Diabetes Mellitus Type 2 Flashcards
1
Q
How can type 2 diabetes mellitus be diagnosed?
A
Type 2 diabetes mellitus can be diagnosed by either a plasma glucose or a HbA1c sample.
2
Q
What are the diagnostic criteria for symptomatic patients?
A
For symptomatic patients, the criteria are:
- Fasting glucose ≥ 7.0 mmol/l
- Random glucose ≥ 11.1 mmol/l (or after 75g oral glucose tolerance test)
3
Q
What are the diagnostic criteria for asymptomatic patients?
A
For asymptomatic patients, the same criteria apply but must be demonstrated on two separate occasions.
4
Q
What HbA1c value is diagnostic of diabetes mellitus?
A
A HbA1c of ≥ 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus.
5
Q
Does a HbA1c value less than 48 mmol/mol exclude diabetes?
A
No, a HbA1c value < 48 mmol/mol (6.5%) does not exclude diabetes.
6
Q
What must be done if the HbA1c test is used for diagnosis in asymptomatic patients?
A
In asymptomatic patients, the HbA1c test must be repeated to confirm the diagnosis.
7
Q
What can cause misleading HbA1c results?
A
Increased red cell turnover can cause misleading HbA1c results.
8
Q
What conditions may prevent the use of HbA1c for diagnosis?
A
Conditions include:
- Haemoglobinopathies
- Haemolytic anaemia
- Untreated iron deficiency anaemia
- Suspected gestational diabetes
- Children
- HIV
- Chronic kidney disease
- Medications causing hyperglycaemia (e.g., corticosteroids)
9
Q
What indicates impaired fasting glucose (IFG)?
A
A fasting glucose ≥ 6.1 but < 7.0 mmol/l indicates impaired fasting glucose (IFG).
10
Q
How is impaired glucose tolerance (IGT) defined?
A
Impaired glucose tolerance (IGT) is defined as fasting plasma glucose < 7.0 mmol/l and OGTT 2-hour value ≥ 7.8 but < 11.1 mmol/l.
11
Q
What does Diabetes UK suggest for people with IFG?
A
Diabetes UK suggests that people with IFG should be offered an oral glucose tolerance test to rule out diabetes.
12
Q
What is diabetes mellitus?
A
Diabetes mellitus is a group of diseases that result in high blood sugar (too much glucose) due to insulin resistance or insufficient insulin production.
13
Q
What role does GLP-1 play in diabetes treatment?
A
GLP-1 is a hormone released by the small intestine in response to an oral glucose load, and it mediates the incretin effect, which is decreased in type 2 diabetes mellitus (T2DM).
14
Q
What are GLP-1 mimetics?
A
GLP-1 mimetics are drugs that mimic the action of glucagon-like peptide-1 to increase insulin secretion and inhibit glucagon secretion.
15
Q
What is an example of a GLP-1 mimetic?
A
Exenatide is an example of a GLP-1 mimetic.
16
Q
How does exenatide affect weight?
A
Exenatide typically results in weight loss, unlike many other diabetes medications.
17
Q
How is exenatide administered?
A
Exenatide must be given by subcutaneous injection within 60 minutes before the morning and evening meals.
18
Q
What is an advantage of liraglutide over exenatide?
A
Liraglutide only needs to be given once a day, compared to exenatide.
19
Q
What are the NICE recommendations for adding exenatide to treatment?
A
Consider adding exenatide to metformin and a sulfonylurea if BMI >= 35 kg/m² with associated problems, or BMI < 35 kg/m² with unacceptable insulin use or weight loss benefits.
20
Q
What are the major adverse effects of GLP-1 mimetics?
A
The major adverse effects are nausea and vomiting, with specific warnings about severe pancreatitis linked to exenatide.
21
Q
What are DPP-4 inhibitors?
A
DPP-4 inhibitors are drugs that increase levels of incretins (GLP-1 and GIP) by decreasing their peripheral breakdown.
22
Q
How are DPP-4 inhibitors administered?
A
DPP-4 inhibitors are available in oral preparation.
23
Q
What are the benefits of DPP-4 inhibitors?
A
DPP-4 inhibitors are relatively well tolerated, do not cause weight gain, and show no increased incidence of hypoglycaemia.
24
Q
What does NICE suggest regarding DPP-4 inhibitors?
A
NICE suggests that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems or if there has been a poor response to a thiazolidinedione.
25
What is the traditional approach to blood pressure management in patients with diabetes mellitus?
Patients with diabetes mellitus have traditionally had their blood pressure controlled more aggressively to reduce cardiovascular risk.
