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Medicine > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

Definition

A

A clinical syndrome characterized by
*Chronic persistent hyperglycemia
*Disturbed metabolism of protein, fat, carbohydrates and electrolytes
*Microangiopathy esp. in retina, glomeruli and vase nervosa

Caused by absolute or relative lack of insulin

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2
Q

Classification of DM

A

Type 1
a. Immune mediated
b. Idiopathic

Type 2
Gestational Diabetes
Other specific types
- Genetic defects of B-cell function - Type 1
- Genetic defects in insulin action
- Exocrine pancreatic causes
* Congenital cystic fibrosis
* Chronic pancreatitis, hemochromatosis - works through autoimmunity
* Fibrocalculous pancreatopathy (tropical DM - tropical malnutrition) - Pancreas is hardened, looses ability to produce insulin.

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3
Q

Other endocrine + infectious + drugs causes of Diabetes

A

*Cushing’s syndrome, Conn’s syndrome
*Acromegaly, Pheochromocytoma
*Somastatinoma (delta cell tumors), Glucagonoma
*Thyrotoxicosis

Infections
*Congenital rubella
*Cytomegalovirus

Drugs - Interferon, Corticosteroids, CCP (Cyclic citrullinated peptides)

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4
Q

Genetic causes and Other types of Diabetes

A
  • Genetic syndromes: Down syndrome, Klinefelter syndrome
  • Uncommon forms of immune mediated diabetes: anti- insulin receptor Ab
  • MODY type - Type 2
  • Represents 15% of cases
  • Autosomal dominant, in young obese people
  • Treated by oral anti diabetics
  • Less liable for microangiopathy
  • Latent Autoimmune Diabetes in Adult
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5
Q

Etiology of Type 1

A

Type 1A - from autoimmunity destruction of the beta cells of the pancreas and involves both genetic predisposition and environmental component.

~ 90 to 95% of young children with type 1DM carry HLA-DR3 or HLA - DR4
- Carraige of both haplotypes confers highest susceptibility of Diabetes Mellitus

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6
Q

Extra-Genetic factors that can contribute or trigger immunologically mediated destruction of the beta cells:

A
  • Viruses (eg. Enterovirus, mumps, rubella and Coxsackie virus B4)
  • Toxic chemicals
  • Exposure to cow’s milk in infancy
  • Cytotoxins
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7
Q

What is Type 2 diabetes

A

It is an islet paracrinopathy in which the reciprocal relationship between the glucagon-secreting alpha cell and insulin secreting beta cell is lost, leading to hyperglucagonemia and hence consequent hyperglycemia

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8
Q

Risk Factors of Type 2

A
  • Age greater than 45
  • Weight greater than 120% of desirable body weight
  • Family history of type 2 diabetes in a first degree relative (eg. Parent or sibling)
  • History of previous impaired glucose tolerance or impaired glucose fasting or HbA1C > 5.7
  • Hypertension (>140/90 mmHg) or dyslipidemia
  • History of gestational diabetes Mellitus or delivering a baby with a birth weight greater than 4.5kg
  • PCOS - which results in insulin resistance.
  • Sedentry lifestyle
  • Hypertryglyceridemia
  • Ethnicity
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9
Q

How is Diabetes Diagnosed: Clinical Picture

A

1/3 of cases are asymptomatic
Classic symptoms
* Polyuria
* Polydipsia
* Polyphagia with weight loss
* Prutitis especially of vulva
* Pains and paresthesia
* Premature loosening of teeth
* Blurred vision: due to osmotic swelling of lens

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10
Q

How is Diabetes Diagnosed: Acute Complications

A

Acute
* Diabetic Comas
* Infections
* Complications related to systems
- Acute Kidney Injury
- Acute Myocardial infarction
- Acute neuropathy

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11
Q

How is Diabetes Diagnosed: Chronic Complications

A

Neurological, Ocular (Blurred vision), CVS, Pulmonary, GIT, Renal, Genital, Skin (Diabetic Foot), Rheumatological (Joint pain), Infection, Psychiatric

