Diabetes Mellitus

Question 1

What is diabetes mellitus?

Answer 1

lack of or decreased effectiveness of endogenous insulin –> diabetic hyperglycaemia

Question 2

What causes T1DM?

Answer 2

there is autoimmune b-cell destruction –> no insulin signal –> diabetic hyperglycaemia

~ often occurs before puberty.

HLA-D3 & D4 gene linked!

Question 3

What antibodies are made in LADA? aka latent autoimmune diabetes of adulthood

Answer 3

islet cell antibodies
[islet cells contain alpha, beta, delta and C-cells]
- is like a subset of T1DM tf as there is no insulin signal

Question 4

What causes T2DM?

Answer 4

no response to insulin
there is resistance / b-cell dysfunction
~older patients
there is ketosis prone T2DM and MODY

Question 5

What is MODY and its inheritance pattern?

Answer 5

Mature Onset Diabetes of the Young (MODY)
AD inheritance, e.g < 25 years
- genetic DEFECT of B-cell function –> dysregulation
(not destruction so tf = T2DM)
–> Increased risk of HCC (hepatic carcinoma)

Question 6

What do these conditions cause:
steroids
pancreatic: surgery/trauma, infection, haemochomatosis, CF, cancer
endocrine - cushings, acromegaly, phaeochromocytoma, hyperthyroidism
congenital lipodystrophy, glycogen storage disease?

Answer 6

secondary diabetes!

specifically haemochomatosis –>bronze diabetes
CF –> mucus blocks pancreatic duct
Cushings -> as Increased glucocorticoid, hyperglycaemia = increased insulin –> tolerance

Question 7

What is a non-diabetic hyperglycaemia?

Answer 7

GDM - gestational diabetes

Question 8

What are the OGTT fasting glucose values to diagnose GDM?

Answer 8

OGTT =>
0 mins > 5.6 mmol/L
2 hr > 7.8 mmol/L

Question 9

What do these represent:
miscarriage
preterm labour
pre-eclampsia
congenital malformations
macrosomia
worsening of diabetic complications e.g. retinopathy, nephropathy?

Answer 9

the increased risks
that all forms of DM
- T1 or T2 or GDM
bringto both the mother and foetus

Question 10

What are the increased risks that all forms of DM bring to mother & foetus

Answer 10

to mum: 
- worsening of diabetic complications, retinopathy, nephropathy
- pre-eclampsia
to child:
- miscarriage
- preterm labour
- congenital malformations
- macrosomia

Question 11

What are RFs for GDM?

Answer 11

> 25 y/o
previous GDM
Fhx
inc BMI
non-caucasian
HIV +ve

Question 12

What is recommended for those at risk of GDM or with DM before conception?

Answer 12

folic acid 5mg/daily until 12 weeks pregnant
weight loss
good glucose control, discuss risks

Question 13

How do you screen for GDM?

Answer 13

1) OGTT
2) then 6 wks post partum = fasting glucose
[75g glucose @
0 mins > 5.6 mmol/L
2 hr > 7.8 mmol/L]
NB: 6 wks later – 50% go onto develop DM eventually

Question 14

What hypoglycaemics can carry on in pregnancy?

Answer 14

all oral hypoglycaemics other than metformin should be discontinued
- metformin as an adjunct/alternative to insulin in T2 or GDM

Question 15

What are the differences between T1DM and T2DM typically in:
age
body habitus
onset
symptoms
diagnosis route/presentation
genetic dispositon
population?

Answer 15

T1DM are young, normal weight, onset over days w: moderate/severe symptoms; polydipsia, polyuria, weight loss, ketosis –> acute diagnosis. population = 5-10%

FOR both there is a genetic predisposition (more in T2DM even)

T2DM are old, overweight, weeks of onset, none or mild syx - or present with complications e.g. MI. diagnosed on routine check and = 90-95% of DM population.

Question 16

A pregnant lady’s fasting glucose result is 5.6 mmol/L is this normal or DM or GDM?

Answer 16

it is normal as ≤ 6 is normal

but because she is pregnant it is boarderline GDM ( ≥ = 5.6)

Question 17

Someones fasting glucose if 6.5 is this normal?

Answer 17

it is impaired
e.g. 6.1 - 6.9 = impaired
normal is ≤ = 6
DM = ≥7

Question 18

Someones fasting glucose is 7.1, is this normal?

