Diabetes Mellitus Type 2 Flashcards
Define Diabetes Mellitus Type 2
Chronic syndrome of impaired carbohydrate, protein and fat metabolism characterised by increased peripheral target-tissue resistance to insulin action, impaired insulin secretion and a raised hepatic glucose output
What is the aetiology of T2DM
Insulin resistance + impaired secretion → hyperglycaemia
Insulin resistance primarily affects the liver, muscle and adipocytes
BG genetic predisposition (90% MZ twin concordance)
Secondary to
- pancreatic disease: chronic pancreatitis, haemochromatosis, pancreatic cancer, iatrogenic
- Endocrine: Cushing’s, acromegaly, phaeos, glucagonoma
- Drugs e.g. steroids, antipsychotics, protease inhibitors
What are the risk factors for T2DM
Strong family history
Obesity or overweight
Older age
Physical inactivity
Black or Asian ethnicity
Hypertension
Lipid disorders (hypercholesterolaemia)
What are the symptoms of T2DM
Asymptomatic
Tiredness, fatigue
Blurred vision
Polyuria, polydipsia, nocturia
Paraesthesia
Polyphagia
Increased risk of infections: foot ulcers, candidiasis, balanitis, pruritus vulvae, cellulitis, UTIs
What are the signs of T2DM on examination
BMI: raised
BP: ?HTN
Skin:
- Acanthosis nigricans (Light brown-black marking on the neck, on the axillar or on the groin)
- Necrobiosis lipodica (well-demarcated plaques on shins/arms with shiny atrophic surface and red-brown edges)
- Granuloma annulare (flesh-coloured papules coalescing in rings on hands and fingers)
- Diabetic dermopathy (depressed pigmented scars on shins)
Diabetic foot: dry skin, reduced SC tissue corns, calluses, ulceration, gangrene, Charcot’s arthropathy, reduced/absent foot pulses
What investigations should be done for T2DM
Bedside: BM, urine dip, urinary ketones (+ve = T1DM, -ve = T2), ECG, fundoscopy
Bloods
- Random plasma glucose: >11
- Fasting plasma glucose: >6.9
- HbA1c: >48 (glucose for 2-3 months)
- OGTT >11.1 (impaired = 7.9-11.1) - for borderline/GDM
- Plasma ketones: negative (diff from T1)
- Fasting C peptide: >1 (diff from T1)
- Auto-immune markers: -ve
- Fasting lipid: often normal, may be raised
- Renal function
What is the management for T2DM
- Lifestyle changes: Personalised self-management programme, usually developed by a diabetes education nurse or nutritionist.
- Glycaemic management
- Monitoring
What are the lifestyle changes recommended to those with T2DM
Limiting caloric intake
Moderate physical activity (improve control, weight maintenance, CV risk reduction): 3-4 aerobic activities per week
Weight loss
Reduce alcohol intake
Smoking cessation
What are the options for glycaemic control in T2DM
After lifestyle advice → HbA1c remains >48 →
1. Metformin
2. Metformin + DPP4i, pioglitazone, SU, SGLTI-2i
3. Metformin + 2 glycaemic control drugs OR insulin
What monitoring should be done for children with T2DM
Hypertension
Dyslipidaemia
Albuminuria (Kidney disease) via ACR
Retinopathy (refer)
Periodontitis
What are the complications of T2DM
Hyperosmolar hyperglycaemic state (HHS)
Microvascular: retinopathy, neuropathy, nephropathy
Macrovascular:
Diabetic foot
What is Hyperosmolar hyperglycaemic state
Insulin deficiency, hyperglycaemia (NO ketonaemia as enough insulin to suppress ketogenesis)
Dehydration → increased osmolality
Presents with:
Weakness, leg cramps, visual disturbance, N&V, confusion & lethargy, focal neurological symptoms
Marked dehydration
Hypernatraemia
Hyperglycaemia
Hyperosmolar
What is the management for Hyperosmolar hyperglycaemic state
- 0.9% sodium at a rate of 15-20ml/kg/hour for the first hour + replace K+ if required
- Continue fluid resus at a slower rate
- Insulin should be started to correct the hyperglycaemia, initially with a bolus of 0.1units/kg, followed by a fixed rate insulin infusion at 0.1units/kg/hour.
