Endocrinology - Diabetes Flashcards
Normal fasting glucose levels
Up to 6mmol/L
Impaired fasting glucose levels
6-7mmol/L
Diabetic fasting glucose levels
> 7mmol/L
Pathophysiology T1DM
Autoimmune disease w/ antibodies targeted against B cells –> cell death Inadequate Insulin secretion
PS T1DM (1st ep)
2-6w Hx of
Polyuria
Polydipsia
W loss
Pathophysiology T2DM
Blood levels insulin initially normal
Insulin resistance
Beta cells then decompensate and stop XS insulin production –> hyperglycaemia
PS T2DM
Over m/y
Lack of E
Visual blurring
Pruritis vulvae/balanitis b/c candida infection
PS older pt of T2DM
Retinopathy Polyneuropathy ED Aa disease Staph skin infections
Hereditary links T1DM
HLA-DR3/DR4
Concordance in twins - T1DM
30-50%
Concordance in twins - T2DM
50%
2’ causes of DM
CF Chronic pancreatitis Pancreatectomy Hereditary haemochromatosis Carcinoma pancreas Cushing's Acromegaly Thyrotoxicosis Phaeochromocytoma Glucagonoma Drug induced Freidreich's ataxia Dystrophia myotonica
HbA1c levels diabetic
> 48mmol/L
Pre-diabetic levels HbA1c
42-7mmol/L
Who would using HbA1c be inappropriate in?
<18 y/o T1DM Pregnancy Acutely unwell Those on meds that raise blood sugars Any haemolytic disorder ESRD HIV certain drugs
Patients taking which 3 drugs would it be inappropriate to do a HbA1c on
Dapsone
Erythropoetin
Ribavirin
75g glucose load test - normal values
fasting < 7
2 h < 7.8
75g glucose load test - impaired fasting glucose
Fasting 6.1-7
2h <7.8
75g glucose load test - imapired glucose tolerance
Fasting <7
2h 7.8-11
75g glucose load test - DM
fasting <7
2h >11
+ves of HbA1c over glucose tests (3)
Non-fasting
Quicker for patient than GGT
Avoids glucose load
Genetic linkage MODY
Autosomal dominant
When should you suspect T1DM in a patient > 40?
If comorbid autoimmune disease
And BMI <25
Non-medication Mx T2DM (9)
Individualised care plan Group education programme Screen - complications Monitor CV risk Diet advice Weight loss (5-10%) Increase PAL Stop smoking Alcohol advice
Alcohol advice for pt w/ DM
Limit intake
Carb containing snack before and after consumption
How to monitor CV risk for pt w/ T2DM
BP control
Qrisk score
Relevance of Qrisk score + T2DM
If 10y risk >10% - offer 20mg atorvastatin
Screening for complications yearly T2DM (3)
Fundoscopy
Nephropathy screen
Foot check
Target HbA1c diabetics
6.5% (48)
1st line Dx regime T2DM
Metformin - 500mg od –> every meal
1st line Dx regime T2DM if metformin isn’t tolerated/CI
Gliptin Or Thiazolidinedone Or Sulphonylurea
2nd line Dx regime T2DM
Metformin + 2nd Dx
3rd line Dx regime T2DM
Triple therapy = Metformin \+ Sulphonylurea \+ Gliptin/pioglitazone
Alternative to triple therapy T2DM if metfomin C/I
Insulin regimen
Mode of action Metformin
Decr hepatic glucose prod
Increase peripheral insulin sensitivity
C/I metformin (4)
eGFR 30 or <
Alcoholic
If pt risk lactic acidosis (DKA)
If Pt at risk tissue hypoxia
What must be monitored when on metformin annually
Renal fct
SE metformin (3)
GI Sx
Lactic acidosis
Vit B12 defic
E.g. S acting Sulphonylureas
Tolbutamide
E.g. Med acting Sulphonylureas
Glicazide
E.g. long acting Sulphonylureas
Glibenclamide
Mode of action Sulphonylureas
Increase insulin secretion
Who should Sulphonylureas be prescribed with caution? (2)
Elderly - risk hypoglycaemic events
Obese
SE Sulphonylureas (2)
Norm well tolerated
GI
LIver
E.g. of Thiazolidinediones
Pioglitazone
mode of action Thiazolidinediones
PPARy activators - increase peripheral insulin senstivity
SE Thiazolidinediones (4)
Fl retention
W gain
Liver dysfunction
Bladder cancer
What must be monitored with Thiazolidinediones
LFTs
Who are Thiazolidinediones C/I in ?
CCF
Because of fl retention
E.g. of gliptin
Sitagliptin