Week 8 - Diabetes

Question 1

Diagnostic Features of Diabetes

Type 1
Type 2
Type 2 Risk Factors x6
HbA1c
Finger Prick Test

Answer 1

1.) Type 1 - random plasma BG >11mM w/ one of sx :
- ketosis, rapid weight loss, <50, BMI <25, FH of autoimmune disease
- refer to diabetes specialist team for confirmation

2.) Type 2 - HbA1c >48mM (6.5%) (2 readings needed)
- fasting plasma BG >7mM (if HbA1c inappropriate)
- sx: polyuria, polydipsia, weight loss, fatigue/lethargy

3.) Type 2 Risk Factors - obesity (80-85% risk)
- FH, ethnicity, diet, low birth weight
- drugs: thiazides, glucocorticoids, beta blocker

4.) HbA1c - avg BG over last 3 months, in mM or %
- inaccurate if patients have factors affecting:
- erythropoeisis: anaemia, iron or B12/folate deficiency
- glycation: CKD, chronic alcoholism
- RBC destruction: splenectomy (↑RBC lifespan)
- assays: chronic aspirin/opioid use, ↑bilirubin
- altered haemoglobin: haemoglobinopathies

5.) Finger Prick Test - measures plasma BG
- can be done instantly but not completely diagnostic
- fasting >7mM, random >11mM suggests diabetes

Question 2

NICE guidelines for management of type 2 diabetes w/ metformin

Standard Treatment
First Intensification
Second Intensification
Additional Information

Answer 2

1.) Standard Treatment - if HbA1c >48mM (6.5%)
- lifestyle modification for 3 months, if ineffective:
- metformin (modified-release if standard not tolerated)
- target: <48mM

2.) First Intensification - HbA1c >58mM (7.5%)
- metformin + DPP-4i/pioglitazone/SU/SGLT-2i
- target: 53mM (7.0%)

3.) Second Intensification - HbA1c still >58mM, options:
- metformin + SU + DPP-4i/pioglitazone/SGLT-2i
- metformin + SGLT-2i + pioglitazone
- metformin + SU + GLP-1 agonist (last resort, if BMI >35)
- if triple therapy doesn’t work, consider insulin treatment

4.) Additional Information
- metformin is contraindicated in eGFR <30: SU/DPP-4i/pioglitazone becomes first line unless the patient has established/high risk of CVD
- SGLT-2i are preferred in any patient w/ established/high risk of CVD
- avoid gliclazide if patients are at increased risk of hypos

Question 3

5 features of using biguanides to treat type 2 diabetes

Drug Name
Mechanism x2
Effect on Weight
Side Effects x3
Caution x2

Answer 3

1.) Drug Name - metformin

2.) Mechanism - ↓hepatic production of glucose via:
- ↓gluconeogenesis and glycogenolysis
- ↑glucose utilisation in skeletal muscle

3.) Effect on Weight - weight loss
- supresses appetite

4.) Side Effects
- GI upset (nausea, vomiting, diarrhoea)
- renal impairment (stop if eGFR < 30ml/min)
- lactic acidosis (rare)

5.) Caution
- nephrotoxic drugs: ACEi, NSAIDs
- thiazide-like diuretics: ↑glucose, reducing efficacy

Question 4

Lifestyle Advice for Type 2 Diabetes

Diet
Exercise
Alcohol
Diabetes Structured Education Programmes

Answer 4

1.) Diet - low-glycaemic-index sources of carbohydrates:
- fruit, vegetables, wholegrain, and pulses
- fibre, low-fat dairy products, and oily fish
- reduce saturated and trans fatty acids
- can refer to dietician if obese
- should carry a source of sugar at all times if taking hypo drugs: gliclazide, pioglitazone, insulin

2.) Exercise - can lower blood glucose levels
- active daily, reduce time being sedentary
- 150 mins of moderate intensity OR 75mins of vigorous intensity across the week
- risk of hypoglycaemia when insulin levels are low

3.) Alcohol
- less than 14 units a week spread across 3 days
- avoid drinking on an empty stomach
- can prolong hypoglycaemic effect of antidiabetics

4.) Diabetes Structured Education Programmes
- DESMOND: Diabetes Education for Self-Management for Ongoing and Newly Diagnosed (for type 2)
- DAFNE: dose adjustment for normal eating, for type 1 diabetics

Question 5

Complications of Diabetes

Macrovascular
Microvascular
Hypoglycaemic Episodes (‘hypos’)
Screening

Answer 5

1.) Macrovascular - hyperglycaemia and insulin resistance ultimately leads to atherosclerosis causing:
- CVD (e.g. MI), cerebrovascular disease (stroke, TIA)
- peripheral arterial disease (intermittent claudication)

2.) Microvascular - hyperglycaemia causing damage to kidneys, retina, and peripheral nerves
- nephropathy, retinopathy, neuropathy
- autonomic neuropathy can cause sweating, postural hypotension, gastroparesis, diarrhoea, ED

3.) Hypos - BG < 3.5 mM, side effect of injecting insulin
- mild: hunger, anxiety or irritability, palpitations,
- moderate: confusion,lethargy, impaired vision,
- severe: convulsions, LOC, coma
- causes: injection issues, physical activity, drugs, CKD, addisons, hyperthyroidism, psychological problems

4.) Screening
- each review: measure BMI, assess for depression and anxiety, smoking cessation, assess neuropathic sx
- every 6 months: measure HbA1c levels
- every year: screen for retinopathy, diabetic foot problems, nephropathy (ACR, eGFR), cardiovascular risk factors
- urinary ACR >3 (microalbuminaemia) suggests nephropathy so should be started on an ACEi or ARB as it is renoprotective

Question 6

Diabetic Ketoacidosis (DKA)

Clinical Triad
Symptoms
Precipitating Factors
Management

Answer 6

1.) Clincal Triad - hyperglycaemia, acidosis, ketosis
- either ketones in urine or high plasma concentration
- can present w/o ketonaemia or hyperglycaemia
- presents in type 1 diabetics, very rare in type 2

2.) Symptoms
- polyuria, polydipsia, can’t tolerate fluids, weight loss,
- persistent vomiting or diarrhoea, abdominal pain
- visual disturbance, lethargy, confusion
- fruity acetone smell on breath, acidotic breathing
- dehydration, shock signs (from severe dehydration)

3.) Precipitating Factors - must assess for
- poor insulin adherance, infection, stress (e.g. trauma)
- other conditions e.g. hypothyroidism, pancreatitis
- ADR e.g. corticosteroids, diuretics, sympathomimetics e.g salbutamol

4.) Management - if suspected, admit to A/E for:
- treatment with IV fluids and insulin
- fluids should contain glucose and K+ (inuslin ↓K+)