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Year 3: Medicine Block ENDOCRINOLOGY > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

What are symptoms of Type 2 Diabetes Mellitus ?

A
  • Polydipsia
  • Polyuria
  • Often picked up incidentally on routine blood tests
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2
Q

What does HbA1c levels depend on?

A
  • Red Blood cell lifespan
  • Average blood glucose concentration
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3
Q

Which pathologies present with lower than expected HbA1c?

A
  • Sickle Cell Anaemia
  • Hereditary spherocytosis
  • GP6D deficiency
  • Haemolytic anaemia
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4
Q

Which pathologies present with higher than expected HbA1c?

A
  • Untreated iron deficiency anaemia
  • Vitamin B12/folic acid deficiency
  • Splenectomy
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5
Q

What are Iatrogenic/Physiological causes of altered HbA1c on test results?

A
  • Suspected gestational diabetes
  • Children
  • HIV
  • Chronic kidney disease
  • People taking medication that may cause hyperglycaemia (for example corticosteroids)
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6
Q

How is a diagnosis of Type 2 Diabetes mellitus made based on plasma glucose?

A

If the patient is symptomatic:

  • fasting glucose greater than or equal to 7.0 mmol/l
  • random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

If the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions.

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7
Q

How is Glycaemic Control monitored based on HbA1c?

A
  • Normal Glycaemic control <=41 mmol/mol (6.0 mmol/l)
  • HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus
    • HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes. It should be remembered that misleading HbA1c results can be caused by increased red cell turnover (see below)
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8
Q

What is Imapired gasting glucose and impaired glucose tolerance?

A

Impaired Fasting Glucose

  • A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)
  • ‘People with IFG should then be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn’t have diabetes but does have IGT.

Impaired glucose tolerance

  • Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
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9
Q

What is the dietary advice given to Type 2 diabetics?

A
  • Encourage high fibre, low glycaemic index sources of carbohydrates. Includes low-fat dairy products and oily fish
  • Control intake of food containing saturated fats and trans fatty acids
  • Target wright loss of 5-10% in overweight people initially
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10
Q

What are HbA1c targets used in the treatment of Type 2 Diabetes Mellitus?

A

Targets are dependant on treatments:

  • Lifestyle: 48 mmol/mol (6.5%)
  • Lifestyle + Metformin: 48 mmol/mol (6.5%)
  • Includes any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea): 53 mmol/mol (7.0%)
  • Already on one drug, but HbA1c has risen to 58 mmol/mol (7.5%): 53 mmol/mol (7.0%)

Checked every 3-6 months until stable then 6 monthly. Consider relaxing on case by case basis

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11
Q

What is the drug treatment pathway for patients that tolerte Metformin?

A
  • Metformin is still first-line and should be offered if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions
  • If the HbA1c has risen to 58 mmol/mol (7.5%) then a second drug should be added from the following list:
    • Sulfonylurea, Gliptin, Pioglitazone, SGLT-2 inhibitor
  • If despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then triple therapy with one of the following combinations should be offered:
    • metformin + gliptin + sulfonylurea
    • metformin + pioglitazone + sulfonylurea
    • metformin + sulfonylurea + SGLT-2 inhibitor
    • metformin + pioglitazone + SGLT-2 inhibitor
    • OR insulin therapy should be considered
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12
Q

What is the drug treatment pathway for patients that cannot tolerte Metformin?

A
  • If the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions, consider one of the following:
    • Sulfonylurea/Gliptin/Pioglitazone
  • If the HbA1c has risen to 58 mmol/mol (7.5%) then a one of the following combinations should be used:
    • Gliptin + pioglitazone
    • Gliptin + sulfonylurea
    • Pioglitazone + sulfonylurea
  • If despite this the HbA1c rises to, or remains above 58 mmol/mol (7.5%) then consider insulin therapy
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13
Q

How is Insulin started in Type 2 Diabetes Mellitus?

A
  • Metformin should be continued. Other drugs need reviewing
  • Start with human NPH insulin (isophane, intermediate acting) taken at bed-time or twice daily according to need
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14
Q

Which risk factors have to modified in the tretment of Type 2 diabetes?

