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diabetes Flashcards

1
Q

what is involved in type 1 diabetes

A

absolute insulin deficiency - autoimmune beta cell destruction

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2
Q

what is the inflammation seen in beta cells in diabetes called

A

insulitis

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3
Q

T1DM has a strong link to what HLA genes

A

HLA DQA
HLA DQB
HLA DR3 +/- DR4

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4
Q

what antibodies are seen in T1DM

A

anti-GAD (GAD65)
anti-islet cell
tyrosine phosphatases (IA-2, IA2B, ZnT8)

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5
Q

what age does T1DM usually present

A

pre-school and puberty

small peak in late 30s

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6
Q

is the onset of T1DM acute or gradual

A

acute

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7
Q

what are the s/s of T1DM

A 
polyuria
polydipsia
fatigue
weight loss
ketonuria
blurred vision
genital thrush
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8
Q

is there normally evidence of microvascular disease at diagnosis in T1DM

A

no

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9
Q

what infections are people with diabetes more prone to

A

candida infections

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10
Q

what is the treatment for T1DM

A

insulin

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11
Q

what is target blood glucose pre meal

A

4-7 mmol/L

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12
Q

what is the target glucose 1-2 hours after a meal

A

5-9 mmol/L

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13
Q

what is LADA

A

late onset diabetes of adulthood - elevated levels of pancreatic autoantibodies in a patient with previously diagnosed diabetes who did not initially require insulin

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14
Q

who tends to get LADA

A

non-obese males, 25-40

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15
Q

how is LADA differentiated from T2DM

A

patient is thin/losing weight or has a history of pancreatic disease

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16
Q

is LADA autoantibody positive or negative

A

positive

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17
Q

what is idiopathic T1DM

A

patients have permanent insulinopenia and prone to DKA but no evidence of Beta cell autoimmunity

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18
Q

what race are people with idiopathic T1DM

A

african/asian

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19
Q

is idiopathic T1DM familial/HLA assocaited

A

strongly inherited

not HLA associated

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20
Q

what is T2DM

A

non insulin dependent diabetes mellitus

relative insulin deficiency

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21
Q

what is the first line management in T2DM

A

diet control

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22
Q

who tends to get T2DM

A

elderly/middle aged

usually obese

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23
Q

are there usually complications at the point of diagnosis of T2DM

A

yes (prediagnosis time of 6-10 years) e.g. blurred vision

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24
Q

what are 2 causes of insulin resistance

A

ectopic fat accumulation and increased circulating fatty acids
increased inflammatory mediators

