diabetes mellitus

Question 1

what is the difference between type 1 and type 2 diabetes?

Answer 1

type 1 =absolute insulin defiency
type 2 =insulin resistance and relative insulin defiency

Question 2

what is the pathophysiology of t1dm?

Answer 2

autoimmune destruction of beta cells in islets of langerhans leading to absolute insulin deficiency

Question 3

what can trigger t1dm?

Answer 3

viruses eg cocksackie, enterovirus, CMV

Question 4

which autoantibodies are involved in t1dm?

Answer 4

GAD65
islet cell antibodies
insulin antibodies
tyrosine phosphatase (IA2)
zinc transport (znt8)

Question 5

what is the pathophysiology of t2dm?

Answer 5

peripheral insulin resistance strongly linked to obesity and physical inactivity in genetically susceptible individuals

Question 6

what is the genetic element of t2dm?

Answer 6

polygenetic -up to 50 genes influence it -TCF7L2 most powerful

Question 7

what is LADA?

Answer 7

latent autoimmune diabetes in adults
autoantibodies to beta cell antigens, genetic components of t1 and t2. common in scandanavia. variable phenotype -usually not obese or hypertensive

Question 8

what are the causes of secondary diabetes mellitus?

Answer 8

baso pancreas not being able to work properly:
pancreatitis
CF
haemachromatosis (iron deposits in pancreas)
drug induced

Question 9

which drugs can induce secondary diabetes mellitus?

Answer 9

chronic steroid use
calcineurin inhibitors (immunosuppressants-cyclosporin, tacrolimus)
statins
major anti-psychotic agents
HAART ( 3 or more antiretrovirals at once)

Question 10

what is MODY and its cause?

Answer 10

maturity onset diabetes of the young
monogenic -mostly autosomal dominant but can be autosomal recessive

Question 11

what happens in mitochondrial diabetes mellitus?

Answer 11

maternal inheritance
also comes with deafness and cardio/neural problems

Question 12

what are the risk factors for t1dm?

Answer 12

FH
HLA-DR3 and HLA-DR4 genes -you need 3 or 4 doctors to understand diabetes
breastfeeding is protective

Question 13

what are the risk factors for t2dm?

Answer 13

FH (2.4x)
classics -sedentary, obesity, ethnicity, low fibre high glycaemic index, metabolic syndrome)
hx of gestational diabetes
PCOS
genetic conditions -down’s, klinefelter’s, turner’s

Question 14

what are the clinical features of diabetes mellitus?

Answer 14

polyuria
polydipsia
lethargy
DKA at presentation
weight loss (t1)
recurrent infections
recurrent thrush

Question 15

what are the diagnostic criteria for diabetes mellitus?

Answer 15

2 abnormal test in asx or 1 with sx:
-fasting BM 7+
-random BM 11.1+
-OGTT 11.1+ 2h after
-Hba1c 48+

Question 16

what is the Hba1c values for pre diabetes?

Answer 16

42-47

Question 17

what is the OGTT levels for impaired glucose tolerance?

Answer 17

2xOGTT 7.8-11.0

Question 18

what is the fasting glucose levels of impaired glucose tolerance?

Answer 18

> 6.0, <7

Question 19

which bloods do you need with a new diagnosis of t1dm?

Answer 19

FBC
U+E
lab glucose
Hba1c
TFTs and anti-TPO -checking for associated autoimmune thyroid disease
anti-TTG -check for coeliac
insulin antibodies, anti-GAD antibodies, islet cell antibodies -check pathology of diabetes itself

Question 20

which non pharmacological treatments are needed for t1dm?

Answer 20

education and information
healthy balanced diet
30 min exercise 5x a week

Question 21

what is the main drug treatment for t1dm?

Answer 21

insulin. MDI (multiple daily injection) basal bolus is the regimen of choice.

Question 22

2 examples of fast acting insulin?

Answer 22

actrapid
insulin aspart

Question 23

example of intermediate acting insulin?

Answer 23

humulin 1

Question 24

1 example of long acting insulin?

Answer 24

glargine

Question 25

2 examples of mixed insulin?

Answer 25

novomix 30% (30% short acting) humalog 20%

Question 26

what is the secondline treatment for t1dm after MDI basal bolus?

Answer 26

continuous SC insulin infusion (insulin pump) can be tethered or patch

Question 27

when do you start antihypertensive treatment for people with type 1 DM?

Answer 27

if BP >135/85

Question 28

when do you start a statin for people with t1dm?

Answer 28

if >40, diabetes for >10y, established nephropathy, or any other CVD RFs

Question 29

what is the target hba1c for people with t1dm?

