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General Medicine Pt1 > Type 2 diabetes mellitus > Flashcards

Type 2 diabetes mellitus Flashcards

1
Q

What is the diagnostic criteria for diabetes mellitus?

A

Either:

  • Symptoms + one abnormal glucose test
    • Polyuria, polydipsia, weight change, fatigue, frequent UTI or candida infections
  • Two abnormal glucose tests at separate times

Glucose tests:

  • Fasting >7.0mmol/L
  • Random >11.1mmol/L
  • HbA1c >6.5% (48mmol/mol)
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2
Q

Give five risk factors for T2DM

A
  • Obesity and inactivity
  • Poor diet: low fibre; high glycaemic index
  • FHx
  • Asian; african; black communities
  • PMH of gestational diabetes
  • Drugs: eg. statins; corticosteroids
  • PCOS
  • Metabolic syndrome
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3
Q

List five complications of T2DM

A
  • Macrovascular: CVD; stroke; TIA; peripheral artery disease
  • Microvascular: nephropathy; retinopathy; neuropathy
  • Metabolic: dyslipidaemia; DKA; HHS
  • Psychological: anxiety; depression
  • Frequent infections
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4
Q

What is metabolic syndrome?

A

Three of the following:

  • Increased waist circumference
  • Hypertriglyceridaemia
  • HTN
  • Insulin resistance
  • Prothrombotic state

Greatly increases the risk of developing T2DM

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5
Q

Outline monitoring of HbA1c and CBG in T2DM

A
  • HbA1c monitoring
    • 3-6-monthly until HbA1c stable on unchanging therapy
    • 6-monthly thereafter
  • CBG self-monitoring, only offer if any of:
    • On insulin
    • Evidence of hypoglycaemic episodes
    • Oral medication that increases risk hypoglycaemia while driving or operating machinery
    • Pregnant, or planning to become pregnant
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6
Q

What are the targets for HbA1c, BP, total cholesterol, and LDLs in diabetes mellitus?

A
  • HbA1c 48-59 mmols/mol (6.5-7.5%)
  • BP <140/80
    • <130/80 if end organ damage present
  • Total cholesterol <4 mmol/L
  • LDL <2 mmol/L
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7
Q

What HbA1c targets are given for T2DM?

A
  • 48 mmol/mol (6.5%)
    • Monotherapy not associated with hypoglycaemia
  • 53 mmol/mol (7.0%)
    • Sulfonylurea monotherapy: risk of hypoglycaemia
    • Not adequately controlled by single drug
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8
Q

State three pieces of lifestyle management for diabetes mellitus

A
  • Diet:
    • High fibre
    • Low-glycaemic index carbohydrates
    • Low saturated and trans fatty acids
  • Weight loss (5-10% target)
  • Increase exercise: improves insulin sensitivity
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9
Q

Outline patient education courses for diabetes mellitus

A

Offer structured education with annual reinforcement and review

  • T1DM: DAFNE course
    • Education on glycaemic index of food, and insulin doses
  • T2DM: DESMOND course
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10
Q

What is the DVLA guidance for diabetes mellitus?

A

All patients must be able to:

  • Produce CBG >5 mmol/L
  • At least 45 minutes prior to driving
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11
Q

What medications are considered if a person is symptomatically hyperglycaemic?

A

Insulin or sulfonylurea

Review treatment once blood glucose control is achieved

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12
Q

Outline the initial drug treatment options for T2DM

A
  • Metformin
    • Started once HbA1c rises to 48 mmol/mol on lifestyle
    • Consider modified release if not tolerated
  • DPP-4i; pioglitazone; sulfonylurea; or SGLT-2i
    • If metformin not tolerated
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13
Q

Outline the first intensification of drug treatment for T2DM who can take metformin

A

If HbA1c >58 mmol/mol (7.5%) whilst taking monotherapy, consider:

  • Metformin, plus:
    • DPP-4i
    • Pioglitazone
    • Sulfonylurea
    • SGLT-2i
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14
Q

Outline the second intensification of drug treatment for T2DM who can take metformin

A

If HbA1c rises to 58 mmol/mol (7.5%) on dual therapy, consider:

  • Triple therapy:
    • Metformin + DPP-4i + SU
    • Metformin + pioglitazone + SU
    • Metformin + pioglitazone/SU + SGLT-2i
  • Insulin-based treatment
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15
Q

What is the indication for GLP-1 mimetics in T2DM?

A

All of:

  • Triple therapy not effective/tolerated, or contraindicated
  • BMI 35+, and
    • Obesity-associated psychological or medical problems
  • BMI <35, and either
    • Contraindications to insulin therapy
    • Weight loss will benefit other obesity-related problems
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16
Q

Describe the mechanism of action of Metformin

A
  • Decreases hepatic glucose production
  • Decreases glucose absorption
  • Increases insulin-mediated glucose uptake
17
Q

Name two side-effects of Metformin?

