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3152 Endocrine (DM + Thyroid) > DM: Patho, S&S, Diagnosis, Goals, Monitoring > Flashcards

DM: Patho, S&S, Diagnosis, Goals, Monitoring Flashcards

1
Q

DM is a metabolic disorder can be characterized by ___________ or _____________, or both.

A
  1. Resistance to the action of insulin
  2. Insufficient insulin secretion

*Or both

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2
Q

List the different types of DM

A

Type 1
Type 2
Gestational
Others: infections, drugs (corticosteroids, immunosuppressants, antibiotics such as fluoroquinolones, HIV drugs), pancreas destruction, endocrinopathies

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3
Q

Describe the pathophysiology of T1DM

A

Absolute deficiency of pancreatic B-cell function
- Immune mediated destruction
- Positive antibodies

*Can be due to genetic and environmental factors

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4
Q

Name the autoantibodies associated with T1DM

A
  • Islet cell autoantibodies
  • Autoantibodies GAD (GAD65)
  • Autoantibodies to insulin
  • Autoantibodies to tyrosine phosphatases IA-2 and IA-2b
  • Autoantibodies to zinc transporter 8 (ZnT8)
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5
Q

Describe the staging of T1DM

A

Stage 1:
- Positive antibodies
- Normoglycemia
- Presymptomatic

Stage 2:
- Positive antibodies
- Dysglycemia
- Presymptomatic

Stage 3:
- Positive antibodies
- New onset hyperglycemia
- Symptomatic

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6
Q

T1DM has long and variable clinical period, but mostly occurs in _____

A

Children

*If occur in late adult, known as latent autoimmune diabetes of adults

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7
Q

What is the relevance of C-peptide in DM

A

C-peptide is a byproduct released from proinsulin to form insulin

Absence of C-peptide signifies no insulin release from pancreas (Beta cells destroyed, likely T1DM)

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8
Q

What would C-peptide levels look like in T1DM and T2DM respectively

A

T1DM: absent

T2DM: normal or abnormal (since there is still some insulin secretion)

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9
Q

Why do we measure C-peptide levels instead of insulin levels?

A

C-peptide is measured because insulin has short half-life and is hard to measure

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10
Q

Describe the pathophysiology of T2DM

A

Progressive loss of adequate B cell insulin secretion, due to insulin resistance

=> Impaired glucose utilization
=> Increased hepatic glucose output

Decrease muscle glucose uptake => hyperglycemia => incr insulin secretion => hyperinsulinemia

Decrease liver glucose uptake => incr hepatic gluconeogenesis => hyperglycemia => incr insulin secretion => hyperinsulinemia

*Both GLUCOSE + INSULIN levels increase at early stage

*Can be due to lifestyle and genetic factors

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11
Q

What is the age of onset of T1DM vs T2DM

A

T1DM: <30yo, childhood onset

T2DM: >40yo, although increasing prevalence in obese children and young adults

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12
Q

T1DM has ____ onset of clinical presentation, while T2DM has ____ onset of clinical presentation

A

T1DM - abrupt (typically sudden high BG levels, diagnosed in hospital due to sudden ketosis episode)

T2DM - gradual

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13
Q

T1DM patients often have ____ physical appearance, while T2DM patients are often _____

A

T1DM: often thin

T2DM: often overweight

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14
Q

Ketosis frequently occurs in _____ due to?

A

Ketosis frequently occurs in T1DM (*uncommon in T2DM)

Ketosis occurs as a result of insulin deficiency causing lipolysis and metabolism of FFA which releases ketones

*Diabetic ketoacidosis (DKA) is an emergency!

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15
Q

What are the 5 syndrome in metabolic syndrome?

A
  1. Abdominal obesity
  2. Triglycerides
  3. HDL (low)
  4. Blood pressure
  5. Fasting glucose

=> 5 fold increase in CVD
=> Metbolic syndrome is abdominal obestity + any 2 of the other factors

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16
Q

What are the signs and symptoms of hyperglycemia?

