DIABETES MELLITUS

Question 1

WHAT IS TYPE 2 DIABETES MELLITUS?

Answer 1

Chronic metabolic condition characterised by insulin resistance. Insufficient pancreatic insulin production also occurs progressively over time, resulting in hyperglycaemia.

Question 2

WHAT ARE THE RISK FACTORS FOR T2DM?

Answer 2

1) Obesity
2) FHx
3) Physical inactivity
4) Hypertension
5) High blood cholesterol
6) Cardiovascular disease
7) Older age

Question 3

WHAT ARE THE SYMPTOMS OF T1DM/ T2DM?

Answer 3

1) Nocturia
2) Polydipsia
3) Polyuria
4) Blurred vision
5) UTI
6) Candidal infection
7) Unintentional weight loss
8) Fatigue

Question 4

WHAT ARE THE INVESTIGATIONS FOR T1DM/T2DM?

Answer 4

1) HbA1C - average blood glucose for last 2/3 months >48 mmol/mol. Also used to measure glycaemic control at 3-6 month intervals
2) Fasting plasma glucose - >6.9 mmol/L
3) Random plasma glucose - >11.1 mmol/L
4) Urine ketones - if patient symptomatic for hyperglycaemia
5) Serum creatinine + eGFR - look at renal insufficiency

Question 5

WHAT IS THE LIFETYLE MANAGEMENT FOR T2DM?

Answer 5

1) Weight loss
2) Regular exercise
3) Smoking cessation
4) Nutritional support - monitor calorie intake
5) Mental health management
6) Alcohol reduction

Question 6

WHAT IS THE PHARMACOLOGICAL MANAGEMENT FOR T2DM?

Answer 6

FIRST LINE: metformin
SECOND LINE : metformin plus gliptin/ pioglitazone/ sulfonylurea/ SGLUT2 inhibitor
THIRD LINE (triple therapy): metformin, gliptin, sulfonylurea/ metformin, pioglitazone, sulfonylurea/ insulin therapy

Question 7

WHAT IS THE RECOMMENDED HbA1C TARGET FOR PATIENTS ON LIFESTYLE AND DIET MANAGEMENT +/- DRUG WITH HYPOGLYCAEMIA EFFECT?

Answer 7

48 mmol/mol

Question 8

WHAT IS THE RECOMMEDED HbA1C TARGET FOR PATIENTS ON DRUGS WITH ASSOCIATED HYPOGLYCAEMIA?

Answer 8

53 mmol/mol

Question 9

WHEN SHOULD BLOOD GLUCOSE SELF MONITORING BE ADVISED?

Answer 9

1) person on insulin therapy
2) person taking a drug making them at risk of hypoglycaemia when driving or operating machinery
3) repeated hypoglycaemic episodes
4) pregnancy

Question 10

WHEN IS METFORMIN CONTRAINDICATED?

Answer 10

1) Lactic acidosis
2) DKA
3) eGFR <30 ml/min

Question 11

WHAT IMMEDIATE THERAPY IS OFFERED TO T2DM PATIENTS WITH SYMPTOMS OF HYPERGLYCAEMIA?

Answer 11

Insulin therapy or sulphonylureas

Question 12

WHAT ARE THE 6 CLASSES OF ORAL ANTI-DIABETIC DRUGS, NAMES, MOA AND SIDE EFFECTS?

