Endo Flashcards
Risk factors for TYPE 2 DIABETES MELLITUS?
✔️ obesity ✔️ family history ✔️ metabolic syndrome ✔️ polycystic ovarian syndrome ✔️ medications that promote / induce insulin resistance (e.g. atypical antipsychotic medications)
Clinical symptoms suggest of TYPE 2 DM?
✔️ polyuria, polydipsia, polyphagia, nocturia
✔️ fatigue
✔️ recurrent bacterial infections (particularly of the skin and urinary tract)
✔️ weight gain or weight loss
✔️ poorly healing wounds / ulcers
✔️ acanthosis nigricans and skin tags
Symptoms suggestive of the complications of diabetes include: ✔️ blurred vision (retinopathy) ✔️ peripheral neuropathy ✔️ non-healing ulcers ✔️ urinary changes ✔️arterial disease (ACS, MI and PVD)
What are the current screening guidelines for T2DM?
All adults should be screened for T2DM from the age of 40 years (non-ATSI people) or from the age of 18 years (ATSI people). Screening is via the AUSDRISK tool, every 3 years.
What risk factors make a person “high risk” for T2DM, and therefore, not suitable for screening via the AUSDRISK?
✔️ individual aged > 40 years who is also overweight / obese
✔️ first degree relative with diabetes mellitus
✔️ females with PCOS
✔️ females with history of gestational diabetes
✔️ any individual with prior MI or stroke
✔️ AUSDRISK > 12
✔️ individuals using atypical antipsychotics
All patients who are HIGH RISK should have fasting BGL or HbA1c performed every three years.
What is the diagnostic criteria for T2DM in symptomatic versus asymptomatic individuals?
SYMPTOMATIC INDIVIDUALS Any person who is symptomatic for diabetes (e.g. polyuria, polydipsia, polyphagia, nocturia, fatigue) or has clinical signs of insulin resistance (e.g. acanthosis nigricans, skin tags, hirsituism, central adiposity) requires only ONE reading of elevated HbA1c, elevated FBG or RBG or OGTT for diagnosis of diabetes. ✔️ HbA1c > / = 6.5% (48 mmol / L) ✔️ FBG > / = 7.0 mmol / L ✔️ RBG > = 11.1 mmol / L
ASYMPTOMATIC INDIVIDUALS
Any person who is asymptomatic for diabetes mellitus requires two HbA1c readings of > / = 6.5% on two seperate occasions OR two readings of elevated FBG or RBG on two seperate occasions OR one elevated HbA1c plus one elevated FBG.
What lifestyle modifications can be implemented for the management of T2DM?
Lifestyle modifications are first line for the management of T2DM and should be encouraged in all patients. Examples include:
✔️ weight reduction of 5 to 10%
✔️ 150 mins moderate physical activity per week OR 60 mins of vigorous physical activity per week (2-3 20 minute sessions)
✔️ wholegrain carbohydrates (low GI foods), abundance of fruit and vegetables, low saturated fat, low salt
✔️ reduce processed foods + sugar
✔️ smoking cessation
✔️ appropriate alcohol consumption
METFORMIN
✔️ impact on weight
✔️ advantages
✔️ disadvantages
IMPACT ON WEIGHT: weight neutral / ↓
ADVANTAGES: ✔️ weight natural / can help with weight loss ✔️ good efficacy for ↓ HbA1c ✔️ hypoglycaemia unlikely ✔️ improves cardiovascular outcomes ✔️ low cost
DISADVANTAGES
✔️ commonly causes GI upset
✔️ can cause Vitamin B12 deficiency
✔️ must reduce / alter dose in patients with renal failure (eGFR < 30)
