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Finals: Medicine > Type 2 Diabetes > Flashcards

Type 2 Diabetes Flashcards

1
Q

What is diabetes

A

It is a group of conditions, which are all characterised by an abnormally raised levels of blood glucose

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2
Q

What is the normal blood glucose concentration

A

4.4 - 6.1 mmol/L

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3
Q

What is the most common form of diabetes

A

T2DM

90% of cases

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4
Q

How would you describe T2DM

A

Characterised by a combination of reduced sensitivity to the action of insulin and inadequate production of insulin by the pancreatic beta cells to overcome the insulin resistance

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5
Q

Which diabetic emergency can be a first presentation of T2DM

A

Hyperosmolar hyperglycaemic state (HHS)

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6
Q

Describe the pathogenesis of T2DM

A

T2DM is a progressive disorder

Repeated exposure to glucose and insulin makes the cells in the body become resistant to the effects of the insulin

One of the insulin’s functions is to tell the body cells to take up glucose therefore the decrease in insulin sensitivity impairs glucose uptake into the cells, raising blood glucose levels (hyperglycaemia).

In a compensatory effort to deal with the hyperglycaemia, the pancreatic beta cells produce more insulin, resulting in a rise in plasma insulin levels, hyperinsulinemia.

The production of hyperinsulinemia cannot be sustained and over time, the pancreatic beta cells become fatigued and damaged and eventually leads to a relative insulin deficiency.

The result is insulin resistance by the body’s cell, relative insulin deficiency due to beta cell fatigue and damage, chronic hyperglycaemia

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7
Q

What causes T2DM

A

Combination of genetic predisposition and environmental factors

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8
Q

Name some of the non-modifiable risk factors of T2DM

A

Older age

Ethnicity (Black, Chinese, South Asian)

Family history of diabetes i.e. the genetic predisposition

Polycystic ovary syndrome

Hypertension

Dyslipidaemia

Known cardiovascular disease

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9
Q

Name some of the modifiable risk factors of T2DM

A

Overweight/Obesity – main risk factor

Sedentary lifestyles

High carbohydrate (particularly refined carbohydrate) diet

Presence of pre-diabetes

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10
Q

What is the biggest risk factor for T2DM

A

Overweight/Obesity

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11
Q

T2DM commonly present with a triad of symptoms.

Name these symptoms

A

Polyuria

Polydipsia

Weight loss

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12
Q

Diabetes often present with a triad of symptoms: Polyuria, polydipsia and weight loss.

Symptoms are more noticeable in which diabetes

a) T1
b) T2

A

a) T1

Not T2 as it is a more gradual process.

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13
Q

What investigations can be used to diagnosis T2DM

A

Fasting Glucose >= 7 mmol/l

Random plasma Glucose >= 11 mmol/l

HbA1c >= 48 mmol/mol

OGTT 2 hour result >= 11 mmol/l (2 hours after 75g glucose)

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14
Q

T2DM can be diagnosed using the following tests: Fasting glucose, random plasma glucose, HbA1c and oral glucose tolerance test (OGTT).

How many diagnostic tests are required to confirm diabetes in a symptomatic patient?

A

One

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15
Q

T2DM can be diagnosed using the following tests: Fasting glucose, random plasma glucose, HbA1c and oral glucose tolerance test (OGTT).

How many diagnostic tests are rquired to confirm diabetes in a asymptomatic patient?

A

Two

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16
Q

What is the cut off for the diangosis of T2DM in fasting glucose test

A

Greater than or equal to 7 mmol/L

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17
Q

What is the cut off for the diagnosis of T2DM in random plasma glucose test

A

Greater than or equal to 11 mmol/L

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18
Q

HbA1c greater than what is diagnostic of T2DM

A

Greater than or equal to 48 mmol/L

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19
Q

Oral glucose tolerance test (OGTT) greater than what is diagnostic of T2DM

A

Greater than or equal to 11 mmol/L

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20
Q

What is the gold standard investigation for T2DM

A

HbA1c

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21
Q

What is HbA1c

A

Glycated haemoglobin

The average blood glucose concentration over a 3 month period i.e. average life span of an erythrocyte

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22
Q

Why does glycated haemoglobin levels increase with blood glucose levels (as evident on HbA1c)

A

Glycated haemoglobin occurs due to non-enzymatic irreversible modification of the beta globin chain in haemoglobin. As blood glucose levels increase the amount of glycation of haemoglobin also increases.

