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Endocrine > Type 2 Diabetes > Flashcards

Type 2 Diabetes Flashcards

1
Q

Goals for Optimum Management of Type 2 Diabetes

A
  1. Diet
    - Eat according to Australian Dietary Guidelines
  2. BMI
    - 5-10% weight loss If BMI >=25
  3. Physical Activity
    - Children/adolescents - >= 60mins/day of moderate to vigorous exercise + muscle and bone strengthening activities 3x per week
    - Adults - 150mins aerobic activity + 2-3 sessions resistance exercise (to total of >=60mins) per week.
  4. Cessation of smoking
  5. EtOH - <= 2 std drinks per day
  6. BSL monitoring
    - Fasting 4-7mmol/L
    - Post-prandial 5-10mmol/L
  7. HbA1C Target
    - Generally <= 7% (53mmol/mol)
  8. Lipids - According to CVDRisk. If >15%, following targets
    • Total < 4.0mmol/L
      - HDL > 1.0mmol/L
      - LDL < 2.0mmol/L (<1.8 if CVD present)
      - Non-HDL < 2.5mmol/L
      - TAG < 2.0mmol/L
  9. BP < 140/90mmHg
    > Urine ACR? Target < 130/80mmHg
  10. Urine ACR
    - Men < 2.5mg/mmol
    - Women < 3.5mg/mmol
  11. Vaccination
    - Influenza, Pneumococcus, dTpa.
    - Consider Hep B if travelling and HZV.
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2
Q

Indications for Self-monitored blood glucose

A
  • Insulin-user
  • If not using insulin, consider on case-by-case basis basesd on type of hypoglycaemic agents, risk of hypoglycaemia, level of glycaemic control.
  • Pregnancy complicated by diabetes of gestational diabetes
  • Sick Days - Hyperglycaemia arising from intercurrent illness.
  • Haemoglobinopathies or other conditions where HbA1c measurements unreliable.
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3
Q

Screening For Type 2 Diabetes

A
  • Screen for diabetes every three years from 40yo on using AUSDRISK assessment tool.
  • ATSI? Screen from 18yo annually.
  • AUSDRISK >= 12? Screen with fasting BSL or HbA1C every 3 years.
  • Impaired GTT or FBG, screen every 12 months.
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4
Q

Early-Onset Diabetes Recommendations

A

Early- onset = diagnosis <= 25yo.
- Refer to endocrinologist. If not available, refer to specialist physician with interest in diabetes.

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5
Q

Indications for metabolic surgery in T2DM

A
  • BMI >40kg/m^2
  • BMI 35.0-39.9kg/m^2 with inadequate diabetic control despite optimal medical therapy and lifestyle management.
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6
Q

HbA1C Targets

A

< 7% - General recommendation
< 8% - Severe hypoglycaemia risk, limited life expectancy, advanced micro or macrovascular complications,

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7
Q

Diabetes and cases for clinically determined high CVDRisk

A
  • Age > 60 + T2DM
  • Diabetes with UACR > 2.5 men or > 3.5 women
  • eGFR < 45
  • Diagnosis of familial hypercholesterolaemia
  • Total Chol > 7.5mmol/L
  • ATSI + Diabetes
  • SBP > 180mmHg or DBP > 110mmHg
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8
Q

Diabetic Retinopathy Guideline Recommendations

A

Screening by optometrist/opthalmologist:
- At diagnosis of T2DM
- Annually

  • Established retinopathy, add Fenofibrate to Statin to reduce rate of progression.
  • Patients with established retinopathy planning pregnancy or who are pregnant must be counselled regarding risk of progression of diabetic retinopathy.
    • Eye examination should occur before pregnancy and monitored every trimester during pregnancy and for one year post-partum.
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9
Q

Diabetes-related neuropathy Guideline Recommendations

A

Screen on diagnosis and annually
Small Fibre
- Pinprick sensation
Large Fibre
- Touch Sensitivity to 10g monofilament
- Vibration Sensitivity to 128Hz tuning fork
- Ankle Reflexes

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10
Q

Foot care Guideline recommendations

A

Screening
- Low risk - Annually
- Higher risk - 3-6months.

  • Foot protection program
  • Podiatrist review
  • Appropriate footwear
  • Offloading of foot if plantar foot ulcer present. (Use total contact cast)
  • Non-viable tissue should be debrided
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11
Q

Diabetic Nephropathy Guideline Recommendations

A

Screening - Annually via eGFR and uACR

  • CKD established? Commence ACE-i or ARB
    • Review eGFR and K levels prior to commencing medication and 2 weeks post.
  • Consider SGLT2-i, or GLP1-RA to reduce risk of progression of CKD or CVD.
  • Sick day management - Review medications to avoid and withhold during sick days.
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12
Q

T2DM and Reproductive health Recommendations

A
  • Aim HbA1C < 6.5% ideally prior to conception to reduce risk of congenital abnormalities, pre-eclampsia, macrosomia, other complications.
  • Cease ACE-i, ARB and Statins prior to pregnancy.
  • Metformin and Sulfonylureas can continue until pregnancy is achieved.
    5mg daily dose of folic acid at least 1 month prior to conception.
    -
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13
Q

Causes of secondary diabetes

A
  • Diseases of the exocrine pancreas
    • Pancreatic cancer
    • Cystic Fibrosis
    • Haemochromatosis
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14
Q

Cases of inaccuracy of HbA1C

A

Percentage measure of glycated N-terminal residue on beta chain haemoglobin.