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25
is there usually ketonuria at diagnosis of T2DM
no
26
what is the WHO criteria for T1DM
``` raised venous glucose on 2 occasions or OGTT 2 hr value > 11.1 or HbA1c > or = 48 mmol/L ```
27
according to WHO, what must a person have in addition to symptoms of hyperglycaemia to have T1DM
raised venous glucose detected once (fasting > 7 or random > 11.1)
28
according to WHO what must a persons venous glucose be on 2 occasions to have T1DM
raised venous glucose on 2 occasions (fasting > 7 or random > 11.1)
29
according to WHO what must a persons results be from a OGTT to have T1DM
OGTT 2hr value > 11.1
30
according to WHO what must a persons HbA1c be to have T1DM
> or = 48mmol/L
31
what is more accurate to measure glucose levels - urine or blood
blood
32
what ethnicity is more prone to diabetes
asian/african/afro-carribean
33
what is the pathophysiology of T2DM
hyperglycaemia --> hyperinsulinaemia --> insulin resistance compensatory Beta cell hyperplasia causing normoglycaemia beta cell early failure causing impaired glucose tolerance beta cell late failure causing diabetes
34
increased what causes the hyperglycaemia in diabetes
lipolysis glucose reabsorption glucagon secretion hepatic glucose production
35
decreased what causes the hyperglycaemia in diabetes
insulin secretion incretin effect glucose uptake neurotransmitter dysfunction
36
what does HbA1c measure
glucose control over past 2-3 months
37
what is a normal HbA1c
< or = 41
38
what is a diabetic HbA1c
> or = 48
39
what is a normal fasting glucose
< or = 6
40
what is a diabetic fasting glucose
> or = 7
41
what is a normal 2 hr glucose in OGTT
< or = 7.7
42
what is a diabetic 2 hr glucose in OGTT
> or = 11.1
43
what would a diabetic random glucose test be
> 11.1 mmol/L
44
what are the levels of C peptide like in T1 and T2 diabetes
T1 diabetes - no C peptide | T2 diabetes - some C peptide
45
what type of diabetes is gestational diabetes
type 3
46
what is gestational diabetes
any degree of glucose intolerance arising or diagnosed during pregnancy
47
how is gestational diabetes caused
placental hormones that cause insulin resistance in mother - human placental lactogen and placental progesterone
48
when is gestational diabetes most likely to occur and why
3rd trimester | - placenta grows most so levels of placental hormones increase
49
what are the 3 main complications of gestational diabetes in utero
macrosomia polyhydramnios intrauterine death
50
what are the 3 main complications of gestational diabetes in the baby after delivery
respiratory death due to immature lungs hypoglycaemia hypocalcaemia
51
why would you get macrosomia in a baby whose mother has gestational diabetes
hyperglycaemia causes excess insulin production which is a growth factor
52
why would a neonate whose mother has gestational diabetes become hypoglycaemic
high sugar load from mother near birth causes excess insulin production - once the baby is born no longer getting the high blood sugars yet still has high insulin producing hypoglycaemia
53
what should be done 6 weeks after delivery to decide if the gestational diabetes is now actually T2DM
glucose tolerance test
54
what is gestational diabetes screened for with
OGTT
55
Monogenic diabetes is... young/old onset GAD positive/negative C peptide negative/positive
young onset GAD negative C peptide positive
56
monogenic diabetes has a strong family history | true/false
true
57
what are some assocaited features of monogenic diabetes
renal cysts
58
what is MODY
mature onset diabetes of young | monogenic diabetes with genetic defect in beta cell function - primary defect in insulin secretion
59
what is the inheritance of MODY
autosomal dominant
60
how is MODY differentiated from T1DM
genetic screening
61
what is the treatment of MODY
diet treatment and sulfonylurea
62
do MODY patients usually have no Beta function or some
some beta function
63
where can mutations occur to cause MODY
glucokinase (GCK/MODY2) | several transcription factors
64
how does a defect in glucokinase cause MODY
alters the point where glucokinase can sense present of glucose, meaning body can only sense glucose above 7 leading to stable hyperglycaemia
65
when is the onset of MODY2
birth
66
what is the treatment of MODY2 with a genetic defect in glucokinase
diet treatment
67
what is the onset of MODY if the defect is in one of the transcription factors
young adult onset
68
what is the most common form of MODY
genetic defect in transcription factors
69
what is MODY1
defect in HNF-4alpha
70
what is MODY3
defect in HNF-1alpha
71
what is MODY4
defect in IPF1
72
what is MODY6
NDF1/neuroD1/B2
73
