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Year 2 RE > Type 1 Diabetes Mellitus > Flashcards

Type 1 Diabetes Mellitus Flashcards

1
Q

What is type 1 diabetes?

A
  • no or low levels of insulin being secreted by beta cells in the pancreas
  • normally secondary due to chronic inflammation
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2
Q

Where does the name diabetes come from?

A
  • latin for ‘pass through’ and ‘sweet’
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3
Q

How many people in the UK have T1DM, of which how many are children?

A
  • 400,000

- 29,000 are children

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4
Q

What is the annual incidence (new cases every year) of T1DM in the UK?

A
  • 4%
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5
Q

Do all patients with T1DM have a family history of T1DM?

A
  • no

- majority (85%) have no family history

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6
Q

What age does the peak incidence of T1DM occur?

A
  • in childhood

- 6 months to age 5

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7
Q

The peak incidence of T1DM occurs in childhood, between 6 months and 5 years of age. Are all patients diagnosed at this age?

A
  • no

- 50% are diagnosed >18 years of age

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8
Q

In younger and older ages, are men or women more likely to be diagnosed with T1DM?

A
  • men in younger ages

- women in older ages

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9
Q

Although most patients with T1DM (85%) do not have a family history of T1DM, there is a small genetic predisposition. What is the genetic predisposition in monozygotic twins?

A
  • 36%
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10
Q

T1DM is a polygenic disorder. What does polygenic mean?

A
  • poly = many
  • genic = genetics/genes
  • so lots of genes cause the phenotype
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11
Q

T1DM is a polygenic disorder, meaning there are a lot of genes that can cause the clinical phenotype. There are >40 loci (specific locations on chromosomes) linked with T1DM, but the majority occur where?

A
  • in human leukocyte antigen (HLA) system
  • this is essentially the major histocompatibility complex (MHC) present on immune cells
  • MHC-1 = CD8 and MHC-II - CD4 cells
  • increased risk linked with HLA DR3-DQ2 and DR4-DQ8
  • decreased risk linked with HLA-DMA and DQB1
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12
Q

What is the term given to the group of cells in the pancreas that secrete glucagon and insulin?

A
  • islets of langerhans
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13
Q

The islets of langerhans is the term given to the group of cells in the pancreas that secrete glucagon and insulin. Which cells specifically secrete glucagon and insulin?

A
  • glucagon = alpha cells

- insulin = beta cells

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14
Q

In addition to secreting glucagon and insulin, the pancreas also posses Delta cells. What 2 molecules do these delta cells secrete?

A
  • somatostatin (inhibits insulin and glucagon secretion)

- collagen

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15
Q

In the pancreas which cells are responsible for secreting GIT juices?

A
  • acinar cells through ducts
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16
Q

Once beta cells have atrophied, is there any potential for regeneration of these beta cells?

A
  • no
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17
Q

T1DM is an auto immune disease. What type of hypersensitivity is T1DM?

A
  • type IV hypersensitivity
  • T cell mediated (CD4 and CD8)
  • also called delayed type hypersensitivity
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18
Q

T1DM is an auto immune disease, caused by a type IV hypersensitivity. What are the most common antibodies that patients have?

A
  • glutamic acid decarboxylase (GAD)
  • zinc Transporter 8 (ZnT8)
  • islet antigen 2 (IA2)
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19
Q

What are the 4 stages that make up the natural history of T1DM?

A

1 - genetic preposition for developing T1DM
2 - insulitis (inflammation of islets of langerhans) triggered by environmental trigger
3 - pre-diabetes
4 - diabetes
- during the process beta cell mass declines

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20
Q

What are the 4 most common autoimmune diseases that are associated with T1DM (that we have studied or are currently studying)?

A
  • hashimoto’s thyroiditis (hypothyroidism)
  • coeliac disease (triggered by gluten)
  • graves disease (hyperthyroidism)
  • addison’s disease (adrenal insufficiency, lack of cortisol secretion)
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21
Q

What are the main symptoms of T1DM?

A
  • thirst
  • polyuria
  • lethargy
  • unintentional weight loss
  • recurrent candidiasis (yeast infection)
  • visual changes
  • ketone breath (smells sweet like pear drops due to acetone)
  • diabetic ketoacidosis (build up of ketones in the body that can be dangerous)
  • coma and death
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22
Q

Why is age important when diagnosing T1DM?

A
  • T1DM generally present at a young age
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23
Q

Why is speed of symptom onset important when diagnosing T1DM?

