Type 2 Diabetes Mellitus (1)

Question 1

What occurs here?

What are its risk factors?

How does it present?

Answer 1

➊ Repeated exposure to high levels of glucose and insulin leads to insulin resistance, and the over-worked pancreas becomes damaged, causing chronic hyperglycaemia

➋ Elderly, Ethnicity (black, south asian, chinese), Family hx, Obesity, Lack of exercise

➌ • Polyuria
• Polydipsia
• Weight loss

Question 2

Investigations:
How is it diagnosed?

What is HbA1c?
→ When should it not be used?

How is Pre-diabetes diagnosed?

Answer 2

➊ If symptomatic, 1 of the following is sufficient:
• HbA1c of 48+
• Fasting glucose of 7+
• Random glucose of 11+

N.B. If asymptomatic, 2 +ve results are required from different days

➋ Average glucose levels from last 3 months
→ • Children/Young adults
• Pregnant women
• Haemoglobinopathy
• Recent blood transfusion
• Anaemia

➌ • HbA1c between 42 and 47
• Fasting glucose between 5.5 and 6.9

Question 3

Management:
What are the lifestyle changes to make?

How is it managed?

What’s the aim HbA1c level?

Answer 3

➊ Diet advice, regular physical activity, smoking cessation, blood pressure control

➋ • Metformin 1st line
• Pioglitazone, DPP‑4 inhibitors, Sulphonylureas or SGLT-2 inhibitors can be added on
• Insulin

➌ • 48 for those with a new diagnosis
• 53 for those past metformin

Question 4

Anti-Diabetic Drugs:
How does Metformin work?
→ What are its SEs?

How does Pioglitazone work?
→ What are its SEs?

What is Sitagliptin?
→ What are its SEs?

What is Gliclazide and how does it work?
→ What are its SEs?

What’s an example of a SGLT2 inhibitor? How does it work?
→ What are its SEs?

Answer 4

➊ Biguanide that increases peripheral insulin sensitivity, and doesn’t affect weight
→ Lactic acidosis, GI disturbance

➋ Increases peripheral insulin sensitivity
→ Weight gain, Fluid retention, worsening heart failure

➌ DPP4 inhibitor
→ Hypoglycaemia, GI upset

➍ Sulphonylurea, which stimulates insulin secretion
→ Hypoglycaemia, Weight gain

➎ -gliflozin, which increases urinary glucose loss
→ Weight loss, UTIs

N.B. With SGLT2 inhibitors, they cause there to be lots of glucose in the bladder, which acts as a substrate for bacteria and fungi to grow, therefore leading to infection.

Question 5

What are some of its complications?

Answer 5

• Hyperosmolar Hyperglycaemic State (HHS):
  ‣ Insulin deficiency and increased counter-regulatory hormones (small amount of insulin prevents the production of ketones)
  ‣ Gradual confusion, Hypercoagulable state, VTE
• Gastroparesis:
  ‣ Caused by nerve damage to the autonomic vagus nerve, which controls gastric muscles
  ‣ Leads to delayed gastric emptying, presenting with offensive-smelling burps, early satiety, and morning nausea
  ‣ Management - Metoclopramide 1st line, Domperidone 2nd line
• Postural Hypotension
• Peripheral Arterial Disease
• Renal Disease
• Diabetic Foot Infections
• Sexual Dysfunction
• Cardiac Complications