T2DM

Question 1

define

Answer 1

this is hyperinsulinaemia with insulin resistance

progressive disease, if you live long enough you will end up on insulin

Question 2

describe the process of diagnosis of exclusion for T2DM

Answer 2

• first consider T1DM as this is serious and requires insulin for life
• then consider whether it is something unusual e.g. MODY

Question 3

cause

Answer 3

genetic and environment (obesity and adiposity lead to increased free fatty acids and adipokines that circulate causing insulin resistance and excessive deposition of fat in liver and muscle which cause genetically vulnerable beta cells to produce excessive insulin)

Question 4

three presentation settings

Answer 4

1. with symptoms e.g. thirst, polyuria, blurred vision, recurrent UTIs, malaise
2. screening e.g. obese/overweight or those with FH/high risk ethnicity
3. concurrent illness e.g. glucose measured in workup for heart disease

Question 5

presentation

Answer 5

• slow onset (prediabetes) but can present with DKA/HHS
• middle-aged/elderly (can be young in obese children/high-risk ethnicity is non-Caucasian)
• obese (can be non-obese in elderly)
• FH

Question 6

diagnosis

Answer 6

• random blood glucose, fasting glucose (2/3 samples must be positive)
• high risk groups should be screened e.g. past history of GDM and those with PCOS

Question 7

aims of management

Answer 7

manage symptoms
prevent complications
screen for these while preventable

Question 8

why should patients lower blood sugar despite feeling fine with a high blood sugar?

Answer 8

important to reduce risk of complications

Question 9

how can blood glucose control be assessed?

Answer 9

HbA1c with target of 48-53mmol/L (doesn’t need to be as low as possible as this can increase risk of cardiovascular complications)

Question 10

management

Answer 10

lifestyle changes (3 month trial) e.g. diet and exercise
pharmacology pathway:
- metformin
- SUs or TZDs or DPP4i or SGLT2i
- insulin or GLP-RA
for high BP use ACEI/ARB or SGLT2i

Question 11

in primary care when should admission to hospital be done?

Answer 11

newly diagnosed T1DM
low/normal BMI
pregnancy
pre-existing chronic renal impairment under 40
specific concern

Question 12

pharmacological therapies that are harmful for CV

Answer 12

rosigilitazone

Question 13

pharmacological therapies that are neutral to CV

Answer 13

lixisenatide
DPP4i
SUs

Question 14

pharmacological therapies that are probably beneficial for CV

Answer 14

exenatide and metformin

Question 15

pharmacological therapies that are beneficial for CV disease

Answer 15

empagliflozin (and other SGLT2i)
liraglutide
semaglutide
pioglitzone