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CP3 @ UoN - Medicine & Surgery > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

What are the WHO criteria for a diagnosis of Diabetes Mellitus?

A

Symptoms of hypergylcaemia AND raised venous glucose/HbA1c (1x) OR
Raised venous glucose (2x) OR
Markedly raised HbA1c

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2
Q

What are the symptoms of hyperglycaemia?

A 
Polyuria
Polydipsia
Unexplained weight loss
Visual blurring
Genital thrush
Lethargy
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3
Q

What glucose levels are used as the cutoff for diagnosis?

A

Fasting >7mmol/L
Random/OGTT >11.1mmol/L
HbA1c >48mmol/mol (6.5%) if symptomatic

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4
Q

What is impaired glucose tolerance?

A

Fasting glucose <7mmol/L AND OGTT >7.8mmol/L but less than 11.1mmol/L
Abnormality of post prandial glucose regulation

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5
Q

What is impaired fasting glucose?

A

Fasting glucose >6.1mmol/L but <7mmol/L

Abnormality of fasting glucose regulation

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6
Q

What is DM?

A

Multisystem disease resulting from inadequate action of Insulin

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7
Q

What causes T1DM?

A

Insulin deficiency from autoimmune destruction of pancreatic B-cells
Triggered by viral infection

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8
Q

What causes T2DM?

A

Decreased insulin secretion w/ insulin resistance

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9
Q

How does T1DM present?

A 
USUALLY adolescent onset (can have LADA)
2-6wk Hx of:
-Polyuria (osmotic diuresis)
-Polydipsia
-Wt loss
-DKA
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10
Q

How does T2DM present?

A

> 40yrs, long clinical onset
Lack of energy, visual blurring, pruritis vulvae/balanitis
Obesity, lack of exercise, alcohol/calorie excess
Asymptomatic on presentation
Can present w/ complications (retinopathy, neuropathy etc.)

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11
Q

What are the secondary causes of DM?

A

Iatrogenic - steroids, anti-HIV drugs, antipsychotics, thiazides
Pancreatic - pancreatitis, surgery, trauma, pancreatic destruction/cancer
Endocrine - cushing’s, acromegaly, phaeochromocytoma, hyperthyroidism, pregnancy
Others - cogenital lipodystrophy, glycogen storage diseases

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12
Q

What are the key components of the DM management plan?

A 
Group education on dx
Screen for complications (at dx &amp; annually)
-fundoscopy
-nephropathy
-foot check
Monitor CV risk (BP <140/80 OR <130/80 if complications)
Assess QRisk2 score
Lifestyle modifications
Medications
Insulin
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13
Q

How does the QRisk 2 score affect management?

A

If >10% risk over 10yrs offer Atorvastatin 20mg

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14
Q

What lifestyle advice should be given for T2DM?

A

Diet - High in low GI, limit sugars/sat fats etc.
Wt loss - If overweight lose 5-10% of body weight
Exercise - 20-30mins/day
Stop smoking
Limit alcohol, have carb snack before/after

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15
Q

What are the target Hba1c measurements for T2DM?

A

<48mmol/mol (6.5%) initially

<52mmol/mol (7%) if on Insulin/taking hypo causing meds

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16
Q

When should drug treatment be started in T2DM?

A

HbA1c >58mmol/mol

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17
Q

What is the 1st line medication in T2DM?

A

Biguanide (Metformin)

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18
Q

In which groups is the use of HbA1c for diagnosis inappropriate?

A 
<18yrs
Acutely unwell
Pts taking medication that can raise blood glucose
End stage CKD pts
HIV pts
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19
Q

How should Metformin be titrated up?

A

500mg w/ breakfast for 1wk
500mg w/ breakfast & dinner for 1wk
500mg w/ all 3 meals

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20
Q

What medications can be considered in T2DM if Metformin is contraindicated/not tolerated?

A

Gliptin (DDP-4 inhib. sitagliptin)
Thiazolidinedione (PPAR-Y activator, pioglitazone)
Sulphonylurea (glibenclamide)

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21
Q

What is 2nd line therapy in T2DM?

A

Metformin + 2nd drug OR

Any 2 of gliptin, thiazolidinedione, sulphonylurea

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22
Q

What is 3rd line therapy in T2DM??

A 
Triple therapy (Metformin + Sulphonylurea + Gliptin/Pioglitazone) OR
Insulin regimes (if metformin contraindicated)
23
Q

What blood glucose monitoring is available?

A

Self-monitoring kits
Continuous monitors
Not routinely advised in T2DM

24
Q

How do Biguanides (Metformin) work?

A

Decrease hepatic glucose production

Increase peripheral insulin sensitivity

25
Q

What are the s/e of Biguanides?

A

GI - N/V, abdo pain, loss of appetite
Lactic Acidosis - insidious onset, common if combined w/ alcohol
Vit B12 deficiency
Hypo (if not monotherapy)

26
Q

What are the contraindications to Biguanide therapy?

