Diabetes Mellitus Flashcards
1
Q
What is diabetes?
A
Loss of control of blood glucose levels resulting in chronic elevation
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
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
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)
5
Q
What are the causes of type 1 diabetes?
A
Genetic risk
- HLA-DR3
- DR4
Autoimmune conditions
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
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
8
Q
What hypoglycaemic drug are MODY patients most sensitive to?
A
Sulfonylureas
9
Q
What % of diabetes is type 1?
A
10%
10
Q
What % of diabetes is type 2?
A
90%
11
Q
How does type 1 diabetes present?
A
Develops over days-months
Thirst/polydipsia
Weight loss
Fatigue
Polyuria/nocturia
Blurred vision
Abdominal pain
12
Q
How does type 2 diabetes present?
A
Overweight
May be asymptomatic
13
Q
What can be presentations of both type 1 and type 2 diabetes?
A
Dehydration
Tachycardia
Hypotension
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
15
Q
Describe the oral glucose tolerance test
A
Measure baseline fasting glucose and then 2 hour post glucose load (75g of carbohydrate)
16
Q
What value is diagnostic of diabetes (post glucose load)?
A
>11.1mmol/l
17
Q
What value is diagnostic of diabetes (after fasting)?
A
>7.0mmol/l
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)
19
Q
What is the most reliable diabetic test?
A
HbA1C
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.
21
Q
What HbA1c value is diagnostic of diabetes?
A
>48mmol/l
22
Q
What should the HbA1c target be in patients with lifestyle management or metformin?
A
48mmol/l
23
Q
What should the HbA1c target be in patients on hypoglycaemic drugs?
A
53mmol/l
24
Q
How often should Hba1c levels be checked in diabetic patients?
A
3-6 months until stable, then every 6 months
25
What is the HbA1c level for pre-diabetes?
42-47mmol/l
26
What can cause higher than expected Hb1ac levels?
Vitamin B12/folic acid deficiency
Iron deficiency anaemia
Splenectomy
27
What can cause lower than expected HbA1c levels?
Sickle cell anaemia
GP6D deficiency
Hereditary spherocytosis
28
How many tests do asymptomatic patients require before being diagnosed with type 2 DM?
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
29
How often should DM1 monitor their blood glucose?
At least 4 times a day, including before each meal and before bed
30
What are the DM1 blood glucose targets?
5-7mmol/l waking
4-7mmol/l before meals and at other times of the day
31
What does unrecordable glucose levels mean?
Blood sugar is too high to record, not too low
32
Give examples of oral hypoglycaemics?
Biguanides
Sulphonylureas
Thiazolidinediones
Alpha-Glucosidase inhibitors
SGLT-2 inhibitors
DDP-4 inhibitors
33
What is the mechanism of action of Biguanides?
Improves sensitivity to insulin
Decreases hepatic gluconeogenesis
34
Give an example of a biguanide
Metformin
35
Give side effects of biguanides/metformin
Gastrointestinal upset
Lactic acidosis
36
Give contraindications for metformin
Patients with eGFR \<30 ml/min
37
When should metformin be initiated in diabetic management?
If Hb1Ac rises to 48mmol/l on lifestyle modifications
38
What can be done if metformin is not tolerated due to GI side effects?
Try modified release formulation before switching to a second line agent
39
What is the mechanism of action of sulphonylureas?
Stimulates pancreatic insulin release
40
When should a 2nd drug be added to metformin in diabetic management?
If HbA1c levels rise to 58mmol/l on metformin
41
Give examples of sulphonylureas
Gliclazide
Glimepiride
42
Give side effects of sulphyonylureas
Hypoglycaemia
* Increased insulin and C peptide levels
Weight gain
Hyponatraemia/syndrome of inappropriate ADH secretion
Bone marrow suppression
Hepatotoxicity
Peripheral neuropathy
43
What is the mechanism of action of thiazolidinediones?
Improves sensitivity to insulin
44
Give an example of a thiazolidinedione
Rosiglitazone
Pioglitazone
45
Give side effects of thiazolidinediones
Weight gain
Fluid retention
Bladder cancer
\>Risk of fractures
Hepatotoxicity
46
Give a contraindication for Thiazolidinediones
HF
Generally are not really used as first or second line managemebt
47
What is the mechanism of action of Alpha-Glucosidase inhibitors?
Prevents intestinal sugar absorption
48
Give an example of Alpha-Glucosidase inhibitor
Acarbose
49
Give an example of a DDP-4 Inhibitor
Gliptin
Sitagliptin
50
Give an example of SGLT-2 Inhibitor
Empagliflozin
51
What are the side effects of SGLT-2 inhibitors?
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
What is the mechanism of action of SGLT-2 Inhibitor?
Increase urinary glucose excretion
53
What hypoglycaemic drug is most suitable in obese patients?
DDP-4 Inhibitors
SGLT-2 Inhibitors
54
When should triple therapy be initiated in diabetic management?
