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Endocrine > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

What is diabetes?

A

Loss of control of blood glucose levels resulting in chronic elevation

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2
Q

Describe the pathophysiology of type 1 diabetes

A

Autoimmune destruction of the pancreatic beta cells, destroying the ability to produce insulin and compromising the ability to absorb glucose

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3
Q

Describe the pathophysiology of type 2 diabetes

A

Peripheral tissues become insensitive to insulin due to abnormal response of insulin receptors or a reduction in their number, resulting in built up tolerance

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4
Q

What are the classifications of diabetes?

A

Type 1

Type 2

Other

  • Gestational
  • Secondary
  • Maturity Onset Diabetes of the Young (MODY)
  • Latent Autoimmune Diabetes of Adults (LADA)
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5
Q

What are the causes of type 1 diabetes?

A

Genetic risk

  • HLA-DR3
  • DR4

Autoimmune conditions

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6
Q

What are the causes of type 2 diabetes?

A

Obesity

FH

PH of gestational diabetes

Big baby

PH of high blood glucose/impaired glucose tolerance

Chronic pancreatitis

Cushing’s syndrome

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7
Q

What is Maturity Onset Diabetes of the Young (MODY)?

A

Autosomal dominant condition/single gene defect resulting in impaired beta-cell function and type 2 diabetes under the age of 25

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8
Q

What hypoglycaemic drug are MODY patients most sensitive to?

A

Sulfonylureas

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9
Q

What % of diabetes is type 1?

A

10%

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10
Q

What % of diabetes is type 2?

A

90%

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11
Q

How does type 1 diabetes present?

A

Develops over days-months

Thirst/polydipsia

Weight loss

Fatigue

Polyuria/nocturia

Blurred vision

Abdominal pain

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12
Q

How does type 2 diabetes present?

A

Overweight

May be asymptomatic

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13
Q

What can be presentations of both type 1 and type 2 diabetes?

A

Dehydration

Tachycardia

Hypotension

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14
Q

What investigations are used in diabetes diagnosis?

A

Oral glucose tolerance test

Diagnostic glucose plasma levels

HbA1C/Glycated glucose

Urinalysis

  • Glucose
  • Ketones
  • Albumin for nephropathy
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15
Q

Describe the oral glucose tolerance test

A

Measure baseline fasting glucose and then 2 hour post glucose load (75g of carbohydrate)

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16
Q

What value is diagnostic of diabetes (post glucose load)?

A

>11.1mmol/l

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17
Q

What value is diagnostic of diabetes (after fasting)?

A

>7.0mmol/l

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18
Q

Why is C-peptide assessed in diabetes?

A

To compare injected insulin and pancreatic insulin

Can also differentiate between type 1 (low) and type 2 (normal or high)

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19
Q

What is the most reliable diabetic test?

A

HbA1C

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20
Q

What is HbA1C/glycated glucose a measure of?

A

Measurement of blood glucose over the previous 3 months (although more strongly accurate for 2-4 weeks)

Produced by the glycosylation of haemoglobin at a rate proportional to the glucose concentration.

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21
Q

What HbA1c value is diagnostic of diabetes?

A

>48mmol/l

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22
Q

What should the HbA1c target be in patients with lifestyle management or metformin?

A

48mmol/l

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23
Q

What should the HbA1c target be in patients on hypoglycaemic drugs?

A

53mmol/l

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24
Q

How often should Hba1c levels be checked in diabetic patients?

A

3-6 months until stable, then every 6 months

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25
Q

What is the HbA1c level for pre-diabetes?

A

42-47mmol/l

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26
Q

What can cause higher than expected Hb1ac levels?

A

Vitamin B12/folic acid deficiency

Iron deficiency anaemia

Splenectomy

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27
Q

What can cause lower than expected HbA1c levels?

A

Sickle cell anaemia

GP6D deficiency

Hereditary spherocytosis

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28
Q

How many tests do asymptomatic patients require before being diagnosed with type 2 DM?

A

Asymptomatic patients with an abnormal HbA1c or fasting glucose must be confirmed with a second abnormal reading before a diagnosis of type 2 diabetes is confirmed

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29
Q

How often should DM1 monitor their blood glucose?

A

At least 4 times a day, including before each meal and before bed

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30
Q

What are the DM1 blood glucose targets?

A

5-7mmol/l waking

4-7mmol/l before meals and at other times of the day

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31
Q

What does unrecordable glucose levels mean?

A

Blood sugar is too high to record, not too low

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32
Q

Give examples of oral hypoglycaemics?

A

Biguanides

Sulphonylureas

Thiazolidinediones

Alpha-Glucosidase inhibitors

SGLT-2 inhibitors

DDP-4 inhibitors

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33
Q

What is the mechanism of action of Biguanides?

A

Improves sensitivity to insulin

Decreases hepatic gluconeogenesis

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34
Q

Give an example of a biguanide

A

Metformin

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35
Q

Give side effects of biguanides/metformin

A

Gastrointestinal upset

Lactic acidosis

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36
Q

Give contraindications for metformin

A

Patients with eGFR <30 ml/min

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37
Q

When should metformin be initiated in diabetic management?

