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ENDOCRINOLOGY > Type 2 Diabetes > Flashcards

Type 2 Diabetes Flashcards

1
Q

Type 2 diabetes diagnosed in childhood is associated with _____ and _____ onset of complications

A

Severe and early

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2
Q

Which ethnic groups are at highest risk for DM2?

A
  • African
  • Arab
  • Asian
  • Hispanic
  • Indigenous
  • South Asian
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3
Q

What is the incidence of DM2 in children in Canada?

A

1.54 per 100,000

Highest in Manitoba (12.45)

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4
Q

_____ % of children with DM2 also have a first or second degree relative who also has DM2

A

90%

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5
Q

List 5 behaviours associated with prevention of DM2

A
  1. Breastfeeding
  2. Prevention/management of obesity (not very effective)
  3. Improve sleep quality/quantity
  4. Decrease sedentary behaviuors
  5. Increase light and vigorous physical activity
  6. Reduce sugar-sweetened beverages
  7. Reduce screen time
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6
Q

List 8 risk factors for the development of DM2 in children

A
  1. DM2 in a first or second degree relative
  2. High-risk ethnic population (African, Arab, Asian, Hispanic, Indigenous, South Asian)
  3. Obesity (BMI >95th percentile)
  4. Impaired glucose tolerance
  5. PCOS
  6. Exposure to daibetes in utero
  7. Acanthosis nigricans
  8. Hypertension
  9. Dyslipidemia
  10. NAFLD
  11. (Possibly) atypical antipsychotic medications
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7
Q

What is the mean age of diagnosis of DM2 in Canadian youth?

A

13.7 years

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8
Q

What is the preferred screening test for DM2?

A

HbA1c and fasting or random BG

2-hour OGTT should be considered in children with 3 or more risk factors or if there is a discrepancy between A1c and fasting/random BG

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9
Q

Who should be screened for DM2? and how often?

A

Every 2 years in children with any of the following:

  1. 3+ risk factors in prepubertal children beginning at age 8 OR 2+ risk factors in pubertal children
  2. PCOS
  3. IFG and/or IGT
  4. Use of atypical antipsychotic medications
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10
Q

Who are the members of an interprofessional team managing children with DM2?

A
  • Pediatric endocrinologist or pediatrician with diabetes expertise
  • Dietician
  • Diabetes nurse educator
  • Mental health professional
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11
Q

What is the target HbA1c for children with DM2?

A

= 7.0%

HOWEVER, there is evidence that achieving an A1c of = 6.0% within the first 6 months of diagnosis may reduce the risk of treatment failure

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12
Q

Name 3 lifestyle factors to address in diabetes management

A

Healthy eating

Physical activity (60 minutes/day of moderate to vigorous)

Screen time (<2 hours)

Smoking prevention/cessation

Contraception in females (high risk of congenital anomalies)

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13
Q

When is treatment with insulin indicated in DM2?

A

Severe metabolic decompensation at diagnosis (ex. DKA, HbA1c >/= 9.0%, symptoms of severe hyperglycemia)

May be successfully weaned once glycemic targets are achieved

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14
Q

How should insulin be started in DM2?

A

Once daily, long-acting basal insulin

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15
Q

How should metformin be started in DM2?

A

At diagnosis, even if also starting insulin (except if acidosis is present)

500 mg PO daily x7 days, increase by 500 mg daily until reach maximum dose of 1,000 mg PO BID

Reduce increments to 250 if GI side effects

If not reaching glycemic targest within 3-6 months, add insulin

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16
Q

What oral antihyperglycemic agents have been studied in children?

A

Metformin (reduced A1c and FPG)

Glimepiride (sulfonylurea, reduced A1c but significant weight gain)

Rosiglitazone (TODAY study, no evidence re: long-term safety)

Bariatric surgery (case reports)

17
Q

What extra vaccines should be recommended in children with DM2?

A

Pneumococcal

Influenza (annual)

18
Q

____ % of Canadian youth with DM2 present with DKA at the time of diagnosis.

A

10%

19
Q

List 3 management principles of HHS

A
  • More aggressive fluid resuscitation
  • Delayed insulin administration at a lower dose
  • Careful replacement of potassium, phosphate and magnesium
20
Q

What are the screening recommendations for complications and comorbidities of DM2?

A
  • Neuropathy (at diagnosis + yearly): ask about symptoms of neuropathy, examine vibration sense, light touch and ankle reflexes
  • Retinopathy (at diagnosis + yearly): 7-standard field stereoscopic-colour fundus photography with interpretation by a trained reader OR direct ophthalmoscopy OR indirect slit-lamp fundoscopy through dilated pupil OR digital fundus photograph
  • Nephropathy (at diagnosis + yearly): first morning ACR
  • Dyslipidemia (at diagnosis + yearly): fasting TC, HDL, TG, calculated LDL
  • Hypertension (at diagnosis + at least twice yearly): BP measurement using appropriately sized cuff
  • NAFLD (yearly, at diagnosis): ALT and/or fatty liver on ultrasound
  • PCOS (yearly, at diagnosis in pubertal females): clinical assessment for oligo/amenorrhea, acne, or hirsutism
  • OSA (at diagnosis + yearly): symptoms of snoring, apnea, AM headaches, fatigue, daytime sleepiness, nocturia, enuresis
  • Depression (at diagnosis + yearly): clinical symptoms of fatigue, depressed mood, anhedonia, feelings of worthlessess/guilt
  • Binge eating (at diagnosis + yearly): clinical symptoms of loss of control/eating large amounts
21
Q

What should you do in the case of one abnormal ACR in a child with DM2?