  • Acute-onset glycaemic states (post-traumatic type-2 diabetes, rapid onset glycaemia in sepsis, steroid use)
  • Within four months post-partum
  • Haemoglobinopathy
  • Haemolysis
  • People with iron deficiency (artificially inflated)
  • Recent blood or iron transfusion.
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15
Q

Screening and diagnosis of T2DM

A

FBG
- 5.5-6.9? Perform OGTT
- >=7.0? Confirm with repeat FBG

OGTT
- FBG 6.1-6.9 - IFG
- 2H 7.8-11.1 - IGT
- Re-test in IFG or IGT in 1 year.
- FBG >= 7.0 or 2H >=11.1? Diabetes

Normal FBG or OGTT? Re-test in 3 years
Impaired? Re-rest in 1 year.

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16
Q

Diagnosing type 2 diabetes in symptomatic patients

A

Symptoms
- Lethargy, polyuria, polydipsia, frequent fungal or bacterial infections, blurred vision, loss of sensation, poor wound healing, weight loss.
Signs
- Acanthosis nigricans
- Skin tags
- Central obesity
- Hirsutism

17
Q

Type 1 Diabetes Diagnosis considerations

A
  • Ketosis / Ketonuria
  • Polyuria
  • Polydipsia
  • Acute weight loss (>5% in less than 4 weeks)
  • <50 yo
  • Personal and family history of autoimmune disease
  • Acute onset of symptoms

Investigations
Antibodies (Present in 90% patients with T1DM)
- Glutamic Acid Decarboxylase (GAD)
- Insulinoma antigen-2 (IA-2)
- C-Peptide level (<0.2nmol/L on non-fasting sample support diagnosis)

If suspicious, bedside testing with fingerprick BSL and blood ketones recommended.

18
Q

Latent Autoimmune Diabetes of Adults

A

Type 1.5 Diabetes
- Occurs more commonly in adults
- Diabetes with b-islet cell antibodies
- Presents similarly to T2DM but involves more rapid course of b-cell destruction, poorer metabolic response to non-insulin therapy and a more rapid progression requiring insulin to control hyperglycaemia due to b-cell failure

19
Q

Monogenic Diabetes

A

Collection of single-gene mutations that account for 1-2% of diabetes cases
- Types
- Neonatal diabetes mellitus
- MODY (Maturity onset diabetes of the young)
- Related genes for MODY: HNF1A, GCK, HNF4A

If suspected, refer to endocrinologist

20
Q

Person-centred care

A

Holistic treatment of patients considering their individual preferences, priorities and sociocultural contexts.
- Patients more likely to engage in self-management and achieve optimal health outcomes if their care plans are person-centered.

Methods
- Use shared decision-making process
- Care is personalised
- Care is enabling
- Care is co-ordinated
- Person is treated with dignity, compassion and respect.

21
Q

Review Rule - What if medication is not working?

A
  • Check patient health literacy and compliance with treatment
  • Assess persistence and adherence to both lifestyle and pharmacological management
  • Review for confounders (UTI, Steroids, Antipsychotics)
  • Consider LADA or MODY as possibilities
  • Review-rule used to optimize effect of current management prior to advancing through additional glucose-lowering medications
22
Q

GLP1-RA and insulin injectable recommendations

A
  • Single use of pen needles and syringes recommended to reduce risk of lipohypertrophy
  • Shorter (4mm) needles adequate for injection and reduce risk of IM injection.
  • Ensure rotation of injection sites
23
Q

Hypoglycaemia

A

BSL <= 3.9mmol/L

Symptoms vary between people
- Adrenaline activation symptoms - Pale skin, sweating, shaking, palpitations, feeling of anxiety, dizziness
- Neuroglycopenic symptoms - Hunger, change in intellectual processing, confusion, irritability, seizures, coma

24
Q

Hyperglycaemia

A

HHS and DKA

Signs
- Severe dehydration, polyuria, polydipsia
- Abdominal pain, nausea, vomiting
- Altered consciousness
- Shock
- Ketotic Breath (DKA only)

Review for underlying cause of hyperglycaemia (Infection, Myocardial infarction)

25
Q

Indications for Continuous Glucose Monitoring (CGM) and Continuous subcutaneous insulin infusion CSII)

A

Patients at
- High Risk of Hypoglycaemia
- Hypoglycaemic unawareness
- High glycaemic variability

26
Q

Guide to insulin initiation and titration

A
  • Basal insulin 0.1units/kg or 10 units Nocte
  • Continue oral glucose-lowering medications
  • Adjust insulin dose twice weekly based on Mean FBG over 2 days
27
Q

Management of hypoglycaemia

A

Provide 15g quick acting carbohydrate
- Half a can of softdrink, half a glass of fruit juice, six jelly beans

  • Review in 15 mins
  • Test glucose hourly for next 4 hours.

Severe with altered LOC?
- Glucagon 1mg IM
- IV access - 50% glucose 20mL

28
Q

Components of Annual Diabetic Cycle of Care Examination

A
  • Weight
  • BP
  • Feet examination
  • Eye Examination
  • Fasting Lipids
  • HbA1C
  • Urine ACR
  • eGFR
29
Q

Diabetic Foot Examination

A
  • Pinprick sensation
  • 10g Monofilament

Endocrine (10 decks)

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