A
  • Extreme thirst (polydipsia)
  • Frequent urination (polyuria)
  • Dry skin/itchy skin
  • Hunger (polyphagia)
  • Blurred vision
  • Drowsiness
  • Decreased healing (impaired immune system)

Others:
- Tired
- Sexual problems
- Numb or tingling hands or feet
- Vagina infections

17
Q

What are the signs and symptoms of hypoglycemia?

A
  • Shaking, tremor
  • Fast heartbeat
  • Sweating
  • Dizziness
  • Anxious
  • Hunger
  • Impaired (blurry) vision
  • Weakness, fatigue
  • Headache
  • Irritable
  • Confusion
18
Q

What are 4 parameters that can be used to measure DM?

A
  1. Fasting plasma glucose (FPG)
  • No calorie intake for >=8h, e.g., in the morning
  1. Random or casual plasma glucose
  • Any time of the day, regardless of meal
  1. Postprandial plasma glucose (PPG)
  • Glucose levels measured 2h after meal (2h-PPG)
  • Using a standardized 75g oral glucose tolerance test (OGTT)
  1. Hemoglobin A1c (HbA1c or A1c)
  • Average amount of glucose in blood over the past 3 months
  • Dependent on RBCs (low RBC => low HbA1c, high RBC => high HbA1c)
19
Q

How is HbA1c related to FPG and PPG?

A

HbA1c = 3 month average of (FPG + PPG)

Basal/fasting and postprandial contributions to hyperglycemia:

  • As HbA1c increases, basal/fasting contribution increases
    (*Therefore basal insulin is initiated first, postprandial insulin is initiated if A1c still above goal despite basal dose >0.5IU/kg or FPG at goal)
20
Q

Glucometers measure ______ and can be used to monitor hypo/hyperglycemia, adjust medications, monitor diet and exercise

A

Blood glucose levels (BG levels)

21
Q

What should the frequency of measurements using glucometers?

A

Frequency varies depending on risk of hyperglycemia

High risk of hypoglycemia: T1DM, pregnant women, insulin pump users

  • 4 times or more per day
  • Before meals/snacks, at bedtime, at 3am

T2DM

  • 3 times or more per day if on multiple injections of insulin (risk of hypo)
  • For pts using less frequent insulin, noninsulin therapies, or medical nutrition therapy alone, SMBG useful to guide success of therapy

In practice

  • check 2 times (once before breakfast FPG and once 2h after largest meal PPG)
  • More frequent if self-titrating, changing therapies, ill
22
Q

[DM DIAGNOSIS]

HbA1c cut off for diabetes is ____

A

HbA1c >= 7.0%
No further test required.

23
Q

[DM DIAGNOSIS]

What HbA1c cut off determines that the patient is NOT diabetic?

A

HbA1c =<6.0%

No further test required, but can recommend if theres presence of clinical suspicion of diabetes

Recommended to repeat test in 3 years

24
Q

[DM DIAGNOSIS]

If HbA1c is 6.1-6.9%, what does this determine?

A

It does not determine or diagnose anything!!!!!

If HbA1c 6.1-6.9%, further test (FPG or 2hOGTT) must be done

25
Q

[DM DIAGNOSIS]

Given that HbA1c is 6.1-6.9%, what cut off of FPG or 2hOGTT will diagnose the patient as diabetic?

A

HbA1c 6.1-6.9% AND

FPG >= 7.0mmol/L OR 2hOGTT >=11.1mmol/L

26
Q

[DM DIAGNOSIS]

Given that HbA1c is 6.1-6.9%, what cut off of FPG or 2hOGTT will diagnose the patient as prediabetic?

A

HbA1c 6.1-6.9% AND

FPG 6.1-6.9mmol/L OR 2hOGTT 7.8-11mmol/L
(impaired fasting glucose and impaired glucose tolerance)

27
Q

[DM DIAGNOSIS]

Given that HbA1c is 6.1-6.9%, what cut off of FPG or 2hOGTT will determine that the patient is NOT diabetic?

