Endo - T1DM Flashcards

1
Q

What is Type 1 DM?

A

→ autoimmune condition in which insulin-producing beta-cells in the pancreas are attacked and destroyed by immune system
→ causes partial or complete deficiency of insulin production, which results in hyperglycaemia
→ requires life-long insulin treatment

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2
Q

What does T1DM management depend on?

A

individual clinical presentation

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3
Q

What are the 2 biggest triggers for T1DM?

A

→ environmental factor

→ underlying genetic risk

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4
Q

What is LADA?

A

latent autoimmune diabetes in adults

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5
Q

What are the 5 stages of T1DM development?

A

→ genetic predisposition to T1DM
→ potential precipitating event
→ overt immunological abnormalities + normal insulin release
→ progressive loss of insulin release but glucose normal
→ over diabetes with C-peptide present
→ no c-peptide present?

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6
Q

What are the various stages of T1DM development in the immune system?

A

→ genetic risk
→ immune activation (beta cells are attacked)
→ immune response (development of single autoantibody)
→ stage 1 = normal blood sugar
→ stage 2 = abnormal blood sugar
→ stage 3 = clinical diagnosis
→ long-standing T1DM

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7
Q

Why is the immune basis of T1DM important?

A

→ Increased prevalence of other autoimmune disease
→ Risk of autoimmunity in relatives
→ More complete destruction of B-cells
→ Auto antibodies can be useful clinically
→ Immune modulation offers the possibility of novel treatments

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8
Q

How do the autoantibodies start attacking the beta cells?

A

→ presentation of auto-antigen to autoreactive CD4+ T lymphocytes
→ CD4+ cells activate CD8+ T lymphocytes
→ CD8+ cells travel to islets and lyse beta-cells expressing auto-antigen
→ Exacerbated by release of pro-inflammatory cytokines
→ Underpinned also, by defects in regulatory T-cells that fail to suppress autoimmunity

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9
Q

Do all T1DM patients eventually not produce insulin at all?

A

→ no, some continue to produce small amounts of insulin

→ not enough to negate the need for insulin therapy

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10
Q

What are the positives of the people with T1DM who can still produce small amounts of insulin?

A

less complications compared to those who can’t produce some insulin

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11
Q

What are the environmental factors that can also influence T1DM?

A

→ Enteroviral infections
→ Cow’s milk protein exposure
→ Seasonal variation
→ Changes in microbiota

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12
Q

How does T1DM present?

A
→ Excessive urination (polyuria) 
→ Nocturia
→ Excessive thirst (polydipsia) 
→ Blurring of vision 
→ Recurrent infections eg thrush
→ Weight loss
→ Fatigue
→ dehydration 
→ cachexia (weight + muscle loss)
→ hyperventilation
→ smell of ketones
→ glycosuria 
→ ketonuria
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13
Q

What are the auto-antibodies detectable in T1DM?

A

→ pancreatic auto-antibodies
→ not generally needed for diagnosis
• Insulin antibodies (IAA)
• Glutamic acid decarboxylase (GADA) – widespread
neurotransmitter
• Insulinoma-associated-2 autoantibodies (IA-2A)-Zinc-
transporter 8 (ZnT8)

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14
Q

What are the proteins in beta cells that act as receptors to the pancreatic AAs?

A
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15
Q

What are the metabolic results of insulin deficiency?

A

→ proteinolysis in muscles = AAs
→ hepatic glucose output increases from liver = glucose in blood
→ lipolysis of adiposes = glycogen + NEFAs

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16
Q

What causes the production of ketone bodies? What does that progress to?

A

→ lack of insulin = no inhibition of fatty acyl-CoA
→ ketone bodies produced in liver
→ progresses to diabetic ketoacidosis

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17
Q

Why does T1DM cause blurred vision?

A

antibodies bind to eyeballs, osmosis causes water to move into eyeball, swelling eyeballs and impinging on the lenses

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18
Q

What are the aims of treatment of T1DM?

A

→ Maintain glucose levels without excessive hypoglycaemia
→ Restore a close to physiological insulin profile
→ Prevent acute metabolic decompensation
→ Prevent microvascular and macrovascular complications

19
Q

What are the acute complications of hyperglycaemia from T1DM?