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12
Q

Differentials of reducing substance in urine -

A

*Glucosuria
- Renal glucosuria due to low renal threshold: Pregnancy, De-Toni Fanconi syndrome

  • Alimentary glucosuria: After gastrectomy ; liver cirrhosis
  • Cerebral glucosuria: Subarachnoid hemorrhage, Meningitis
  • Other sugar in urine: Frucosuria, Galactosuria, Pentosuria
  • Other reducing substances in urine: Vit. C, salicylates
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13
Q

Differentials of symptomatology

A

*Loss of weight in spite of good appetite
- Malabsorption syndrome
- Parasitic infection
- Thyrotoxicosis

*Other causes of polyuria

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14
Q

To diagnose type of DM

A
  1. Plasma insulin levels
    - Low in type 1DM and show early rise in type 2 DM
  2. C-peptide levels
    - Assess endogenous insulin secretion
  3. Auto-antibodies
    - Anti insulin receptor Ab in immune mediated type 1 DM
    - Anti GAD (glutamic acid decarboxylase)
    - Islet Cell Antibodies (ISA)
  4. For the cause
    - If secondary DM is suspected e.g. Cushing’s syndrome
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15
Q

To monitor Diabetic Patients

A
  • Retinopathy - Fundus exam
  • Nephropathy - Urinalysis for microalbuminuria
  • Fatty liver - USG by Gastroenterologist
  • ECG
  • Lipid profile
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16
Q

Tests to monitor Diabetic patients

A

Fasting Blood Sugar
Hb A1c (for monitoring and diagnosis)
- Target in diabetics - <6.5% (Patient is diabetic if more than 6.5)
- it’s percentage gives gives an estimate of diabetic control for the preceding 3 months.
- Normal level 4-6% of total Hb

  • Fructosamine (glycosylated albumin) - Done after 2-3 weeks to monitor pt.
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17
Q

Factors interfering with measurement of A1c

A
  • False high values
    -Uremia from ESKD/CKD
    -High concentrations of fetal Hb
    -High aspirin doses (usually>10g/day)
    -High concentrations of ethanol

*False low values
-Hemoglobinopathies & other hemolytic disorders
-Hemorrhage

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18
Q

Neurological complications of Diabetes - Brain and Diabetic Coma

A

Brain complication
-Cerebral atherosclerosis

*Diabetic Coma
-DKA coma - Type 1
-Hyperglycemia hyperosmolar non-ketotic state (HHNK) - Type 2& older pts
-Hypoglycemic coma
-Lactic acid coma

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19
Q

Neurological complications of Diabetes - Spinal Cord and Nerve

A

Spinal Cord
- Pyramidal tract affection - diabetic lateral sclerosis
- Anterior spinal artery occlusion
-Diabetic pseudotabes

*Nerve
Peripheral neuropathy
Autonomic neuropathy

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20
Q

Acute Complications- Hypoglycemia (<3.5mmol/L)
Definition in diabetics + non-diabetics (whipples triad)

A

In patients with Diabetes
It’s defined as all episodes of an abnormally low plasma glucose concentration (with or without symptoms) that expose the individual to harm, (at a self monitored blood glucose (SMBG)level </= 3.5mmol/l)

In patients without diabetes
Whipple’s triad
- Patient’s symptoms of hypoglycemia
- Documented low patient’s plasma glucose when the symptoms are present. <3.5
- The symptoms can be relieved by administration of glucose.

21
Q

Neurogenic (autonomic) symptoms of hypoglycemia

A

(Warning symptoms) Caused by sympathetic neural response to blood glucose <3.5mmol/l

Sweating
Weakness
Palpitations
Tremors
Nervousness
Hunger
Paresthesias

May not be seen if pt has autonomic neuropathy - may be blighted

22
Q

Neuroglycopenia - symptoms in Hypoglycemia

A

Confusion
Loss of consciousness
Cognitive impairment
Seizure
Focal neurological deficits
Visual disturbances
Death

