Diabetes Mellitus Type 2

Question 1

Define Type 2 Diabetes Mellitus?

Answer 1

Characterised by increased peripheral resistance to insulin action, impaired insulin secretion and increased hepatic glucose output

Question 2

What is the aetiology of Type 2 Diabetes Mellitus?

Answer 2

Genetic and environmental
There are a few monogenic causes of diabetes (e.g. MODY, mitochondrial diabetes)
Obesity increases the risk of T2DM (due to the action of adipocytokines)

Question 3

What can Diabetes happen secondary to?

Answer 3

Pancreatic Disease (e.g. chronic pancreatitis)
Endocrine Disease (e.g. Cushing's Syndrome, acromegaly, phaeochromocytoma, glucagonoma)
Drugs (e.g. corticosteroids, atypical antipsychotics, protease inhibitors)

Question 4

What is the epidemiology of Type 2 Diabetes Mellitus?

Answer 4

UK prevalence: 5-10%
Asian, African and Hispanic people are at greater risk
Incidence has increased over the past 20 yrs
This is linked to an increasing prevalence of obesity

Question 5

What are the presenting symptoms of Type 2 Diabetes Mellitus?

Answer 5

May be an incidental ginding
Polyuria
Polydipsia 
Tiredness 
Patients may present with hyperosmolar hyperglycaemic state (HHS)
Infections
Assess cardiovascular risk factors

Question 6

What are some examples of infections patients with Type 2 Diabetes Mellitus might present with?

Answer 6

Infected foot ulcers
Candidiasis
Balanitis

Question 7

What cardiovascular risk factors do we need to assess in Type 2 Diabetes Mellitus?

Answer 7

Hypertension
Hyperlipidaemia
Smoking

Question 8

What are the signs of Type 2 Diabetes Mellitus on physical examination?

Answer 8

Calculate BMI
Waist Circumference 
Blood Pressure 
Diabetic foot (ischaemic and neuropathic signs)
Skin changes (rare)

Question 9

What are the signs of Diabetic Foot in Type 2 Diabetes Mellitus?

Answer 9

Dry Skin
Reduced subcutaneous Tissue 
Ulceration
Gangrene 
Charcot's arthropathy
Weak foot pulses

Question 10

What are some of the rare skin changes in Type 2 Diabetes Mellitus?

Answer 10

Necrobiosis Lipoidica Diabeticorum
Granuloma Annulare
Diabetic Dermopathy

Question 11

What is Necrobiosis Lipoidica Diabeticorum?

Answer 11

Well-demarcated plaques on shins or arms with shiny atrophic surface and red-brown edges

Question 12

What is Granuloma Annulare?

Answer 12

Flesh-coloured papules in rings on the back of hands and fingers

Question 13

What is Diabetic Dermopathy?

Answer 13

Depressed pigmented scars on shins

Question 14

How is Type 2 Diabetes Mellitus diagnosed?

Answer 14

If one or more of the following are present:

• Symptoms of diabetes and a random plasma glucose > 11.1 mmol/L
• Fasting plasma glucose > 7 mmol/L
• Two-hour plasma glucose > 11.1 mmol/L after 75 g oral glucose tolerance test

Question 15

What do you monitor in Type 2 Diabetes Mellitus?

Answer 15

HbA1c
U&Es 
Lipid Profile 
eGFR 
Urine albumin: creatinine ratio (look out for microalbuminuria)

Question 16

What is the step-wise approach to glycaemic control in the management of T2DM?

Answer 16

At diagnosis: lifestyle + metformin
If HbA1c > 7% after 3 months: Lifestyle + merformin + sulphonylurea/basal insulin
If HbA1c > 7% after 3 months and fasting blood glucose > 7 mmol/L: add premeal rapid-acting insulin

Question 17

When is sulphonyurea given as a monotherapy in Type 2 Diabetes Mellitus treatment?

Answer 17

If patients can’t tolerate metformin

Question 18

What can be given alongside metformin and a sulphonyurea in the treatment of Type 2 Diabetes Mellitus?

Answer 18

Pioglitazone (thiazolidinedione)

Question 19

How do we screen for complications of Type 2 Diabetes Mellitus?

Answer 19

Retinopathy
Nephropathy
Vascular Disease 
Diabetic foot
Cardiovascular risk factors (e.g. BP, cholesterol)

Question 20

What do you have to do with pregnancy if you’re a patient with Type 2 Diabetes Mellitus?

Answer 20

Requires strict glycaemic control and planning of conception

Question 21

What is the management if the patient is in the Hyperosmolar Hyperglycaemic State in Type 2 Diabetes Mellitus?

Answer 21

Management is similar to DKA

Expect use 0.45% saline if serum Na+ > 170 mmol/L

Question 22

What are the possible complications of Type 2 Diabetes Mellitus?

Answer 22

Hyperosmolar Hyperglycaemic State 
Neuropathy
Nephropathy
Retinopathy
Macrovascular Complications

Question 23

What are the specific complications of a patient in the Hyperosmolar Hyperglycaemic State?

Answer 23

Due to insulin deficiency 
Marked dehydration
High Na+ 
High glucose
High osmolality 
No acidosis

Question 24

What are the specific complications related to Neuropathy in a patient with Type 2 Diabetes Mellitus?

Answer 24

Distal symmetrical sensory neuropathy
Painful neuropathy
Carpel Tunnel syndrome
Diabetic amyotrophy
Mononeuritis 
Autonomic Neuropathy
Gastroparesis (abdominal pain, nausea, vomiting)
Impotence 
Urinary Retention

Question 25

What are the specific complications related to Nephropathy in Type 2 Diabetes Mellitus?

Answer 25

Microalbuminuria
Proteinuria 
Renal Failure 
Prone to UTI
Renal papillary necrosis

Question 26

What are the specific complications related to Retinopathy in Type 2 Diabetes Mellitus?

Answer 26

Background
Pre-proliferative 
Proliferative 
Maculopathy
Prone to glaucoma, cataracts and transient visual loss

Question 27

What are the macrovascular complications of Type 2 Diabetes Mellitus?

Answer 27

Ischaemic Heart Disease
Stroke
Peripheral Vascular Disease

Question 28

What is the prognosis for patients with Type 2 Diabetes Mellitus?

Answer 28

Good prognosis with good control

Question 29

How can pre-diabetes be diagnosed?

Answer 29

Based on fasting blood glucose and oral glucose tolerance test:
Impaired Fasting Glucose (IFG) = Fasting blood glucose 5.6-6.9 mmol/L
Impaired Glucose Tolerance (IGT) = plasma glucose level of 7.8-11.0 mmol/L measured 2 hrs after a 75 g oral glucose tolerance test
People with IFG or IGT are at high risk of developing Type 2 Diabetes Mellitus