus Optic Atrophy Deafness Neurological anomalies
What are the symptoms of Bardet-Biedl syndrome
Obesity Polydactyly Hypogonadal Visual and hearing impairment Mental retardation Diabetes
HHS mainly affects which class of diabetics
Type2
What are the main nutritional considerations in T1DM
Consistency and timing of meals
CHO - carbs
Timing of insulin
Monitoring blood glucose regularly
What are the main nutritional considerations in T2DM
Weight loss
Smaller meals and snacks
Physical activity
Monitoring blood glucose and medication
What are the benefits of advanced carb counting
Can have wider variety of food
Learn to predict BG
Promotes self management
What are the cons of advanced carb counting
Complex - needs education and support
Needs regular BG monitoring
What are the usual causes of hypoglycaemia
Missed/delayed meal
Not enough carbs in meal
Too much insulin Exercise
Alcohol
What are the risks of alcohol and diabetes
Hidden calories
Hypoglycaemia - alcohol increases activity of insulin
Hypo symptoms can be confused with drunkenness
What can lead to insulin resistance in expecting mother
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
When does GDM usually present
Last trimester
Placenta gets much bigger so greater hormone effect
What complications can T1/T2 DM cause in pregnancy
Congenital Malformation
Prematurity
Intra-uterine growth retardation (IUGR)
Caused by high blood sugars so need great control in pregnancy
What complications can GDM cause in pregnancy
Same as T1/2 - malformation, prematurity and IUGR Also macrosomia (large baby which can cause delivery problems), polyhydramnios (excess fluid), intrauterine death
What complications can occur in the new-born due to GDM
Respiratory distress - immature lungs
Hypoglycaemia - sugar level suddenly drops as not supplied my mother and baby will have developed high insulin in womb
Hypocalcaemia
What CNS defects are higher risk in diabetic mothers
Anencephaly - absence of major portions of the skull, brain etc
Spina bifida
Risk 5x higher
Can diabetes increase risk of caudal regression syndrome
YES
by 200x
Skeletal abnormality in lower limbs and CNS problems
How do you manage T1 and T2 DM in pregnancy
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
How is GDM treated
Good diabetic diet and lifestyle
Counselling
Good sugar control and regular monitoring
May use metformin and/or insulin
Does GDM resolve?
Usually does after birth - check fasting glucose after 6 weeks
However, greatly increases risk of developing T2 - 50% will have it after 10 years
How can you prevent diabetes after GDM
Keep a healthy weight
Healthy diet and exercise
May use tablets
Annual fasting glucose tests
Which type of diabetes is more ‘genetic’
Type 2
Which drug would be the usual second line drug for type 2 diabetes?
Glicazide - sulphonylurea