26
What did the 2013 Cochrane review find regarding blood pressure targets for diabetic patients?
The review cast doubt on the wisdom of lower blood pressure targets, showing that tight control (< 130/85 mmHg) had slightly reduced stroke rates but no significant difference in other outcomes.
27
What is the NICE recommended blood pressure target for type 2 diabetics?
NICE recommends a blood pressure target of < 140/90 mmHg for type 2 diabetics, the same as for patients without diabetes.
28
What are the NICE recommendations for blood pressure management in type 1 diabetes?
For type 1 diabetes, intervention levels should be 135/85 mmHg unless the patient has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg.
29
What is the first-line antihypertensive for patients with diabetes?
ACE inhibitors or angiotensin-II receptor antagonists (A2RBs) are the first-line antihypertensive regardless of age.
30
Which antihypertensive is preferred for black African or African-Caribbean diabetic patients?
A2RBs are preferred for black African or African-Caribbean diabetic patients.
31
What should be considered regarding autonomic neuropathy in patients on antihypertensive therapy?
Autonomic neuropathy may result in more postural symptoms in patients taking antihypertensive therapy.
32
What is the recommendation regarding the routine use of beta-blockers in uncomplicated hypertension?
The routine use of beta-blockers should be avoided, particularly in combination with thiazides, due to potential insulin resistance and altered autonomic response to hypoglycaemia.
33
What did NICE update in 2022 regarding type 2 diabetes mellitus (T2DM)?
NICE updated its guidance to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors.
34
What is the target HbA1c for a patient taking metformin for T2DM?
Aim for a HbA1c of 48 mmol/mol (6.5%). Only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%).
35
What dietary advice is recommended for managing T2DM?
Encourage high fibre, low glycaemic index sources of carbohydrates, include low-fat dairy products and oily fish, control intake of saturated fats and trans fatty acids, and discourage foods marketed specifically at people with diabetes.
36
What is the initial target weight loss for an overweight person with T2DM?
Initial target weight loss is 5-10%.
37
How often should HbA1c be checked in T2DM management?
HbA1c should be checked every 3-6 months until stable, then 6 monthly.
38
What are the HbA1c targets for lifestyle or single-drug treatment in T2DM?
Lifestyle: 48 mmol/mol (6.5%); Lifestyle + metformin: 48 mmol/mol (6.5%); Lifestyle + sulfonylurea: 53 mmol/mol (7.0%).
39
What should be done if a patient's HbA1c rises to 58 mmol/mol (7.5%)?
Further treatment is indicated.
40
What is the first-line drug of choice for T2DM?
Metformin remains the first-line drug of choice.
41
When should SGLT-2 inhibitors be added to metformin?
If the patient has a high risk of developing cardiovascular disease, established CVD, or chronic heart failure.
42
What should be done if metformin is contraindicated?
If the patient has a risk of CVD, established CVD, or chronic heart failure: SGLT-2 monotherapy. Otherwise, consider DPP-4 inhibitor, pioglitazone, or sulfonylurea.
43
What is the second-line therapy for T2DM if HbA1c targets are not met?
Dual therapy: metformin + DPP-4 inhibitor, metformin + pioglitazone, metformin + sulfonylurea, or metformin + SGLT-2 inhibitor (if NICE criteria met).
44
What should be considered if triple therapy for T2DM is not effective?
Consider switching one of the drugs for a GLP-1 mimetic.
45
What is the starting insulin recommendation for T2DM?
Continue metformin and start with human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily.
46
What are the blood pressure targets for patients with T2DM?
Same as for patients without type 2 diabetes: Age < 80 years: 140/90 mmHg; Age > 80 years: 150/90 mmHg.
47
What is the first-line statin of choice for patients with T2DM?
Atorvastatin 20mg.
48
What is the prevalence of type 2 diabetes mellitus among Asian ethnicity in the UK?
Type 2 diabetes mellitus is more common in people of Asian ethnicity, and a significant proportion of those patients in the UK will be Muslim.
49
Why is it important to give advice to Muslim patients during Ramadan?
It is important to give appropriate advice to Muslim patients to allow them to safely observe their fast, especially as Ramadan will fall in the long days of summer for several years.
50
What is the personal decision regarding fasting for patients with chronic conditions?
It is a personal decision whether a patient decides to fast, but people with chronic conditions are exempt from fasting or may delay fasting to shorter days.
51
What percentage of Muslim patients with type 2 diabetes mellitus fast during Ramadan?
Around 79% of Muslim patients with type 2 diabetes mellitus fast during Ramadan.