A

→ diabetic ketoacidosis

→ uncontrolled hyperglycaemia

20
Q

What are the chronic microvascular complications of hyperglycaemia from T1DM?

A

→ Retinopathy
→ Neuropathy
→ Nephropathy

21
Q

What are the chronic macro vascular complications of hyperglycaemia from T1DM?

A

→ Ischaemic heart disease
→ Cerebrovascular disease
→ Peripheral vascular disease

22
Q

What are the complications of treatment of T1DM?

A

hypoglycaemia

23
Q

How is T1DM is treated?

A
self-managed to an extent:
→ Insulin Treatment
→ Dietary support / structured educations
→ Technology
→ Transplantation
24
Q

What are the 2 types of insulin given?

A

→ short acting

→ long acting , basal

25
Q

What are the 2 types of short-acting insulin?

A

→ Human insulin – exact molecular replicate of human insulin (actrapid)
→ Insulin analogue (Lispro, Aspart, Glulisine)

26
Q

What are the 2 types of basal + long-acting insulin?

A

→ Bound to zinc or protamine (Neutral Protamine Hagedorn, NPH)
→ Insulin analogue (Glargine, Determir, Degludec)

27
Q

How does insulin pump therapy work?

A

→ Continuous delivery of short-acting insulin analogue e.g. novorapid via pump
→ Delivery of insulin into subcutaneous space
→ Programme the device to deliver fixed units / hour throughout the day (basal)
→ Actively bolus for meals

28
Q

What are the NICE guidelines for dietary advice to people with T1DM?

A

→ All people with type 1 diabetes should be offered a Structured Education Programme
→ e.g. DAFNE but many others (5 day course on skills and training in self-management)

29
Q

What are the principles of the dietary advice gievn?

A

→ Dose adjustment for carbohydrate content of food.
→ All people with type 1 diabetes should receive training for carbohydrate counting
→ Where possible, substitute refined carbohydrate containing foods (sugary / high glycaemic index) with complex carbohydrates (starchy / low glycaemic index)

30
Q

What is a closed-loop pump / artificial pancreas?

A

→ Real-time continuous glucose sensor
→ Change in glucose calculated
→ Algorithm to use glucose value to calculate insulin requirement
→ Insulin pump delivers calculated insulin

31
Q

What are the limitations of closed loop / artificial pancreas?

A

v

32
Q

What are the 2 types of transplantation?

A
33
Q

What is an islet cell transplant?

A
34
Q

What is simulatneous pancreas + kidney transplants?i

A
35
Q

What are the disadvantages of transplantations?

A
36
Q

Why do we measure Hb1Ac?

A

→ Reflects last 3 months (red blood cell lifespan) of glycaemia
→ Biased to the 30 days preceding measurement
→ Glycated NOT glycosylated (enzymatic)
→ Therefore linear relationship
→ Irreversible reaction

37
Q

What is used to guide insulin doses?

A

→ Using self-monitoring of blood glucose results at home and HbA1c results every 3-4 months
→ Based on results, increase or decrease insulin doses

38
Q

How many hypoglycaemic episodes with T1DM management is normal?

A

1-2 per week

39
Q

What are the signs and symptoms of hypoglycaemic episodes?

A
40
Q

When does hypoglycaemia become a problem?

A

→ Excessive frequency of hypoglycaemic episodes
→ Impaired awareness (unable to detect low blood glucose)
→ Nocturnal hypoglycaemia
→ Recurrent severe hypoglycaemia

41
Q

What are the risks of hypoglycaemia?

A
→ Seizure / coma/ death (dead in bed)
→ Impacts on emotional well-being
→ Impacts on driving
→ Impacts on day to day function
→ Impacts on cognition
42
Q

What puts people at risk of having hypoglycaemic episodes with T1DM?

A
→ Exercise
→ Missed meals
→ Inappropriate insulin regime
→ Alcohol intake
→ Lower HbA1c
→ Lack of training around dose-adjustment for meals
43
Q

What strategies are in place to support problematic hypoglycaemia?

A

→ Indication for insulin-pump therapy (CSII)
→ May try different insulin analogues
→ Revisit carbohydrate counting / structured education
→ Behavioural psychology support
→ Transplantation

44
Q

How can hypoglycaemia be acutely managed?

A