Metabolism - Diabetes Mellitus Type 2 Diagnosis and management of neuropathy, T1DM and MODY

Question 1

What are the criteria for diagnosing T2DM if a patient is symptomatic vs asymptomatic?

Answer 1

• Fasting glucose >= 7.0 mmol/L
• Random glucose >= 11.1 mmol/L (or after 75g oral glucose tolerance test)
• If the patient is asymptomatic (polyuria, polydipsia, etc) the above criteria must be demonstrated on two separate occasions

Question 2

Outline the spectrum values for Diabetes diagnosis

Answer 2

Normal glycaemic control:

• Fasting glucose <= 6.0 mmol/L
• HBA1c <= 42 mmol/mol (5.9%)

Prediabetes

• Fasting glucose between 6.1 and 6.9
• HBA1c between 42-47 mmol/mol or between 6.4-6.5%

Diabetes

• Fasting glocuse >= 7.0 mmol/L
• HBAc1 >= 48 mmol (6.5%)

Question 3

Name a few conditions in which HBA1c cannot be used for diagnosis

Answer 3

• Haemoglobinopathies
• Haemolytic anaemia
• Intreated iron deficient anaemia
• Suspected gestational diabetes
• Children
• HIV
• CKD

Question 4

Outline the new HBA1c targets for T2DM patients

Answer 4

• Lifestyle management targe: 48 mmol/mol (6.5%)
• Can titrate the metformin and encourage lifestyle changes to aim for an HBA1c of 48 mmol/mol (6.5%) but only add a second drug if HBAc1 rises to 58 mmol/mol (7.5%). Chose from following list: sulphonylurea, gliptins, pioglitazone, SGLT2 inhibitor.
• If despite 2 drugs the HBA1c rises to or remains above 58 mmol/mol (7.5%), then triple therapy.
• Any drug which may cause hypoglycaemia (lifestyle + sulfonylureas): aim for 54 mmol/mol (7.0%)

Question 5

Outline the antiplatelet and blood pressure portion of risk factor modification we can target with the help of drugs

Answer 5

Blood pressure
-Target is <140/89 mmHg (or <130/80 mmHg if end-organ damage is present) for diabetic patients.

Antiplatelets
-Only offer if patient has existing CVS disease

Question 6

Outline the lipid portion of risk factor modification we can target with the help of drugs

Answer 6

Lipids

• Only patients with a 10 year QRISK score > 10% should be offered a statin
• Primary prevention: Atorvastatin 20mg OD if QRISK >10%, T1DM for >10 years or CKD eGFR <60
• Secondary prevention: Atorvatstatin 80 mg OD if known ischaemic heart disease or peripheral arterial disease

Question 7

Outline the management for diabetic neuropathic pain

Answer 7

• First line: amitriptyline, fluoxetine, gabapentin or pregabalin
• If the first line drug treatment does not work try one fo the other 3 drugs
• Tramadol: may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
• Topical capsaicin: may be used for localised neuropathic pain
• pain management can also be done via pain clinics

Question 8

What is gastroparesis and what is the management?

Answer 8

• Diabetic neuropathy where the stomach cannot empty its gastric contents normally (usually due to damage to the vagus nerve).
• Symptoms: erratic blood glucose control, bloating and vomiting
• Management: Metoclopramide, do péri done or erythromycin (pro kinetic agents)

Question 9

Diabetic foot disease: outline the two main factors that lead to diabetic foot disease

Answer 9

• Neuropathy: resulting in loss of protective sensation (can’t feel stone in shoe), Charcot’s arthropathy, dry skin
• Peripheral arterial disease: diabetes is a risk factor for both macro and micro vascular ischaemia

Question 10

Diabetic foot disease: give presentations for neuropathy, ischaemia and complications

Answer 10

• Neuropathy: loss of sensation
• Ischaemia: absent foot pulses, reduced ABPI, intermittent claudication
• Complications: calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, gangrene

Question 11

Diabetic foot disease: what screening should be performed on annual basis?

Answer 11

• Screening for ischaemia: palpate dorsalis pedis and posterior tibial artery pulse
• Screenign for neuropathy: 10g monofilament used in various parts of sole of foot

Question 15

T1DM: management -HbA1c targets and self monitoring requirements

Answer 15

• HBA1c: should be monitored every 3-6 months, adults should have a target of 48 mmol/mol (6.5%)
• Self monitoring of glucose recommended QDS, including before each meal and before bed.
• Increase in self monitoring if frequency of hypos increases, during periods of illness, during/after sport, pregnancy and breastfeeding

Question 16

T1DM: what are the blood glucose targets for these patients?

Answer 16

• 5-7 mmol/L on waking

- 4-7 mmol/L before meals at other times of the day

Question 17

Give an example of a daily insulin regimen for a T1DM patient

Answer 17

• Twice daily insulin Detemir (long acting - lasts 24h) is regimen of choice
• Rapid acting insulin analogues injected before meals
• Nice recommend considering adding metformin if BMI >25 kg/m^2

Question 26

What is MODY?

Answer 26

• Maturity onset diabetes of the young
• Characterised by development of T2DM in patients <25 years old
• Typically inherited autosomal dominant condition
• Patients with most common form are very sensitive to sulfonylureas, insulin not usually necessary