what do HNF-transcription factors play a key role in
pancreas foetal development and neogenesis | also regulate B cell differentiation and function
74
what is the hyperglycaemia like that is seen in MODY with defects in transcription factors
progressive
75
what is the treatment for MODY with defects in transcription factors
diet treatent sulfonylureas insulin
76
are complications frequent with MODY with defects in transcription factors
yes
77
what are the 4 categories of type 4 diabetes
pancreatic disease endocrine disease drug induced problems with insulin and its receptor
78
what pancreatic diseases cause type 4 diabetes
chronic or recurrent pancreatitis haemochromatosis cystic fibrosis
79
what endocrine diseases can cause type 4 diabetes
cushings acromegaly phaeochromocytoma glucagonoma
80
what drugs can cause diabetes
glucocorticoids diuretics BBs
81
give 3 genetic diseases that can cause diabetes
cystic fibrosis myotonic dystrophy turners syndrome
82
what is the incretin effect
insulin response to oral glucose is greater than the response to IV glucose
83
what happens to the incretin effect in T2DM
it is reduced
84
ingestion of food stimulates the release of what (2)
GLP-1 | GIP
85
where is GLP-1 released from
L cells of the ileum
86
where is GIP released from
K cells in the duodenum
87
where do GLP-1 and GIP go when they are released
into the hepatic portal vein
88
what do GLP-1 and GIP do
enhance insulin release from pancreatic B cells and delay gastric emptying causing enhanced glucose uptake and utilisation
89
what effect do GLP-1 and GIP have on the diet
cause feeling of satiety
90
what does GLP-1 do to liver gluconeogenesis
reduces
91
what effect does GLP-1 have on glucagon release from pancreatic alpha cells
decreases glucagon production --> decreased glucose production
92
how are the actions of GLP-1 and GIP terminated and by what
DPP4 within minutes | dipeptidyl peptidase 4
93
where is insulin released into
hepatic portal vein
94
what does insulin do to gluconeogenesis
inhibits
95
what does insulin do to glycogenolysis
inhibits
96
what does insulin do to glucogenesis
stimulates
97
how does insulin inhibit lipolysis
encourages entry of fatty acids into adipose tissues of body
98
how does insulin promote protein synthesis
promotes uptake of amino acids into muscles and other tissues
99
how would you describe the normal release of insulin
biphasic - rapid phase of preformed insulin (5-10 mins) and slow phase (1-2 hours)
100
what are 2 macrovascular complications of diabetes
heart disease | stroke
101
what does AGE-RAGE stand for
Advanced Glycation End products | Receptor for AGE
102
what is glycation
non-enzymatic covalent bonding of a protein or lipid molecule with carbohydrates such as glucose
103
what are the 3 main microvascular complications of diabetes
retinopathy nephropathy neuropathy
104
how do these microvascular complications happen
Hyperglycaemia + hyperlipidaemia --> AGE-RAGE, hypoxia, oxidative stress, inflammation, mitochondrial dysfunction
105
how does neuropathy occur
small blood vessels to vessels become damaged due to high glucose levels - reduced oxygen supply causes nerves to become damaged
106
how do you describe the distribution of peripheral neuropathy in diabetes
glove and stocking distribution | distal symmetric or sensorimotor neuropathy
107
what are some s/s that indicate peripheral neuropathy
``` numbness//insensitivity tingling/bussing sharp pains/cramps sensitivity to touch allodynia loss of balance coordination ```
108
what are some treatments for painful neuropathy
``` amitriptyline duloxetine gabapentin pregabalin (Combinations not recommended) ```
109
what is diabetic focal neuropathy
appears suddenly and affects specific nerve/group of nerves
110
what nerves/groups of nerves are most commonly affected in focal neuropathy
head torso leg
111
what are some s/s of focal neuropathy
unable to focus eye/double vision/aching behind eyes bell's palsy pain in thigh/chest/lower back/pelvis pain on outside of foot
112
proximal neuropathy is more common in who
elderly T2DM
113
what is proximal neuropathy assoc. with
proximal muscle weakness and marked weight loss
114
what are some other names for proximal neuropathy
lumbosacral plexus neuropathy, femoral neuropathy or diabetic amyotrophy
115
what does proximal neuropathy start with
pain in the thighs, hips, buttocks or legs
116
does proximal neuropathy usually start on one or both sides of the body
one
117
what is the name for the neuropathy that affects nerves regulating heart rate and blood pressure as well as control of internal organs e.g. those involved in gastric motility, respiratory function, urination, sexual function and vision
