Type 2 Diabetes Flashcards
What is Diabetes?
Diabetes is caused by a deficiency in or resistance to insulin. There are 4 main types of diabetes: Type 1, Type 2, Secondary or gestational diabetes.
Type 2 Diabetes is caused by a resistance to the body’s insulin, to the point that levels are effectively reduced, even with normal or raised levels of insulin. This is due to chronically raised blood sugar levels and an upregulation of receptors.
Type 2 diabetics are at risk of Hyperosmolar Hyperglycaemic State (HHS), this is a state of very high blood glucose levels (often over 30) that is precipitated during illness or due to a lack of medication being taken. This abnormally elevated level of glucose in the body causes osmotic diuresis leading to dehydration. Patients present very similarly to DKA (present less acutely, lasting about a week), however ketone levels will be normal as there is still a basal level of insulin.
Secondary Diabetes is diabetes secondary to damage to the pancreas or a multitude of endocrine conditions
Gestational diabetes occurs in pregnant women
What are the causes of Diabetes?
Type 2 - Metabolic Syndrome, Fatty Liver Disease
Secondary - Pancreatic trauma, Chronic pancreatitis, Steroid Use, Cystic Fibrosis, Carcinoma of the pancreas, Endocrine (Cushing’s, Acromegaly, Thyrotoxicosis, phaeochromocytoma), Thiazide Diuretics,
Gestational – Pregnancy
What will you find on a history of Type 2 Diabetes?
Symptoms:
Polyuria
Polydipsia
Lethargy
Recurrent Infections E.g. Specifically Thrush
Microvascular Complications - Retinopathy, maculopathy, nephropathy, Neuropathy, cardiomyopathy
Macrovascular complications - Stroke, MI, Peripheral vascular disease
Risk Factors: Older age Obesity Family history of type 2 diabetes History of gestational diabetes Presence of pre-diabetes Low Physical inactivity Hypertension Hyperlipidaemia Cardiovascular Risk Factors History of Metabolic syndrome or fatty liver disease
Specific Questions to ask:
Assess cardiovascular risks - Smoking, BP control, high cholesterol. Previous MI/Stroke or PVD
Assess for Retinopathy - painless, gradual loss of central vision. Or sudden loss of vision over the area in haemorrhage
Asses for Diabetic Nephropathy - Same signs as CKD e.g. pruritus, peripheral oedema, dyspepsia, hiccups, pericarditis, confusion/coma, lethargy
Assess Neuropathy - Any numbness/tingling. Damage to their feet they didn’t notice when it happened. Slow healing wounds on feet etc
Differentials:
Type 1 diabetes – Affects younger Patients, who do not possess risk factors e.g. obesity, they may also have DKA. Ask about other autoimmune conditions
Pre-Diabetes – Will not be symptomatic but bloods will show elevated glucose levels, however not elevated enough to be diagnostic
Gestational Diabetes – Pregnant
Secondary Diabetes – Ask about history of steroid use, pancreatitis or symptoms of pancreatic carcinoma (weight loss, steatorrhea), Look for stigmata of endocrinopathy e.g. Cushingoid features
What will you find on examination of Type 2 Diabetes?
Hands:
Raised BP – Look at lying and standing BP, Postural hypotension indicates autonomic neuropathy
Glove and stocking distribution Neuropathy
Face:
Acuity may be reduced in maculopathy
Ophthalmoscope - Retinopathy (Cotton Wool Spots, Micro-aneurisms, Oedema/exudate, Neovascularisation), Maculopathy (Macular Oedema and Hard exudates)
Abdomen:
Examine injection sites if any
Listen for renal bruit
Legs:
Listen for femoral bruit
Foot ulcers
Weak peripheral pulses
Vibration/Sensation assessment
Glove and stocking distribution Neuropathy
What investigations will you order in Type 2 Diabetes?
Bedside Tests:
Urinalysis – Looking for ketones that will rule out type 1 diabetes, and looking for urinary albumin, haematuria, proteinuria used to assess kidney damage
ECG - Assess cardiovascular risk and look for any previous MI that could have been silent
Bloods:
HBa1C - Gives 3-month indication of glucose levels
Serum Glucose – 2 different results of >11.1 (random) or >7 (fasting) is diagnostic. Only 1 result is required in presence of symptoms
Lipids - Assess cardiovascular risk
U&E - Assess renal function. Microalbuminuria >300mg/day indicates diabetic nephropathy is ongoing.
Special Tests:
ABPI to evaluate any peripheral vascular disease
Ophthalmologist review for eyes
What is the treatment of Type 2 Diabetes?
Lifestyle:
Reduce Weight
Regular exercise
Consider Dietitian referral
Smoking cessation
Annual Review and annual optician check up
Foot Management - Remove dead skin regularly, keep foot clean to prevent infection/abscess. Check feet with mirror.
Medical:
1st Line – Metformin
2nd Line (added if HBA1c >7.5) - Add 2nd line drug depending on specific circumstances – Sulfonylurea, Dpp4 inhibitor, SGLT2 Inhibitors, Glitazone
Last Line - Insulin therapy + Metformin (remove all others)
Reduce other cardiovascular risk factors: Manage BP (Use Ace inhibitors in patients with diabetic nephropathy), Statin therapy, Dual antiplatelet therapy (if indicated). Consider use of orlistat in patient who care unable to lose weight
Refer to specialist for any complications e.g. Ophthalmologist. While waiting for the referral manage blood glucose and lifestyle as well as possible.
What is the treatment of Hyperosmolar Hyperglycaemic State?
Resuscitation:
Patients have 100-200ml/Kg deficit in fluid. Slowly replace this via IV fluids.
Don’t give insulin initially as the glucose may reduce as fluids are added. But may be given later if they are not reducing
Medical:
Treat any electrolyte deficiency after fluid resuscitation unless severe.
Keep Glucose 10-15 during first 24 hours as low level can precipitate cerebral oedema
LMWH given to everyone
