Endocrinology Flashcards
What is the initial drug therapy for management of T2DM?
- metformin 1st line.
- SGLT2s added in if QRISK >10%, established CVD, chronic heart failure.
What is the further management of T2DM if HbA1c targets not met?
- If the HbA1c rises to 58 - further treatment is indicated
- Add in: DPP4/pioglitazone/sulfonylurea
- Third line - add in another of the above.
- If triple therapy not effective/not tolerated - consider switching one of the drugs for a GLP-1 mimetic.
- Onlt continue GLP-1 if reduction of 11 mmol/mol HbA1c and weight loss of 3% body weight in 6 months.
- Insulin (GLP-1 should only be added to insulin under specialist care). Continue metformin - consider if the other oral therapies are still needed.
What are the blood pressure targets for patients with T2DM? Which medication is 1st line?
- blood pressure targets are the same as for patients without type 2 diabetes
- ACE inhibitors or angiotensin II receptor blockers (ARB) are first-line. ARB if the patient has a black African or African-Caribbean family origin
How is T2DM diagnosed?
If symptomatic (polyuria/polydipsia):
* fasting glucose greater than or equal to 7.0 mmol/l
* random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
If asymptomatic - need the above criteria on two separate occasions.
HbA1c can be used:
* HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus
* in patients without symptoms, the test must be repeated to confirm the diagnosis
* a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes (i.e. it is not as sensitive as fasting samples for detecting diabetes)
What are the diagnostic criteria for DKA?
- Hyperglycaemia (blood glucose greater than 11.0 mmol/L)
- Raised plasma ketones (blood ketones greater than 3.0 mmol/L or, ketonuria two + on urine dipstix)
- Acidosis (venous pH less than 7.3 or low bicarbonate)
Euglycaemic DKA in T2DM- where blood glucose is not raised (occurs with SGLT2 inhibitors and pregnancy, in children on insulin therapy, alcohol excess/chronic liver disease).
In a child test for blood ketones - if not possible - acute admission.
In which groups should HbA1c not be used to diagnose DM?
- Children <18 years of age.
- Pregnant women or women who are 2 months postpartum.
- People with symptoms of diabetes for less than 2 months.
- People at high diabetes risk who are acutely ill.
- People taking medication that may cause hyperglycaemia (for example long-term corticosteroid treatment).
- People with acute pancreatic damage, including pancreatic surgery.
- People with end-stage renal disease (ESRD)
- People with HIV infection
Interpret with caution in:
* haemoglobinopathy
* severe anaemia
* post-splenectomy (altered RBC lifespan)
* recent blood transfusion
What are the clinical symptoms and signs of DKA?
- polydipsia, polyuria
- weight loss
- abdo pain, nausea, vomiting
- SOB
- lethargy, confusion
- fruity acetone breath
- deep sighing acidotic breathing ‘Kussmaul respiration’
- tachycardia, dehydration, shock
What are the clinical symptoms and signs of HHS? (Hyperosmolar hyperglycaemic state)
- Typically seen in T2DM (who are still producing some insulin, which is enough to stop ketogenesis and development of acidosis, but not enough to stop hepatic gluconeogenesis)
- Usually in elderly
- Develops over days
- Suspect if a patient is unwell with severe hyperglycaemia (usually >30) for several days
- Disorientation, confusion, drowsy
- Polyuria/polydipsia
- Nausea
- Severe dehyration, hypovolaemia
- No blood or urinary ketones.
What are common precipitating factors for DKA and HHS?
- Infection.
- Inadequate insulin or non-adherence with insulin treatment.
- New onset of diabetes mellitus
- physiological stress (such as trauma or surgery).
- Other medical conditions (such as hypothyroidism or pancreatitis).
- Drugs (corticosteroids, diuretics, atypical antipsychotics, and sympathomimetic drugs such as salbutamol).
