DM Flashcards
1
Q
What are the 3 major cell types of endocrine pancreas and what do they release?
A
- β→ insulin
- α→ glucagon
- δ→ Somatostatin
2
Q
What is the sequence of events involved in insulin release
A
↑BM→ ↑ glucose in β cells (GLUT2) → ATP ↑→ATP-sensitive K+ channel closing →depolarisation→ ↑Ca →exocytosis of vesicles
3
Q
What are the main target tissues of insulin
A
liver, skeletal muscles, adipose tissue
4
Q
what is the difference between actions of insulin and glucagon
A
insulin is anabolic and glucagon catabolic
5
Q
what is the aetiology of T1DM
A
autoimmune destruction of β cells
6
Q
what are the causative factors in T1DM
A
Genetic: concordance of 30% IT
Triggers: Coxsackie B4, vit D deficiency, dietary
HLA DR3/4 (also other autoimmunity)
7
Q
what s the demographics of T1DM
A
↑ Scandinavian/Caucasian
8
Q
What is the aetiology of T2DM
A
- Loss of first phase of insulin response
- ↑↑↑insulin secretion + ↓↓tissue response
- Followed by ↓↓ function of β cells (due to glucotoxicity)
9
Q
what is the prevalence of DM and what age group
A
> 40s 4.45% but undiagnosed
10
Q
What ethnic groups are more at risk
A
South Asian, African, and African-Caribbean, , Middle-Eastern and American-Indian ancestry.
11
Q
What is MODY
A
Maturity onset diabetes of the young (MODY) is a rare autosomal dominant form of type 2 DM affecting young people with a +ve family history
12
Q
What are the RF for T2DM
A
- ↓exercise ↑ alcohol +calories
- FH: 80% concordance in IT/2xrisk
- Ethnicity: South Asian, African, and African-Caribbean, , Middle-Eastern and American-Indian ancestry
- Gestational diabetes
- Impaired glucose tolerance and/or fasting glucose
- Combination of thiazide diuretic + β-blocker
- Diet: ↓fiber, ↑glucose
- Metabolic syndrome
- Polycystic ovarian syndrome
- Low birth weight
13
Q
Define IGT
A
Impaired glucose tolerance
it is either
Fasting plasma glucose 6.1- 6.9 mmol/L OR OGTT 7.8-11.1 and it is a RF for DM
14
Q
Define IFG
A
impaired fasting glucose: fasting plasma glucose between 6.1-6.9 mmol/L
15
Q
What is the significance if IGT and IFG
A
increased risk of T2Dm i.e. incidence of DM is 25% with upper level of normal IFG and HbA1c
16
Q
Name 3 other cause + examples of DM
A
Drugs: e.g steroids
pancreatitis/ pancreatic cancer/CF destruction
Endocrine: Cushion’s, acromegaly, pheochromocytoma; hyperthyroidism; pregnancy
17
Q
What is the prevalence of DM among pregnant women
A
4%
18
Q
What are the criteria for diagnosis of gestational DM
A
FG 5.6 mmol/litre or above
OGTT 7.8 mmol/litre or above,
19
Q
What are the risks of gestational DM
A
o miscarriage, o pre-term labour, o pre-eclampsia, o congenital malformations, o macrosomia, o A worsening of diabetic complications, e.g. retinopathy, nephropathy.
20
Q
What are the RF for gestational DM
A
Risk factors: >25, FH, PMH, ↑BMI, non-Caucasian, HIV (screen at 16-18 week check if RF
21
Q
What sort of advice can be offer per-conception in terms of DM
A
↓BMI, discuss risks, folic acid, stop hypoglycemics, metformin ok
22
Q
What dietary advice could be offered to a t2DM
A
- 3 meals per day
- ↓ sugar, fat (35% of intake), salt (6g/24h), alcohol
- ↑ starchy carbohydrates (40-60%), fibres
- 2/7 x oily fish, eg mackerel, sardines, salmon and pilchards.
- Exercise: 30min 5/7
23
Q
What driving advice should be given to DM patients
A
• Inform DVLA/car insurance if: on insulin/oral hypoglycaemics, diabetic retinopathy
loss of hypoglycaemia awareness may lead to loss of license
24
Q
What are the common sites for insulin injunctions?
A
buttock, abdomen, upper outer arm and thigh
25
what are the steps that can betaken to prevent CVS disease in DM patients
* Stop smoking
| * BP
26
What is the oral hypoglycameic regiment for treatment T2DM
* 1st line: Metformin
* If HbA1c ≥53mmol/L 16wks later, add: Sulfonylurea/gliptins if BMI≥35
* If at 6mths, HbA1c ≥57mmol/L consider: insulin or glitazone
27
What sort of short-term and long term montoring is required in DM patients
• Fingerpick BM: before and after meals to adjust insulin
• HbA1c→mean glucose level in 8 weeks
o Target 48–57mmol/L
• Hypoglycaemic awareness
28
How would you instruct someone about use of insulin syringes?