A

If Hb1Ac rises to 48mmol/l on lifestyle modifications

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38
Q

What can be done if metformin is not tolerated due to GI side effects?

A

Try modified release formulation before switching to a second line agent

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39
Q

What is the mechanism of action of sulphonylureas?

A

Stimulates pancreatic insulin release

40
Q

When should a 2nd drug be added to metformin in diabetic management?

A

If HbA1c levels rise to 58mmol/l on metformin

41
Q

Give examples of sulphonylureas

A

Gliclazide

Glimepiride

42
Q

Give side effects of sulphyonylureas

A

Hypoglycaemia

  • Increased insulin and C peptide levels

Weight gain

Hyponatraemia/syndrome of inappropriate ADH secretion

Bone marrow suppression

Hepatotoxicity

Peripheral neuropathy

43
Q

What is the mechanism of action of thiazolidinediones?

A

Improves sensitivity to insulin

44
Q

Give an example of a thiazolidinedione

A

Rosiglitazone

Pioglitazone

45
Q

Give side effects of thiazolidinediones

A

Weight gain

Fluid retention

Bladder cancer

>Risk of fractures

Hepatotoxicity

46
Q

Give a contraindication for Thiazolidinediones

A

HF

Generally are not really used as first or second line managemebt

47
Q

What is the mechanism of action of Alpha-Glucosidase inhibitors?

A

Prevents intestinal sugar absorption

48
Q

Give an example of Alpha-Glucosidase inhibitor

A

Acarbose

49
Q

Give an example of a DDP-4 Inhibitor

A

Gliptin

Sitagliptin

50
Q

Give an example of SGLT-2 Inhibitor

A

Empagliflozin

51
Q

What are the side effects of SGLT-2 inhibitors?

A

UTI

  • Urinary or genital infection)

Weight loss

Inceased risk of lower limb amputation

Fournier’s gangrene

  • Infective necrotising fasciitis affecting the genitalia and/or perineum)
52
Q

What is the mechanism of action of SGLT-2 Inhibitor?

A

Increase urinary glucose excretion

53
Q

What hypoglycaemic drug is most suitable in obese patients?

A

DDP-4 Inhibitors

SGLT-2 Inhibitors

54
Q

When should triple therapy be initiated in diabetic management?

A

If Hb1Ac remains at 58mmol/l despite metformin and a second agent

55
Q

When are GLP-1 agonists added in DM2 management?

A

If triple therapy is not effective, tolerated or contraindicated and

BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or

BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity related comobordities

56
Q

Give an example of a GLP-1 agonist

A

Exenatide

57
Q

What is first line management for steroid induced DM?

A

Gliclazide/sulphonylurea

58
Q

Describe the type 2 DM management scale?

A
59
Q

Give side effects of insulin therapy

A

Hypoglycaemia

  • Only increased insulin, not C-peptide

Lipodystrophy, presenting as atrophy/lumps of subcutaneous fat on injection sites

Weight gain

60
Q

What insulin should be prescribed for newly diagnosed DM1?

A

Basal–bolus insulin, using twice‑daily insulin detemir

Rapid acting insulin analogues before meals

61
Q

How should insulin regime be adapted in DKA management?

A

Insulin should be fixed rate whilst continuing regular injected long-acting insulin but stopping short actin injected insulin

62
Q

What is the supportive management for diabetes?

A

Patient education

Dietary advice

63
Q

How does exercise effect blood glucose levels?

A

Exercise increases the risk of an early and late drop in blood glucose due to muscle uptake and replacement of glycogen

64
Q

How does alcohol effect blood glucose levels?

A

Alcohol inhibits glycogenolysis causing late hypoglycaemia

65
Q

Describe the driving rules for diabetics

A

Can now hold HGV licence if patient meets strict hypoglycaemic criteria

If diet controlled diabetes, no need to inform DVLA

If on tablets, no need to inform DVLA, if tablets may induce hypoglycaemia then there must not be more than one episode of hypoglycaemia requiring assistance in last 12 months

If on insulin, must inform DVLA and there must not be more than one episode of hypoglycaemia requiring assistance in last 12 months or visual impairment

66
Q

Describe the sick day rules for diabetes

A

When unwell, If a patient is on insulin, 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 (four hourly)

If a patient is taking oral hypoglycaemic medication, they should be advised to continue taking their medication even if they are not eating muc

67
Q

What is involved in complication surveillance for diabetes?

A

Annual eye screening/fundoscopy

Annual foot screening

Check insulin sights

BP monitoring

Monitor renal function

  • Increased urea and creatinine

Thyroid function

68
Q

Name some microvascular complications of diabetes

A

Retinopathy

Neuropathy

Nephropathy

Erectile dysfunction

69
Q

Give some macrovascular complications of diabetes

A

Stroke

MI

Peripheral vascular disease

HF

70
Q

What causes diabetic foot disease?