23
Q

Signs of hypoglycemia

A

Diaphoresis & Pallor
Heart rates and systolic blood pressures are raised

24
Q

Outcome and complications of Hypoglycemia

A

Vast majority of episodes are reversed after the glucose level is raised to normal.
- Prolonged untreated hypoglycemia ca lead to : Transient neurological effects, but permanent neurological damage is rare.
-Death

25
Q

Causes of Hypoglycemia in diabetics

A

Drugs (most common)
A - In Diabetics
- Exogenous insulin and insulin secretagogue - (giblencamide - 2nd gen long acting secretagogue, stimulate pancreas and prod excess insulin) (sulfonylureas)
- Less common causes - insulin sensitizers (metformin taken with sulfonylureas , thiazolidinediones), gluconidase inhibitors, glucagon like peptide 1 (GLP-1) receptor agonists, and dipeptidyl peptidase IV inhibitors

26
Q

Causes of hypoglycemia in patients without Diabetes

A

Drugs
Insulin
Sulfonylureas
Quinolones
Pentamidine
Quinine
Angiotensin converting enzyme inhibitors - increase insulin sensitivity
IGF - 1 (Insulin Like Growth Factor 1)
Alcohol
Salicylates

27
Q

Endocrine causes of hypoglycemia+ endogenous hyperinsulinism

A

Endocrine causes - Hypopituitarism, ACTH deficiency, and Addison’s disease

Endogenous hyperinsulinism
- Beta cell secretagogue- such as sulfonylurea (gibenclamide)
- Insulinoma - can be in pancreas
- Insulin autoimmune hypoglycemia

28
Q

Insulinoma - Another cause of hypoglycemia

A

-Pancreatic islet cell tumour that secrete insulin
- Diagnosed by Whipple’s triad, plus measurement of overnight fasting (16 hours) glucose and insulin levels, C-peptide or pro insulin during a spontaneous episode of hypoglycemia.

29
Q

Tumors - Another cause of Hypoglycemia

A

Mesenchymal tumors, fibromas, carcinoid, myelomas, lymphomas, hepatocellular and colorectal carcinomas.

They lower glucose by:
*Secretion of insulin-like growth factor-2
*Excessive consumption of glucose by the tumour
*True ectopic insulin secretion is extremely rare.

30
Q

Critical Illness leading to Hypoglyemia

A

*Sepsis - Because of cytokine induced inhibition of gluconeogenesis in the setting of glycogen depletion .

*CKD - Impaired gluconeogenesis, reduced renal clearance of insulin,
reduced renal glucose production.

*In fulminant liver failure, Gluconeogenesis is also impaired.

31
Q

Critical Illness leading to Hypoglyemia

A

*Sepsis - Because of cytokine induced inhibition of gluconeogenesis in the setting of glycogen depletion .

*CKD - Impaired gluconeogenesis, reduced renal clearance of insulin,
reduced renal glucose production.

*In fulminant liver failure, Gluconeogenesis is also impaired.

Malnourishment - as a result of substrate limitation of gluconeogenesis and glycogenolysis in the setting of glycogen depletion.

32
Q

Postprandial hypoglycemia (Reactive hypoglycemia)

A

Occurs within four hours after meals after gastric surgery

33
Q

Factitious hypoglycemia

A

Take insulin injections or anti-psychotics.

*Measurement of C-peptide levels during hypoglycaemia should identify patients who are injecting insulin;
*Sulphonylurea abuse can be detected by chromatography of plasma or urine.

34
Q

Special types of Hypoglycemia - Nocturnal hypoglycemia

A

Nocturnal hypoglycemia
Can lead to disruption of sleep and delays in correction of the hypoglycemia.
If high morning sugars preceded by an episode of Nocturnal hypoglycemia (Somogyi effect).

35
Q

Special types of hypoglycemia - Hypoglycemia unawareness

A

occurs in longstanding diabetes, especially type 1. It is an impairment of counter regulatory response to hypoglycemia (epinephrine and glucagon), so many patients will develop neuroglycopenic symptoms, without warnings symptoms of hypoglycemia which is dangerous .