• Instruction: dial dose→ insert needle 90° to
29
what are the 4 insulin types
* Ultra-fats acting (Humalog, Novarapid) → just before meal/meal dependent dose
* Isophane: peak 4-12h
* Long acting e.g. Glargine; OD/BD, no peak →good nocturnal control
* Pre-mixed: short and long acting component e.g. 30 = 30% Short acting and 70% long acting
30
What is the demand for insulin during acute illness
it may increase hence monitor BM and adjust the dose...get help if difficult to control
31
Why is it important to rotate injunction sites for insulin
to prevent lipohypertrophy and poor insulin absorption
32
Name some effects of automatic neuropathy
o Postural BP drop; ↓cerebrovascular autoregulation; loss of respiratory sinus arrhythmia (vagal neuropathy); gastroparesis; urine retention; erectile dysfunction (ED); gustatory sweating; diarrhoea
33
What is autonomic neuropathy
it is damage to autonomic nerves that can have an effect on number of organs, deneravtion of the heart is particularly concerning and leads to sinus arrhythmia
34
what is symmetric sensory polyneuropathy
glovs and stocking distribution of loss of sensation, proprioception, pain , numbness tingling
35
What is Sequelae neuropathy?
: interosseous wasting due to abnormal nerve supply to small muscles of the feet
o abnormally high arch of the foot and callus formation due to abnormal pressure distribution
36
What is mononeuritis multiplex
o Isolated damage to at least two separate nerve areas particularly cranial nerves
o Painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy
37
What is amyotrophy
o Asymmetrical motor diabetic neuropathy resulting
o Painful wasting of quadriceps and shoulder muscles
o Particularly older men with DM
38
What are the microvascular complications of DM?
o Asymmetrical motor diabetic neuropathy resulting
o Painful wasting of quadriceps and shoulder muscles
o Particularly older men with DM
39
What are the macrovascular complications of DM
* Stroke
* MI
* ↓ leg blood supply
40
What is the correlation between DM and vascular disease
o Common cause of death
o Stroke 2x as common
o MI 4 x as common and likely silent
o Women at ↑↑risk as removal of sex related advantage
41
what steps can be taken to prevent vascular disease in DM
Stop smoking, aspirin and Statins, fibrates, HTN control
42
What is the advice on HTN in DM?
15% Antihypertensive; target:
43
What is maculopathy and what are associated sign
macular oedema leading to reduced acuity
44
What are the changes in peripheral retina
microaneurisms, cotton wool spits,haemorrhages, hard exudate, proliferation of blood vessels, venous beading
45
what is the treatment for maculopathy/
laser photocoagulation that stops production of angiogenic factors
46
what is the treatment for changes in peripheral retina
o Intravitreal triamcinolone→ steroid injections
47
what is the treatment for macular oedema
Prompt laser, intravitreal steroids or anti-angiogenic agents may be needed in macular oedema.
48
What examinations should be carried out when checking DM feet
* Absent ankle jerks
| * test sensation with a 10g monofilament fibra applied with just sufficient force to bend it
49
What are the evidence of ischameia and neuropathy in diabetic feet
```
o loss of leg pulses
o can be examined with Doppler
o Neuropathy
o Bone deformity
o Infection → swabs and check for osteomyelitis with x-ray
```
50
What are the management options for diabetic foot ischaemia
o Surgery → endovascular angioplasty balloons, stents, and subintimal recanalization
51
What sort of steps should patients be taking to prevent foot ulcers when suffering from DM
o Daily foot exam →with the mirror to check the soles
o Comfortable shoes
o No barefoot walking
o No corn plasters
52
Who can be involved in diabetic foot care
o Regular chiropody → removal of callus (ulcers can develop below it)
consultant diabetologist
o Regular pediatrist checks
53
What are the 3 characteristics of diabetic feet ulcers
o Painless
o Pouched out in area of thick callus
o May be infected
54
What are the possible management steps for foot ulcers
o Relieve high pressure areas with bed rest
| o Surgery → metatarsal head
55
How should cellulitis be treated in DM and what are the common causes
o Relieve high pressure areas with bed rest
| o Surgery → metatarsal head
56
what are diagnostic criteria for metabolic syndrome
o central obesity (BMI >30, or ↑ waist circ),
o plus 2 of
BP ≥130/85,
triglycerides ≥1.7mmol/L,
HDL ≤ 1.03♂/1.29♀mmol/L,
fasting glucose ≥5.6mmol/L or DM (∼20% are affected)
57
What are the risks related to metabolic syndeome
```
o Vascular events i.e. MI
o DM
o Neurodegeneration
o Microalbuminuria
o Gallstones
o Cancers i.e. pancreas
o Fertility problems in M and F
```
58
What is the management of metabolic syndrome
```
o Lifestyle: exercise, weight loss, diet
o Antihypertensive
o Hypoglycemics
o Statins
o Antidepressants
```
59
What are the symptoms of hypoglycaemia
• Autonomic
o Sweating, anxiety, hunger, tremor, palpitations, dizziness.
