Type 2 Diabetes Mellitus

Question 1

Pathophysiology

Answer 1

Insulin resistance due to sustained hyperglycaemia

Question 2

Symptoms

Answer 2

Polyuria
Polydipsia
Weight loss

Nocturia
Fatigue

Question 3

Investigations if symptomatic

Answer 3

Measure BMI
Random capillary glucose test > 11
Urine dipstick - glucose

Question 4

Which channel does glucose enter muscles and adipose with

Answer 4

GLUT 4

Question 5

Risk factors for T2DM

Answer 5

Obesity
FHx
South East Asian

Question 6

Investigations if asymptomatic

Answer 6

3 investigation at 2 separate intervals

• random blood glucose > 11
• fasting blood glucose > 7
• HbA1c > 48mmol

Question 7

Microvascular complications

Answer 7

Retinopathy - blindness
Neuropathy - peripheral vascular disease and foot ulcer
Nephropathy - chronic kidney disease

Due to hyperglycaemia causing production of sorbitol and advanced glycation end products and oxidative stress which results in endothelial damage

Question 8

Macrovascular complications

Answer 8

Atherosclerosis formation leaving to CVD
Increased risk of: 
- MI 
- HF
- Stroke 
- peripheral arterial disease

Question 9

Atherosclerosis formation

Answer 9

1. Endothelial damage
2. Accumulation of oxidised lipids
3. Foam cells accumulate
4. Smooth muscle proliferation and collagen - fibrous cap

Question 10

Diabetic screening

Answer 10

• check eyes - fundoscopy
• check feet
• bloods - U+Es, lipid profile, HbA1c
• BP
• Qrisk
• BMI

Question 11

Hyperosmolar hyperglycaemia state pathophysiology

Answer 11

Hyperglycaemia > 30mmol causes osmolarity in blood plasma to increase

Question 12

Symptoms of HHS

Answer 12

Confusion
Drowsiness
Dehydration - loss of skin turgor and sunken eyelids

Question 13

Signs of HHS

Answer 13

Reduced GCS
Hypotension
Capillary blood glucose increases > 35mm

NO KETONES ON ACIDOSIS

Question 14

Investigations of HHS

Answer 14

Obs A-E - BP, VBG
CBG
Bloods - U+Es
Fundoscopy

Question 15

Management of HHS

Answer 15

Fluids - 0.9% saline
Insulin - FRIII
2-3 hours later - K+
Prophylactic LMWH

Question 16

Reasons for HHS

Answer 16

Poor diabetes control
High glucose load
Medication - thiazide like diuretic

Question 17

Already on metformin drug to add in obese pt

Answer 17

DPP5 inhibitor - sitagliptin

- non weight gaining

Question 18

Diabetes education programmes

Answer 18

Type 2 newly diagnosed - DESMOND

Type 1 - DAFNE - dose adjustment for normal eating

Question 19

Diabetic medication

Answer 19

1. Lifestyle modification
2. Metformin - biguanide
3. Gliptin
4. Gliclazide - Sulfonylurea
5. Glitazone -thiazolidinediones
6. Gliflozin - SGLT2 inhibitor
7. Exenatide - GLP -1 analogue

Question 20

Side effects of diabetic medication

Answer 20

Metformin

• GI upset
• diarrhoea
• N + V
• lactic acidosis
• stop if eGFR below 39

Sulfonylurea

• weight gain
• hypoglycaemia

DPPV inhibitor

• GI upset
• small risk of pancreatitis
• CANT BE USED IN PREGNANCY

thiazolidinediones
- weight gain

SGLT2 inhibitor

• UTI
• hyponatraemia
• polyuria
• polydipsia

Exenatide

• GI upset
• GORD
• stop of eGFR below 30

Question 21

Which medication interacts with diabetic medication

Answer 21

Thiazide like diuretics - increase glucose
ACEi - impair renal function
NSAIDs - impair renal function

Question 22

HbA1c target

Answer 22

6.5% - 7.5%

Question 23

Albumin: creatinine ratio

Answer 23

Albumin creatinine ratio indicates extra protein in urine.

Should not be more than 3g

Question 24

Addressing risk factors

Answer 24

Tight BP control 
Smoking cessation 
Lose weight 
Decrease carbs and fats in diet 
Qrisk - statin

Question 25

Causes of HHS (6 I’s)

Answer 25

Infection - pneumonia, UTI 
Inflammation - pancreatitis, cholangitis 
Insulin deficiency - type 2
Intoxication - cocaine or alcohol 
Infarction - MI, stroke 
Iatrogenic - steroids, surgery

Question 26

Metformin

Answer 26

• inhibits gluconeogenesis and glycogenolysis
• promotes satiety
• increased glucose utilisation

Question 27

Gliptin

Answer 27

• DPPV inhibitor

- prevents breakdown of incretin

Question 28

Sulfonylurea - Gliclazide

Answer 28

• inhibits ATP dependent K+ channels

- increases insulin sensitivity

Question 29

Thiazolidinediones - Glitazone

Answer 29

• activates PPAR - gamma
• increases insulin sensitivity
• decreased hepatic production of glucose
• increases hepatic storage of FA so glucose used

Question 30

Gliflozin

Answer 30

SGLT2 inhibitor

- inhibits sodium glucose transporter so more glucose excreted

Question 31

Exenatide

Answer 31

GLP -1 analogue

• increased insulin secretion and synthesis
• increased satiety
• decreased hepatic production of glucose
• increased glucose uptake
• decreased gastric emptying

Question 32

Diabetic retinopathy Tx

Answer 32

Laser Photocoagulation

Question 33

Signs of diabetic retinopathy

Answer 33

Background Retinopathy:
Dots: microaneurysms
Blot haemorrhages
Hard exudates: yellow lipid patches

Pre-proliferative Retinopathy:
Cotton-wool spots (retinal infarcts)
Venous beading
Haemorrhages

Proliferative Retinopathy:
New vessels
Pre-retinal or vitreous haemorrhage

Maculopathy
↓ acuity may be only sign
Hard exudates near macula

Question 34

Lifestyle management alone

Answer 34

if metformin was first declined and the HbA1c level was between 48-56 mmol/mol and the patient is presenting with no diabetic complications