Answer 18

no, DM is ≥7

Question 19

Someones random glucose is 10.0 mmol/L is this normal?

Answer 19

yes ≥ 11.1 = DM

cant do GDM off random glucose

Question 20

Somones OGTT is 5.0 mmol/L is this normal?

Answer 20

yes as < 7.8

Question 21

Someones OGTT is 10 is this normal?

Answer 21

no it is impaired

7.8 - 11 = impaired

Question 22

A pregnant ladys OGTT is 7.9 is this normal

Answer 22

no it is not as
≥ 7.8 = GDM
NB: for OGTT it is the same for DM as GDM (>7.8)

Question 23

Someones HBA1C is 43 mmol/mol is this normal?

Answer 23

no normal is < 42 mmol/mol

Question 24

Someones HBA1C is 43 is this DM?

Answer 24

no it is impaired

e.g. 42 - 47 is impaired

Question 25

Someones HBA1C is 50 mmol/mil is this DM?

Answer 25

yes

≥48 = DM (6.5%)

Question 26

What is HBA1C?

Answer 26

glycosylated Hb

average blood glucose for 2 - 3 months

Question 27

What doe these groups indicate?
ALL children & young people
-T1DM
- Symptoms < 2 months
- Acutely ill (i.e. hosp admission) + high diabetes risk
- Meds that may cause rapid glucose rise e.g. steroids, antipsychotics
- Acute pancreatic damage, inc. surgery
-Pregnancy
- High RBC turnover or abnormal haemoglobin (haemolytic anaemia/ haemoglobinopathies)
- Recent blood transfusion

Answer 27

these are all times when HbA1c is not appropriate to take

Question 28

What groups is HbA1c not appropriate to take from?

Answer 28

Patient factors:

• ALL children & young people
• Pregnancy
• T1DM
• DM Symptoms <2 months
• Acutely ill (i.e. hosp admission) + high diabetes risk
• High RBC turnover or abnormal haemoglobin (haemolytic anaemia/ haemoglobinopathies)

Iatrogenic:

• Meds that may cause rapid glucose rise e.g. steroids, antipsychotics
• Acute pancreatic damage, inc. surgery
• Recent blood transfusion

Question 29

What blood tests are used for monitoring diabetes?

Answer 29

HbA1C (not T1DM or GDM though)
Fructosamine
creatinine
lipid profile
glycaemic records

Question 30

How often are glycaemic records taken?

Answer 30

QDS e.g. 4x daily –>

before meals and before beds

Question 31

why is creatinine used for monitoring diabetes?

Answer 31

renal function indicator

Question 32

What is fructosamine?

Answer 32

a blood test useful for DM monitoring when unable to measure HbA1C

Question 33

What is HbA1C used for in T2DM monitoring?

Answer 33

is a glycaemic control indicator

as it could be an average of hyper and hypo episodes want to aim for 48-59mmol/mil control or 6.5-7.5% (>48 (6.5%) = DM)

Question 34

If someone has a hba1c and it is below 42 mmol/mol but they still have symptoms what should they do?

Answer 34

< 42 is normal range for HBA1C
BUT if symptoms present consider glucose test (fasting, random, oral) as they may still be at risk
– communicate risk of developing diabetes & benefits of a healthy lifestyle
–> recheck HbA1C in 3 years
or earlier if clinically indicated

Question 35

If someone has a hba1c and it is between 42 - 47 mmol/mol but they still have symptoms what should they do?

Answer 35

they are at high risk of diabetes

• -> INTENSIVE lifestyle modification
• recheck HbA1c in 1 year - or earlier if clinically indicated

Question 36

If someone has HbA1c ≥ 48 mmol/mol and are asymptomatic what do you do?

Answer 36

they are in the DM range e.g ≥48
but as asymptomatic …
– REPEAT HbA1c in 2 weeks
if it is STILL ≥ 48 = dx diabetes – follow diabetes management pathway
if it is < 48 – follow high risk of diabetes
e.g. intense lifestyle modification and recheck HbA1c in 1 year

Question 37

If someone has HbA1c ≥ 48 mmol/mol and are symptomatic what do you do?

Answer 37

≥ 48 mmol/mol is diabetic, the dx is diabetes so follow diabetes management pathway
NB; w/ T2DM it is likely routine Dx e.g. asymp so TF rememeber about repeating hba1c in 2w unless heart attack etc as DM syx?