Answer 12

1) BIGUANIDES
- Metformin
- acts in presence of insulin to decreases gluconeogenesis in liver and increase peripheral utilisation of glucose. Doesn’t cause hypoglycaemia as insulin secretion unaltered. Only effective if there is some residual functioning pancreatic islet cells
- Side effects - abdominal pain, decrease appetite, nausea
2) SULFONYLUREAS
- Gliclazide, glipizide, tolbutamide
- Blocks ATP sensitive K+ channels on pancreatic beta-cells. Augments insulin secretion and effective if there are residual pancreatic beta-cells actively present.
- Side effects - abdominal pain, hypoglycaemia, nausea, weight gain
3) PIOGLITAZONES
- PPAR-alpha receptor agonist, reduces peripheral insulin resistance
4) SGLUT2 INHIBITORS
- canagliflozin
- Blocks SGLUT2 channel found on PCT of kidney preventing glucose reabsorption back into blood and removed via urine.
- Side effects - UTI, genital infection, hypoglycaemia (with sulfonylurea)
5) DDP4 INHIBITORS
- linagliptin, sitagliptin
- increase insulin secretion and lower glucagon secretion. DPP4 is an enzyme that inactivates incretin (hormone that lowers blood glucose)
6) GLUCAGON LIKE PEPTIDE 1 ANALOGUES
- exenatide
- binds and activates GLP-1 receptor to increase insulin secretion, supress glucagon secretion and slow gastric emptying. No risk of hypoglycaemia
- Side effects - decrease appetite, constipation, GI discomfort

Question 13

WHAT ARE THE SYMPTOMS OF HYPOGLYCAEMIA?

Answer 13

1) Sweating
2) Palpitations
3) Feeling hungry
4) Irritable
5) Dizzy
6) Pale
7) Tingling lips
8) Shaking

Question 14

HOW IS HYPOGLYCAEMIA MANAGED IN THE CONCIOUS AND UNCONCIOUS PATIENT?

Answer 14

1) CONCIOUS - 10–20g oral glucose in liquid form or sugar lumps. If necessary this may be repeated after 10–15 minutes. Then a snack for sustained carbohydrate availability.
2) UNCOCNSIOUS - glucagon injection

Question 15

WHAT ADDITIONAL THERAPY ARE T2DM PATIENTS ON?

Answer 15

1) Statins ( simvastatin, atorvastatin) - cholesterol lowering medication
2) ACEI (Ramipril/ lisinopril) - hypertension
3) CCB (amlodipine) - hypertension

Question 16

WHAT ADDITIONAL MONITORING IS CARRIED OUT FOR T2DM?

Answer 16

1) Dilated eye examination - visual acuity, visual field, dilation, pupil response
2) Foot examination- ankle reflexes, 10g monofilament touch sensation, vibratory sensation, dorsalis pedis pulse
3) Renal function assessment - urine albumin excretion, serum creatinine, eGFR

Question 17

WHAWHAT ARE THE COMPLICATIONS OF T1DM/ T2DM?

Answer 17

1) TIA/ stroke
2) Diabetic retinopathy - increase glucose damage bv
3) Nephropathy (kidney disease)
4) DKA
5) Treatment induced hypoglycaemia
6) Coronary artery disease
7) Neuropathy (nerve damage) - foot then hands

Question 18

WHAT IS T1DM?

Answer 18

Metabolic condition causing hyperglycaemia due to absolute insulin deficiency.
Caused by immune- mediated destruction of pancreatic beta-cells.

Question 19

WHAT IS THE TARGET HbA1C FOR T1DM?

Answer 19

48 mmol/mol

Question 20

HOW OF OFTEN SHOULD HbA1C BE MONITORED?

Answer 20

every 3-6 months

Question 21

WHAT IS THE TREATMENT FOR T1DM?

Answer 21

Insulin therapy (via pump or pen) and managing risk factors

Question 22

WHAT ARE THE 4 TYPES OF INSULIN THERAPY AVAILABLE?

Answer 22

1) SHORT ACTING - Humulin/ 20 min before you eat
2) RAPID ACTING - novolog, Humalog/ taken shortly before and after meals
3) INTERMEDIATE ACTING - Humulin N/ works throughout day so only take once or twice a day
4) LONG ACTING - lantus, Levemir/ once a day and same time each day

Question 23

WHAT ARE THE SIDE EFFECTS OF INSULIN THERAPY?

Answer 23

1) hypoglycaemia
2) initial weight gain
3) Rash or swelling at injection site