Diabetes Flashcards
Name an anabolic hormone
Insulin
Name 4 catabolic hormones
Glucagon
Catecholamine
Growth hormone
Cortisol
What causes hyperglycaemia?
Inadequate insulin action
- Reduced insulin production
- Reduced insulin target organ sensitivity
- Overwhelming increases in catabolic hormones
What is the definition of diabetes mellitus?
A reduction in insulin action sufficient to cause a level of hyperglycaemia that over time will result in diabetes-specific microvascular pathology in eyes, kidneys, and nerves
What is non-diabetic hyperglycaemia (pre-diabetes)?
Aka impaired glucose tolerance
Results if insulin action is reduced such that blood glucose is raised above normal but not to a level that will cause microvascular damage
5-10% progress to T2 diabetes each year
What are the WHO definitions of diabetes mellitus in plasma glucose concentration (mmol/L)?
Fasting (x2 or + symptoms) ≥ 7
OR
2h post glucose load (or random glucose) ≥ 11.1
What is the WHO definition of impaired glucose tolerance by plasma glucose concentration (mmol/L)?
Fasting < 7
OR
2h post glucose load < 11.1 ≥ 7.8
With respect to HbA1c what level diagnoses a patient with DM? With NDH (IGT, pre-diabetes)?
≥ 48mmol/mol = diagnosed DM
42-47mmol/mol = NDH
What is the benefit of using HbA1c?
Gives an integrated view of what glucose levels have been like over the past 3 months.
Name 4 other types of diabetes
- Genetic defects of b-cell function or insulin action (Maturity onset diabetes of the young)
- Diseases of exocrine pancreas (I.e. pancreatitis, cancer, cystic fibrosis)
- Endocrinopathies (i.e. Cushing’s, Acroegaly, phaeochromocytoma)
- Drug induced (I.e. steroids, antipsychotics)
What are the main traits of type 1 diabetes?
- B-cell destruction
- Organ specific/autoimmune
- Most childhood onset
- Early viral trigger
- Ketosis prone -> will burn fat inappropriately b/c no insulin thus generate ketones
What are the main traits of type 2 diabetes?
- Insulin resistance + b-cell dysfunction
- Most adult onset
- Ketosis resistant -> overweight
What are modifiable and non-modifiable risk factors for type 2 diabetes?
Non-Modifiable:
- Family history
- Ethnicity (Black, Caribbean, South Asian)
- Age
- Socio-economic deprivation
Modifiable:
- Overweight + obesity (intra-abdominal fat)
- Diet composition
- Lack of exercise
What is the twin cycle hypothesis of diabetes?
That chronic calorie excess leads to accumulation of liver fat with eventual spill over into the pancreas. These self-reinforcing cycles between the liver and pancreas eventually cause metabolic inhibition of insulin secretion after meals and onset of hyperglycaemia.
What happens initially for someone with NDH/IGT to maintain normoglycemia?
As their insulin sensitivity decreases, their levels of insulin secretion increases to compensate and keep blood glucose levels normal.
What are the key differences between T1 and T2 diabetes?
Age of onset: <30//>30 Autoimmune (associations - thyroid disease, pernicious anemia, Addison’s disease, celiac disease): Yes//No Prone to ketosis: Yes//No Family history/Ethnicity: +/-//+++ Obesity a risk factor: No//+++ Inactivity a risk factor: No//+++ Social deprivation a risk: No//++ Insulin-treated: All//Some
What are 3 main causes of polyuria?
- Diabetes -> sugar build up in bloodstream unable to be filtered out by kidneys.
- Diabetes insipidus -> lack of antidiuretic hormone (ADH) from posterior pituitary means kidneys cannot make enough concentrated urine and too much water is passed from the body.
- Hypercalcemia -> Too much calcium in blood can affect ADH levels or kidney’s response to it. This can affect the way your kidneys produce urine. Symptoms = constipation, anorexia, N/V, abdominal pain, ileus
Why is infection more likely in diabetes?
Caused by the hyperglycaemic environment that favours immune dysfunction (I.e. damage to the neutrophil function, depression of the antioxidant system, and humoral immunity), micro and macro-angioplasties, neuropathy, decrease in the antibacterial activity of urine, gastrointestinal and urinary dysmotility, and greater number of medical interventions in these patients
What tests would you perform on someone with suspect diabetes?
- Capillary glucose (random blood glucose > 13mmol/l is sufficient to make a diagnosis of DM)
- HbA1c
What are 5 main symptoms of diabetes?
- Thirst
- Polyuria
- Polyphagia
- Tiredness
- Weight loss
Remember glucose is an osmotic diuretic
Name 2 hyperglycaemic emergencies
Diabetic ketoacidosis (T1DM)
Hyperosmolar Hyperglycemic state (T2DM) -> increased mortality than DKA, more fluids needed
- Can be caused by dehydration, steroids, improper medication use
What are some diabetic complications?
- Microvascular (neuropathy, retinopathy, nephropathy)
2. Macrovascular (ACS, Stroke, PVD)
What are the treatment goals for diabetes?
- Minimise treatment side effects (I.e. hypoglycaemia, weight gain)
- Maintain glucose levels as near-normal as possible (to minimise acute/long-term complications
- Cardiovascular risk management (CV risk increased even with target glucose; diet, exercise, smoking, BP, lipid management)
What are the types of insulin?
