Diabetes Mellitus Flashcards
1
Q
Definition of DM
A
A group of metabolic diseases of multiple aetiologies characterised by hyperglycaemia together with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both
2
Q
Types of DM
A
Type I Type II Recognised genetic syndromes; MODY Gestational diabetes Secondary diabetes
3
Q
What is the only hormone that lowers [BG]?
A
Insulin
4
Q
What hormone dominates the absorptive state?
A
Insulin
5
Q
Risk to get T1DM if monozygotic twins
A
30-50% concordance
6
Q
Risk to get T1DM if both parents have it
A
30%
7
Q
Risk to get T1DM with father having T1DM
A
6%
8
Q
Risk to get T1DM if mother has it
A
1%
9
Q
Risk to get T1DM if sibling has it
A
8%
10
Q
Effect of insulin on adipose tissue
A
Reduced lipolysis
11
Q
Effect of insulin on liver
A
Reduced glucose production
12
Q
Effect of insulin on muscle
A
Increased glucose uptake
13
Q
Risk of T2DM in identical twin
A
90-100%
14
Q
Risk of T2DM if one parent has it
A
15%
15
Q
Risk of T2DM if both parents have it
A
75%
16
Q
Risk of T2DM if sibling has it
A
10%
17
Q
Risk of T2DM if non identical twin
A
10%
18
Q
Inheritance of MODY
A
Autosomal dominant
19
Q
What does MODY stand for?
A
Maturity onset diabetes in the young
20
Q
Pathology of MODY
A
single gene defect
impaired Beta-cell function
21
Q
Two types of mutations of MODY
A
Glucokinase mutations
Transcription factor mutations
22
Q
When is the onset of diabetes in MODY glucokinase mutations patients?
A
Birth
23
Q
Status of hyperglycaemia in MODY glucokinase mutation patients
A
Stable
24
Q
Treatment of MODY glucokinase mutations patients
A
Diet
25
How common are complications in MODY glucokinase mutations patients?
Rare
26
Examples of MODY transcription factor mutations
HNF-1a
HNF-1B
HNF-4a
27
Age of onset of MODY transcription factor mutations
Adolescence/young adult onset
28
State of hyperglycaemia in MODY transcription factor mutations patients
Progressive
29
Treatment of MODY transcription factor mutations patients
1/3 diet
1/3 OHA
1/3 insulin
30
How common are complications in patients with MODY transcription factor mutations?
Frequent
31
Causes of secondary DM
```
drug therapy e.g. corticosteriods
pancreatic destruction
- CF
- haemachromatosis
- Chronic pancreatitis
- Pancreatectomy
Recognised genetic syndromes - DIDMOAD
Cushings
Acromegaly
Phenochromocytoma
```
32
What can gestational diabetes be associated with?
FH of type II diabetes
33
What does having gestational diabetes leave you with an increased risk of developing later in life?
Type II diabetes
34
What trimester does gestational diabetes develop in?
2nd/3rd trimester
35
Who is gestational diabetes more common in?
Overweight
| Inactive
36
Neonatal problems related to gestational diabetes
Macrosomia
Respiratory distress
Neonatal hypoglycaemia
37
Symptoms of hyperglycaemia
```
Polydipsia
Polyuria
Blurred vision
Weight loss
Infections
```
38
Long term microvascular complications of hyperglycaemia
retinopathy
neuropathy
nephropathy
39
Long term macrovascular complications of hyperglycaemia
Stroke
MI
PVD
40
What group does diabetes diagnostic criteria identify?
Those with significantly increased premature mortality and increased risk of microvascular and cardiovascular complications
41
What is 'normoglycaemia' used for?
Glucose levels associated with low risk of developing diabetes or cardiovascular disease
42
What group does intermediate hyperglycaemia (IGT and IFG) identify?
A group at higher risk of future diabetes and adverse outcomes such as cardiovascular disease
43
Diagnostic level of diabetes with HbA1c
>_ 48 mmol/mol
44
How many lab and symptoms are needed to diagnose diabetes?
ONE diagnostic lab glucose PLUS symptoms
or
TWO diagnostic lab glucose WITHOUT symptoms
45
What lab values can be diagnostic of diabetes?
Diagnostic glucose levels (venous plasma) fasting >7.0mmol/l, random > 11.1 mmol/l
OGTT 2 hours after 75g CHO >11.1 mmol/l
Diagnostic HbA1c >_ 48 mmol/mol
46
What is HbA1c?
