Type 2 Diabetes and its complications

Question 1

What percentage of patients with diabetes in the UK do not know they have it

Answer 1

50%

Question 2

Describe the onset of T2DM

Answer 2

Insidious

Question 3

Compare presentation of T1DM with T2DM

Answer 3

Compared to type 1 diabetes that always presents acutely with ketosis, type 2 diabetes patients spend months to years not knowing they have diabetes at all: insidious.

If the patients ignore the polyuria, the first time they present might be with a complication …

Question 4

What are the symptoms of T2DM

Answer 4

Slowly rising glucose:

• Polyuria and polydipsia
• Genital infections
• Tiredness and lethargy

Question 5

What happens to the sodium and the glucose in TD2M

Answer 5

The glucose causes osmotic diuresis which causes a loss of water and a rise in sodium

EVENTUALLY the glucose is VERY high, as is the sodium

Question 6

What is the equation for osmolality

Answer 6

Osmolality= cations (K+, Na+), + anions (Cl-, bicarb) + glucose + urea

Osmolality= 2(cations) + glucose + urea

Question 7

What can happen to osmolality of the plasma in diabetes

Answer 7

Glucose rises to 90mM (5.5)
Na rises to 160mM (137-142)
Osmolality = 430mM (275-295)

Question 8

T/f Patients with T2DM who do not know they have it have hyperglycaemia but not acidosis

Answer 8

T

Question 9

What can the urinary symptoms of T2DM sometimes be attributed to by patients

Answer 9

Assumed to be “prostate trouble” or “water work infections”

Question 10

How long have patients you diagnose with T2DM had hyperglycaemia for

Answer 10

Often months to years

Question 11

What are the complications of T2DM

Answer 11

Macrovascular: IHD, CVA, peripheral gangrene

Microvacular: retinopathy, nephropathy, neuropathy

Question 12

Differentiate the aetiology of the micro and macrovascular complications

Answer 12

Microvascular
Aetiology: Glycosylation of basement membrane proteins -> “leaky” capillaries

Macrovascular
Aetiology: Dyslipidaemia, hypertension, hypercholesterolaemia

Question 13

Categorise the retinal changes associated with diabetic retinopathy

Answer 13

1. Normal retina
2. Background diabetic retinopathy:
   - hard exudates (which is cholesterol)
   - dots (microaneurysms) and
   - blot haemorrhages
3. Pre-proliferative retinopathy
   - Cotton wall spots or ‘soft exudates’ which suggest retinal ischaemia
4. Proliferative retinopathy
   - Neovascularisation

Question 14

How can diabetes lead to blindness

Answer 14

If it gets to the proliferative retinopathy stage, then the new vessels that form as a result of ischaemia, can bleed into the vitreous fluid.

This causes blindness

Question 15

How do we manage background diabetic retinopathy

Answer 15

improve control of blood glucose

warn patient that warning signs are present

Question 16

T/F in the case of pre-proliferative diabetic retinopathy we shouldn’t leave it because new vessels might grow

Answer 16

TRUE that we shouldn’t leave it but because new vessels WILL grow

Question 17

What is the management of pre-proliferative diabetic

retinopathy

Answer 17

Pan retinal photocoagulation (laser)

Question 18

RECOGNISE WHAT A EYE THAT HAS HAD PAN RETINAL PHOTOCOAGULATION LOOKS LIKE

Answer 18

….

Question 19

How long does it take to see the benefits of good glycaemic control in diabetics

Answer 19

After around 15 years in NEWLY diagnosed T2DM patients there is a significant difference in the percentage of patients with events in those with good vs poor glycaemic control, for any diabetes-related endpoint

Question 20

What is a legacy effect?

Answer 20

In the patients who took part in a trial of conventional vs intensive sugar control, they followed these patients up.

In the intensive group, these patients soon had poor glycaemic control again after the intesive monitoring stopped.

But these patients, despite returning to poor gylcaemic control, still prevented heart disease in the future.

Question 21

T/F aggressively reducing high sugar in patients who have been hyperglycaemic for a long time is good

Answer 21

In the ACCORD, which aimed to bring HbA1c down to 6% (very intense), they actually found a higher death rate in the intensive-therapy group comapred to the standard-therapy group.

So rosiglitazone was taken off market

Question 22

What did DCCT find

Answer 22

type 1 diabetes, good control improves outcome

Question 23

What did UKPDS find

Answer 23

New type 2 diabetes put onto good control

Low mortality in both groups for 15 years, but then good control improved outcome, LEGACY EFFECT

Question 24

What did accord find

Answer 24

ACCORD: take older people who had poor control for a long time, and suddenly massively tighten control (A1c=6%): they already had coronary artery disease, so increased unexpected death

Question 25

What did advance find

Answer 25

ADVANCE: (A1c=6.5%, reduced death)