Diabetes Mellitus Flashcards

1
Q

Define diabetes mellitus

A

Type 1: metabolic disorder of hyperglycaemia due to absolute insulin deficiency
Type 2: metabolic disorder of hyperglycaemia due to impaired insulin secretion and insulin
resistance

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2
Q

What are the causes/risk factors of diabetes mellitus?

A

Type 1: destruction of pancreatic beta-cells -> absolute insulin deficiency
• Autoimmune disease with environmental trigger
• HLA-DQ, -DR
Associated autoimmune conditions
• Vitiligo
• Addison’s disease
• Hashimoto’s thyroiditis

Type 2
Causes
• MODY (maturity onset diabetes of the young) – autosomal
dominant
• Pancreatic disease e.g. chronic pancreatitis, pancreatic ca.
• Endocrinopathies e.g. Cushing’s syndrome, acromegaly, PCOS
• Drugs e.g. corticosteroids
Risk Factors
• Genetic predisposition: 90% concordance amongst monozygotic twins
• Older age
• Physical inactivity
• Obesity - ↑FFAs, hyperglycaemia
• Hypertension
• Dysplipidaemia
• Cardiovascular disease

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3
Q

What are the symptoms of diabetes mellitus?

A
  • Polyuria/nocturia
  • Polydipsia
  • Weight loss
  • Fatigue
  • Blurred vision
Type 1
Symptoms of DKA:
• N&V
• Abdominal pain
• Drowsiness
• Confusion
• Coma
Type 2
• Asymptomatic
• Paraesthesia
• Candida e.g. candidiasis,
balanitis, pruritus vulvae
• Skin infections e.g. cellulitis
• UTIs
Symptoms of HHS/HONK
(hyperglycaemic symptoms as above)
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4
Q

What are the signs of diabetes mellitus?

A
Type 1
Signs of DKA:
• Kussmaul breathing
• Ketotic breath
• Dry mucous membranes
• Reduced tissue turgor
Type 2
• Acanthosis nigricans
• Necrobiosis lipoidica (welldemarcated plaques with shiny
atrophic surface and redbrown edges)
• Granuloma annulare (fleshcoloured papules in rings)
• Diabetic dermopathy
(depressed pigmented scars)
Signs of HHS/HONK
• Dry mucous membranes
• Poor skin turgor
• Hypotension
• Tachycardia
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5
Q

What investigations are carried out for diabetes mellitus?

A
• Bloods
o Glucose
▪ Fasting blood glucose >7mmol/l
▪ 2hr after 75g OGTT ≥11.1mmol/l
▪ Random blood glucose ≥11.1mmol/l
▪ Symptomatic plus one positive result
▪ Asymptomatic plus two positive results
- HbA1c >48mmol/mol or 6.5%
- U&Es
- Lipid profile
• Urine albumin:creatinine ratio – microalbuminuria
• eGFR – renal insufficiency
Suspected DKA
• Bloods
- FBC – elevated WCC
- U&Es – high urea and Cr
- Glucose >11mmol/l
-o Ketones >3mmol/l
- Culture
- ABG – metabolic acidosis with high anion gap (VBG pH <7.3)
• Urine
- Glycosuria
- Ketonuria ++
- MC&amp;S
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6
Q

What is the management for diabetes mellitus?

A
Type 1
Patient education and advice
• Diabetic nurse/dietitian
• DAFNE (dose adjustment for normal eating) – measure carbohydrate intake and
adjust insulin dose
• Regular finger prick tests

Glycaemic control – insulin
• Basal bolus regimen
- Short-acting insulin e.g. lispro, aspart SC injection 3x/daily before meals
- Long-acting insulin e.g. glargine, determir SC injection 1x/daily
• Insulin pump

Hypoglycaemia
• 50g oral glucose e.g. Lucozade, sweets followed by a starchy snack
• 50ml IV 50% glucose
• 1mg IM glucagon

DKA
• IV fluid replacement with 0.9% saline
• Start IV dextrose when glucose reaches 15mmol/l
• Insulin infusion
• Potassium (in fluids)
• Monitor blood glucose, ketones, urine output and venous blood gases

Type 2
Patient education and advice
• Diabetic nurse/dietitian
Risk factor modification
• Diet – high fibre, low GI carbohydrates, low‑fat dairy products, oily fish, reduce
saturated fat
• Exercise
• Weight loss
• BP control e.g. ACE-I +/- diuretic
• Lipid control e.g. statins
• Smoking cessation
• Antiplatelet therapy e.g. aspirin (if associated CV disease)
Glycaemic control
• Measure HbA1c every 3-6 months
• Metformin (biguanide)
- Inhibits hepatic gluconeogenesis
- SE: GI upset, MALA
• Sulphonylureas (secretagogue)
- e.g. gliclazide, glibenclamide
- Blocks K+ sensitive channels in beta cells -> insulin release
- SE: hypoglycaemia, weight gain
• Thiazolinedione (insulin sensitiser)
- e.g. pioglitazone
- Activates PPARγ and ↓ insulin resistance
• Acarbose (alpha-glucosidase inhibitor)
- Reduces carbohydrate digestion
- SE: bloating, flatulence
• Incretin (GLP-1 analogue)
- e.g. exenatide, liraglutide
- ↑ insulin secretion, ↓ glucagon release, gastric emptying and appetite
• Gliptin (DPP4-inhibitor)
- e.g. sitagliptin, vildagliptin
• Gliflozin (SGLT-2 inhibitor)
- e.g. canagliflozin
- ↓ renal threshold for glucose -> ↓ glucose reabsorption
• Insulin
- SE: weight gain, lipid hypertrophy at injection sites
HHS/HONK
• IV fluid replacement (0.45% saline if Na+ >170mmol/l)
• Start IV dextrose when glucose reaches 15mmol/l
• Insulin infusion
• Potassium (in fluids)
• Monitor blood glucose, ketones, urine output and venous blood gases
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7
Q

What are the complications of diabetes mellitus?

A

Type 1
• Diabetic ketoacidosis
- Infection
- Newly diagnosed diabetes

Type 2
• Hyperosmolar non-ketotic state

Type 1 and Type 2
• Microvascular
- Retinopathy – regular digital retinal photography
- Neuropathy – foot care/hygiene
▪ Peripheral neuropathy
▪ Painful neuropathy - amityrptilline, duloxetine, gabapentin
▪ Carpal tunnel syndrome
▪ Diabetic amyotrophy
▪ Mononeuritis multiplex e.g. pupil sparing IIIrd nerve palsy
▪ Autonomic neuropathy
- Nephropathy – monitor U&amp;Es, eGFR, Alb:Cr, BP control
▪ Microalbuminuria
▪ Proteinuria
▪ Renal failure
• Macrovascular
- Peripheral vascular disease
- Ischaemic heart disease
- Stroke/TIA
• Gastroparesis
• Impotence/erectile dysfunction
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8
Q

What are the features of different retinopathies?

A
Background
• Hard exudates (cholesterol)
• Microaneurysms
• Blot haemorrhages
Treatment:
- Improve blood
glucose control
Pre-proliferative 
• Cotton wool spots (soft
exudates) – retinal ischaemia
Treatment:
- Pan retinal
photocoagulation

Proliferative
• New vessels – angiogenesis
• Vessels may bleed into
vitreous humour -> blindness

Maculopathy
• Macular oedema
• Exudates/haemorrhages closeto fovea

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