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23
Q

A fasting plasma glucose should be tested after a minimum of how much time fasting

A

Minimum of 8 hours fasting

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24
Q

Which of the diabetic drugs is known to give CV benefit:

a) Metformin
b) Sulphonylurea
c) Thiazolidinedione
d) DPP-4 Inhibitor
e) SGLT2 inhibitor
f) GLP-1 agonist
g) Basal insulin

A

a) Metformin
e) SGLT2 inhibitor
f) GLP-1 agonist
c) Thiazolidinedione - probable

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25
Q

Which of the diabetic drugs is known to have a high risk of hypoglycaemia:

a) Metformin
b) Sulphonylurea
c) Thiazolidinedione
d) DPP-4 Inhibitor
e) SGLT2 inhibitor
f) GLP-1 agonist
g) Basal insulin

A

b) Sulphonylurea
g) Basal insulin

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26
Q

Which of the diabetic drugs is known to cause weight gain:

a) Metformin
b) Sulphonylurea
c) Thiazolidinedione
d) DPP-4 Inhibitor
e) SGLT2 inhibitor
f) GLP-1 agonist
g) Basal insulin

A

b) Sulphonylurea
c) Thiazolidinedione
g) Basal insulin

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27
Q

Which of the diabetic drugs is known to cause weight loss:

a) Metformin
b) Sulphonylurea
c) Thiazolidinedione
d) DPP-4 Inhibitor
e) SGLT2 inhibitor
f) GLP-1 agonist
g) Basal insulin

A

a) Metformin
e) SGLT2 inhibitor
f) GLP-1 agonist

28
Q

Which of the diabetic drugs is known to cause weight neutral:

a) Metformin
b) Sulphonylurea
c) Thiazolidinedione
d) DPP-4 Inhibitor
e) SGLT2 inhibitor
f) GLP-1 agonist
g) Basal insulin

A

d) DPP-4 Inhibitor

29
Q

What is the 1st line management option in T2DM

A

Diet and Lifestyle changes

Dietary Modification: Typical advice is low glycaemic, high fibre diet. Less refined carbohydrate e.g. white bread.

Optimise Other Risk Factors: Exercise and weight loss; Stop smoking; Optimise treatment for other illnesses e.g. hypertension.

30
Q

T2DM is intially managed with diet and lifestyle changes as it can be reversible.

How long would the trial period be before thinking about adding in medication

A

3 months

31
Q

What are the choices in the 1st line medical management of T2DM

A

Metformin or sulfonylurea if metformin is not tolerated.

32
Q

Metformin:

a) CV benefit?
b) Hypoglycaemia risk?
c) Weight?

A

a) Yes is CV benefit
b) Low risk of hypoglycaemia
c) Weight loss

33
Q

Sulphonylurea:

a) CV benefit?
b) Hypoglycaemia risk?
c) Weight?

A

a) No
b) High hypoglycaemic risk
c) Weight gain

34
Q

What is the main adverse effect of metformin

A

GI upset

35
Q

What is the main adverse effect of sulphonylurea

A

Risk of hypoglycaemia

36
Q

What is the second line medical management of T2DM

A

1st therapy (Metformin OR Sulfonylurea)

AND

Sulfonylurea (if not 1st line) OR Pioglitazone OR DPP-4 inhibitor OR SGLT-2 inhibitor

37
Q

What is the third line medical management of T2DM

A

Triple therapy with (metformin + 2x oral agents)

OR

Injectable agent

38
Q

Which diabetic drug increases insulin sensitivity

A

Thiazolidinediones i.e. Piglitazone

39
Q

Name the two injectible drugs that may be used in the treatment of T2DM

A

GLP-1 agonist

Basal insulin

40
Q

The choice of injectable agent as part of the third line management of T2DM depends on BMI.

At what BMI would you use GLP-1 agonist as the first option

A

BMI ≥30Kg/m2

41
Q

The choice of injectable agent as part of the third line management of T2DM depends on BMI.