A 
eGFR <30ml/min/1.73m2 (standard release)
eGFR <40ml/min/1.73m2 (modified release)
Alcohol addiction
Pts at risk of lactic acidosis
Pts at risk of tissue hypoxia
27
Q

How do Sulphonylureas (Tolbutamide) work?

A

Increase insulin secretion

28
Q

What are the three common Sulphonylureas, and what is the main difference b/w them?

A

Tolbutamide - short acting
Gliclazide - medium acting
Glibenclamide - long acting

29
Q

What are the contraindications to Sulphonylurea therapy?

A

Elderly (hypos)

Obese (wt gain)

30
Q

What are the s/e of Sulphonylureas?

A

GI disturbances

Liver dysfunction

31
Q

How do Thiazolidinediones (Pioglitazone) work?

A

PPAR-Y activators

Increase peripheral insulin sensitivity

32
Q

What are the s/e of Thiazolidinediones?

A 
Wt gain (redistribution of ectopically stored lipid)
Fluid retention (contraindicated in CCF)
Liver dysfunction
Bladder cancer
33
Q

How do Gliptins (Sitaglitpin) work?

A

DPP-4 inhibitors

Increase post-prandial release

34
Q

What are the contraindications to Gliptin therapy?

A

Cardiac/hepatic/renal dysfunction

35
Q

What are the s/e of Gliptins?

A 
GI disturbances
Acute pancreatitis (rare)
36
Q

How are GLP-1 memetics (Enaxatide) used?

A

Replace Gliptin/Pioglitazone if triple therapy ineffective

37
Q

What are the indications for the use of GLP-1 memetics?

A

Triple therapy ineffective AND:

  • BMI >35 OR
  • BMI <35 AND wt loss would be beneficial, insulin therapy would have -ve impact on occupation
38
Q

What are the s/e of GLP-1 memetics?

A 
GI disturbances
Acute pancreatitis (rare)
39
Q

What are the indications for Insulin therapy?

A

All pts w/ T1DM <40yrs

All pts w/ T2DM that fail to respond to/are unsuitable for medical treatment

40
Q

What are the three main types of Insulin? (source)

A

Human
Human analogue
Animal (rarely used)

41
Q

What are the three main types of Insulin? (release)

A

Short acting
Intermediate acting
Long acting
(biphasic)

42
Q

Describe short acting Insulin

A

Mimic body’s insulin secretion in response to food
Rapid acting (Humalog) - Inject w/ food, onset 15mins, duration 2-5hrs
Soluble (Actrapid) - Inject 30mins before food, onset 30-60mins, duration 8hrs

43
Q

Describe intermediate acting Insulin

A

Mimic basal insulin secretion

Humulin - Onset 1-2hrs, duration 16-35hrs. Max effect 4-12hrs

44
Q

Describe long acting Insulin

A

Mimic basal insulin secretion

Lantus - Used 1/2x per day, achieve SSL after 2-4 days

45
Q

Describe biphasic Insulin

A

Mixed preparations of SA & LA

46
Q

What Insulin regime is recommended for T1DM?

A

Basal bolus
-2x daily LA (Detemir)
-RA w/ each meal (Novorapid)
Otherwise 2x daily mixed insulin regimes

47
Q

When should Insulin pumps be considered?

A

Pt cannot achieve HbA1c <69.4mmol/mol

Specialist decision

48
Q

What Insulin regime is recommended for T2DM?

A

Continue Metformin (prevent wt gain)
1/2x daily IA
Biphasic preparations if HbA1c v. high

49
Q

What are the complications of Insulin therapy?

A

General - Wt gain, insulin resistance

Local - Pain, redness, abscesses, lipohypertrophy

50
Q

What self-monitoring are pts required to do when on Insulin?

A

4x finger prick BM on 2/7 each week

51
Q

What are the optimal targets for self-monitoring when on Insulin?

A

Fasting plasma glucose 5-7mmol/L on waking
Plasma glucose 4-7mmol/L before meals
Plasma glucose 5-9mmol/L 90mins after eating

52
Q

What are the Sick Day Rules?

A

Rules to help pts deal w/ intercurrent illness

  • Do not stop insulin therapy
  • Monitor BM 3-4hrly, including overnight
  • Monitor blood/urine ketones
  • Maintain normal meal pattern
  • Drink >3L/day
53
Q

When are pts required to notify the DVLA?

A

2 episodes of severe hypo w/i last 12mo
Reduced awareness of hypos
On insulin therapy

54
Q

What are the essential components of the annual diabetic review?

A

Cardiovascular risk - BMI, BP, smoking, lipids, ECG
Microvascular - ED, neuropathic pain, foot exam, fundoscopy, urine dip
Diabetic control - HbA1c
Diet/lifestyle?
Adverse events?
Driving?
Depression/Anxiety?

CP3 @ UoN - Medicine & Surgery (135 decks)

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