- Quick Acting -> given SC injection/infusion; IV infusion
- Slow acting -> slowed entry into bloodstream; SC injection only (I.e. isoprene, lente)
- Bi-Phasic -> mixtures of #1 + #2; ratio usually 25/75 or 30/70
Name 3 rapid acting insulin analogues
- Lispro
- As part
- Glulisine
Name 1 slow acting insulin analogue
Isoprene
Name 3 basal insulin analogues
- Glargine
- Detimir
- Deluded
List the 6 main drug categories for type 2 diabetes
- Reduce insulin resistance
- Biguanide (metformin) -> work on liver
- Thiazolidenediones (pioglitazone) -> work on fat + muscle - Increase B cell activity
- Sulphonylureas (gliclazide, glipizide, glibenclamide)
- Meglitinides (nateglinide, repaglinide) - Increase GLP1 activity -> glycolipid protein 1, important in metabolism; slows down metabolism of food + increases satiety signal to the brain
- DPP4 inhibitors (sitagliptin, vildagliptin) -> enzyme responsible for GLP1 metabolism
- Incretins (exenatide, liraglutide) -> GLP1 agonists - Slow glucose absorption -> not very effective
- Acarbose (a-glucosidase inhibitor) -> stops metabolism of starches ++ side effects b/c they ferment in bowel - Enhance glucose excretion
- SGL2 antagonists (dapagliflozin, canagliflozin, empagliflozin) - Insulin supplementation
What are the main side effects of drugs for type 2 diabetes?
- Weight gain
- Increase B cell activity
- Insulin - Hypoglycaemia
- Increase B cell activity
- Insulin - GI symptoms (N/V/abdo discomfort)
- Metformin
- Incretins
- Acarbose - Weight loss
- Metformin
- Incretins
- SGLT2 inhibitors - Others
- Osteoporosis -> pioglitazone
- UTI -> SGLT2 inhibitors
What is the negotiated treatment escalation plan for type 2 diabetes?
- Lifestyle
- Lifestyle + metformin
- Lifestyle + metformin + further drugs
- Lifestyle + metformin + further drugs + insulin
What are the annual checks for diabetes?
- Lipids
- UACR (urine albumin-to-creatinine ratio)
- eGFR
- Foot exam
- Diabetic eye screening program
What are the 4 systems that can be affected by long-term type 2 diabetes?
- Eyes
- Kidneys
- Feet
- CVS
What increases the risk of microvascular diabetic complications?
- Hyperglycaemia
- Hypertension
- Insulin resistance
- Certain genes
What is the pathophysiology of diabetic eye disease leading to loss of central vision?
- Capillary leakage
- Intra-retinal haemorrhages
- Intra-retinal oedema
- Intra-retinal hard exudates
- Peripheral retina (non-sight threatening)
- Macular area (maculopathy)
—> Loss of central vision
What is the pathophysiology of total blindness due to diabetic eye disease?
- Capillary occlusion
- Retinal ischemia
- Retinal new vessels formation
- Intra-vitreal haemorrhage
- Intro-vitreal fibrosis
- Traction retinal detachment
- Secondary new vessel glaucoma
—> total blindness
How many stages are there of chronic kidney disease?
5
1 -> microproteinuria -> GFR > 90ml/min/1.72m2 2 -> mic/macroproteinuria -> 60-90 3 -> macroproteinuria -> 30-59 4 -> macroproteinuria -> 15-29 5 -> macroproteinuria -> <15
What is the salvage therapy used for minimising blindness?
Vitrectomy
What is the salvage therapy for end stage kidney disease?
- Diet, Epo, Calcium + Vitamin D, bicarbonate
- Early AVF (atriovenous fistula), early transplantation
- Dialysis + transplantation
What are symptoms of neuropathy?
- Burning, cold, tingling
- Stabbing, toothache
- Walking on glass
- Contact sensitivity
- Allodynia (Pain from stimuli which normally don’t provoke pain)
- Numbness, restlessness
- Worse at night, eased by exercise or counter irritation
What are some signs of autonomic neuropathy?
- Sudomotor (sweating abnormalities)
- Pupils (sluggish pupillary reflexes)
- GI (reduced motility, Diarrhea, enlarged gall-bladder)
- CVS (postural hypotension, tachycardia)
- GU (bladder dysfunction, impotence)
- Vasomotor (peripheral vascular changes, oedema, Charcot joint, osteopathy)
- Glucose metabolism (hypoglycaemic unawareness)
What is Charcot’s joint?
A condition causing the weakening of the bones in the foot that can occur in people who have significant nerve damage. The bones are weakened enough to fracture and with continued walking, the foot eventually changes shape
What is the salvage therapy to minimise risk of amputation?
Revascularisation or local amputation
What are some complications of diabetic pregnancy?
- Congenital anomalies
2. 2nd/3rd trimester accelerated growth
What is cheiroarthropathy and give an example condition
A syndrome of limited joint mobility that occurs in patients with diabetes. It’s characterised by thickening of the skin resulting in contracture of the fingers
I.e. Dupuytren’s contracture
What are the measures to minimise cardiovascular disease and premature death as a complication of diabetes?
Primary prevention:
- Lifestyle (diet, weight, exercise, smoking, alcohol)
- Metabolic control (glucose, BP, lipids)
- ACEI, A2RB, Aspirin, Statins/Fibrates
Secondary Prevention:
- Post angina, ACS, MI, TIA, CVA, Claudication, ED
- Aspirin, thrombolysis, DIGAMI, beta blockers
- As for primary
Salvage Therapy
- Revascularisation
What is the goal blood pressure for a diabetic?
< 130/85mmHg