At what BMI would you use basal insulin as the first option

A

BMI < 30 Kg/m2

42
Q

Give an example of a Biguanide

A

Metformin

43
Q

What drug class does Metformin belong to

A

Biguanide

44
Q

What is the mechanism of action of Biguanide e.g. metformin

A

Increase the activity of AMP-dependent protein kinase (AMPK)

This inhibits hepatic gluconeogenesis (production of glucose from certain non-carbohydrate substrates)

Reduces insulin resistance

45
Q

What is the main side effect of metformin

A

GI upset e.g. diarrhoea

46
Q

In what patient groups is Biguanide e.g. metformin not recommended in

A

Not recommended in pregnancy and renal failure (eGFR <30 mls/min)

47
Q

Give an example of a Sulphonylureas

A

Gliclazide

48
Q

What is the mechanism of action of Sulphonylureas

A

Stimulates B cells of the pancreas to produce more insulin

Increase cellular glucose uptake and glycogenesis; reduces gluconeogenesis

Glicazide is short acting (12 hours approx.)

49
Q

Give an example of a Thiazolidinedione

A

Pioglitazone

50
Q

What is the mechanism of action of Thiazolidinedione

A

Reduces peripheral insulin resistance, leading to a reduction of blood-glucose concentration.

51
Q

Name some of the side effects of Thiazolidinedione

A

Bone fracture

Increased risk of infection

Numbness

Visual impairment

Weight gain

Fluid retention – oedema

52
Q

Thiazolidinedione are excreted?

a) by the kidneys
b) by the liver

A

a) by the kidneys

53
Q

Sulphonylureas are excreted?

a) by the kidneys
b) by the liver

A

a) by the kidneys

54
Q

Biguanide are excreted?

a) by the kidneys
b) by the liver

A

a) by the kidneys

55
Q

Incretins are hormones produced by the GI tract. They are secreted in response to large meals and act to reduce blood sugar.

Name the main incretin in the body

A

Glucagon-like peptide 1 (GLP-1)

56
Q

Incretins are hormones produced by the GI tract. They are secreted in response to large meals and act to reduce blood sugar.

Incretins are inhibited by what enzyme

A

Dipeptidyl peptidase-4 (DPP-4)

57
Q

Give an example of a SGLT-2 Inhibitors

A

End with the suffix “-gliflozin” e.g. empagliflozin, canagliflozin and dapagliflozin

58
Q

What is the mechanism of action of SGLT-2 Inhibitors

A

The SGLT-2 protein is responsible for reabsorbing glucose from the urine in to the blood in the proximaltubules of the kidneys.

SGLT-2 inhibitors block the action of this protein and cause glucose to be excreted in the urine.

59
Q

Name some of the side effects of SGLT-2 inhibitors

A

Glucoseuria (glucose in the urine)

Increased rate of urinary tract infections

Weight loss

Diabetic ketoacidosis, notably with only moderately raised glucose. This is a rare complication

Lower limb amputation appears to be more common in patients on canagliflozin. It is not clear if this applies to other SGLT-2 inhibitors

60
Q

Hyperosmolar hyperglycaemic state (HHS) can be a first presentation of what kind of diabetes

A

T2DM

61
Q

Which glucose test is less accurate:

a) Random
b) Fasting

A

Random glucose test is less accurate

For that reason is not usually a good first choice for diagnosing diagnosis

62
Q

What is the difference between the fasting glucose test and the random glucose test

A

Fasting glucose test involves measuring blood glucose concentration after a minimum of an 8-hour fast. High level suggests diabetes

Random glucose test does not involve fasting. Useful for rapid assessment of blood glucose

63
Q

Oral Glucose Tolerance Test (OGTT) involves fasting then measuring blood glucose and then giving a glucose drink and waiting a period of time before measuring the blood glucose again.

How long do you wait until you measure the blood glucose again

A

2 hours

64
Q

Oral glucose tolerance test is not done routinely now as its time consuming as it measures the ability of the body to deal with a glucose load over a two-hour period.

When would it be used?

A

Required where there is a diagnostic uncertainty

Required for diagnosis of gestational diabetes.

65
Q

What investigation is used to monitor glycaemic control

A

HbA1c

66
Q
A

Finals: Medicine (91 decks)

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