A
  • Blood pressure
    • target is < 140/80 mmHg (or < 130/80 mmHg if end-organ damage is present)
    • ACE inhibitors are first-line
  • Lipids
    • PRMARY PREVENTION: Only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg on
      • If non hdl has not fallen by >= 40% then tritrate up to 80mg
    • SECONDARY PREVENTION: 80mg od
      • Known IHD, CVD, PAD
  • Antiplatelets
    • Should not be offered unless a patient has existing cardiovascular disease
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15
Q

What is the pathophysiology of Type 1 Diabetes Mellitus?

A
  • Autoimmune disorder where the insulin-producing beta cells of the islets of Langerhans in the pancreas are destroyed by the immune system
  • This results in an absolute deficiency of insulin resulting in raised glucose levels
  • Patients tend to develop T1DM in childhood/early adult life and typically present unwell, possibly in diabetic ketoacidosis
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16
Q

What are symptoms of Type 1 Diabetes Mellitus?

A
  • Polydipsia
  • Weight Loss
  • Polyuria
  • Ketosis
17
Q

What is the history of a patient with Type 1 Diabetes Mellitus?

A
  • Age of onset below 50 years
  • BMI below 25kg/m2
  • Personal and/or family history of autoimmune disease
18
Q

What are investigaitons for Type 1 Diabetes Mellitus?

A

Done if there is doubt in clinical diagnosis as diagnosed clinically usually

  • C-peptide: released with insulin
  • Diabetes specific autoantibody titres
19
Q

How does monitoring of HbA1c occur in the management of Type 1 Diabetes Mellitus?

A
  • Should be monitored every 3-6 months
  • Adults should have a target of HbA1c level of 48 mmol/mol (6.5%) or lower.
  • Prevention of Ketosis
  • Take into account factors such as the person’s daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia
20
Q

How should patients with Type 1 Diabetes monitor themselves?

A
  • Recommend testing at least 4 times a day, including before each meal and before bed
  • More frequent monitoring is recommended
    • If frequency of hypoglycaemic episodes increases
    • During periods of illness
    • Before, during and after sport
    • When planning pregnancy
    • During pregnancy and while breastfeeding
21
Q

What are blood glucose targets to aim for in the day to day of a patient with Type 1 Diabetes?

A
  • 5-7 mmol/litre on waking
  • 4-7 mmol/litre before meals at other times of the day
  • Aim to target plasma glucose level of 5-8 mmol/litre with type 1 diabetes during surgery or acute illness
22
Q

What are features of MODY?

A
  • Typically develops in patients < 25 years
  • Family history of early onset diabetes is often present
    • typically inherited as an autosomal dominant condition
  • Ketosis is not a feature at presentation
  • Patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary
23
Q

What are key messages that should be given to all patient with diabetes if they become unwell?

A
  • Important to rotate injection site to prevent lipodystrophy
  • Increase frequency of blood glucose monitoring to four hourly or more frequently
  • Encourage fluid intake aiming for at least 3 litres in 24hrs
  • If unable to take struggling to eat may need sugary drinks to maintain carbohydrate intake
  • Box of ‘sick day supplies’ that they can access if they become unwell
24
Q

What is advise given to patients on oral hypoglycaemic medication when they are sick?

A
  • Continue taking their medication even if they are not eating much.
  • Stress response to illness increases cortisol levels pushing blood sugars high even without much oral intake.
  • Possible exception is with metformin, which should be stopped if a patient is becoming dehydrated because of the potential impact upon renal function.
25
Q

What is the advise given to patient who are on insulin when they are sick?

A
  • They must not stop it due to the risk of diabetic ketoacidosis.
  • They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently.
  • Patients should be able to check their ketone levels and if these are raised and blood sugars are also raised they may need to give corrective doses of insulin. The corrective dose to be given varies by patient, but a rule of thumb would be total daily insulin dose divided by 6 (maximum 15 units)
26
Q

What are possible indications that a patient might require admission to hospital?

A
  • They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently.
  • Suspicion of underlying illness requiring hospital treatment eg myocardial infarction
  • Inability to keep fluids down - admit if persisting more than a few hours
  • Persistent diarrhoea
  • Significant ketosis in an insulin dependent diabetic despite additional insulin
  • Blood glucose persistently >20mmol/l despite additional insulin
  • Patient unable to manage adjustments to usual diabetes management
  • Lack of support at home e.g. a patient who lives alone and is at risk of becoming unconscious

Year 3: Medicine Block ENDOCRINOLOGY (9 decks)

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