Long term conditions Flashcards
What factors predispose you to Type 2 Diabetes Mellitus?
- Old age (>40)
- Overweight/Obese
- Gestational diabetes
- Family history of T2DM
- Hypertension or CVS disease
- Dyslipidaemia
- Polycistic Ovary syndrome
- Pre-diabetes (impaired glucose tolerance)
- Depression (comfort eating)
Describe how type 2 diabetes mellitus occurs?
Insulin resistance results in some people. Eg. sedentary, o
(insulin is still binding to receptors, just not generating the same effect)
Type 2 diabetes results when the person’s Beta islet cells cannot secrete enough insulin to overcome this resistance.
What is the complications of type 2 diabetes mellitus?
Uncontrolled BP and glucose increase microvascular complications eg. Retinopathy, Nephropathy, Neuropathy
High BP and glucose and lipid abnormalities result in macrovascular complications eg. ischaemic heart disease, peripheral vascular disease, cerebrovascular disease.
How would Type 2 diabetes mellitius present?
Acute diabetic presentations are usually Type 1 = polyuria, thirst, weight loss, ketonuria/ketoacidosis
Symptomatic Type 2 is more suble (asymptomatic until screening):
- Lethargy/ lack of energy
- Polyuria/polydipsia
- Visual blurring (glucose affects refraction)
- Frequent fungal or bacterial infection - often of the genitals due to high glucose in urine
(eg. UTI, balantis, pruritis vulvae due to candida in females) - Loss of sensation
- Weight loss
How would you diagnose T2DM? What other investigations would you do?
- confirmed fasting plasma glucose >6.9mmol/L
- Hba1c >6.5%
- Random plasma glucose >= 11.1mmol/L
- Urine ketones (ketoacidosis)
- Urinary albumin excretion (nephropathy)
- eGFR and serum creatinine
Talk me through the first step of how you would manage a newly diagnosed t2DM.
Lifestyle changes for first 3-6 months.
- Set a goal of Hba1c <7% for most patients
- Smoking cessation to reduce CVS risk (varenicline + nicotine replacement therapy)
- Control BP with ACE1, ARB, CCB, Thiazide
- Statin or lipid lowering agents
- physical activity
- lower calorific intake
How would you start to medically manage a T2DM patient after his Hba1c was still >6.5% after lifestyle measures?
1st line = Metformin (Biguanides)
- decreases amount of glucose released by liver into blood
- SE = nausea, diarrhoea, GI
If Metformin does not achieve goal in 3 months = dual therapy
- SGLT2 inhibitors (canagliflozin, empagliflozin, dapagliflozin)
- reduce CVS risk by reducing BP
- SE = increased UTI
- DPP-4 inhibitors (sitagliptin, linagliptin)
- Sulfonylureas (glipizide, pioglitazone, glimepiride)
- increase insulin produced by pancreas, reduce microvascular complciations
- SE = weight gain !!! hypoglycaemia
- Alpha-glucoside inhibitors (miglitol, acarbose)
- GI side effects minimised by adherance
- Causes reduced absorption of carbohydrates
- Thiazolidinediones (pioglitazone, troglitazone)
- SE = weight gain, decreased bone density, increased bladder cancer risk, increased congestive HF risk
How would you manage a patient if dual therapy was not working?
Triple therapy
Eg. Metformin + DPP4 + sulfonylurea
OR
Insulin therapy
Daily insulin injections/insulin pump and self monitor blood glucose
SE = complications with injection site eg. allergic response,
What specific therapy would you use for a patient with a BMI of >35?
GLP-1 agonist (liraglutide, exenatide)
- stimulate insulin secretion in response to glucse
- reduces glucagon release after meals
- CONS = nausea, hypoglycaemia, injections once weekly
- PROS = weight loss
OR bariatric surgery for obesity
How do you follow up on diabetes?
- Dilated eye exam every 1-2 years
- Annual assessment of renal function
- Annual foot exam
What history predisposes you to Depression?
- >65 years old
- women
- Alzheimers/Parkinsons
- Postnatal women
- FHX of depression
- SE of corticosteroids, interferon, propanolol, oral contraceptives
- Conditions eg. diabetes, cancer, stroke, HIV, chronic pain, polycistic ovarian syndrome
How would a depressed patient present? What criteria would you use to diagnose them?
DSM-5 criterion (DEAD SWAMP)
D = Depressed mood for most of the day, nearly daily for 2 weeks
E = Energy levels - low
A = Anhedonia (reduced interest/pleasure in activities) nearly daily for 2 weeks
D = recurrent thoughts of death or suicide without a specific plan
S = Sleep problems eg. Insomnia/ hypersomnia nearly daily
W = Inappropriate feelings of guilt or worthlessness nearly daily
A = Appetite/ weight change nearly daily
M = Mentation - poor concentration nearly daily
P = Psychomotor agitation/retardation nearly daily
What investigations would you do for potential depression?
- DSM-5
- Metabolic panel
- FBC to rule out fatigue causes like anaemia
- Thyroid function tests
- PHQ-2 for depression in primary care
- Edinburgh Post-natal depression scale
- Geriatric Depression scale
- Cornell scale for depression in dementia
- 24 hour free cortisol (elevated for Cushings)
- Vit B12 to rule out deficiency
- Folic acid test
What non-medical ways could you use to manage depression?
- Suicide risk assessment
- Identify safeguarding issues
- PHQ-9, HADS, BDI-II
- Manage comorbidites eg. ED, anxiety, substance abuse
- Counselling or Psychotherapy
- CBT (especially in pregnancy to avoid drug SE)
- Electroconvulsive Therapy (avoids pharm SE etc)
- SE = memory loss, risk of ischaemia in Coronary Heart disease
- Crisis Resolution and Home Treatment (CRHT) team for people who need intensive care
What medicines would you use to manage depression?
1st line = SSRI
- citalopram, fluoxetine, paraoxetine, sertraline (fewer interactions)
- SE = nausea, vomiting, abdo pain (gastroprotection in older people on NSAIDs/aspirin)
If not effective in 4-6 weeks, trial others:
SNRI (Serotonin-Noradrenaline Reuptake Inhibitors)
- venlafaxine
Tricyclic antidepressants
- amitriptyline, dexepin, nortriptyline, desipramine
Monoamine Oxidase Inhibitors
- Tranylcypromine, phenelzine, isocarboxazid
- Lots of diet/drug interactions