SULFONYLUREA
✔️ impact on weight
✔️ advantages
✔️ disadvantages
IMPACT ON WEIGHT: ↑
ADVANTAGES:
✔️ highly effective in reducing HbA1c
✔️ low cost
DISADVANTAGES:
✔️ high risk for hypoglycaemia
✔️ must reduce / alter dose in patients with renal failure (eGFR < 30)
DDP-4 INHIBITORS
✔️ impact on weight
✔️ advantages
✔️ disadvantages
IMPACT ON WEIGHT: weight neutral
ADVANTAGES:
✔️ cardio-protective
✔️ highly effective in improving post-prandial glucose levels
✔️ moderate reduction in HbA1c
DISADVANTAGES:
✔️ not to be used in patients with CCF
✔️ not to be used in patients with chronic pancreatitis
✔️ can cause MSK pain
✔️ must reduce / alter dose in patients with renal failure
GLP1 RECEPTOR AGONISTS
✔️ impact on weight
✔️ advantages
✔️ disadvantages
IMPACT ON WEIGHT: ↓↓
ADVANTAGES: ✔️ significantly improves weight loss ✔️ great HbA1c lowering efficacy ✔️ cardioprotective ✔️ slows the progression of CKD ✔️ improves post-prandial glucose levels
DISADVANTAGES:
✔️ avoid in patients with chronic pancreatitis
✔️ may cause transient GIT side effects
SLGT2 INHIBITORS
✔️ impact on weight
✔️ advantages
✔️ disadvantages
IMPACT ON WEIGHT: ↓
ADVANTAGES: ✔️ good HbA1c lowering efficacy ✔️ cardioprotective ✔️ low risk of hypoglycaemia ✔️ lowers blood pressure
DISADVANTAGES: ✔️ risk of UTIs ✔️ may cause volume depletion ✔️ risk of ketoacidosis ✔️ reversible rise in creatinine
INSULIN
✔️ impact on weight
✔️ advantages
✔️ disadvantages
IMPACT ON WEIGHT: ↑
ADVNATAGES:
✔️ best efficacy for lowering HbA1c
✔️ theoretically unlimited efficacy
✔️ universally effective
DISADVANTAGES
✔️ causes weight gain
✔️ risk of hypoglycaemia
✔️ comes only in injectable form
Outline an appropriate management algorithm / plan for a patient with T2DM.
- Appropriate diagnosis
- Encourage lifestyle modification. Review in 3 months time.
- Commence metformin. Review in 3 months time.
- If HbA1c remains uncontrolled, add in a second anti-hypoglycaemic agent, such as:
✔️ sulfonylurea
✔️ DDP-4 inhibitor
✔️ GLP-1 agonist
✔️ SLGT2 inhibitor - Review patient in 3 months. If HbA1c still remains uncontrolled, consider adding in a third agent or referring to specialist endocrinologist.
Outline the goals for treatment management of T2DM in terms of: ✔️ weight / BMI ✔️ sugar levels ✔️ HbA1c ✔️ BP ✔️ urea creatinine clearance ✔️ lipid levels
WEIGHT / BMI: aim for a 5 to 10% reduction
GLUCOSE LEVELS:
✔️ 4 - 7 mmol / L fasting
✔️ 5 - 10 mmol / L post-prandial
HbA1c < / = 7% (53 mmol / L)
BP < 130 / 80 mmHg OR < 125 / 75 mmHg (if proteinuria > 1 g per day)
UCR:
✔️ females 3.5mg / mmol
✔️ males 2.5mg / mmol
LIPIDS: ✔️ total-C < / = 4.0 mmol / L ✔️ HDL-C > / = 1.0 mmol / L ✔️ LDL-C < 2.5 mmol / L ✔️ triglycerides < 2.0 mmol / L
What are some complications of T2DM?
KNIVES
K - kidney problems (nephropathy) –> leading cause of CKD
N - nerve problems (neuropathy) –> both autonomic and peripheral
I - infection (e.g. UTI, skin infections, non-healing ulcers)
V - vascular problems (macro and micro) –> cardiovascular complications is leading cause of death in diabetic patients
E - eye problems (retinopathy) –> diabetic retinopathy can cause blindness
S - skin (ulcers, infections)
