Diabetic Mellitus: diagnosis, clinical features & management Flashcards
1
Q
what is the definition of diabetes mellitus
A
a group of metabolic diseases characterised by hyperglycaemia resulting from defects in insulin secretion, insulin action or both. the chronic hyperglycaemia is associated with long-term damage, dysfunction and failure of various organs, especially the eyes, kidney, nerves, heart and blood vessels
2
Q
what is diabetes a group of metabolic diseases in
A
the endocrine
3
Q
what is hyperglycaemia
A
raised blood glucose
4
Q
what is a defect in insulin secretion from
A
problems with the pancreas
5
Q
what is a defect in insulin action
A
the tissues don’t receive the insulin properly or respond to it properly
6
Q
what can still occur even if diabetes is treated
A
long term damage, dysfunction, failure of various organs
7
Q
what do diabetes sufferers have a higher risk of
A
heart attack & stroke
8
Q
what does insulin lower
A
lowers blood glucose
9
Q
how does insulin lower blood glucose level
A
by suppressing glycogenolysis and gluconeogenesis in the liver
10
Q
what is gluconeogenesis
A
synthesis of glucose
11
Q
what does insulin stimulate
A
glucose uptake into skeletal muscle (and to a lesser extent, fat and cardiac muscle)
12
Q
what limits are blood glucose levels maintained within
A
narrow limits, 3.5 - 8.0 mmol/l
13
Q
what levels remains the least changed during the day
A
blood glucose levels
14
Q
what also goes up as well as blood glucose levels after having a meal and why
A
insulin production, to maintain homeostasis (they mirror each other)
15
Q
which organ does the insulin act on in order for glucose to be taken up by the cells
A
the liver which breaks down glycogen into glucose
16
Q
what is the most common group of diabetics
A
it is age related and people are living longer, so cases will rise
17
Q
what do most healthcare costs of diabetes result from
A
complications requiring hospital admission and treatment e.g. coronary heart disease, cerebrovascular disease, microvascular disease
18
Q
how common is diabetes
A
very common, England 5.1% Northern Ireland 4.5% Wales 4.6% Scotland 3.9%
19
Q
what are the two classifications of diabetes
A
primary or secondary
20
Q
how many new cases does secondary diabetes represent
A
1-2%
21
Q
how many new cases does primary diabetes represent
A
98%
22
Q
what can cause secondary diabetes
A
- pancreatic daises/cancer
- drug induced - steroids which impacts cardiovascular metabolism
- gestational diabetes
23
Q
what is gestational diabetes
A
diabetes that arises during pregnancy (usually during 2nd or 3rd trimester) become normal after birth
24
Q
what implications can gestational diabetes have on a woman
A
they can develop diabetes later in life
25
what can primary diabetes be classified as
type 1 - insulin dependent
or
type 2 - non insulin dependent
26
in the UK, how many % of people have type 1 diabetes
10%
27
in the UK, how many % of people have type 2 diabetes
90%
28
what is type 1 diabetes due to
destruction of beta cells in the pancreas islets of langerhans by autoimmune attack
loss of insulin production
29
what is the autoimmune attack triggered by in type 1 diabetes
combination of genetic and environmental factors
30
how long can type 2 diabetes patients survive without insulin for after diagnosis
at least 6 months, put on another therapy to start off with
31
what is the underlying mechanism of type 2 diabetes
either due to:
- diminished insulin secretion (associated with increased insulin resistance = tissue not responsive to insulin)
or
- increased hepatic glucose output (decline is insulin & glycogen production, so will need to treat disease more aggressively over time)
32
what is the onset of type 2 diabetes
slowly progressive disease with a decline in insulin secretion over several years resulting in deterioration of glycemic control
33
what are the diagnosis methods for diabetes set out by the WHO criteria
- symptoms of diabetes plus casual (anytime of the ay without regard to time since last meal) venous plasma glucose > or = 11.1 mmol/l
- fasting plasma glucose (no calorie intake for atleast 8 hours prior to measurement) > or = 7.0 mmol/l
- 2 hour plasma glucose (give known amount of glucose usually 75g, dissolved in water & drink & measure blood glucose level 2 hrs later) > = or 11.1 mmol/l
