T1DM

Question 1

What is the current T1DM WHO classification?

Answer 1

Genetics + environmental trigger causes an autoimmune destruction of islet cells leading to islet deficiency leading to hyperglycaemia

Question 2

What is the current T2DM WHO classification?

Answer 2

Genetics and obesity causes insulin resistance leading to B cell failure leading to hyperglycaemia

Question 3

Why is the immune basis of T2Dm importnt

Answer 3

Increased prevalence of other autoimmune diseases, and leads to a risk of autoimmunity in relatives. It also leads to more complete destruction of B cells. Auto-antibodies can be useful clinically and immune modulation offers the possibility of novel treatments

Question 4

What are markers for T1DM?

Answer 4

Islet cell antibodies (ICA)- grp O human pancreas
Insulin antibodies (IAA)
Glutamic acid decarboxylase (GADA) – widespread nuerotransmitter
Insulinoma-associated-2 autoantibodies (IA-2A)-receptor like family

Question 5

What are symptoms of diabetes?

Answer 5

polyuria 
nocturia
polydipsia 
blurring of vision
‘thrush’ 
weight loss
fatigue

Question 6

What are signs of diabetes?

Answer 6

dehydration 
cachexia
hyperventilation
smell of ketones
glycosuria 
ketonuria

Question 7

What are aims of treatment in type 1 diabetes?

Answer 7

• Reduce early mortality and avoid acute metabolic decompensation
• Prevent long term complications; retinopathy, nephropathy, neuropathy, vascular disease

Question 8

What is the recommended diet in type 1 diabetes?

Answer 8

• reduce calories as fat
• reduce calories as refined carbohydrate
• increase calories as complex carbohydrate
• increase soluble fibre
• balanced distribution of food over course of day with regular meals and snacks

Question 9

What insulin analogues are used in insulin treatments with meals and which are background treatments

Answer 9

Lispro, aspart, glulisine with meals or Glargine, Determir, degludec in the background

Question 10

What is the acting speed of insulin treatment with meals and in the background

Answer 10

With meals: short acting and background: long acting

Question 11

What is the type of insulin used with meals and which in the background

Answer 11

Human insulin with meals or non-c bound to zinc or protamine in the background

Question 12

What does an insulin pump do?

Answer 12

Provides continuous insulin delivery - preprogrammed basal rates and bolus for meals

Question 13

What is the disadvantage of insulin pumps

Answer 13

They do not measure glucose and there is no completion of feedback loops

Question 14

What is a surgical treatment option for treating diabetes T1

Answer 14

Islet cell transplants

Question 15

What are the consequences of hypoglycaemia in diabetes?

Answer 15

• most mental processes impaired at <3 mmol/l
• consciousness impaired at <2 mmol/l
• severe hypoglycaemia may contribute to arrhythmia and sudden death
• may have long-term effects on the brain
  recurrent hypos result in loss of warnings

Question 16

What is the main risk factor of diabetic hypoglycaemia?

Answer 16

Quality of glycaemic control

Question 17

Which patients have more frequent diabetic hypoglycaemia?

Answer 17

Patients with a low HbA1c

Question 18

When can diabetic hypoglycaemia occur?

Answer 18

Anytime but often a clear pattern, pre lunch hypos common and nocturnal hypos very common and often not recognised

Question 19

Why can diabetic hypoglycaemia occur?

Answer 19

• unaccustomed exercise
• missed meals
• inadequate snacks
• alcohol
• inappropriate insulin regime

Question 20

What are signs and symptoms of hypoglycaemia that are due to increased autonomic activation?

Answer 20

Palpitations (tachycardia)
Tremor
Sweating
Pallow/cold extremities
Anxiety

Question 21

What are signs and symptoms of hypoglycaemia that are due to impaired CNS function

Answer 21

• drowsiness
• confusion
• altered behaviouor
• focal neurology
• coma

Question 22

What are oral ways of treating hypoglycaemia?

Answer 22

feed the patient!
glucose
- rapidly absorbed as solution or tablets
complex CHO
- to maintain blood glucose after initial treatment

Question 23

What are parenteral ways of treating hypoglycaemia

Answer 23

give if consciousness impaired
IV dextrose e.g 10% glucose infusion
1mg Glucagon IM
avoid concentrated solutions if possible (e.g 50% glucose)

Question 24

What are causes of the ketoacidosis complication of diabetes?

Answer 24

new presentation
insulin omission
infection / other illness

Question 25

What is ketoacidosis

Answer 25

An acute complication of T1DM; a rapid decompensation of type 1 diabetes that causes hyperglycaemia and metabolic acidosis

Question 26

How does ketoacidosis cause hyperglycaemia?

Answer 26

Reduced tissue glucose utilisation and increased hepatic glucose production

Question 27

How does ketoacidosis cause metabolic acidosis?

Answer 27

Circulating acetoacetate and hydroxybutyrate leading to osmotic dehydration and poor tissue perfusion

Question 28

What does the HbA1c red cells reacting with glucose depend on?

Answer 28

Lifespan of red cell, rate of glycation, Hb opathy, renal failure etc, level of glucose

Question 29

Why is the HbA1c red cell reaction with glucose measured in diabetics

Answer 29

It forms an ideal measure of long term glycaemic controls and has been shown to be related to risk of complications. Lowering the HbA1c associated lower risk of complication particularly in microvascular complication

Question 30

What are different ways of monitoring blood glucose for diabetes

Answer 30

Capillary monitoring

Hba1C red cell monitoring

Question 31

How is capillary monitoring done in diabetes

Answer 31

Either by a continuous monitor attached to the belly or through finger pricks

Question 32

How does HbA1C help with glucose monitoring in diabetes

Answer 32

Glucose binds to RBCs irreversibly so can give you a long term view of blood glucose control

Question 33

What are examples of acute complications caused in diabetes

Answer 33

Metabolic acidosis

Hyperglycaemia

Question 34

What is metabolic acidosis due to in diabetes?

Answer 34

Circulating acetoacetate/hydroxybutyrate and osmotic dehydration and poor tissue perfusion