autonomic neuropathy
118
why might someone with autonomic neuropathy not be able to see well in the dark
autonomic system not working so not able to dilate pupil properly
119
what are 4 manifestations of autonomic neuropathy affecting the digestive system
constipation (gastric slowing) diarrhoea (gastric frequency) gastroparesis oesophagus nerve damage
120
what is gastroparesis
slow stomach emptying
121
what are some s/s of gastroparesis
persistent nausea and vomiting, bloating and loss of appetite
122
how can gastroparesis make someone at risk of hypo
can make blood glucose fluctuate widely and insulin may be in system before food is digested due to abnormal digestion
123
what is some dietary advice you could give to someone with gastroparesis
smaller, more frequent food portions low fat, low fibre may need liquid meals
124
what drugs can help with gastroparesis
promotility drugs anti-nausea medications serotonin antagonists
125
what are 3 examples of promotility drugs
metoclopramide domperidone erythromycin
126
what is an example of an anti-nausea drug
prochlorperazine
127
what is an example of a serotonin antagonist
ondansetron
128
how could you treat the abdominal pain in gastroparesis
``` NSAIDs low dose tricyclic antidepressents gabapentin tramadol fentanyl ```
129
what are 2 other treatments for gatroparesis
botulinum toxin | gastric pacemaker
130
what would be a symptom of oesophageal nerve damage
difficulty swallowing
131
how can diabetic autonomic neuropathy affect the sweat glands
stops them working so cant regulate temperature or causes perfuse sweating at night or while eating (gustatory)
132
what are some treatments for diabetic autonomic neuropathy affecting the sweat glands
topical glycopymolate clonidine botulinum toxin
133
how does diabetic autonomic neuropathy affect the heart and blood vessels
interferes with ability to adjust BP and HR
134
in diabetic foot screening for diabetic neuropathy what is considered low risk
no loss of sensation or pulses
135
in diabetic foot screening for diabetic neuropathy what is considered moderate risk
loss of sensation or pulses
136
in diabetic foot screening for diabetic neuropathy what is considered high risk
loss of sensation and pulses
137
what are 4 other diagnostic tools for diabetic neuropathy
nerve conduction studies/electromyography HR variability US of bladder/urinary tract gastric emptying study
138
what is diabetic nephropathy
progressive kidney disease caused by damage to capillaries in kidney glomeruli
139
what is diabetic nephropathy characterised by
nephrotic syndrome and diffuse scarring of glomeruli
140
what are 2 other names for diabetic nephropathy
kimmelsteil wilson syndrome | nodular glomerulosclerosis
141
what are the consequences of diabetic nephropathy
hypertension decline in renal function accelerated vascular disease
142
who is screened for diabetic nephropathy
all patients 12 or older at diagnosis and annually
143
what is used to screen for diabetic nephropathy
urinary ACR dipstick test U+Es (eGFR) may use random rather than first pass sample as initial check
144
what are some risk factors for nephropathy progression
``` hypertension cholesterol smoking poor glycaemic control albuminuria ```
145
what is the target BP in all diabetic patients
< 130/80
146
what is the target HbA1c in diabetic patients
around 53 (48-58)
147
what should diabetic patients with microalbuminuria or proteinuria be started on
ACEI/ARB
148
what eye changes occur in acute hyperglycaemia
visual blurring (reversible)
149
what 4 other diabetic eye diseases are there
diabetic retinopathy cataracts glaucoma retinal detachment
150
what are the 4 stages of diabetic retinopathy
mild non-proliferative (background) moderate non-proliferative severe non-proliferative proliferative
151
how is retinopathy graded
R0-R4 | M1 and M2
152
how often should diabetic patients be screened for retinopathy
annually
153
what are cotton wool spots
ischaemic areas
154
what are hard exudates
lipid breakdown products
155
what is IRMA
intra-retinal microvascular abnormalities - abnormalities of blood vessels/precursor to neovascularisation but blood vessels aren't leaking
156
what are some treatments for diabetic retinopathy
laser vitrectomy anti-VEGF injections
157
what % of diabetic men have erectile dysfunction
50%
158
what are the 2 causes of erectile dysfunction in diabetes
vascular | neuropathy
159
what causes diabetic ketoacidosis
uncontrolled lipolysis
160
what are some precipitants of DKA
insulin omission infection MI
161
who is more prone to DKA type 1 or 2
type 1
162
in DKA what would ketonaemia be
> 3 mmol
163
in DKA what would ketonuria be
> ++
164
in DKA what would blood glucose be