34
what diagnosis method is done when not eating during the night and test is carried out in the morning
fasting plasma glucose
35
what is the HbA1c diabetes type 2 diagnosis
HbA1C = glycated haemoglobin
could be used as an alternative to standard glucose measures to diagnose type 2 diabetes amongst non pregnant adults
HbA1c measures the amount of glucose that is being carried by the red blood cells in the body
HbA1c levels of 6.5% (48 mmol/l) or above indicate that someone has type 2 diabetes
36
what is the normal % of haemoglobin that is glycated/glucose attached
6%
37
what happens to glycemic levels when your diabetic
more and more glycemic, as more glucose attaches to haemoglobin carried in red blood cells so the % goes up
38
what age is the peak incidence of type 1 diabetes
10-12 years but can effect any age
39
how many % of all diabetics are type 1
5-10%
40
what difficulties can arise if someone is presented with type 1 diabetes later in life i.e. latent autoimmune diabetes
difficult to differentiate from type 2 diabetes
41
what has there been an increase of with type 1 diabetes in recent decades
increased prevalence
42
what do 95% of type 1 diabetics carry
HLA DR3 and DR4 antigens (which are a particular component of the MHC protein)
43
how many % of all diabetics are type 2
85-95%
44
what is the most common age to get type 2 diabetes
middle age 50-70 years
45
why do rich countries account type 2 diabetes as the disease of the poor
as poor people have unhealthy lifestyles
46
why to poor countries account type 2 diabetes as the disease of the rich
as countries of people with more money can eat more & do less manual labour
47
what has increased steadily in type 2 diabetes
prevalence
48
where is the geographical prevalence of type 2 diabetes and by how much
people of asian or african ancestry but 3-4x
49
which country has the highest population of diabetics
india
50
what is the genetic chance of developing diabetes with an identical twin with the disease
50%
51
what is the diabetogenic lifestyle
physical inactivity
high intake of saturated fat
obesity
52
what has there been a relationship in which has resulted in the increase of type 2 diabetes
number of fast food chains and type 2 diabetes
53
what can a treatment of blood glucose result in, in type 2 diabetes
symptoms of type 2 diabetes
| eg blurred vision
54
list the epidemiology of type 1 diabetes
- younger (usually < 30yrs)
- usually lean (underweight as causes weight loss)
- increased incidence in north european ancestry
55
what is the pathogenesis of type 1 diabetes
autoimmune attack of beta cells in the pancreas, islets of langerhan
56
what is the clinical implications of type 1 diabetes
- insulin deficiency
| - always need insulin (no alternative)
57
what is the epidemiology of type 2 diabetes
- older (> 30yrs)
- often overweight
- all racial groups (increased in again, african, polynesian)
58
what is the pathogenesis of type 2 diabetes
insulin resistance (tissues not responding adequately to the insulin)
59
what is the clinical implications of type 2 diabetes
- partial insulin resistance (50% will eventually need insulin) (produced as lower level)
60
what are the acute clinical presentations/symptoms of diabetes
- polyuria (excessive urination)
- thirst
- sudden weight loss, fatigue and ketonuria (in type 1 patient < 30yrs)
- obesity (in type 2)
61
what are the sub-acute presentations of diabetes
- lack of energy
- blurred vision/refractive changes
- candida infection
62
what is the blurred vision/refractive changes in diabetes due to
excessive hyperglycaemia
63
what is a symptomatic patient's diagnosis based on
a single elevated plasma glucose of > 11 mmol/l
64
what is an asymptomatic patient's diagnosis based on
2 fasting plasma glucose levels > 7 mmol/l or two random values of > 11.1 mmol/l
65
what HbA1c levels indicate a diabetic diagnosis
levels of 6.5% (48 mmol/l) or above
66
what test id only needed for borderline diabetes cases
a glucose tolerance test
67
what would be the next check for a person aged 40-74 without diagnosed to have existing cardiovascular disease
BMI
68
