Diabetes Mellitus Flashcards
What are the WHO criteria for a diagnosis of Diabetes Mellitus?
Symptoms of hypergylcaemia AND raised venous glucose/HbA1c (1x) OR
Raised venous glucose (2x) OR
Markedly raised HbA1c
What are the symptoms of hyperglycaemia?
Polyuria Polydipsia Unexplained weight loss Visual blurring Genital thrush Lethargy
What glucose levels are used as the cutoff for diagnosis?
Fasting >7mmol/L
Random/OGTT >11.1mmol/L
HbA1c >48mmol/mol (6.5%) if sy,[tp,atoc
What is impaired glucose tolerance?
Fasting glucose <7mmol/L AND OGTT >7.8mmol/L but less than 11.1mmol/L
Abnormality of post prandial glucose regulation
What is impaired fasting glucose?
Fasting glucose >6.1mmol/L but <7mmol/L
Abnormality of fasting glucose regulation
What is DM?
Multisystem disease resulting from inadequate action of Insulin
What causes T1DM?
Insulin deficiency from autoimmune destruction of pancreatic B-cells
Triggered by viral infection
What causes T2DM?
Decreased insulin secretion w/ insulin resistance
How does T1DM present?
USUALLY adolescent onset (can have LADA) 2-6wk Hx of: -Polyuria (osmotic diuresis) -Polydipsia -Wt loss -DKA
How does T2DM present?
> 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.)
What are the secondary causes of DM?
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
What are the key components of the DM management plan?
Group education on dx Screen for complications (at dx & annually) -fundoscopy -nephropathy -foot check Monitor CV risk (BP <140/80 OR <130/80 if complications) Assess QRisk2 score Lifestyle modifications Medications Insulin
How does the QRisk 2 score affect management?
If >10% risk over 10yrs offer Atorvastatin 20mg
What lifestyle advice should be given for T2DM?
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
What are the target Hba1c measurements for T2DM?
<48mmol/mol initially
<52mmol/mol if on Insulin/taking hypo causing meds
When should drug treatment be started in T2DM?
HbA1c >58mmol/mol
What is the 1st line medication in T2DM?
Biguanide (Metformin)
In which groups is the use of HbA1c for diagnosis inappropriate?
<18yrs Acutely unwell Pts taking medication that can raise blood glucose End stage CKD pts HIV pts
How should Metformin be titrated up?
500mg w/ breakfast for 1wk
500mg w/ breakfast & dinner for 1wk
500mg w/ all 3 meals
What medications can be considered in T2DM if Metformin is contraindicated/not tolerated?
Gliptin (DDP-4 inhib. sitagliptin)
Thiazolidinedione (PPAR-Y activator, pioglitazone)
Sulphonylurea (glibenclamide)
What is 2nd line therapy in T2DM?
Metformin + 2nd drug OR
Any 2 of gliptin, thiazolidinedione, sulphonylurea
What is 3rd line therapy in T2DM??
Triple therapy (Metformin + Sulphonylurea + Gliptin/Pioglitazone) OR Insulin regimes (if metformin contraindicated)
What blood glucose monitoring is available?
Self-monitoring kits
Continuous monitors
Not routinely advised in T2DM
How do Biguanides (Metformin) work?
Decrease hepatic glucose production
Increase peripheral insulin sensitivity
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)
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
How do Sulphonylureas (Tolbutamide) work?
Increase insulin secretion
What are the three common Sulphonylureas, and what is the main difference b/w them?
Tolbutamide - short acting
Gliclazide - medium acting
Glibenclamide - long acting
What are the contraindications to Sulphonylurea therapy?
Elderly (hypos)
Obse (wt gain)
What are the s/e of Sulphonylureas?
GI disturbances
Liver dysfunction
How do Thiazolidinediones (Pioglitazone) work?
PPAR-Y activators
Increase peripheral insulin sensitivity
What are the s/e of Thiazolidinediones?
Wt gain (redistribution of ectopically stored lipid) Fluid retention (contraindicated in CCF) Liver dysfunction Bladder cancer
How do Gliptins (Sitaglitpin) work?
DPP-4 inhibitors
Increase post-prandial release
What are the contraindications to Gliptin therapy?
Cardiac/hepatic/renal dysfunction
What are the s/e of Gliptins?
GI disturbances Acute pancreatitis (rare)
How are GLP-1 memetics (Enaxatide) used?
Replace Gliptin/Pioglitazone if triple therapy ineffective
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
What are the s/e of GLP-1 memetics?
GI disturbances Acute pancreatitis (rare)
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
What are the three main types of Insulin? (source)
Human
Human analogue
Animal (rarely used)
What are the three main types of Insulin? (release)
Short acting
Intermediate acting
Long acting
(biphasic)
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
Describe intermediate acting Insulin
Mimic basal insulin secretion
Humulin - Onset 1-2hrs, duration 16-35hrs. Max effect 4-12hrs
Describe long acting Insulin
Mimic basal insulin secretion
Lantus - Used 1/2x per day, achieve SSL after 2-4 days
Describe biphasic Insulin
Mixed preparations of SA & LA
What Insulin regime is recommended for T1DM?
Basal bolus
-2x daily LA (Detemir)
-RA w/ each meal (Novorapid)
Otherwise 2x daily mixed insulin regimes
When should Insulin pumps be considered?
Pt cannot achieve HbA1c <69.4mmol/mol
Specialist decision
What Insulin regime is recommended for T2DM?
Continue Metformin (prevent wt gain)
1/2x daily IA
Biphasic preparations if HbA1c v. high
What are the complications of Insulin therapy?
General - Wt gain, insulin resistance
Local - Pain, redness, abscesses, lipohypertrophy
What self-monitoring are pts required to do when on Insulin?
4x finger prick BM on 2/7 each week
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
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
When are pts required to notify the DVLA?
2 episodes of severe hypo w/i last 12mo
Reduced awareness of hypos
On insulin therapy
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?
