Kumar and Clark type 2 diabetes Clinical

Question 1

Diabetes can present acutely, subacutely or with complications as the presenting feature

(or it might just be asymptomatic)

Describe the acute presentation for diabetes?

What causes these symptoms?

Answer 1

Usually 2-6 week history of:

Polyuria

• ^{due to osmotic diuresis that results when glucose levels exceed renal threshold}

Thirst

• ^{due to resulting loss in fluid and electrolytes}

Weight loss

• ^{Fluid depletion + breakdown of fat and muscle secondary to insulin deficiency}

Question 2

Describe the subacute presentation of diabetes

Answer 2

Clinical onset of polyuria, thirst, weight loss but over several months

Patients may also complain of:

Lethargy/fatigue

Visual blurring

Itching (if has any skin infections)

Question 3

What complications may cause presentation of diabetes?

Answer 3

Staphylococcal skin infections (itchy rashes n stuff)

Retinopathy

Polyneuropathy in feet

Erectile dysfunction

MI/Gangrene/stroke etc due to vascular damage

Question 4

How is overt diabetes diagnosed?

Answer 4

Can be diagnosed based on overt symptoms and random blood glucose of > 11 mmol/L

Question 5

How is diabetes diagnosed in the absence of clear symptoms?

Answer 5

Any of 3 measures of blood glucose:

1. Oral glucose tolerance test (OGTT)*
2. Fasting plasma [glucose] - > 7 mmol/L
3. HbA1c > 6.5 (48 mmol/mol)

Question 6

What result of HbA1c test is diagnostic of Diabetes?

Answer 6

Fasting Results (mmol/L):

• Normal = < 6.0
• Impaired GT = < 7.0
• Diabetes = > 7.0

2 hours after glucose (mmol/L):

• Normal = < 7.8
• Impaired GT = 7.8 - 11.0
• Diabetes = > 11.1

Question 7

Give an overview of the non-pharma management of type 2 diabetes?

Answer 7

Diet:

• Low in sugar (but not sugar-free)
• Starchy carbohydrates
• Fibre
• Low in fat (esp sat fat)

Exercise:

• Encourage participation in formal exercise programmes
• Educate on risks of hypoglycaemia following exercise

Lifestyle:

• Smoking and alcohol stuff

Question 8

Give an overview of the treatment pathway of type 2 diabetes

Answer 8

{First line}

Lifestyle changes + Biguanide (Metformin)

{second line}

add Sulphonylurea (eg Glipizide/Glimepiride)

{third line}

add either Thiazolidinedione or insulin

Question 9

For Metformin and Sulphonylureas - when should they be stopped and what are their contraindications?

Answer 9

Biguanides (Metformin):

• Stop if significant weight loss, diarrhoea, osmotic symptoms
• Contraindications - Renal/Hepatic impairment

Sulphonylureas (glipizide etc):

• Ineffective in patients with no functional B-cell mass
• Risk of causing HYPOs
• Contraindications - obesity (causes weight gain),