A
  • Gastric: abdominal pain, anorexia, diarrhoea, NaV
  • Vitamin-B12 deficiency
  • Lactic acidosis
18
Q

Name three contraindications for metformin

A
  • CKD eGFR <30 ml/min: increased risk of lactic acidosis
  • Liver failure
  • Cardiac failure
19
Q

Outline the first intensification of drug treatment for T2DM where metformin is contraindicated or not tolerated

A

If HbA1c rises to 58 mmol/mol, consider:

  • DPP-4i + pioglitazone
  • DPP-4i + sulfonylurea
  • Pioglitazone + sulfonylurea
20
Q

Outline the second intensification of drug treatment for T2DM where metformin is contraindicated or not tolerated

A

If HbA1c rises to 58 mmol/mol on dual therapy, consider:

  • Insulin-based treatment
21
Q

Name one drug in the DPP-4 inhibitors class

Outline their mechanism of action

A

Sitagliptin; Vildagliptin

22
Q

Name two side effects of Sitagliptin (DPP-4i)?

A
  • GI disturbances
  • Hypoglycaemia (uncommon)
  • Pancreatitis
23
Q

What is a benefit of DPP-4i over other oral hypoglycaemic medication?

A

Weight neutral

24
Q

Name three side effects of Pioglitazone

A
  • GI disturbance
  • Oedema
  • Weight gain
  • Liver impairment
  • Associated with increased risk of:
    • Heart failure
    • Bladder cancer
    • Bone fracture
25
Q

Name and outline the mechanism of action of sulfonylureas

A

Gliclazide; Glimepiride; Tolbutamide

Stimulate insulin secretion by binding to ATP-sensitive potassium channels

26
Q

Name two side-effects of sulfonylureas

A
  • Weight gain: avoid in obese patients
  • Hypoglycaemia
27
Q

Name one side effect of SGLT-2 inhibitors

A
  • Increased risk of DKA in T2DM
  • Increased risk of UTI and STI
  • Polyuria
  • Hypoglycaemia
28
Q

Outline the types of insulin analogues available

A
  • Rapid acting (4-6hr)
  • Short acting (8-10hr)
  • Intermediate acting (NPH) (12-20hr)
  • Long acting (24hr)
  • Very long acting (50+hr)
29
Q

What initial insulin regimes are recommended by NICE for T2DM?

A
  • Intermediate (NPH) injections once or twice daily
  • Consider starting NPH and short-acting insulin
  • Consider long-acting insulin (Insulin Glargine) if:
    • requires care assistance
    • restricted by recurrent hypoglycaemia
30
Q

State three side-effects of insulin

A
  • Weight gain: inappropriate dose
  • Hypoglycaemia; coma
  • Hyperglycaemia
  • Lipoatrophy or lipohypertrophy
  • Painful injections: insufficient injection depth
  • Insulin allergic reaction (exceptionally rare)
31
Q

How is insulin-associated lipohypertrophy treated?

A
  • Prevention by rotating injection sites
  • Avoid injecting into affected area for 2-3 months
32
Q

What advice should be given regarding insulin injections?

A
  • Subcutaneous injections
    • Abdomen
    • Thighs
    • Upper arm
  • Needle inserted to its full length
  • Rotate injection site to prevent lipohypertrophy
33
Q

What is pre-diabetes?

A

A risk category for DM featuring:

  • Elevated blood sugar
  • Does not meet the criteria for DM
  • HbA1c between 5.6-6.4% (38-46mmol/mol)
34
Q

Define impaired glucose tolerance

A

Both:

  • Fasting plasma glucsoe <7.0 mmol/l
  • OGTT 2h value ≥7.8 mmol/l, but <11.1 mmol/l
35
Q

Define impaired fasting glucose

A

Fasting glucose ≥6.1 mmol/l, but <7.0 mmol/l

36
Q

What conditions can cause secondary diabetes?

A

Pancreatitis Pancreatic carcinoma Trauma Haemochromatosis Cystic fibrosis Acromegaly Cushing’s disease Hyperthyroidism Pheochromocytoma

37
Q

List the other types of diabetes mellitus besides T1DM, T2DM, and GDM

A

Latent autoimmune diabetes of adults (LADA): T1DM occurring in adults (30-50), may not require insulin initially. Maturity onset diabetes of the young (MODY): Autosomal dominant DM in under 25s. May be of healthy BMI, and not require insulin. Drug-induced: Corticosteroids, thiazides, anti-psychotics Secondary: Pancreatitis, pancreatic carcinoma, trauma, haemochromatosis, CF, Acromegaly, Cushing’s disease, hyperthyroidism, Pheochromocytoma

General Medicine Pt1 (25 decks)

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