• Neuroglycopenic
o Confusion, Drowsiness, Visual trouble, Seizures, Coma.
o Rarely focal symptoms, e.g. transient hemiplegia. Mutism, personality change, restlessness and incoherence → prone to misdiagnosis of alcohol intoxication
60
define hypoglycaemia
Plasma glucose ≲3mmol/L. Threshold for symptoms varies.
61
what are the two types of hypoglycaemia
* Fating
| * Post-prandial
62
what are the causes of fasting hypoglycaemia
o Insulin or sulfonylureas treatment → ↑activity, skipped meals, overdose etc.
o In NON-DM
Exogenous →
• Insulin, oral hypoglycemics→ body builders
• Alcohol
• aspirin poisoning; ACE-i; β-blockers; pentamidine; quinine sulfate; aminoglutethamide; insulin-like growth factor.
Pituitary insufficiency
Liver failure, plus some rare inherited enzyme defects
Addison's disease.
Islet cell tumours (insulinoma) and immune hypoglycaemia
Non-pancreatic neoplasms, e.g. fibrosarcomas
63
how is hypoglycamia assessed
o BM
o Blood glucose, c-peptide, plasma ketones
o Drug history
64
what is o Hypoglycaemic hyperinsulinaemia
Low blood glucose due to excessive insulin i.e. insulinoma, sulfonylureas, insulin
65
what causes hypoglycaemia with normal insulin and ketones
non-pancreatic neoplasia, anti-insulin receptor antibody
66
What causes hypoglycaemia with Insulin↓, ketones↑.
o Insulin↓, ketones↑.
| Causes: Alcohol, pituitary insufficiency, Addison's disease.
67
what is Post-prandial hypoglycaemia
Hypoglycemia occurring few hours post ↑↑↑carbohydrate meal due to excess insulin secretion, common with bariatric surgery
68
how is Post-prandial hypoglycaemia managed
o 1st line Oral sugar or long-acting starch
o 2nd line: 25-50ml of 50% glucose +flash to prevent phlebitis
o Small high starch meals if recurrent
69
What is the Whipple's triad
Symptoms due to fasting/exercise→ hypoglycaemia + symptoms →relief of symptoms with serum glucose returning to normal
70
what is insulinoma what are the symptoms and screening test
pancreatic endocrine tumour
• Symptoms
o Fasting hypoglycaemia with Whipple’s triad
• Screening test
o Hypoglycaemia + ↑insulin during fasting
71
what is the cositive process in diabetic ketoacidosis
o Alternative metabolic pathway in starvation →acetate production → fruity breath
o If ↓↓insulin → glucose not taken in → starvation-like state
o Combination of sever acidosis and hyperglycaemia
72
what are the signs of dehydration
```
Dry mucus membranes
Decreased skin turgor
Sunken eyes
Slow capillary refill
Tachycardia and weak pulse
Hypotension
```
73
what are the tiggers for diabetic ketoacidosis
o Infection, MI, surgery, pancreatitis
o Chemotherapy, antipsychotic
o Medication problem
74
What criteria can be used for transfer to ITU
o Blood ketones >6mmol/L
| o Venous bicarbonate 100 or
75
what is the initial management of diabetic ketoacidosis
```
o ABCDE
SATs, ECG, BP, HR, EWS
Long-bore peripheral IV access
Urinary catheter → urine output
? TED stockings/LMWH
NG tube if vomiting/ ↓GCS
Fluids → saline → replace with 5% dextrose when BM 5.5 mmol/l => no
o 3.5-5.5. => 40mmol
o Insulin:
Sliding scale insulin or weight based IV infusion
Infusion even with ↓BM as DKA required to clear (0.1 U/kg)
↓ BM by 3mmol/L/h
```
76
What are the complications of diabetic ketoacidosis
```
o Cerebral oedema (get help if sudden CNS decline),
o Aspiration pneumonia,
o Hypokalaemia,
o Hypomagnesaemia,
o Hypophosphataemia,
o Thromboembolism.
```
77
How is hypoglycaemic coma managed
o Give 20–30g glucose IV, e.g.
200–300mL of 10% dextrose.
This is preferable to 50–100mL 50% glucose i.e. phlebitis
o Expect prompt recovery
78
what are the symptoms of hypoglycaemic coma
• Usually rapid onset; may be preceded by odd behavior (e.g. aggression), sweating, pulse↑, seizures.
79
what is Hyperosmolar non-ketotic (HONK) coma
marked dehydration and glucose >35mmol/L. leads to increased osmolarity
80
what is the management of HONK
o DVT—give LMWH prophylaxis to all unless contraindication
o Rehydrate slowly with 0.9% saline IVI over 48h, typical deficits are 110–220mL/kg, i.e. 8–15L for a 70kg adult.
o Replace K+ when urine starts to flow.
o Only use insulin if blood glucose not falling by 5mmol/L/h with rehydration or if ketonaemia—start slowly 0.05u/kg/h.
o Keep blood glucose at least 10–15mmol/L for first 24 hours to avoid cerebral oedema.
o Look for the cause, e.g. MI, drugs, or bowel infarct.
81
what is the high risk HbA1c
42-47 mmol/mol
82
What is the HbA1c that is consider to be DM
48 mmol/mol
