Endocrine - Diabetes and Hyperglycaemia Flashcards
GLP-1 is secreted by which cells and in response to what?
L cells in the jejunum and ileum when food enters
What does GLP-1 do?
- stimulates insulin secretion (glucose dependent)
- suppresses glucagon secretion
- slows gastric emptying
- improves insulin sensitivity
- reduces food intake
What is the incretin effect?
Amplification of insulin response in ORAL compared to intravenous glucose
There is a diminished effect in diabetes
Increased insulin does what to glucagon levels?
Increased insulin DECREASES glucagon
Difference in glucagon levels between early and late diabetes
Usually low BSL –> decreased insulin –> increased glucagon BUT in T1DM glucagon doesn’t get this signal as there is already no insulin.
Early DM: high glucagon
Late DM with recurrent hypos: low glucagon, cortisol, GH and adrenaline
Genetic Predisposition to T1DM?
Lifetime risk for T1DM in 1st degree relative <25 years old:
- identical twin?
30 - 40%
Genetic Predisposition to T1DM?
Lifetime risk for T1DM in 1st degree relative <25 years old:
- parent and sibling?
25%
Genetic Predisposition to T1DM?
Lifetime risk for T1DM in 1st degree relative <25 years old:
- HLA identical sibling?
16%
Genetic Predisposition to T1DM?
Lifetime risk for T1DM in 1st degree relative <25 years old:
- Sibling
7%
Genetic Predisposition to T1DM?
Lifetime risk for T1DM in 1st degree relative <25 years old:
- Child
5%
Geographical impact on incidence of T1DM?
Increased in Finland
Which genes are SUSCEPTIBLE to T1DM?
HLA-DQ
HLA DR3 and DR4 (MOST diabetogenic)
(Both are on Chromosome 6)
Insulin VNTR on Ch 11
Which genes are PROTECTIVE for T1DM?
HLA DR2
Which chromosome is HLA-DQ and DR3 and DR4 located?
Chromosome 6
Which chromosome is VNTR on?
VNTR is on Ch 11
What perinatal factors increase risk of T1DM?
- Infections (congential rubella)
- maternal age >25yrs
- pre-eclampsia
- neonatal respiratory disease
- c-section
- neonatal jaundice (esp ASO incompatibility)
What non-perinatal factors increase risk of T1DM?
Viral infection: children with T1DM are 10x more likely to have ENTEROVIRUS
- Vitamin D deficiency
- Early gluten exposure in infancy
- adiposity
Pathodevelopment of T1DM?
T cell mediated autoimmunity, predominantly CD8+
Which T cells is predominantly involved in T1DM?
CD8+ T cells
What four antibodies are involved in pathodevelopment of T1DM?
(pro)insulin Ab
Anti-GAD
Anti-IA2
Anti-Zn Transporter 8 (ZnT8)
Importance of Anti-ZnT8?
Anti-Zn Transporter 8 (Anti-ZnT8) is a beta-cell specific antigen.
ZnT8 is positive in 5% of patients with NEGATIVE GAD/IA2/insulin
What is fulminant DM?
Severe onset suddenly Antibody negative Pancreatic enzymes positive BUT no pancreatitis Usually Asian
Diagnostic criteria of LADA?
LADA = Latent Autoimmune Diabetes of Adulthood - Adult 30 - 75yrs - Diabetes diagnosis - Evidence of islet autoimmunity (anti-GD >5) - Period of insulin dependence
Five features more frequent in LADA at diagnosis?
- Age <50yrs
- Acute symptoms
- BMI <25
- Personal hx of autoimmunity
- FHx of autoimmunity
Importance of LADA?
- theoretical risk of ketoacidosis
- preference for basal-bolus regime
- screen for associated autoimmune conditions (ie thyroid / coeliac)
Definition of MODY?
Features?
Maturity-onset diabetes of the young (MODY) is characterised by the development of type 2 diabetes mellitus in patients < 25 years old.
Features of MODY
typically develops in patients < 25 years
a family history of early onset diabetes is often present
ketosis is NOT a feature at presentation
patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary
Inheritance pattern of MODY
What are the two most genetic causes?
Autosomal Dominant
MODY 3
60% of cases
due to a defect in the HNF-1 alpha gene
MODY 2
20% of cases
due to a defect in the glucokinase gene
MODY 3 underlying genetic defect?
defect in the HNF-1 alpha gene
MODY 3 underlying genetic defect?
defect in the glucokinase gene
HbA1c target in T1DM?
General: <=7%
Pregnancy: <=7%
Hypoglycaemia recurrence or unawareness <=8%
What was the DCCT Trial?
Intensive vs convensional sugar control in T1DM.
- reduced risk of retinopathy, micro and macro albuminaemia, and neuropathy
In the DCCT Trial which subgroups were NOT supported?
- Recurrent hypoglycaemia
- Macrovascular complications
- Young children <13 years old
What was the EDIC Study?
Follow on from DCCT Trial, over the next 8 years HbA1c became the same but in the INTESNIVE treatment:
- reduced macro and micro albuminaemia
- reduced neuropathy
- nonfatal MI/stroke/CVS and cardiac mortaliy
Diagnostic Criteria for T2DM?
FASTING Glucose:
BSL 5.5 - 6.9 (–> needs OGTT)
BSL >7 (likely diabetes, need to repeat test if asymptomatic)
OGTT:
If fasting glucose 6-7 and 2hr glucose <7.8
–> impaired fasting glucose (IFG)
If fasting glucose 6-7 and 2hr glucose 7.8-11
–> impaired glucose tolerance (IGT)
If fasting glucose >7 and 2hr glucose >11
–> diabetes
If HbA1c >=6.5 and confirmed on repeat test
Diagnosing T2DM:
Fasting glucose BSL 5.5 - 6.9?
need OGTT
Diagnosing T2DM:
Fasting glucose BSL >7
Likely diabetes, need to repeat test if asymptomatic
Diagnosing T2DM:
If fasting glucose 6-7 and 2hr glucose <7.8
–> impaired fasting glucose (IFG)
Diagnosing T2DM:
If fasting glucose 6-7 and 2hr glucose 7.8-11
–> impaired glucose tolerance (IGT)
Diagnosing T2DM:
If fasting glucose >7 and 2hr glucose >11
–> Diabetes
Diagnosing T2DM:
Impaired fasting glucose (IFG)
If fasting glucose 6-7 and 2hr glucose <7.8
Diagnosing T2DM:
Impaired glucose tolerance (IGT)
If fasting glucose 6-7 and 2hr glucose 7.8-11
Diagnosing T2DM:
Diabetes
If fasting glucose >7 and 2hr glucose >11
Diagnosing T2DM with HbA1c?
If HbA1c >=6.5 and confirmed on repeat test
Treatment goals in T2DM?
Newly diagnosed early disease: <6.5%
Target HbA1c <7% in general
Except:
- if no insulin –> target <6.5%
- if hypoglycaemia –> target <8%
Treatment goal in T2DM in newly diagnosed early disease?
Target HbA1c <6.5%
Treatment goal in T2DM in general?
Target HbA1c <7%
Treatment goal in T2DM if no insulin?
Target HbA1c <6.5%
Treatment goal in T2DM if hypoglycaemia?
Target HbA1c <8%