A
  • Repeat 1 month later with repeat ACR or timed overnight urine collection
  • Repeat sampling should be done every 3-4 months over a 6-12 month period to demonstrate persistence
  • If persistent: referral to pediatric nephrologist
22
Q

When should you start a statin in children with DM2?

A

If LDL >4.1 after a 3-6 month trial of dietary interventions

23
Q

List 3 risk factors for development of hypertension in children with DM2

A
  1. Male gender
  2. Higher BMI
  3. Older age)

*Note: NOT A1c or ethnicity

24
Q

Biguanides (ex. metformin): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Enhances insulin sensitivty in liver and peripheral tissues by activation of AMP-activated protein kinase
  • HbA1c 1.0%
  • Negligible hypoglycemia as monotherapy
  • Weight-neutral
  • Reduction in MI in overweight individuals
  • Side effects: GI, vitamin B12 deficiency
  • Contraindicated if eGFR <30, caution in 30-60
25
Q

What is the mechanism of action of incretins? List 2 examples of medication classes

A
  • Mechanism: increase glucose-dependent insulin release, slow gastric emptying, inhibit glucagon release
  • Examples: DPP4 inhibitors (linagliptin, saxagliptin, sitagliptin) and GLP-1 receptor agonists (exenatide, liraglutide)
26
Q

DPP4 inhibitors (linagliptin, saxagliptin, sitagliptin): Mechanism of action, impact on A1c lowering/weight/CVD, side effects

A
  • Increases glucose-dependent insulin release, slows gastric emptying, inhibits glucagon release
  • HbA1c decrease 0.5-0.7
  • Negligible hypoglycemia as monotherapy
  • Weight-neutral
  • CVD-neutral
  • Side effects: rarely pancreatitis, joint pain
27
Q

GLP-1 agonists (exanatide, liraglutide): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Increases glucose-dependent insulin release, slows gastric emptying, inhibits glucagon release
  • HbA1c 1.0%
  • Negligible hypoglycemia as monotherapy
  • Weight loss 1.6 to 3kg
  • CVD reduction for liraglutide, CVD-neutral for exanatide
  • SC injection
  • Side effects: nausea, vomiting, diarrhea
  • Contraindicated if history of medullary thyroid cancer or MEN
28
Q

SGLT2 inhibitors (canagliflozin, empagliflozin, dapagliflozin): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Inhibits SGLT-2 transport protein to prevent glucose reabsorption by the kidney
  • HbA1c 0.4 to 0.7
  • Hypoglycemia negligible as monotherapy
  • Weight loss 2-3 kg
  • Reduction in CVD
  • Side effects: genital yeast infections, UTIs, hypotension, euglycemic diabetic ketoacidosis, increased fracture risk and amputation with canagliflozin
  • Contraindicaed if eGFR <45, caution if <60
  • Withhold med if serious illness or surgery
29
Q

Alpha glucosidase inhibitors (acarbose): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Inhibit pancreatic alpha-amylase and intestinal alpha-glucosidase
  • HbA1c 0.7-0.8
  • Hypoglycemia neutral as monotherapy
  • Weight neutral
  • Side effects: GI very common
30
Q

What is the mechanism of action of secretagogues? What are 2 classes?

A
  • Activates sulfonylurea receptor on beta cell
  • Sulfonylureas and Meglitinides
31
Q

Sulfonylureas (Gliclazide): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Activate sulfonylurea receptor on beta cell to stimulate insulin secretion
  • HbA1c 0.7 to 1.3
  • Minimal/moderate risk of hypoglycemia (worse with glyburide)
  • Weight gain 1.5 to 2.5
  • CVD neutral
32
Q

Meglitinides (Repaglinide): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Activates sulfonylurea receptor on beta cell to stimulate insulin secretion
  • HbA1c 0.7 to 1.1
  • Minimal/moderate risk of hypoglycemia
  • Weight gain 0.7 to 1.8 kg
  • CVD neutral
  • Repaglinide contraindicated when co-administered with clopidogrel/gemfibrozil
33
Q

TZDs (pioglitazone/rosiglitazone): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Enhances insulin sensitivity in peripheral tissues and liver by activation of peroxisome proliferator-activated receptor-activated gamma receptors (PPAR-gamma)
  • HbA1c 0.8 to 0.9
  • Negligible risk of hypoglycemia as monotherapy
  • Weight gain 2.5 to 5 kg
  • CVD neutral
  • Side effects: may induce edema/CHF, higher risk of fractures, pioglitazone has bladder CA controversy, rosiglitazone has MI controversy
34
Q

Orlistat: Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects

A
  • Inhibit lipase
  • HbA1c 0.2 to 0.4
  • Negligible risk of hypoglycemia as monotherapy
  • Weight loss 3-4 kg
  • Side effects: GI, diarrhea

ENDOCRINOLOGY (21 decks)

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