If Hb1Ac remains at 58mmol/l despite metformin and a second agent
55
When are GLP-1 agonists added in DM2 management?
If triple therapy is not effective, tolerated or contraindicated and
## Footnote
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
Give an example of a GLP-1 agonist
Exenatide
57
What is first line management for steroid induced DM?
Gliclazide/sulphonylurea
58
Describe the type 2 DM management scale?
59
Give side effects of insulin therapy
Hypoglycaemia
* Only increased insulin, not C-peptide
Lipodystrophy, presenting as atrophy/lumps of subcutaneous fat on injection sites
Weight gain
60
What insulin should be prescribed for newly diagnosed DM1?
**Basal–bolus insulin**, using twice‑daily insulin detemir
Rapid acting insulin analogues before meals
61
How should insulin regime be adapted in DKA management?
Insulin should be fixed rate whilst continuing regular injected long-acting insulin but stopping short actin injected insulin
62
What is the supportive management for diabetes?
Patient education
Dietary advice
63
How does exercise effect blood glucose levels?
Exercise increases the risk of an early and late drop in blood glucose due to muscle uptake and replacement of glycogen
64
How does alcohol effect blood glucose levels?
Alcohol inhibits glycogenolysis causing late hypoglycaemia
65
Describe the driving rules for diabetics
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
Describe the sick day rules for diabetes
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
What is involved in complication surveillance for diabetes?
Annual eye screening/fundoscopy
Annual foot screening
Check insulin sights
BP monitoring
Monitor renal function
* Increased urea and creatinine
Thyroid function
68
Name some microvascular complications of diabetes
Retinopathy
Neuropathy
Nephropathy
Erectile dysfunction
69
Give some macrovascular complications of diabetes
Stroke
MI
Peripheral vascular disease
HF
70
What causes diabetic foot disease?
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
How does diabetic foot disease present?
Neuropathy/loss of sensation
Ischaemia
* Absent foot pulses
* Reduced ankle-brachial pressure index
* Intermittent claudication
72
What is the most appropriate screening test for diabetic neuropathy?
A 10 g monofilament
73
Give features of diabetic neuropathy
Sensory loss in stocking distribution
74
Give complication of diabetic neuropathy
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
How is gastroparesis managed?
Stabilise blood glucose levels via monitoring, insulin dose adjustment and consideration of insulin pump therapy
76
How is diabetic neuropathy managed?
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
What can used as 'rescue therapy' for exacerbations of neuropathic pain in diabetic neuropathy?
Tramadol
78
What investigation is used to screen for diabetic nephropathy?
All patients should be screened annually using on spot urinary albumin/creatinine ratio (ACR)
If abnormal, repeat with first pass morning urine sample
79
How is diabetic nephropathy managed?
Dietary protein restriction
Tight glycaemic control
BP control, aim for \< 130/80 mmHg, with ACEI/ARBs
Control dyslipidaemia with statins
80
What fundoscopy signs are seen in diabetic retinopathy?
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
What can cause ketoacidosis?
Can be precipitated by infections, MI and omitting insulin
82
How does ketoacidosis present?
N&V
Abdominal pain
Ketones on breath
Tachypnoea: Kussmaul respiration secondary to metabolic acidosis
83
What is the management of ketoacidosis?
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
What is first line management for ketoacidosis?
IV fluids (even before IV insulin)
85
What are complications of ketoacidosis?
Cerebral or pulmonary oedema, due to fluid resuscitation
Arrythmias/hyperkalaemia
AKI
Acute respiratory distress syndrome
Gastric stasis
Hypophosphataemia
* Initiate parenteral phosphate therapy
86
What blood abnormality can be seen in DKA
Hypokalaemic acidosis
87
How should insulin be altered in DKA?
Insulin should be fixed rate whilst continuing regular injected long acting insulin but stopping short acting injected insulin
88
What is hyerglycaemic hypersomolar state
Dangerous complication due to hyperglycaemia, characterised as hyperglycaemia with increased serum osmolarity and no ketosis/acidosis
89
What can cause HHS?
Infection
MI
90
How is HHS managed?
Fluid replacement
* IV 0.9% NaCl
Insulin, if ketones only
K replacemet if required
Anticoagulation
* LMWH
91
Give complications of HHS
Vascular complications
* MI
* Stroke
* Peripheral arterial thrombosis
Higher mortality rate than DKA
92
Compare the onset of DKA and HHS
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
How does a hypo present?
Cold sweat
Tremor
Irritability
Confusion
Loss of consciousness
Collapse
94
How is a hypo managed?
IM Glucagon
IV Glucose if impaired GCS
10-20G of short acting carbohydrate, such as Lucozade or non-diet drink
95
What drug can be used in obesity?
Orlistat
96
What is the mechanism of action of orlistat?
Pancreatic lipase inhibitor
97
How should diabetes management be altered for surgery?
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