Glycosated haemoglobin
47
What does HbA1c give an indication of?
Blood glucose levels over the last 8-12 weeks
48
When can HbA1c not be used for diagnosis?
T1DM
All children and young people
Pregnancy - current or recent (< 2 months)
Short duration of diabetes symptoms
Patients at high risk of diabetes who are acutely ill
Patients taking medications that may cause rapid glucose rise e.g. corticosteriods
Acute pancreatic damage or pancreatic surgery
Renal failure
Iron deficiency
B12 deficiency
HIV infection
49
Presentation of T1DM
Short duration of
- thirst
- tiredness
- polyuria/nocturia
- weight loss
- blurred vision
- abdominal pain
50
Signs of DM
```
Ketones on breath
Dehydration
May have increased
- RR
- tachycardia
- hypotension
Low grade infections
- thrush/balanitis
```
51
Symptoms of T2DM
```
MAY HAVE NO SYMPTOMS
thirst
tiredness
polyuria/nocturia
Sometimes weight loss
blurred vision
symptoms of complications e.g. CVD
```
52
Signs of T2DM
NOT ketotic
Usually overweight but not always
Low grade infections; thrush/balanitis
May have microvascular or macrovascular complications at diagnosis
53
Risk factors for DM (any 2 present)
Overweight
FH
Over age 30 years if Maori / Asian / Pacific Island descent
Over age 40 years if European
PMH of gestational diabetes
Had a big baby (more than 4kg) - not in immediate post natal period
Inactive lifestyle, lack of exercise
Previous high blood glucose/impaired glucose tolerance
54
Does a drop in BP lead to acidosis or alkalosis?
Acidosis
A drop in BP leads to increased lactate
Which leads to acidosis
55
Treatment of DKA
Fluids - 0.9% saline
| IV insulin
56
What do you have to keep a close eye on when treating DKA?
The electrolytes
57
3 things needed to diagnose DKA
Raised BG
Raised Ketones
Acidosis
58
Would you do venous or arterial blood gas?
Venous
| Do arterial if concerned about oxygentation
59
Which is better to look at, blood or urine ketones?
Blood
60
Which type of fluids is only used now, crystalloid or colloid?
Crystalloid
61
What is the crystalloid of choice in DKA?
Saline
62
What is DKA not a usual complication of?
T2DM
63
What does LADA stand for?
Latent autoimmune diabetes of the adult
64
What kind of disease is LADA?
Autoimmune
65
When does LADA start?
Later in life, > 30 y/o
66
How much family history is needed to confirm MODY?
FH in 3 generations
67
Test for LADA
Autoantibodies (antiGAP)
68
What does OGTT stand for?
Oral glucose tolerance test
69
When is OGTT used?
Tricky cases
70
What happens during OGTT?
The patient is asked to take a glucose drink and their BG is measured before and after the sugary drink is taken
71
What cannot be used to diagnose diabetes mellitus (i.e. not a diagnostic test)?
Capillary blood glucose
72
When HbA1c
T2DM is unlikely
73
When HbA1c = 42-47, what does this imply?
Imparied/pre-diabetes
74
What HbA1c > 48, what does this imply?
T2DM
75
If cannot get the HbA1c <48, what value is preferable?
<53
76
3rd line therapy for diabetes would be what?
Triple therapy
77
What can progress during pregnancy and therefore must be monitored throughout?
Pre-proliferative retinopathy
| Microalbuminuria
78
Complications of DM in pregnancy
```
Severe hypos +/- unawareness
Progression of microvascular complications
Ketogenic state due to higher ketones leading to damage to the baby
Pre-eclampsia
Maternal infection
Pre-term labour
Miscarriage
Macrosomnia
Hypoglycaemia (neonate)
Congenital anomaly
```
79
Relationship between HbA1c and congenital anomaly
As HbA1c increases, the higher the risk of congenital anomaly increases
80
What helps to prevent neonatal hypoglycaemia?
Breast feeding / feeding
81
What happens to the insulin requirements after labour?
Drop almost immediately
82
Why should you always ask about steroids when there is hyperglycaemia?
Because steroids can raise blood glucose massively.
83
Under what values of ketones is negative?
< 0.6
84
What is normal body pH?
7.35-7.45
85
What contributes to plasma osmolarity?
