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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
What are the s/e of Biguanides?
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
What are the contraindications to Biguanide therapy?
``` 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
How do Sulphonylureas (Tolbutamide) work?
Increase insulin secretion
28
What are the three common Sulphonylureas, and what is the main difference b/w them?
Tolbutamide - short acting Gliclazide - medium acting Glibenclamide - long acting
29
What are the contraindications to Sulphonylurea therapy?
Elderly (hypos) | Obese (wt gain)
30
What are the s/e of Sulphonylureas?
GI disturbances | Liver dysfunction
31
How do Thiazolidinediones (Pioglitazone) work?
PPAR-Y activators | Increase peripheral insulin sensitivity
32
What are the s/e of Thiazolidinediones?
``` Wt gain (redistribution of ectopically stored lipid) Fluid retention (contraindicated in CCF) Liver dysfunction Bladder cancer ```
33
How do Gliptins (Sitaglitpin) work?
DPP-4 inhibitors | Increase post-prandial release
34
What are the contraindications to Gliptin therapy?
Cardiac/hepatic/renal dysfunction
35
What are the s/e of Gliptins?
``` GI disturbances Acute pancreatitis (rare) ```
36
How are GLP-1 memetics (Enaxatide) used?
Replace Gliptin/Pioglitazone if triple therapy ineffective
37
What are the indications for the use of GLP-1 memetics?
Triple therapy ineffective AND: - BMI >35 OR - BMI <35 AND wt loss would be beneficial, insulin therapy would have -ve impact on occupation
38
What are the s/e of GLP-1 memetics?
``` GI disturbances Acute pancreatitis (rare) ```
39
What are the indications for Insulin therapy?
All pts w/ T1DM <40yrs | All pts w/ T2DM that fail to respond to/are unsuitable for medical treatment
40
What are the three main types of Insulin? (source)
Human Human analogue Animal (rarely used)
41
What are the three main types of Insulin? (release)
Short acting Intermediate acting Long acting (biphasic)
42
Describe short acting Insulin
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
Describe intermediate acting Insulin
Mimic basal insulin secretion | Humulin - Onset 1-2hrs, duration 16-35hrs. Max effect 4-12hrs
44
Describe long acting Insulin
Mimic basal insulin secretion | Lantus - Used 1/2x per day, achieve SSL after 2-4 days
45
Describe biphasic Insulin
Mixed preparations of SA & LA
46
What Insulin regime is recommended for T1DM?
Basal bolus -2x daily LA (Detemir) -RA w/ each meal (Novorapid) Otherwise 2x daily mixed insulin regimes
47
When should Insulin pumps be considered?
Pt cannot achieve HbA1c <69.4mmol/mol | Specialist decision
48
What Insulin regime is recommended for T2DM?
Continue Metformin (prevent wt gain) 1/2x daily IA Biphasic preparations if HbA1c v. high
49
What are the complications of Insulin therapy?
General - Wt gain, insulin resistance | Local - Pain, redness, abscesses, lipohypertrophy
50
What self-monitoring are pts required to do when on Insulin?
4x finger prick BM on 2/7 each week
51
What are the optimal targets for self-monitoring when on Insulin?
Fasting plasma glucose 5-7mmol/L on waking Plasma glucose 4-7mmol/L before meals Plasma glucose 5-9mmol/L 90mins after eating
52
What are the Sick Day Rules?
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
When are pts required to notify the DVLA?
2 episodes of severe hypo w/i last 12mo Reduced awareness of hypos On insulin therapy
54
What are the essential components of the annual diabetic review?
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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