T2DM Flashcards
Definition?
Disorder defined by deficits in insulin secretion and action, leading to abnormal glucose metabolism and so metabolic pathologies.
90% of diabetes cases are T2
Risk factors?
- Older age
- Obesity
- Gestational diabetes
- Pre-diabetes
- Family history
- Non-white
- Physical inactivity
- POCS
- Hypertension
- Dyslipidaemia
- CVD
- Stress
- Low birth weight for gestational age
Differentials?
- Pre-diabetes-asymptomatic
- DM T1
- Latent autoimmune diabetes in adults-over 30’s, responsive to treatment, non-obese
- Monogenic diabetes-non-obese, young-family history
- Ketosis-prone diabetes-same as T1D-no evidence of autoimmunity
- Diabetes-gestational-after 24 wks?
Epidemiology?
• Age: Older
• Sex: Women
• Ethnicity: BAME
Prevalence: 3.5 million in UK
Aetiology?
Insulin resistance and insensitivity caused by exposure to risk factors
Clinical presentation?
- Risk factors
- Asymptomatic-screening
- Candidal infections
- Skin infections
- UTIs
- Fatigue
- Blurred vision
- Polydipsia->16.6 mmol/L (>300 mg/dL), HbA1c >95 mmol/mol (>11%).
- Polyphagia
- Polyuria
- Paraesthesias
- Nocturia
- Unintentional weight loss
- Acanthosis nigricans
Pathophysiology?
- Normal amount of insulin needed but insulin receptors not inserted into cell membrane
- Mechanisms not fully understood
- Adipokines -inflammation-linked to insulin resistance
- Genetics-twin studies
- More insulin produced via beta cell hyperplasia and hypertrophy
- Works in the short term
- Amylin aggregates in islets and so they become dysfunctional and die off-insulin levels die and pts develop hyperglycaemia
- But some circulating insulin available
Investigations-first line and findings?
- HbA1c-48 mmol/mol (6.5%) or greater
- Fasting plasma glucose->6.9 mmol/L (>125 mg/dL)
- Random plasma glucose-≥11.1 mmol/L (≥200 mg/dL)
- 2 hr post-load glucose after 75g oral glucose-≥11.1 mmol/L (≥200 mg/dL)
Investigations?-second line and findings?
- Fasting lipid profile
- Urine ketones
- Random C peptide
- Urinary albumin excretion
- Serum creatinine and eGFR
- ECG
- ABI
- Dilated retinal exam
Management-first line?
- Lifestyle changes
- Glycaemic management
- BP management
- Lipid management
- Antiplatelet therapy
Management-HG or symptomatic?
Basal-bolus insulin and CVD risk management
Metformin
Management-NHG-first line?
1-metformin and CVD risk reduction
Management-NHG-second line?
- SGLT2 inhibitor
- GLP-1 agonist
- DPP4 inhibitor
- Sulphonylurea or meglitinide
- Basal insulin
Management-NHG-third line?
- Alpha glucosidase inhibitor
* Thiazolidinedione
Management-NHG-fourth line?
- Individual regimen
- Switch to basal-bolus insulin
- Metformin
- Bariatric
Pregnant management?
Diet and basal-bolus insulin?
Prognosis?
- Increased chance of CVD event
- 15% higher excess mortality
- Insulin deficiency worsens overtime
- Can participate in activities of daily living if well-managed
Complications?
• Diabetic kidney disease • Impaired vision • Lower extremity amputation • CVD • CHF • Stroke • Infection • Periodontal disease • Treatment-related hypoglycaemia • Depression • Obstructive sleep apnoea • DKA Non-ketoic hyperosmolar state Autonomic/peripheral neuropathy
Non-ketoic hyperosmolar state?
- higher plasma osmolarity from dehydration and increased conc
- Water leaves cells into blood vessels down an osmotic gradient, leading to dehydration and polyuria-sometimes ketonemia and acidosis
macrovascular?
• Can be in the form of CHD, cerebrovascular disease, or PAD
• Due to metabolic risk factors like obesity, dyslipidaemia and hypertension
Managing these/anti hypertensives, statins will prevent these-anticoagulants will be secondary
microvascular?
- Diabetic nephropathy, retinopathy and neuropathy
- Due to chronic hyperglycaemia (primary factor) resulting in glycation of proteins and lipids causing impaired protein and cell membrane function and so tissue damage
nephropathy?
Increased permeability and thickening of basement membrane and stiffening of teh efferent arteriole causing glomerulosclerosis and increased filtration
Signs-foamy urine, renal failure and uraemia/proteinuria
M-glycaemic control, anti-hypertensives, diuretics, CCBs and salt/protein dietary restrictions
neuropathy?
Glycation of axonal proteins
Signs-symmetric loss of sensation in distal parts-stocking glove presentation, dysesthesia, pain at night , areflexia, motor control
M-glycaemic control, pain management (anti-convulsant and TCA’s and SNRIs) and opioids
retinopathy?
Glycation of axonal proteins and retinal vessels
Signs-visual impairment, oedema, microaneurysms
M-laser, VEGF injection
Diabetic foot?
- Can be due to ischaemia or neuropathy-impaired wound healing or sensation
- Signs-painless, charcot joints, swelling warmth erythema or cool pale with no pulse
- Prevention-control, regular foot exams and self care
- M-debridement, wound dressing, footwear, antibiotics, revascularisation, amputation