Glucose
Urea
Electrolytes
86
Equation for calculating plasma osmolarity
2 x (Na + K) + urea + glucose
87
What does HHS stand for?
Hyperosmolar hyperglycaemic state
88
HHS vs DKA
HHS more dehydrated than DKA
HHS more serious than DKA due to mortality
HHS more gradual onset than DKA
89
Why does HHS have a slow onset?
Slow dehydration
| No ketones present to make you unwell
90
What can HHS be the first presentation of? And especially in who?
T2DM
| Elderly
91
Risk factors for HHS
Illness
Dehydration
Inability to take normal diabetes medication
92
What criteria is needed to diagnose HHS?
Increased BG
Hypovolaemia
Osmolarity > 320
93
Treatment of HHS
IV insulin
| 0.9% Saline
94
Speed of Tx of HHS compared to DKA
Treat HHS more SLOWLY than DKA to gradually improve things as it came on slower.
95
Do you always have to use IV insulin the treatment of HHS? Why?
Often the sugar comes down with rehydration
96
What can osmotic changes lead to?
Acute blurring of vision
97
Types of retinopathies seen in DM
Background retinopathy
Pre-proliferative
Proliferative
98
Eye problems seen in DM
Retinopathies
Maculopathy
Cataracts
Glaucoma
99
Two groups of symptoms of hypoglycaemia
Autonomic symptoms
| Neuroglycopenic symptoms
100
Which of the two groups of hypoglycaemic symptoms come on first?
Autonomic
101
When do neuroglycopenic symptoms come on in hypoglycaemia?
At a lower BG
| But come on rapidly
102
What is gastroparesis?
Delayed gastric emptying
103
You are more likely to have hypo unawareness if you have had diabetes for how long?
> 15 years
104
What must you do if you have two episodes of severe hypoglycaemia in a year?
Stop driving and inform the DVLA
105
What happens in terms of blood levels if have gastroporesis?
Insulin acts before the sugar rises
106
Treatment of gastroporesis
Prokinetics
Delayed timing of bolus of insulin after food
Liquidised or homogenised foods (absorbed more rapidly)
PEG/Jejunal feeding
Botulinum injection into pylorus
Gastric pacemaker (not always effective)
107
Types of neuropathy
Autonomic
| Peripheral
108
What is the albumin:creatinine ratio more sensitive than?
The protein:creatinine ratio
109
Which appears in the urine first, albumin or protein?
Albumin
110
What result does microalbuminuria give on urine dipstick?
Negative
111
What result does macroalbuminuria give on urine dipstick?
Positive
112
Two types of dialysis
Haemodialysis
| Peritoneal
113
What is the autonomic NS effect of DM?
Postural hypotension
114
When is HbA1c not a very accurate measurement?
If you are anaemic
115
What should be done if you are scared of having a hypo at night?
Take 20% of insulin and have a snack before bed
116
What type of metformin is better tolerated and why is this?
Slow release
| Because of S/Es
117
If are on testosterone and stop taking it, what can happen?
Can become anaemic
118
What is faecal elastase a measurement of?
Pancreatic exocrine insufficiency
119
How long does it take to develop retinopathy?
5 years
120
Target of BG in the morning
5 - 8
121
Effects of fight or flight on BG
Increase in BG
| Then decrease in BG due to the adrenaline
122
1 unit of insulin brings down the BG by how much?
4 mmol
123
What antibodies are looked at in T1DM and LADA?
AI2 antibodies
124
How many grams of CHO in 2 slices of toast?
30g
125
Insulin ratio and what does it mean?
1:10
| 1 insulin unit for every 10g of carbs
126
What should you do to your insulin after exercise?
Drop your insulin a bit
| Because after exercise taking up glucose into muscles is easier
127
How long can LADA last without insulin?
6 months
128
What can happen to an overnight hypo?
It can rebound to high
129
How long does it approx. take to get normal after a correction dose?
4 hours
130
How often are patients with T1DM told to monitor their BG?
At least 4x a day, including before each meal and before bed
131
Inheritance of MODY
Autosomal dominant
132
T2DM BP target if NO end organ damage
< 140/80
133
T2DM BP target if end organ damage
< 130/80
134
What is the most important complication of fluid resus in DKA, and in who?
Cerebral oedema
| In young patients
135
HbA1c level of pre diabetes
42 - 47 mmol/mol
136
What HLA allele is associated with T1DM?
HLA-DR4
