Diabetes Mx in Primary care (1) Flashcards
Physiology review - cells of the pancreas:
- cells that secrete glucagon
- cells that secrete insulin
- cells that secrete somatostatin
- which areas do contain endocrine tissue within the pancreas?
- Glucagon -> alpha cells
- Insulin -> beta cells
- Samatostatin -> delta cells
- Endocrine tissue within the pancreas -> Islets of Langerhans
WHO type 1 DM diagnostic criteria
(symptoms and bloods)
Diabetes Mellitus
symptoms ( Polyuria, Polydipsia and unexplained weight loss) plus
- Random venous plasma glucose concentration of ≥ [11.1] mmol/l or
- Fasting venous plasma glucose concentration of ≥ [7.0] mmol/l or
- Plasma glucose concentration ≥ 11.1 mmol/l [two] hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT)
What’s diagnostic (apart from symptoms) of T1DM in terms of random venous plasma glucose concentration?
Random venous plasma glucose concentration of ≥ [11.1] mmol/l
What’s diagnostic (apart from symptoms) of T1DM in terms of fasting venous plasma glucose concentration?
Fasting venous plasma glucose concentration of ≥ [7.0] mmol/l
How many hours do we check plasma glucose concentration in oral tolerance test?
Plasma glucose concentration ≥ 11.1 mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT)
If no symptoms, can we make a diagnosis of DM based on a single glucose reading?
- with no symptoms, diagnosis should not be based on a a single glucose determination
- requires confirmatory plasma venous determination -> At least one additional glucose test result on another day (with a value in the diabetic range )
- either fasting, from a random sample or from the two hour post glucose load
- if the fasting random values are not diagnostic the two-hour value should be used
What medication is the 1st line in Rx of T2DM?
Metformin
Are statins used in all T2DM in order to lower the risks of CVD?
No, it depends on a patient’s QRISK assessmnet
What’s the commonest reason why the patients would stop taking Metformin?
diarrhoea and GI disturbance
*these are common side effects -> to reduce their likelihood introduce metformin gradually
What pattern of neurological damage does diabetic neuropathy usually present with?
Glove and stocking distribution
What is the most common cause of death in patients with T2DM?
CVD: stroke, MI etc.
What’s:
- glycogenesis
- gluconeogenesis
- glycogenolysis
- glycogenesis = glucose ->glycogen (liver store)
- gluconeogenesis = non-carbohydrate sources -> glucose
- glycogenolysis = glycogen (liver store) *-> glucose-6- phosphate
*this process is induced by glucagon from the pancreas
Symptoms of hypoglycaemia
Hypoglycaemia symptoms
- fatigue
- faint
- seizures
- tachycardia
- neurological damage (may be permanent if hypoglycaemia is not treated for long time)
- LOC -> injury/trauma
Symptoms of hyperglycaemia
Hyperglycaemia symptoms
- polyuria
- polydipsia
*leading to dehydration
- vascular retinopathy/ nephropathy/ neuropathy
- increased CVD risk
- confusion
- DKA (high blood glucose, but low insulin -> so cannot get into the cells)
What’s the classical presentation of T1DM?
T1DM classical presentation
- young patient
- fairly rapid onset of thirst, polyuria and polydipsia
- sometimes may present as acutely unwell, with DKA
What is the most common presentation of T2DM?
Asymptomatic
What other conditions may an otherwise asymptomatic person with T2DM present with?
- lightheadedness
- clumsiness/ weakness/tingling -> diabetic neuropathy
- recurrent cellulitis
- recurrent candidiasis or balanitis (in men)
- cramps -> due to polydipsia and polyuria leading to dehydration = electrolyte imbalance
- visual disturbance -> due to retinopathy
- CKD/AKI -> due to nephropathy
- stroke/MI/ PVD
- erectile dysfunction
- increased BP (nephropathy)
What does HbA1C tell us?
HbA1C = glycosylated haemoglobin -> how much glucose attach to RBCs
*considers period of 2-3 months
Ranges for HbA1C
- normal
- impaired glucose tolerance (pre-diabetic)
- diabetes
Hb1Ac ranges
- Normal:<42
- Impaired glucose tolerance: 42-47
- Diabetes: >/= 48
Ranges for fasting glucose
- normal
- impaired glucose tolerance (pre-diabetic)
- diabetes
Fasting glucose
- normal:<5.5
- impaired glucose tolerance (pre-diabetic):5.5 - 6.9 mmol/L
- diabetes: >/= 7,0 mmol/L
Ranges for random glucose
- diabetes (*just that criteria is provided)
Ranges for random glucose
- diabetes: >/= 11.1 mmol/L
Ranges for 2-hour glucose in OGTT
- normal
- impaired glucose tolerance (pre-diabetic)
- diabetes
Ranges for 2-hour glucose in OGTT
- normal: <7.8 mmol/L
- impaired glucose tolerance (pre-diabetic): 7.8-11.0 mmol/L
- diabetes: >/= 11.1 mmol/L
What to do if the initial testing is within the diabetic range and patient is asymptomatic?
Repeat the same test 2 weeks later (to confirm the diagnosis)
How long before the ‘fasting glucose’ test does a patient need to fast?
6 hours before
How many tests are needed to confirm the diagnosis of diabetes in:
- asymptomatic patient
- symptomatic patient
Asymptomatic -> two tests needed
Symptomatic -> one test is enough
What conditions may alter the results of HbA1C? (in general)
Anything that affects haemoglobin level (as glycosylated haemoglobin tested)
Examples of conditions that may make the HbA1c result too low
Conditions that will cause low RBCs (so fewer RBCs for glucose to be attached - maybe false low result)
- anaemia and haemolytic anaemia
- sickle cell
- leukaemia
- myelodysplastic syndrome
- thalassemia
Examples of conditions and (2) types of medications that may make the HbA1c result too high
More RBCs -> more glucose can attach to it
- splenectomy (no spleen so less old RBCs will be destroyed)
Drugs that increase glucose levels:
- steroids
- anti psychotics
What (3) groups of patients would be taking HbA1c reading not be reliable?
- if blood transfusion -> as someone else’s blood
- pregnancy -> as more foetal Hb
- children -> more foetal haem
What tests to do in patients who would have not reliable HbA1 readings? (e.g. pregnancy, anaemia etc)
- Fasting glucose test
- 2 hours glucose tolerance (18-28 weeks pregnant women)