52
What resources are available for Muslim patients with diabetes regarding fasting?
There is an excellent patient information leaflet from Diabetes UK and the Muslim Council of Britain that explores fasting options in more detail.
53
What should a patient with type 2 diabetes mellitus eat before sunrise during Ramadan?
They should try to eat a meal containing long-acting carbohydrates prior to sunrise (Suhoor).
54
What should patients with diabetes be provided to monitor their health during fasting?
Patients should be given a blood glucose monitor to check their glucose levels, particularly if they feel unwell.
55
How should the metformin dosage be adjusted for fasting patients?
The expert consensus is that the metformin dose should be split one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar).
56
What is recommended for patients taking sulfonylureas during Ramadan?
Expert consensus recommends switching once-daily sulfonylureas to after sunset. For twice-daily preparations like gliclazide, a larger proportion of the dose should be taken after sunset.
57
Is any adjustment needed for patients taking pioglitazone during Ramadan?
No adjustment is needed for patients taking pioglitazone.
58
What should patients with type 2 diabetes do during an acute illness?
Advise the patient to temporarily stop some oral hypoglycaemics.
59
When can medication be restarted for patients with type 2 diabetes after an illness?
Medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours.
60
What should be done with metformin during acute illness?
Stop treatment if there is a risk of dehydration to reduce the risk of lactic acidosis.
61
What is the risk of continuing sulfonylureas during an acute illness?
May increase the risk of hypoglycaemia.
62
What should be checked when using SGLT-2 inhibitors during acute illness?
Check for ketones and stop treatment if acutely unwell and/or at risk of dehydration due to the risk of euglycaemic DKA.
63
What should be done with GLP-1 receptor agonists during acute illness?
Stop treatment if there is a risk of dehydration to reduce the risk of AKI.
64
What should patients on insulin therapy do during an acute illness?
Do not stop treatment.
65
What should be monitored more frequently during an acute illness?
Monitor blood glucose more frequently as necessary.
66
What is diabetic foot disease?
Diabetic foot disease is an important complication of diabetes mellitus that should be screened for on a regular basis.
## Footnote
NICE produced guidelines relating to diabetic foot disease in 2015.
67
What are the main factors contributing to diabetic foot disease?
Diabetic foot disease occurs secondary to two main factors: neuropathy and peripheral arterial disease.
68
What is neuropathy in the context of diabetic foot disease?
Neuropathy results in loss of protective sensation, which can lead to issues such as not noticing a stone in the shoe, Charcot's arthropathy, and dry skin.
69
What is peripheral arterial disease?
Peripheral arterial disease is a condition where diabetes is a risk factor for both macro and microvascular ischaemia.
70
What are the presentations of diabetic foot disease?
Presentations include loss of sensation (neuropathy), absent foot pulses, reduced ankle-brachial pressure index (ABPI), and intermittent claudication.
## Footnote
Complications can include calluses, ulceration, Charcot's arthropathy, cellulitis, osteomyelitis, and gangrene.
71
How often should patients with diabetes be screened for diabetic foot disease?
All patients with diabetes should be screened for diabetic foot disease on at least an annual basis.
72
How is screening for ischaemia performed?
Screening for ischaemia is done by palpating for both the dorsalis pedis pulse and posterior tibial artery pulse.
73
How is screening for neuropathy performed?
Screening for neuropathy is done using a 10 g monofilament on various parts of the sole of the foot.
74
What does NICE recommend regarding risk stratification for diabetic foot disease?
NICE recommends that we risk stratify patients into low risk, moderate risk, and high risk categories.
75
What defines low risk for diabetic foot disease?
Low risk is defined as having no risk factors except callus alone.
76
What defines moderate risk for diabetic foot disease?
Moderate risk includes having deformity, neuropathy, or non-critical limb ischaemia.
77
What defines high risk for diabetic foot disease?
High risk includes previous ulceration, previous amputation, renal replacement therapy, or combinations of neuropathy and non-critical limb ischaemia, callus, or deformity.
78
What should happen to patients who are moderate or high risk?
All patients who are moderate or high risk should be followed up regularly by the local diabetic foot centre.
79
What is Metformin?
Metformin is a biguanide used mainly in the treatment of type 2 diabetes mellitus.
80
What are the main benefits of Metformin?
It improves glucose tolerance, does not cause hypoglycaemia or weight gain, and is first-line treatment, especially for overweight patients.
81
What other conditions is Metformin used for?
It is also used in polycystic ovarian syndrome and non-alcoholic fatty liver disease.
