Wk3 Diabetes Mellitus Flashcards
What is the pathophysiology of diabetes?
Destruction of pancreatic islet beta cells, secondary to an autoimmune reaction.
Who will be affected by type 1 diabetes mostly?
Children and young adults
What is the global incidence of T1DM?
3% per year
T1DM susceptibility is due to…?
one-third genetic factors (HLA locus) & two-thirds environmental factors
True or False: nearly all patients with diabetic food ulcer have neuropathy?
True
If diabetic food ulcers is left untreated, what will it progress into?
Soft tissue infection, gangrene and limb loss (amputation)
Where’s the common place for diabetic food ulcer?
At pressure points:
Venous ulcers= above malleolus
Arterial ulcers=Toes/metatarsal heads/shins
If the patient has peripheral arterial disease, what is the prognosis for diabetic ulcers ?
Peripheral arterial disease is a strong predictor of nonhealing ulcers
By the time diabetic foot ulcer is discovered, what does it present with?
Osteomyelitis (inflammation of bone, usually due to infection)
How often should you examine the feet of low-risk diabetic foot ulcer patient?
At least annually
How often should you examine the feet of high-risk diabetic foot ulcer patient?
Every visit
Diabetic ketoacidosis primarily affect which population?
Type 1 diabetes
What are the three key features of diabetic ketoacidosis?
Hyperglycemia
Ketosis
Acidosis
What do patient with diabetic ketoacidosis usually present with?
- Polyuria
- Polydipsia (excessive thirst)
- Polyphagia (excessive hunger)
- Weakness
- Kussmaul’s respirations
- Acetone breath
- nausea/vomiting
- coffee-ground emesis from hemorrhagic gastritis
- abdominal pain
- Dehydration (dry mucous membranes)
- tachycardia
- hypotension
- altered consciousness (alert/confused/comatose)
For patient with diabetic ketoacidosis due to an infection ,what the body temperature usually look like?
Normal/low
Is diabetic ketoacidosis a serious condition?
LIFE-THREATENING
What is the frequency to monitor patient with diabetic ketoacidosis?
- blood glucose evaluated every 1-2 hours until patient is stable
- blood urea nitrogen
- serum creatinine
- sodium
- potassium
- bicarbonate levels monitored every 2-6 hours depending on the severity of DKA
- for patient with significant electrolyte disturbances, monitor cardiac function
What caution should be made when managing children/adolescents with diabetic ketoacidosis?
Greater care must be taken in administering electrolytes, fluids, insulin. Increased concern of high fluid rates such as cerebral edema.
Can diabetic ketoacidosis occur in children with obesity and type 2 diabetes ?
Yes although less common
Which population is mostly affected hyperosmolar hyperglycemic state?
Older adult with type 2 diabetes
What are the precipitating factors for hyperosmolar hyperglycemia state?
- infections
- medications
- non-compliance with diabetic medications
- undiagnosed diabetes
- substance abuse
What are the symptoms of hyperosmolar hyperglycemic state?
Similar to diabetic ketoacidosis:
- excessive thirst
- hyperglycemia
- dry mouth
- polyuria
- tachypnea (rapid breathing)
- tachycardia
- weakness
- visual disturbance
- leg cramps
- lethargy (lack of energy)
- confusion
- hemiparesis (one-side muscle weakness)
- seizures
- coma
Is hyperosmolar hyperglycemic state a serious condition?
EMERGENT CONCERN
What are some of the complications of diabetes?
Microvascular
Macrovascular
Neuropathic conditions
What can uncontrolled diabetes lead to ?
Blindness
Limb amputation
kidney failure
Vascular/Heart disease
The patient is displaying symptoms of polyuria, polydipsia, fatigue, blurry vision, weight loos, poor wound healing, numbness, tingling. What diagnosis can be considered?
Consider the diagnosis of diabetes
If the patient is between the age of 40 to 70 (now has been updated to include 35-39yoa ) and is overweight/obese, what should we screen? What is the frequency?
Screen for abnormal blood glucose and type 2 diabetes.
