Endo - T2DM Flashcards

1
Q

What is T2DM?

A

→ combination of insulin resistance + beta-cell failure result in hyperglycaemia
→ Associated with obesity but not always
→ resultant chronic hyperglycaemia may initially be managed by changes to diet / weight loss and may even be reversible
→ over time glucose lowering therapy including insulin, is needed

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2
Q

What contributes to the insulin resistance in T2DM?

A

→ genetic risk

→ obesity

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3
Q

Can DKA be a feature of T2DM?

A

yes

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4
Q

When can T2DM present in a person’s life?

A

→ commonly thought to be only a condition of late adulthood

→ literally in every decade tho

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5
Q

What is the trend in prevalence of T2DM? Why?

A

→ varies enormously
→ increasing prevalence
→ occurring + being diagnosed in younger groups
→ greatest ethnic groups moving from rural to urban lifestyle

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6
Q

What are the stages of development for T2DM?

A

→ normal state = normal glucose + insulin production + insulin resistance
→ intermediate state = impaired fasting glucose + impaired glucose tolerance + pre-diabetic or non-diabetic hyperglycaemia + increasing insulin production + insulin resistance
→ T2DM = low insulin production + insulin resistance

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7
Q

What are the fasting glucose levels for someone with impaired fasting glucose?

A

6 < x < 7 mmol/L

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8
Q

What are the glucose levels after an OGTT for impaired glucose tolerance?

A

7.7 < impaired glucose tolerance < 11 mmol/L

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9
Q

What are the HbA1c levels for pre-diabetic or non-diabetic hyperglycaemia

A

42 < pre-diabetic or non-diabetic hyperglycaemia < 48 mmol/L

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10
Q

What is relative insulin deficiency?

A

Insulin is produced by pancreatic beta-cells but not enough to overcome insulin resistance → can’t have DKA under usual hyperglycaemic episodes

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11
Q

What is long-duration T2DM?

A

→ beta-cell failure may progress to complete insulin deficiency
→ usually on insulin but can’t come off at risk of DKA

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12
Q

What happens to the first phase insulin release in T2DM?

A

doesn’t exist

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13
Q

What happens to uptake of glucose in muscles in T2DM?

A

reduced insulin action = less uptake of glucose in skeletal muscles

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14
Q

What happens to hepatic glucose production in T2DM? Why?

A

reduced insulin action = increased hepatic glucose production + increased glucagon action

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15
Q

What is the relationship between insulin resistance and insulin secretion in T2DM?

A

→ as insulin resistance increases, insulin secretion also increases
→ directly proportional

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16
Q

What is MODY?

A

→ maturity onset diabetes of the young

→ monogenic inheritance of Diabetes, can’t avoid it

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17
Q

What is the polygenic risk of T2DM?

A

→ polymorphisms increasing the risk of diabetes

→ not born with it but could develop it later depending on other factors

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18
Q

What if the effect of individual SNPs on risk of T2DM?

A

very little effect

19
Q

What if the effect of cumulative SNPs on risk of T2DM?

A

much bigger

20
Q

What is the role of obesity in T2DM?

A
→ Major risk factor for T2DM
→ Fatty acids + adipocytokines important
→ Central vs visceral obesity
→ 80% T2DM are obese
→ Weight reduction useful treatment
21
Q

What else is associated with risk of T2DM?

A

→ Perturbations in gut microbiota

→ Intra-uterine growth retardation

22
Q

What are the symptoms of of T2DM?

A
→ Hyperglycaemia
→ Overweight
→ Dyslipidaemia
→ Fewer osmotic symptoms
→ With complications
→ Insulin resistance
→ Later insulin deficiency
23
Q

What are the risk factors of T2DM to look for clinically in a patient?

A
→ Age
→ large BMI
→ ethnicity
→ PCOS
→ family history
→ inactivity
24
Q

How is T2DM diagnosed?

A

→ First line test for diagnosis is HbA1c :
→ 1x HbA1c >=48mmol/L with symptoms
→ 2x HbA1c >=48 mmol/mol if asymptomatic

25
Q

What is a hyperosmolar hyperglycaemic state?