A
  • T1DM will develop rapidly (rapid weight loss for example)

- T2DM will develop gradually over time

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24
Q

Why is patients phenotype important when diagnosing T1DM?

A
  • T1DM = young, thin and weight loss

- T2DM = overweight and generally older

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25
Q

In addition to age, speed of symptom onset and patients phenotype, what over aspects are important when trying to diagnose a patient with T1DM?

A
  • associated pathology
  • family history
  • ketosis/DKA
  • antibody positivity
  • C-Peptide measurement
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26
Q

What are ketone bodies?

A
  • carbon containing molecules produced by mitochondria in the liver
  • made from fat in the liver composed of acetyl-CoA
  • insulin normally inhibits this process
27
Q

Ketone bodies are carbon containing molecules produced by mitochondria in the liver, composed of acetyl-CoA. How are these generally made?

A
  • through beta oxidation where fatty acids are broken down to create acetyl-CoA for energy
  • 2 carbon molecules are created that enter KREB cycle
  • 2 carbon molecules combine to form ketone bodies
  • all occurs in the mitochondria of the liver
28
Q

Ketone bodies are carbon containing molecules produced by mitochondria in the liver composed of acetyl-CoA and are made when we are unable to acquire sufficient energy from carbohydrates, fats and proteins and act as a last resort of energy for people. However, what can excessive levels of ketone bodies do to the blood?

A
  • as ketone bodies are acid molecules they donate their protons
  • lowers the blood pH causing metabolic acidosis
29
Q

Ketone bodies are carbon containing molecules produced by mitochondria in the liver, composed of acetyl-CoA. Ketone bodies are made through lipolysis, where fat is converted into fatty acids (FA). FA enter beta-oxidation in matrix of mitochondria and cut into 2 carbon molecules before entering the KREB cycle. Too many 2 carbon molecules means ketones are produced. What are the 3 ketone bodies?

A

1 - acetoacetic acid
2 - beta hydroxybutyric
3 - acetone

30
Q

In a healthy individual the normal ketone body ratio for 2 of the main ketones; acetoacetate and 3 beta hydroxybutyrate is 1:1. However, in ketoacidosis what does this increase to?

A
  • 3 beta hydroxybutyrate:acetoacetate at 10:1 ratio
31
Q

What is C-peptide?

A
  • a 31 amino acid peptide
  • connects insulin’s A-chain to its B-chain in the pro-insulin molecule (not active until C-peptide is removed)
  • C-peptide is removed prior to release from vesicles in the beta cells
32
Q

C-peptide is a 31 amino acid peptide that connects insulin’s A-chain to its B-chain in the pro-insulin molecule (not active until C-peptide is removed). The C-peptide is removed prior to release from vesicles in the beta cells. Why is C-peptide a useful measure

A
  • if insulin is low as in T1DM then so to will C-peptide
33
Q

In fasting blood what level of C-peptide would be diagnosis cut off levels for the following:

  • severe insulin deficiency
  • intermediate insulin secretion
  • substantial endogenous insulin secretion
A
  • severe insulin deficiency = <80 pmol/L
  • intermediate insulin secretion = >80-<250 pmol/L
  • substantial endogenous insulin secretion = >250 pmol/L
34
Q

What would be the diagnosis in the following levels of C-peptide:

  • low
  • intermediate
  • high
A
  • low = T1DM
  • intermediate = favours T2DM over T1DM, consider rare genetic forms of diabetes
  • high = T2DM insulin resistance
35
Q

What is the treatment for T1DM?

A
  • insulin
36
Q

Insulin is used to treat T1DM. Insulin can come in 3 forms (how it has been produced), what are they?

A

1 - animal (bovine (beef) or porcine (pig))
2 - human
3 - synthetic

37
Q

Insulin is used to treat T1DM. Insulin duration affects can vary. What is added to the insulin that determines its duration?

A
  • protamine

- affects insulins solubility meaning it cannot be absorbed as quickly by cells

38
Q

Insulin is used to treat T1DM. Insulin strength can vary, what are the 4 most common strengths?

A
  • 100, 200, 300, 500 Units/ml
39
Q

What is the standard first line 2 stage insulin regime that is recommended clinically?

A

1 - long acting = basal

2 - quick acting to cover meal = bolus

40
Q

In standard insulin regime that is recommended clinically, is a twice-daily mixed [biphasic], basal-only, or bolus-only regimens recommended for patients with T1DM?

