Diabetes Mellitus Flashcards
What is diabetes mellitus?
Diabetes mellitus is a metabolic, chronic disease associated with abnormally high levels of the sugar glucose in the blood.
What two mechanisms is diabetes mellitus caused by?
- inadequate production of insulin (which is made by the pancreas and lowers blood glucose)
- inadequate sensitivity of cells to the action of insulin
What are the clinical manifestations of hypoglycaemia?
Racing pulse
Cold sweats
Pale face
Headache
Feeling incredibly hungry
Shivering, feeling weak in the knees
Feeling restless, nervous or anxious
Difficulty concentrating, confusion
What are the clinical manifestations of hyperglycaemia?
Extreme thirst, drinking a lot and then urinating frequently as a result
Unintentionally losing a lot of weight within a few weeks
Noticeable loss of energy with muscle weakness, tiredness and generally feeling quite unwell
Nausea and stomachache
Trouble seeing
Poor concentration
Frequent infections (cystitis, thrush)
Confusion and drowsiness, or even coma
What is the normal HbA1c?
4-5.6%
What is the best laboratory test for monitoring diabetic control?
HbA1c
Extra:
(1) hemoglobin A1c (HbA1c) ≥ 6.5% (48mmol/mol) OR
(2) fasting plasma glucose (FPG – for at least 8 h) ≥ 126 mg/dl (7.0 mmol/L) OR
(3) two-hour plasma glucose (2-h PG) ≥ 200 mg/dl (11.1mmol/L) during an oral glucose tolerance test (OGTT) (glucose load containing 75 grams anhydrous glucose dissolved in water) OR
(4) in a patient with classic symptoms of diabetes or during a hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dl (11.1 mmol/L)
List risks of DM patients during and after surgery
During – hypoglycemia/hyperglycemia
After – poor wound healing and infection
What are the characteristics of T1DM?
Question asks to compare between the two types of DM
Type 1:
- Insulin dependent (absolute or marked insulin deficiency caused by T cell mediated autoimmune disease, viral infection or trauma)
- Not related to behavioural factors or lifestyle
- Account for 5 -10 %, mainly affect young patients
- Treatment require continuous injection of insulin
What are the characteristics of T2DM?
Question asks to compare between the two types of DM
Type 2:
- Non-insulin dependent
- Caused by insulin resistance + beta cell failure (both needed for disease to occur)
- Accounts for >90% of DM, mainly in adults
- Related to lifestyle
- Reversible by lifestyle changes and medication like OHAs
Note:
Normally insulin sensitive cells throughout the body, most notably adipose, skeletal muscle, and liver, become less sensitive to insulin, which results in the β cells secreting larger quantities of insulin to overcome the resistance and prevent hyperglycemia. Eventually the β cells are no longer able to overcome the insulin resistance, and hyperglycemia results.
What are the two other types of DM?
Gestational:
impaired glucose regulation (elevated fasting glucose or abnormal glucose tolerance) that develops or is first recognized during pregnancy
because placenta release hormones to make it harder to produce insulin
MODY (Maturity onset diabetes of the young)(5% of DM, inherited):
Trauma, pancreatitis, cystic fibrosis, and pancreatic carcinoma –> destroy beta cells
What are the complications of DM?
- Higher risk of periodontitis
- Dental caries (root caries)
- Xerostomia (inversely related to HbA1c levels)
- Candida infection
- Burning mouth syndrome
- Poor wound healing (see below for details)
- Neuropathy
see pdf p144 for more
How does DM cause candida infection?
- Higher levels of glucose in tissues because
- Reduced phagocytosis and killing capacity of PMNs
- Higher risk for denture stomatitis (mucosal surface below the acrylic portion of the denture)
How does DM cause neuropathy?
- Neural cells death due to decreased vasculature
uncontrolled high blood sugar damages nerves and interferes with their ability to send signals, leading to diabetic neuropathy.
- Neuropeptides like nerve growth factors and substance P are relevant to wound healing, which promote cell chemotaxis, induce growth factor production, stimulate cell proliferation
- Decreased neuropeptides is associated with neuropathy
- Moreover, sensation can modulate immune response, with denervated skin exhibit reduced leukocyte infiltration
- Deposition of sorbitol and fructose in axon/ myelin sheath reduce oxidative resistance of neurons
What is the oral condition if the patient continues the diabetic medication without intake of food? (1mark)
Hypoglycemia –> excessive salivation
2 signs that the patient may complain about the condition (2marks)
Drooling, thick saliva, difficulty in speaking
What is the most probable diagnosis? (1mark)
Diabetic hypoglycemia
One device to monitor the oxygen saturation (1mark)
Pulse oximeter
Two ways to resolve airway obstruction (2makrs)
- Chin lift and jaw thrust (lying down)
- Bag-valve-mask ventilation with high flow oxygen
- Take out foreign object causing obstruction
Investigation to delineate the extent of swelling (1mark)
MRI
Two definite treatments (2marks) (pain on left molar + DM)
Incision and drainage
Extraction of molar
Precautions for IDDM patients (2marks)
IDDM = insulin-dependent diabetes mellitus
1. Take good medical history + assess glycemic control
- Schedule visits in the morning (more cortisol –> higher blood sugar level)
- Don’t schedule visits at peak insulin activity
- Tell patient to eat breakfast + take insulin
- Be aware of hypoglycemic episodes
What questions will you ask to assess the diabetic control?
What medications did you take today?
Did you take the same amount as you would normally take?
How often do you check your glucose level?
What was the most recent reading?
How do you manage the condition if the patient is hypoglycaemic?
Depends if patient is conscious?
How do you manage a hypoglycaemic patient that is conscious?
- Treat with 15g simple carbohydrates (one-half can of soda / 3 to 4 glucose tablets)
- Repeat finger-stick glucose test in 15 mins
- If blood glucose level > 3.3 mmol/L –> ask patient to eat meal / mixed snack that include carbohydrate, lipids, fats to maintain blood glucose level (pure carbohydrate diet will cause patient to revert back to hypoglycemia quickly, while sustained glucose release is preferred)
- If blood glucose level < 3.3 mmol/L –> repeat intake of 15g simple carbohydrates and re-measure after 15 mins until > 60 mg/dL
How do you manage a hypoglycaemic patient that is unconscious?
- Administer 5 –25 g of 50% dextrose solution intravenously
Or 1 mg glucagon injection intramuscularly - Refer to A&E
Look over page 4-6 (Old written)
For treatment algorithms
NOW
What is diabetic coma
A life-threatening, reversible form of unconsciousness, caused by severe hypoglycemia, advanced diabetic ketoacidosis or nonketotic hyperosmolar coma
Medication for DM (List 2)
- Metformin/ biguanide
- Decrease hepatic glucose production
- First line therapy, no risk of hypoglycemia
- Can cause diarrhea, abdominal discomffort, nausea, vomiting - Sulfonylurea
- Close K ATP channel on pancreatic B cells, stimulate insulin secretions
- Generics available
- Can cause hypoglycemia, weight gain
How does hyperglycemia activate pathways of inflammation, oxidative stress and apoptosis?
Page 4 old written doc