what will be the next check required for a person with a BMI > 30 (or 27.5 if Indian, Pakistani or Bangladeshi, the asian or Chinese) or have a BP of 140/90
HbA1c - haemoglobin level
or
FPG+ - fasting blood glucose
69
what are the steps for someone who is border line diabetic
may not put straight onto medication, instead advised to change lifestyle & diet e.g. stop smoking, change diet, if these don't work, then must put on treatment/medication
70
what are the aims of treatment for diabetes
- alleviate symptoms ie stop feeling thirsty or going toilet
- reduce risk factors, can be short term but is most important
- prevent long term complications
- manage long term complications (that are potentially life threatening)
71
list the treatments for type 2 diabetes
- achieving glycaemic control (can be via drug therapy that lowers blood glucose)
- healthy lifestyle (lose weight, stop smoking, appropriate exercise)
- control hypertension (blood pressure tablets)
- control hyperlipidaemia (put on statins to lower cholesterol)
72
when must hypertension tablets be given to diabetics
any case, even if their blood pressure isn't high, as it reduces of cardiovascular events
73
when must statins for hyperlipidaemia be given to diabetics
at a threshold lower than someone who isn't diabetic
74
list the three things required for treatment for type 2 diabetes
- achieving glycaemic control by:
controlling diet
oral hypoglycaemic agents eg Metformin or Sulphonylurea (tablets which lower blood glucose)
insulin (in atleast a third of type 2 DM i.e. HbA1c > 9%)
75
name the oral hypoglycaemic agents taken to achieve glycaemic control in type 2 diabetes
Metformin or Sulphonylurea
76
list the 4 types of insulin treatment
- short acting insulin
- intermediate acting insulin
- long lasting insulin
- mixtures of insulin
77
what is short acting insulin
soluble insulin acts quickly and lasts for between 6 and 8 hours
78
what is intermediate acting insulin
isophane insulin acts slightly slower and lasts for between 10 and 14 hours
79
what is long lasting insulin
act slowly and lasts much longer, up to around 24 hours
80
what are mixtures of insulin
mixed short and intermediate acting insulin
81
what does the type of insulin required vary with
how quickly the insulin acts & how long the insulin will last so the aim is to achieve glycaemic control through day & night with a combination of different insulins to get the right blood glucose balance
82
what can happen if the blood glucose becomes too low
px will go into a coma
83
what are the majority of type 1 diabetic patients insulin injection frequency
majority are on 2x or 4x daily
eg 2-3 short acting insulins during the day and 1 medium acting insulin during the night
or
a medium acting insulin in the morning, short acting insulin midday and medium acting insulin a night
84
how many insulin do some type 2 diabetics require per day
1 injection
85
why must type 1 diabetics have to alternate their injection site
as they may get a reaction if its always at the same place
86
what is the importance of glycaemic control by acquiring a narrow range of blood glucose levels as opposed to having a wide range of blood glucose, for a diabetic patient
- reduced chance of diabetic retinopathy
- reduced level of protein urea (protein in urine) measure for kidney function
- reduced progression of clinical neuropathy
87
what is the principle risk factor for developing myocardial infarction and stroke
hypertension
88
what is the outcome for diabetics, for every 10mmHg increase in systolic BP
- any diabetic complication increased by 12%
- deaths related to diabetes increased by 11%
- microvascular complications increased by 13%
89
what does hyperlipidaemia increase
the propensity to microvascular disease
90
what does smoking do for diabetics
exacerbates all complications
| increases chance of a shorter life
91
what do GPs test, for measuring diabetic control
- urine tests
- blood glucose testing
- glycosylated haemoglobin
92
what is a blood glucose monitor useful for
suspected hypoglycaemia
93
what can hypoglycaemia lead to
diabetic coma
94
how is the blood glucose monitoring carried out
- using a spring loaded finger pricking device, and a blood glucose monitor with test strips
- insert the blood glucose test strip
- load finger pricker
- prick the finger