36
Q

Differentials of autonomic symptoms for Hypoglycemia

A
  • Postprandial syndrome
  • Cardiac disease (Arrhythmia, Valvular heart )
  • Medications
  • Psychiatric disease,
  • Hyperthyroidism
  • Pheochromocytoma
37
Q

Approach to management of hypoglycemia - History and examination

A

Clinical evaluation and history including :
Timing of symptoms (particularly in relationship to meals),
Underlying illnesses or conditions
Medications taken by the individual by family members, and Social history.
Clinical examination to explore the cause

38
Q

Laboratory testing for Hypoglycemia

A

Fasting or Postprandial evaluation for :
2. Glucose
3. Insulin
4. C-peptide
5. Beta-hydroxybutyrate6. Proinsulin
7. Sulfonylurea and meglitinide screen

39
Q

Determining the cause of hypoglycemia - insulinoma, endogenous hyperinsulinism and exogenous insulin

A

If plasma insulin, C-peptide, and proinsulin values are elevated - could be an insulinoma or endogenous hyperinsulinism

Plasma insulin values are high, but plasma C-peptide and proinsulin values are low - then caused by Exogenous insulin

40
Q

Determining the cause of hypoglycemia - Non islet cell tumors

A

Plasma insulin, C-peptide, and proinsulin concentrations are not elevated.

41
Q

Localizing studies for hypoglycemia

A

Radiologic studies:
Computed tomography, MRI, and ultrasonography can detect most insulinomas.

42
Q

Hypoglycemia prevention - education and modifying

A

1-Patient education
*Keeping a diary of low blood sugar symptoms
*Regular check of blood sugar
2–Modifying
*Diet (what, when, and how much you eat).
*The dosage or types of medicines.
*The timing and level of physical activity
*Glycemic targets for individual patients - depends on age.

43
Q

Hypoglycemia prevention - awareness and nocturnal hypoglycemia

A

3-Hypoglycemia awareness :
Avoidance of hypoglycemia for several weeks may help to improve it.
4-Nocturnal hypoglycemia
Bedtime snacks
Take the intermediate insulin at bedtime rather than before supper
Reducing the dose of soluble insulin before supper,
changing to a rapid-acting insulin analogue

44
Q

Treatment of acute hypoglycemia - for wwho?

A

Symptomatic diabetic with a low glucose value, <3.5 mmol/l.
Non diabetic with low glucose (3.0mmol/lL) .
Symptomatic hypoglycemia but rapid blood glucose measurement is not available.

45
Q

Rx od Hypoglycemia: f the patient is conscious and able to drink and swallow , administer a rapidly-absorbed oral carbohydrate as:

A

3 teaspoons of sugar (dissolved in water)
1-2 tablespoons of honey
3 or 4 glucose tablets
4-6 small hard candies
200 g regular (not diet) soda (about half a can)
120 g fruit juice

46
Q

Rule of 15”

A

*Fast acting carbohydrates (15g).
*Check blood glucose 10-15 minutes after treatment
*Repeat treatment of 15 grams if blood glucose level remains low and recheck at another 15 minutes

47
Q

Rx of hypoglycemia: If the patient has altered mental status, and is unable to swallow,

A

*give an IV bolus of 12.5 to 25 gm of glucose (25 percent dextrose - 100 mls) (50 ml of 50% - thrombophlebitis, otherwise give saline).
*Measure a blood glucose 10 to 15 minutes after the IV bolus.
*Re-administer 12.5 to 25 grams of glucose as needed to maintain the blood glucose above 5 mmol/l.
*If glucose cannot be given by parenteral or oral routes, give glucagon 1 mg IM or SQ. followed by careful glucose monitoring and oral or intravenous glucose administration - you may repeat after 30 mins.
*Once the patient is able to ingest carbohydrate safely, providing a mixed meal .
Admit patients with ingestion of a long-acting hypoglycemic agent.

48
Q

Treatment of underlying cause - Hypoglycemia

A

*Adjust dose of antidiabetics
*Surgical removal of the insulinoma of the Non islet tumours
*oral glucocorticoids, diazoxide and octreotide, glucagon.
*Replacement therapy for Addison disease - corticosteroids.

Medicine (18 decks)

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