A

Neuropathy

  • Resulting in loss of protective sensation (ie not noticing a stone in the shoe), Charcot’s arthropathy, dry skin

Peripheral arterial disease

  • Diabetes is a risk factor for both macro and microvascular ischaemia
71
Q

How does diabetic foot disease present?

A

Neuropathy/loss of sensation

Ischaemia

  • Absent foot pulses
  • Reduced ankle-brachial pressure index
  • Intermittent claudication
72
Q

What is the most appropriate screening test for diabetic neuropathy?

A

A 10 g monofilament

73
Q

Give features of diabetic neuropathy

A

Sensory loss in stocking distribution

74
Q

Give complication of diabetic neuropathy

A

Gastroparesis

  • Occurs due to neuropathy of the vagus nerve, causing abnormal gut movement
  • Features include abdominal pain, N&V, bloating and post-prandial fullness
  • Can also be caused by bariatric surgery, parkinson’s and scleroderma
75
Q

How is gastroparesis managed?

A

Stabilise blood glucose levels via monitoring, insulin dose adjustment and consideration of insulin pump therapy

76
Q

How is diabetic neuropathy managed?

A

Amitriptyline

Duloxetine, first line in diabetic neuropathic pain

Gabapentin

Pregabalin, first line in standard neuropathic pain

If the first line treatment does not work, try the other 3 drugs

77
Q

What can used as ‘rescue therapy’ for exacerbations of neuropathic pain in diabetic neuropathy?

A

Tramadol

78
Q

What investigation is used to screen for diabetic nephropathy?

A

All patients should be screened annually using on spot urinary albumin/creatinine ratio (ACR)

If abnormal, repeat with first pass morning urine sample

79
Q

How is diabetic nephropathy managed?

A

Dietary protein restriction

Tight glycaemic control

BP control, aim for < 130/80 mmHg, with ACEI/ARBs

Control dyslipidaemia with statins

80
Q

What fundoscopy signs are seen in diabetic retinopathy?

A

Cotton wool spots: Fluffy white patches on the retina due to infarction of small arterioles

Intraretinal haemorrhages: Dot or blot shaped

Microaneurysms: Small red dots due to capillary wall outpouching, earliest sign of diabetic retinopathy

81
Q

What can cause ketoacidosis?

A

Can be precipitated by infections, MI and omitting insulin

82
Q

How does ketoacidosis present?

A

N&V

Abdominal pain

Ketones on breath

Tachypnoea: Kussmaul respiration secondary to metabolic acidosis

83
Q

What is the management of ketoacidosis?

A

Weight based fixed IV insulin infusion

  • 0.1 units/kg/hour

Aggressive fluid replacement

  • IV 0.9% NaCl/saline

Monitor K+ and replace

Treat underlying cause

84
Q

What is first line management for ketoacidosis?

A

IV fluids (even before IV insulin)

85
Q

What are complications of ketoacidosis?

A

Cerebral or pulmonary oedema, due to fluid resuscitation

Arrythmias/hyperkalaemia

AKI

Acute respiratory distress syndrome

Gastric stasis

Hypophosphataemia

  • Initiate parenteral phosphate therapy
86
Q

What blood abnormality can be seen in DKA

A

Hypokalaemic acidosis

87
Q

How should insulin be altered in DKA?

A

Insulin should be fixed rate whilst continuing regular injected long acting insulin but stopping short acting injected insulin

88
Q

What is hyerglycaemic hypersomolar state

A

Dangerous complication due to hyperglycaemia, characterised as hyperglycaemia with increased serum osmolarity and no ketosis/acidosis

89
Q

What can cause HHS?

A

Infection

MI

90
Q

How is HHS managed?

A

Fluid replacement

  • IV 0.9% NaCl

Insulin, if ketones only

K replacemet if required

Anticoagulation

  • LMWH
91
Q

Give complications of HHS

A

Vascular complications

  • MI
  • Stroke
  • Peripheral arterial thrombosis

Higher mortality rate than DKA

92
Q

Compare the onset of DKA and HHS

A

DKA presents within hours of onset whereas HHS comes on over many days, and so concequently the dehydration and electrolyte abnormalities are more extreme

93
Q

How does a hypo present?

A

Cold sweat

Tremor

Irritability

Confusion

Loss of consciousness

Collapse

94
Q

How is a hypo managed?

A

IM Glucagon

IV Glucose if impaired GCS

10-20G of short acting carbohydrate, such as Lucozade or non-diet drink

95
Q

What drug can be used in obesity?

A

Orlistat

96
Q

What is the mechanism of action of orlistat?

A

Pancreatic lipase inhibitor

97
Q

How should diabetes management be altered for surgery?

A

Metformin

  • Take as normal day prior and day of

Sulphonylurea

  • Take as normal day prior
  • Omit dose on day of

DDP-4 and GLP-1

  • Take as normal day prior and day of

SGLT-2

  • Take as normal day prior
  • Omit on day of

Once daily insulin

  • Reduce by 20% day prior and day of

Twice daily or long acting insulin

  • Take as normal day prior
  • Half morning dose, no change to evening

Endocrine (7 decks)

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