Type 2 Diabetes Mellitus Flashcards
how is it diagnosed?
a diagnosis of exclusion
- check if it’s T1DM (give insulin for life)
- check for something more unusual
- if nothing else comes up = T2DM
who gets it?
prevalence of diabetes peaks at 65-69 years old in Scotland - risk increases with age
if parent has T2DM - 40% lifetime risk
9/10 people with T2DM are overweight/obese
pathophysiology
polygenic common complex disease
many genetic variants contribute to risk BUT age and BMI have a huge impact
obesity and lack of activity result in adiposity - increased free fatty acids and adipokines, lead to insulin resistance (fatty acids deposited in liver and muscle)
it is a progressive disease mainly due to deterioration in beta-cell function (with a small increase in insulin resistance over time)
effect on beta cells
normal beta cells - cause a compensatory increase in insulin production causing euglycaemia
vulnerable beta cells (caused by lipotoxicity) - cause an inability to respond to an produce more insulin
what % of people with T2DM have insulin resistance?
90% - although insulin resistance is not just associated with DM
what else other than DM is insulin resistance associated with?
hypertension
hyperlipidaemia
hyperglycaemia (even in absence of diabetes)
Polycystic ovarian syndrome (PCOS)
collectively these are known as insulin resistance syndrome
how can it present?
blurred vision
recurrent UTIs
tiredness
polyuria
what would cause a need to screen for T2DM?
overweight/obese
family history of T2DM
or concurrent illness e.g. glucose measure in work up for heart disease
what is the onset of it?
unlike T1DM it is usually slow onset - there may be a phase of ‘prediabetes’ or frank diabetes present years before presentation
acute presentation?
can present acutely with DKA
the ‘stereotype’ patient
usually middle aged/elderly, though can have young onset (children/young adults) in very obese and/or high risk ethnicity
obese and sedentary although can be non-obese esp. if elderly
do they need insulin
typically non-insulin dependent (but can progress to insulin dependent)
aims of management?
treat symptoms
prevent microvascular complications (control glucose, aim for HbA1c <7% [53mmol/mol])
prevent cardiovascular complications (control BP, cholesterol and antiplatelet therapy)
screen for complications - early while treatable (eye disease - laser, neuropathy - podiatry, kidney disease - BP management, ACEi)
steps of management
diagnosis therapeutic lifestyle change (10-15% weight loss can result in remission) monotherapy combination therapy (not insulin) combination therapy with insulin
Therapeutic lifestyle - diet & exercise
aim for realistic targets with weight maintenance/modest weight loss (i.e. 5-10kg in one year - this can improve health outcomes)
initial guidance on healthy eating - normal intake of unrefined carbohydrate, reduce refined sugar intake, reduce fat intake, increase fruit and veg intake, reduce salt, safe and sensible alcohol consumption
encourage active lifestyle
ideal use of lifestyle intervention
to prevent diabetes in the 1st place - lifestyle intervention 1/2s the odds of developing T2DM
lowering HbA1c - helps reduce CV risk/ long-term risks and helps control symptoms
what is the target HbA1c for T2DM?
7.0% (53mmol/mol)
target of 6.5% may be more appropriate at diagnosis, the targets should also be considered on an individual basis in order to balance benefit and harm (esp. hypoglycaemia and weight gain)
what factors make it harder to reach glycaemia targets?
younger
female
obese
not at BP or lipid targets
when insulin treatment should be used
most T2DM patients produce plenty of insulin until late in disease - insulin treatment different to T1DM - less use of basal-bolus insulin therapy and more use of basal insulin
used when people fail non-insulin therapies (once daily NPH insulin (immediate acting), mixed insulin (Humulin M3) or basal/bolus (e.g. lantus/novorapid))
drug treatments?
1st line = metformin (SU if intolerant) in addition to lifestyle measures
2nd line = add SU or SGLT2i or DDP-4i or pioglitazone in addition to lifestyle measures
3rd line = add another oral agent from a different class: SU or SGLT2i or DDP-4i or pioglitazone in addition to lifestyle measures
GLP-1 agonist and basal insulin can also be used
sick day rules
BG normally rises in response to stress and illness
short-term hyperglycaemia can be tolerated and managed at home if no dehydration and oral fluids are being tolerated
should normally continue oral diabetes medication
severe infection or dehydration stop metformin
admit to hospital if severely dehydrated or severe (intractable) vomiting
What medications should be stopped if major vomiting/diarrhoea or fever, sweats and shaking in T2DM patients?
ACEi ARBs diuretics metformin NSAIDs