A
  • no
41
Q

Patients with T1DM are advised to carbohydrate count, why is this?

A
  • so they can adjust their insulin pumps and insulin secretion
42
Q

There is a normal physiological release of insulin following breakfast, lunch and dinner. When is the largest concentration of insulin release in these 3 meals?

A
  • breakfast
43
Q

What insulin regime is depicted in the image below?

1 - twice daily insulin regime
2 - once daily insulin regime
3 - continuous insulin pump
4 - basal/bolus regime

A
  • once daily insulin regime
  • normally lasts aprox 18-24 hours depending on which insulin is administered
  • does not mimic the physiological meal response but provides slow release
44
Q

What insulin regime is depicted in the image below?

A
  • twice daily insulin regime
  • not recommended in T1DM patients
  • this type of insulin is a form of long and short acting
45
Q

What insulin regime is depicted in the image below?

A
  • basal-bolus regimen/multi-daily injection therapy
  • GOLD STANDARD for T1DM management
  • accounts for post-prandial hyperglycaemia and continued low does of insulin
  • covers entire 24 hour period
46
Q

If a patient continues to inject insulin into the same site, what can this cause to subcutaneous fat?

A
  • lipohypertrophy
47
Q

Lipohypertrophy is when a patient continues to inject insulin into the same site. In addition to causing abnormalities in the appearance what can this cause to insulin release if it is injected at that location?

A
  • insulin response is variable, which can be dangerous

- can cause hypoglycaemia

48
Q

Lipohypertrophy is when a patient continues to inject insulin into the same site. In addition to causing abnormalities in the appearance this can affect the insulin response and be dangerous causing poorer control of their T1DM, such as hypoglycaemia. How can the risk of lipohypertrophy be addressed?

A
  • change the insulin administration site

- use longer lasting insulin so do not need to administer as much

49
Q

There have been new ultra long lasting insulins produced. What are the 2 names of the ultra long lasting drugs and how long do they last for?

A

1 - tresiba = 40 hours

2 - tougeo = 36 hours

50
Q

What is an insulin pump?

A
  • pump connected to the patient

- can provide insulin as basal (long acting) or bolus (quick acting)

51
Q

What is the WeAreNotWaiting campaign?

A
  • using old pumps to update them and allow patients to use them
52
Q

What does DAFNE stand for?

A
  • Dose Adjustment For Normal Eating
53
Q

DAFNE stands for Dose Adjustment For Normal Eating. What is the purpose of DAFNE?

A
  • a method used to count carbohydrates

- important for reducing hypo and hyperglycaemia

54
Q

What is the insulin to carbohydrate ratio?

A
  • 1:1 which equates to 1 unit of insulin:10 grams of carbs
55
Q

What is the insulin sensitivity factor/correction factor?

A
  • refers to the drop in blood sugar level

- 1 unit of insulin will drop blood glucose by 3mmol/L

56
Q

What are some of the common presentations of hypoglycaemia, which can be caused if the patient takes too much insulin?

A
  • blurred vision
  • dizziness
  • sweaty
  • weak and tired
  • upset or nervous
  • headcache
  • hungry
57
Q

What are some of the common presentations of hyperglycaemia, which can be caused if the patient does not take enough insulin?

A
  • extreme thirst
  • dry skin
  • hungry
  • frequent urination
  • blurred vision
  • drowsiness
  • poor wound healing
58
Q

When we carb count to ensure we are administering the correct dose of insulin, what are sick days?

A
  • instructions on how to amend insulin administration based illness
  • ketones in blood or urine need to be monitored
59
Q

Patients who are T1DM taking insulin must inform who before they drive?

A
  • DVLA
60
Q

If a patient drives and has >1 episode of hypoglycaemia whilst awake in the last 12 months, they must not do what and who should they inform?

A
  • drive

- inform the DVLA

61
Q

Patients with T1DM need to have an annual review. This includes DDS, which stands for what?

A
  • diabetes distress scale between 1-6 on patients quality of life and wellbeing
  • 1 is no problem and 6 is a serious problem
62
Q

Patients with T1DM need to have an annual review. This includes diabetes distress scale. What other 4 aspects are covered in the annual review?

A

1 - insulin delivery
2 -glucose monitoring
3 - monitor for complications (microvascular and macrovascular)
4 - hospitalisations

63
Q

What are the 2 aspects for future treatment do we need to know?

A

1 - islets of langerhans transplantation

2 - artificial pancreas (synthetic device to secrete insulin)

Year 2 RE (53 decks)

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