82
What is the mechanism of action of Metformin?
Metformin acts by activation of the AMP-activated protein kinase (AMPK), increases insulin sensitivity, decreases hepatic gluconeogenesis, and may reduce gastrointestinal absorption of carbohydrates.
83
What are common adverse effects of Metformin?
Gastrointestinal upsets such as nausea, anorexia, and diarrhoea are common, intolerable in 20% of patients.
84
What is a rare but serious adverse effect of Metformin?
Lactic acidosis can occur with severe liver disease or renal failure.
85
What are the contraindications for Metformin?
Chronic kidney disease, tissue hypoxia, iodine-containing x-ray contrast media, and alcohol abuse.
86
What should be done if creatinine levels are > 130 µmol/l?
The dose of Metformin should be reviewed.
87
When should Metformin be discontinued?
Metformin should be stopped if creatinine is > 150 µmol/l or during procedures with iodine-containing contrast media.
88
How should Metformin be started?
Metformin should be titrated up slowly to reduce gastrointestinal side effects.
89
What should be considered if patients develop unacceptable side effects?
Modified-release Metformin should be considered.
90
What is prediabetes?
Prediabetes is a term used for impaired glucose levels that are above the normal range but not high enough for a diagnosis of diabetes mellitus.
91
What conditions fall under prediabetes?
Prediabetes includes patients with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT).
92
What is the estimated prevalence of prediabetes in the UK?
Diabetes UK estimates that around 1 in 7 adults in the UK have prediabetes.
93
What is the risk associated with prediabetes?
Many individuals with prediabetes will progress to developing type 2 diabetes mellitus (T2DM) and are at greater risk of microvascular and macrovascular complications.
94
What terminology does Diabetes UK recommend for discussing prediabetes?
Diabetes UK recommends using 'prediabetes' when talking to patients and 'impaired glucose regulation' when talking to healthcare professionals.
95
What tool does NICE recommend for identifying patients with prediabetes?
NICE recommends using a validated computer-based risk assessment tool for all adults aged 40 and over, South Asian and Chinese descent aged 25-39, and adults with conditions that increase the risk of type 2 diabetes.
96
What blood glucose levels indicate high risk for prediabetes?
A fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk.
97
What management strategies are recommended for prediabetes?
Management includes lifestyle modification: weight loss, increased exercise, and dietary changes, along with at least yearly follow-up blood tests.
98
What medication does NICE recommend for high-risk adults with prediabetes?
NICE recommends metformin for adults at high risk whose blood glucose measures indicate progression towards type 2 diabetes despite lifestyle changes.
99
What are the two main types of impaired glucose regulation?
The two main types are impaired fasting glucose (IFG) and impaired glucose tolerance (IGT).
100
What does impaired fasting glucose (IFG) indicate?
IFG is due to hepatic insulin resistance and is defined as a fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l.
101
What defines impaired glucose tolerance (IGT)?
IGT is defined as fasting plasma glucose less than 7.0 mmol/l and an OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l.
102
What should be done for patients with IFG?
Patients with IFG should be offered an oral glucose tolerance test to rule out diabetes.
103
What does a result below 11.1 mmol/l but above 7.8 mmol/l indicate?
It indicates that the person doesn't have diabetes but does have impaired glucose tolerance (IGT).
104
What do SGLT-2 inhibitors do?
SGLT-2 inhibitors reversibly inhibit sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.
105
Name examples of SGLT-2 inhibitors.
Examples include canagliflozin, dapagliflozin, and empagliflozin.
106
What are important adverse effects of SGLT-2 inhibitors?
Important adverse effects include urinary and genital infection (secondary to glycosuria), Fournier's gangrene, normoglycaemic ketoacidosis, and increased risk of lower-limb amputation.
107
What should be monitored in patients taking SGLT-2 inhibitors?
Feet should be closely monitored due to the increased risk of lower-limb amputation.
108
What effect do SGLT-2 inhibitors have on weight in patients with type 2 diabetes mellitus?
Patients taking SGLT-2 drugs often lose weight, which can be beneficial in type 2 diabetes mellitus.
109
What are the side-effects of Metformin?
Gastrointestinal side-effects, Lactic acidosis
110
What are the side-effects of Sulfonylureas?
Hypoglycaemic episodes, Increased appetite and weight gain, Syndrome of inappropriate ADH secretion, Liver dysfunction (cholestatic)
111
What are the side-effects of Glitazones?
Weight gain, Fluid retention, Liver dysfunction, Fractures
112
What are the side-effects of Gliptins?
Pancreatitis
