Type 2 Diabetes Mellitus

Question 1

Symptoms of T2DM

Answer 1

fatigue
lethargy
polyuria
nocturia 
polydipsia
polyphagia
weight loss
pruritus vulvae
balanitis

Question 2

Pathophysiology of T2DM

Answer 2

Progressive decline in beta-cell function associated

with insulin resistance in muscle and adipose tissue

Question 3

Hyperglycemia Mechanism

Answer 3

› insulin-resistant state&raquo_space;> increased hepatic glucose output & reduced utilisation of glucose by organs&raquo_space;> Fasting & PP Hyperglycemia

› Impaired intestinal incretin secretion&raquo_space;> compromised meal-related insulin secretion & glucagon suppression&raquo_space;> postprandial hyperglycemia

› Excessive renal tubular reabsorption of glucose

Question 4

Screening test

Answer 4

Capillary Plasma Glucose

If FPG >= 5.6 OR PPG >=7.8 mmol/L confirm with a diagnostic test

Question 5

Diagnostic Tests

Answer 5

1. Fasting Venous Plasma Glucose (8 hour fasting) in SYMPTOMATIC
   Fasting Random
   T2DM: ≥7.0 mmol/L ≥11.1 mmol/L
   IFG/PreDM : 6.1-6.9 mmol/L
2. Oral Glucose Tolerance Test
   75G Glucose in water
   One FBG sample & 2 hour PP sample
   Fasting Random
   Normal: <6.1 mmol/L <7.8 mmol/L
   T2DM: ≥7.0 mmol/L ≥11.1 mmol/L
   IFG: 6.1-6.9 mmol/L
   IGT: 7.8-11.0 mmol/L

3.HBA1C
Normal Prediabetes T2DM
HbA1c <5.7% 5.7% - <6.3% ≥6.3%

     (<39 mmol/mol)   (39-44 mmol/mol)  (≥45mmol/mol)

Question 6

Diagnosis T2DM

Answer 6

1. Symptomatic - 1 abnormal value

2. Asymptomatic - 2 abnormal values

Question 7

Baseline Ix for T2DM

Answer 7

1. FPG
2. HBA1C
3. RP: Urea & Creatinine
4. Lipid profile: HDL, LDL, TC, TG
5. Urinalysis: Albumin & Microalbuminuria
6. ECG
7. TFT if fly hx/cx suspicion

Question 8

T2DM Targets

Answer 8

glucose mmol/L&raquo_space;> mg/dl
1 mmol/L = 18 mg/dl

Glycemic control

1. Fasting PG = 4.4 - 6.1 mmol/L(80-110 mg/dl)
2. Random = 4.4 - 8.0 mmol/L(80-145 mg/dl)
3. HBA1C < 6.5%

Lipids

1. Triglycerides = = 1.7 mmol/L
2. HDL = >/= 1.1 mmol/L
3. LDL = = 2.6 mmol/L

BP

1. Normal Renal Fxn = =130/80 mmHg
2. Proteinuria = = 125/75 mmHg

Exercise
>/= 150 mins/week

Question 9

Management of T2DM

Answer 9

1. Lifestyle Modification : Diet & Exercise
   3 months to achieve HBA1C<6.5%, FBS < 6.0 mmol/L
2. Medication
   HbA1C FBS
   Monotherapy OHA
   (Metformin) 6.5-8% 6-10
   Combination of OHA 8-10% 10-13
   OHA + Insulin >10% >13

Question 10

Insulin Total Daily Dose Formula

Answer 10

TDD = 0.5U/kg/day
Basal : 50% of TDD
Prandial: 50% divided by the number of meals (usually 3)

Question 11

Insulin Regimen

Answer 11

1. Who?
   - Newly dx T2DM :
   > Osmotic sx regardless of hba1c/fbg
   > HBA1C> 10% or FPG > 13 mmol/L
   - T2DM on maximal OHA with HBA1C > 8%
2. How? Initiation
   - High Daytime BG, Normal FBG = Prandial TDS
   - High FBG, Normal Daytime BG = Basal only/Premixed OD
   - High FBG, High Daytime BG = Basal Bolus/Premixed BD
3. Gradually intensify regime to Basal Bolus and optimise dose

• Basal Bolus = Basal + Prandial
• Basal given at bedtime
• Prandial given pre meal
• Premixed OD given before dinner
• Premixed BD given pre breakfast & dinner

Question 12

Complications

Answer 12

1. Microvascular
   - Retinopathy
   - Neuropathy
   - Nephropathy
   - Diabetic Foot
   - Dermopathy
2. Macrovascular
   - CV Complications
   - Peripheral Vascular Disease
   - Cerebrovascular complication