- apply blood to test strip
- await results
95
list what the annual screening program consists of for diabetics
- weight/height BMI
- BP
- eye examination
- foot examination
- blood tests (HbA1c, lipid profile, creatinine)
- urine tests (proteinuria)
- smoking status
96
why is a foot examination carried out in the annual screening program
to check for foot ulcers due to higher levels of ischemia for diabetes which can lead to amputation
97
what is checked during the eye examination in the annual screening program
retinal screening for diabetic retinopathy, retinal photographs are taken only
98
list the complications which can occur in the eye due to diabetes
- proliferative retinopathy
- retinal detachment
- maculopathy
- cataract
- rubeosis iridis
99
how many people does diabetic neuropathy effect with diabetics
50%
100
which nerves does diabetics neuropathy effect
sensory & autonomic nerves
| effects the peripheral nervous system
101
why does neuropathy effect the sensory nerves
as these nerves need a blood supply which comes from smaller blood vessels and the underlying problem in diabetes is a problem with the smaller blood vessels (angiopathy)
102
what does sensory neuropathy mainly effect
the lower limbs, less commonly the hands and causes initially pain followed by loss of sensation and numbness
103
what does autonomic neuropathy cause damage to
both sympathetic and parasympathetic nerves leading to gastrointestinal problems, incontinence and erectile dysfunction
104
what complications with cranial nerves can occur with diabetes
isolated cranial nerve palsies (however multiple nerves can also be effected i.e. any cranial nerve is at risk)
105
which nerves are preferentially effected in diabetes
nerves to the extra ocular muscles
106
which are the most common nerves effected
3rd, followed by 4th, 5th & 6th
107
what does a third nerve palsy cause in diabetes
ptosis
108
what is often spared with a third nerve palsy in diabetes
the pupil i.e. hey have a normally reactive pupil as opposed to a dilated one
109
why is the pupil reflex spared in a third nerve palsy in diabetes
due to peripheral placement of the autonomic fibres
110
what is the onset of cranial nerve palsies in diabetes
usually spontaneous, complete or partial resolution in 3-6 months
111
what type of foot complications can occur in diabetes
foot ulceration and infection
112
what are the principle causes of foot ulceration and infection
neuropathy and ischemia
113
what does a combination of neuropathy and ischemia carry a high risk of
gangrene and may lead to amputation
114
in how many people with diabetes does nephropathy occur
10-20%
115
what are the early signs of nephropathy
proteinuria (protein in the urine)
116
what can proteinuria cause
kidney complications
117
what can happen if nephropathy is not treated
proteinuria increases and glomerular filtration rate progressively declines with subsequent renal failure
118
what is nephropathy managed by
angiotensin converting enzyme inhibitors (ACE) and strict hypertension control
put on dialysis if they have kidney failure due to diabetes
119
what type of diabetics carry a considerable risk of morbidity and mortality from cardiovascular, cerebrovascular and peripheral vascular disease
particularly type 2 diabetics & those with proteinuria
120
how many % of diabetic deaths are caused by cardiovascular problems and why
75% as increases rick of heart attacks and stroke
121
at what rate does diabetes increase the risk of myocardial infarction in males
doubles
122
at what rate does diabetes increase the risk of myocardial infarction in females
quadruples
123
what is required to reduce the risk of myocardial infarction in males and females
strict control of hypertension and blood lipids
124
what is pregnancy in type 1 diabetes associated with
increased risk of congenital malformations
125
what can pregnancy exacerbate in diabetes
retinopathy and nephropathy
126
what is the control of essential during pregnancy
blood glucose
127
what are all pregnant women screened for
gestational pregnancy
128
when do most gestational diabetics return to normal blood glucose
after giving birth
129
what do women who have had gestational diabetes have an increased risk of later in life
type 2 diabetes