A

→ Presents commonly with renal failure.
→ Insufficient insulin (NOT ABSENT) for prevention of hyperglycemia but sufficient insulin for suppression of lipolysis and ketogenesis.
→ Absence of significant acidosis.
→ Often identifiable precipitating event (infection, MI).
→ osmotic diuresis = dehydration

26
Q

How is T2DM managed?

A
→ Diet
→ Oral medication
→ Structured education
→ May need insulin later
→ Remission / reversal
27
Q

What are the main principles of a T2DM consultation?

A

→ Glycaemia: HbA1c, glucose monitoring if on insulin, medication review
→ Weight assessment
→ Blood pressure
→ Dyslipidaemia: cholesterol profile
→ Screening for complications: foot check, retinal screening

28
Q

What is the dietary advice over T2DM?

A

→ Total calories control
→ Reduce calories as fat
→ Reduce calories as refined carbohydrate
→ Increase calories as complex carbohydrate
→ Increase soluble fibre
→ Decrease sodium

29
Q

What are the 4 facets of pathophysiology of T2DM?

A
30
Q

How are the 4 facets of pathophysiology managed ideally?

A
31
Q

How are the 4 facets of pathophysiology managed pharmacologically?

A
32
Q

How does metaformin work?

A

→ Biguanide, insulin sensitiser
→ First line if dietary / lifestyle adjustment has made no difference
→ Reduces insulin resistance
→ Reduced hepatic glucose output
→ Increases peripheral glucose disposal
→ GI side effects
→ Contraindicated in severe liver, severe cardiac or moderate renal failure

33
Q

How do sulphonylureas work?

A

→ Normal insulin release requires closing of the
ATP-sensitive potassium channel
→ Sulphonylureas e.g. gliclazide, bind to the ATP-sensitive potassium channel and close it, independent of glucose / ATP

34
Q

How does pioglitazone work?

A

→ Peroxisome proliferator-actived receptor agonists PPAR-γ
→ Insulin sensitizer, mainly peripheral
→ Adipocyte differentiation modified, weight gain but peripheral not central
→ Improvement in glycaemia and lipids
→ Evidence base on vascular outcomes
→ Side effects of older types hepatitis, heart failure

35
Q

What is a common side effect of glucose lowering therapies and drugs?

A

weight gain (except in metformin)

36
Q

How can GLP-1 agonists be used to treat T2DM?

A
→ Liraglutide, Semaglutide
→ Injectable –daily, weekly
→ Decrease [glucagon]
→ Decrease [glucose]
→ Weight loss
37
Q

How can DPP4-inhibitors be used to treat T2DM?

A
→ Increase half life of exogenous GLP-1
→ Increase [GLP-1]
→ Decrease [glucagon]
→ Decrease [glucose]
→ Neutral on weight
38
Q

How can SGLT-2 inhibitors be used to treat T2DM?

A

→ Inhibits Na-Glu transporter, increases glycosuria
→ Empagliflozin, dapagliflozin, canagliflozin
→ HbA1c lower
→ 32% lower all cause mortality
→ 35% lower risk heart failure
→ Improve CKD

39
Q

How does beta-cell function change on drug therapies?

A

function of beta-cells still declines

40
Q

What surgery can induce remission of T2DM?

A

gastric bypass surgery

41
Q

How else can remission of T2DM be induced?

A

low calorie diet

42
Q

What are the other aspects need to be considered in T2DM management?

A
blood pressure
  → hypertension is v common
  → clear benefits in reduction
lipid management
  → clear benefit in lipid-lowering therapy
43
Q

What is GLP-1? Why is it useful in T2DM?

A

→ Gut hormone
→ Secreted in response to nutrients in gut
→ Transcription product of pro-glucagon gene, mostly from L-cell
→ Stimulates insulin, suppresses glucagon
→ increases satiety (feeling of ‘fullness’)
→ Short half life due to rapid degradation from enzyme dipeptidyl peptidase-4 (DPP4 inhibitor)