> 11
165
in DKA what would bicarbonate be
< 15 | < 10 in severe
166
in DKA what would venous pH be
< 7.3
167
in DKA what would K be
> 5.5
168
in DKA what would creatinine be
raised
169
in DKA what would Na be
low
170
in DKA what would lactate be
raised
171
in DKA what would amylase be
raised
172
in DKA would the anion gap be raised or decreased
raised
173
what are some s/s of DKA
``` thirs/dehydration polyuria flushed vomiting abdo pain kussmaul breathing smell of ketones on breath (pear drops) increased HR ```
174
what is the treatment for DKA
fluids - 0.9% saline insulin: IV infusion, 0.1 unit/kg/hour once glucose is below 15 start infusion of 5% dextrose
175
what does blood ketone testing measure
beta-hydroxybutyrate
176
what is normal blood ketone level
< 0.6
177
what does urine ketone testing measure
acetoacetate - measures levels 2-4 hours previously
178
what are some life threatening complications of DKA
``` cardiac arrest due to hyperkalaemia - arrhythmias cerebral oedema following fluid resus ARDS aspiration due to gas in stomach gastric stasis thromboembolism AKI ```
179
who is more prone to hyperglycaemic hyperosmolar syndrome
T2DM
180
what is the mortality rate of DKA
<2 %
181
what is the mortality rate of HHS
10-50%
182
who tends to get HHS
older patients or younger afro-carribean
183
what has often occurred pre presentation of HHS
high refined CHO intake
184
what drugs is HHS associated with
glucocorticoids/steroids | thiazide diuretics
185
is diabetes always known on presentation of HHS
not always
186
what are some precipitants of HHS
infection
187
is hyperglycaemia higher in DKA or HHS
HHS, usually > 50
188
is there any ketonuria in HHS
none/mild
189
what is bicarbonate level in HHS
> 15
190
what is the venous pH in HHS
> 7.3 - not acidotic
191
what is osmolality in HHS
> 320, usually around 400
192
what is Na like in HHS
raised
193
what is the treatment of HHS
fluids insulin sodium (o.5 mmol/L/hr) LMWH
194
why should fluids be given more cautiously in HHS
higher risk of fluid overload
195
is insulin always required in HHS
no | also given more slowly as more sensitive (3 units/hour)
196
why is LMWH given in HHS
comorbidities common - screen for vascular events e.g. MI, sepsis
197
what is going on... elderly female heavy alcohol intake for years admitted with recurrent vomiting on 16 different medications including acamprosate she is hypotensive, tachypnoeic and difficult to rouse
alcohol induced ketoacidosis
198
what is the treatment for alcohol induced keto-acidosis
IV pabrinex IV fluids IV antiemetics insulin (maybe)
199
is there ketonuria/ketonaemia in AIKA
ketonaemia > 3 | ketonuria significant
200
what is bicarb usually in AIKA
< 15
201
what is venous pH in AIKA
< 7.3
202
what is glucose levels in AIKA
normal/low
203
what is lactate
end product of anaerobic metabolism of glucose
204
clearance of lactate involves ____ uptake and ____ conversion into _____ then _____
hepatic uptake aerobic conversion pyruvate glucose
205
what is normal lactate
0.6 - 1.2
206
when is lactate lowest
fasting state
207
what can increase lactate to 10
severe exercise
208
what happens to the ion gap in lactic acidosis
raised
209
what is the ion gap
[K+ + Na+] - [HCO3- + Cl-]
210
what is a normal ion gap range
10-18
211
what is lactic acidosis type A
assoc. tissue hypoxaemia | e. g. infarcted tissue (ischaemic bowel), cardiogenic shock, hypovolaemic shock, sepsis, haemorrhage
212
what is lactic acidosis type B associated with
liver disease leukaemic states diabetes rare inherited conditions
213
what are the clinical features of lactic acidosis
hyperventilation mental confusion stupar/coma
214
what happens to bicarbonate in lactic acidosis
reduced
215
is there ketonaemia in lactic acidosis
no
216
what happens to phosphate in lactic acidosis
raised
217
what is the tx of lactic acidosis
fluids, antibiotics
218
what is wolfram syndrome
rare genetic condition causing DI, DM, optic atrophy, deafness and neuro abnormalities (DIMOAD)
219
what is the equation for osmolarity
2(Na + K) + glucose + urea
220
what is charcot foot
progressive degeneration of weight bearing joints leading to deformity
221
how does charcot foot present
hot red swollen foot
222
what can charcot foot often be mistaken for
DVT or cellulitis
223
what causes Bardet Biedl syndrome
insest parents
224
what are some s/s of bardet biedl syndrome
``` polydactyly hypogonadal visual/hearing impairment mental retardation diabetes obese ```
225
what is the folic acid dose for non-diabetic pregnant patient
400mcg
226
what is the folic acid dose for diabetic pregnant patient
5mg

year 2 (19 decks)

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