A

HbA1c 6.1-6.9% AND
FPG =< 6mmol/L OR 2hOGTT <7.8mmol/L

28
Q

[DM DIAGNOSIS]

What happens if the doctor decides to perform FPG or 2hOGTT test first?

A

Any 2 abnormal results of FPG or OGTT can be used to diagnose the pt

29
Q

[FYI?] Which two groups of asymptomatic patients should be screened for DM?

A
  1. Any age with 1 or more risk factor for DM (high risk of DM)
  2. Anyone >= 40 yo

*Subsequent screening is carried out every 3y for normal glucose tolerance, annually for those with impaired fasting glucose (FPG) or impaired glucose tolerance (OGTT)

30
Q

[DM Complications]

What are the microvascular complications of DM?

A
  1. Retinopathy => blindness
  2. Nephropathy => kidney failure
  3. Neuropathy => amputation
31
Q

[DM Complications]

What are the macrovascular complications of DM?

A

Increase cardiovascular disease by 2-4 times
- MI
- Stroke
- Reduced blood circulation can cause gangrene, lead to amputation as well

32
Q

[DM Complications]

DM can cause life expectancy to reduce by _____ years

A

5-10 years

33
Q

[DM Complications]

Describe the usefulness of intensive vs conventional therapy in reducing the risk for microvascular and macrovascular complications?

A

Microvascular:

  • Delays onset and slows progression of retinopathy, nephropathy, neuropathy in T1DM and T2DM
  • Glucose toxicity contribute to development and progression of microvascular complications
  • 1% HbA1c decrease = 35% reduction in risk for microvascular complications

Macrovascular:

  • Degree of glucose control DOES NOT correlate with risk of macrovascular CV outcomes (U-shaped rsp, unknown inflexion point)
  • CVD events not related to hyperglycemia alone (other pathogenesis: BP, LDL, cholesterol)
  • Hypoglycemia can also contribute to CVD mortality
  • Thus, HbA1c should be individualized, lower does not mean better
34
Q

[DM Treatment Goals]

What are the MOH treatment goals for HbA1c, FPG, and PPG

A

HbA1c: =<7% (if vulnerable, 7.0-8.5%)

FPG: 4.0-7.0mmol/L

PPG: <10mmol/L

*To change mmol/L to mg/dL, multiply by 18

35
Q

[DM Treatment Goals]

Individualized treatment goals:

More stringent HbA1c 6.0-6.5% should be considered for:

A
  • Long life expectancy (young patients)
  • Short disease duration (newly diagnosed)
  • No significant CVD
36
Q

[DM Treatment Goals]

Individualized treatment goals:

Less stringent HbA1c 7.5-8.0% should be considered for:

A
  • History of severe hypoglycemia
  • Limited life expectancy
  • Long standing disease duration
  • Advanced complications
  • Extensive comorbid conditions (e.g., many CVDs)
  • Target difficult to obtain despite intensive SMBG, repeated counseling, effective pharmacotherapy
  • Pt preference for less burdensome therapy
  • Pt with limited resources
  • Pt with adverse effects to drugs used
37
Q

[DM Monitoring Parameters]

What are the monitoring parameters for DM?

A
  1. HbA1c
  2. Lipid panel
  3. BP
  4. Eye exam
  5. Albuminuria/renal function
  6. Foot exam
38
Q

[DM Monitoring Parameters]

What is the frequency of monitoring for each of the following parameters:

  1. HbA1c
  2. Lipid panel
  3. BP
  4. Eye exam
  5. Albuminuria/renal function
  6. Foot exam
A
  1. HbA1c - every 3m if uncontrolled, every 6m if stable
  2. Lipid panel - every 3-6m if uncontrolled, 1y if controlled
  3. BP - every visit
  4. Eye exam - every 6m if unstable, 1y if stable
  5. Albuminuria/renal function - every 6m or 1y depending on presence of protein/albumin in urine
  6. Foot exam - every day by pt, 1y by podiatrist

3152 Endocrine (DM + Thyroid) (11 decks)

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