Answer 29

48

Question 30

what additional contacts do children with t1dm need?

Answer 30

clinic 4x a year regular dental examination eye exam at least every 2y annual flu vaccine from 6m old pneumococcal vaccine

Question 31

what is the dietary advice for t1 and t2dm?

Answer 31

t1 -healthy balanced diet and carb counting, don't need to eat low glycaemic index t2- high fibre, low glycaemic index, low sat fats

Question 32

what is the plan for weight loss in t2dm?

Answer 32

step 1- low calorie weight loss -600-800kcal/day step 2-stepwise return to normal eating -1500kcal/day step 3 -long term support to limit calorie intake and encourage physical activity

Question 33

what are the exercise suggestions for people with t2dm?

Answer 33

150min moderate /75 min vigorous exercise a week

Question 34

what is the target BP for people with t2dm?

Answer 34

<140/90 if <80 and <150/90 if 80+

Question 35

what are the hba1c targets for people with t2dm?

Answer 35

managed by lifestyle only or lifestyle and metformin-48 on any drug that can cause hypoglycaemia -53 if HbA1c has risen to 58+ -53 initial target

Question 36

how often should hba1c be checked in someone with t2dm?

Answer 36

6 monthly

Question 37

how does the stepwise treatment of t2dm work?

Answer 37

after adding each drug, check hba1c 3-6 months after and go up a step if they aren't meeting their target.

Question 38

what is the firstline drug treatment for t2dm?

Answer 38

metformin

Question 39

what is the moa of metformin?

Answer 39

increases insulin sensitivity, decreases glucose production in liver, decreases glucose production in gut

Question 40

what is a contraindication of metformin?

Answer 40

egfr<30

Question 41

what are the main side effects of metformin?

Answer 41

GI upset. rare one =lactic acidosis

Question 42

what is the 2nd line drug treatment for t2dm?

Answer 42

metformin + either gliptin, sulfonylurea, SGLT2, or pioglitazone.

Question 43

what are gliptins and examples?

Answer 43

DDP4 inhibitors eg alogliptin, sitagliptin

Question 44

what is an uncommon possible adverse effect of glitpins?

Answer 44

acute pancreatitis

Question 45

what are 2 examples of sulfonylureas?

Answer 45

gliclazide tolbutamide

Question 46

what are 2 bad side effects and a benefit of sulfonylureas?

Answer 46

cause weight gain can cause hypos highly effective

Question 47

what drug class is pioglitazone?

Answer 47

thiazolidinedones

Question 48

what are some disadvantages of pioglitazone?

Answer 48

causes fluid retention which can lead to heart failure causes weight gain increased risk of fractures and bladder cancer

Question 49

what are some examples of SGLT2 inhibitors?

Answer 49

empagliflozin, dapagliflozin

Question 50

how do SGLT2s work?

Answer 50

basically work in your kidney to make you pee out glucose -doesn't effect insulin

Question 51

what are the advantages and disadvantages of SGLT2s?

Answer 51

CV risk reduction, help with heart failure, low risk of hypos, cause weight loss -ve: can cause DKA and genital thrush is common

Question 52

what is the thirdline drug treatment for t2dm?

Answer 52

triple therapy: metformin +SGLT2/pioglitazone/sulfonylurea/glitpin+another one or start insulin based treatment

Question 53

what is the 4thline drug treatment for t2dm?

Answer 53

refer to diabetes specialist team

Question 54

when do you need to inform the dvla with DM?

Answer 54

more than 1 episode of severe hypoglycaemia requiring assistance from another person within last 12 months if you're on insulin you need to tell them -but can still drive as long as regular glucose monitoring and aware of hypo signs.

Question 55

what is gastroparesis?

Answer 55

also called delayed gastric emptying, is a medical disorder consisting of weak muscular contractions of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period of time

Question 56

why does diabetes cause complications?

Answer 56

chronic hyperglycaemia damages endothelial cells of blood vessels, causing microvascular and macrovascular complications.

Question 57

what are the microvascular complications of DM and how to monitor?

Answer 57

nephropathy -patients w t2dm should be put on ACEi/ARB if no contraindications retinopathy -should get retinal exam as part of nhs screening programme peripheral neuropathy -poor healing, ulcers. should get diabetic foot checks autonomic and peripheral neuropathy -eg gastroparesis, erectile dysfunction coeliac -screen for anti-TTG antibodies

Question 58

what are the macrovascular complications of DM?

Answer 58

CVD cerebrovascular disease peripheral arterial disease

Question 59

high metformin dose can lower the levels of which vitamin?

Answer 59

b12