Repeat testing every 3 years if results are within normal limits
What test should be done for individuals with clinical history (sign and symptoms, risk factors) that indicate diabetes?
Diagnostic testing
How often should these population be screened for type 2 diabetes:
- over 45yoa
- under 45yoa with major risk factors
If test results are normal, how often should we repeat?
Every year
At least every 3 years
Is prediabetes common in older adults?
Yes, very common (less likely to progress to diabetes)
Under which condition is ceasing diabetes screening recommended?
Ceasing diabetes screening after 70yoa will avoid overdiagnosis and unnecessary treatment
Does treating borderline glucose values improve quality of life, mortality or any other patient-oriented outcomes?
No
How do you see prediabetes blood glucose level?
Consider it as one of several risk factors for developing type 2 diabetes
What is the leading cause of death in type 2 diabetes?
Myocardial infarction
To prevent complication of type 2 diabetes, what is more significant than glycemic control?
Blood pressure
At time of diagnosis of type 2 diabetes, what monitoring is recommended?
Serum lipid monitoring since patients are also prone to cardiovascular disease
Due to a combination of hyperglycemia, hyperlipidemia, hypertension, platelet adhesiveness, coagulation factors, oxidative stress and inflammation, the risk of which condition is increased?
Increased risk of heart disease
For patient with diabetes, what is the ADA recommendation for blood pressure?
Systolic BP under 140 mmHg and diastolic BP under 90mmHg
For younger patient: 130/80
What other organ systems would be affected by diabetes?
- Cardiovascular
- Skin & mucous membrane
- Bone & joint
What reactions are the most common complications that occur in patients with diabetes treated with insulin?
Hypoglycemic reactions
Sympathetic: tachycardia, palpitations, sweating, tremors.
Parasympathetic: nausea/hunger/nervous system symptoms
What CNS-related condition is due to hypoglycemia?
Neuroglycopenia
- insufficient glycose for normal CNS function
- Irritability/confusion/blurred vision/tiredness/headache/difficulty speaking/loss of consciousness/seizure
What is the prevalence of diabetes in US and Canada?
10-14%
What are some environment factors for T1DM?
breastfeeding in the first 6 months as being protective.
Improvement in public health and reduced infections —>dysregulated immune system & development of autoimmune disorders
What is idiopathic type 1 diabetes?
Patients without evidence of pancreatic bata cell autoimmunity (5%)
What are the sign and symptoms of T1DM?
- Polyuria
- Polydipsia
- Blurred vision
- weight loss
- Parasthesias
-Altered level of consciousness
Is screening for T1DM recommended?
No. Typically patients present with an acute onset of symptoms
T2DM is predominantly diagnosed in which population?
Adults
Risk factors for T2DM?
- obesity
- first-degree relative with T2DM
- Cardiovascular disease
- hypertension
- low HDL (<35)
- high TG (>250)
- acanthosis nigricans
- PCOS
- gestational diabetes
- delivery baby over 9lb
Does gene play a role in T2DM development?
yes
Which environmental factor is the most significant factor causing insulin resistance?
obesity
Does subcutaneous abdominal fat has a strong or weak correlation with insulin resistance?
Weak
what is metabolic obesity?
increased visceral fat in patients with T2DM without overt obesity
what are some environment factors that can contribute to T2DM?
Adipokines secreted by adipocytes which impair insulin signaling
TNF-alpha, IL-6…
How is T2DM recognized ?
Only after glycosuria or hyperglycemia is discovered on routine lab testing
At the time of diagnosis of T2DM, what complication may patient be already having?
Neuropathic or cardiovascular complications
Is screening recommending for T2DM?
yes
What are the obstetrical complications for T2DM?
Delivery baby >9lbs
Polyhydramnios
Preeclampsia
Unexplained fetal losses
Which asymptomatic adults should be screened for T2DM?
BMI>25 and 1+ of the following:
- HbA1C >5.7%
- impaired glucose intolerance
- impaired fasting glucose
What is the sign &symptoms differences between T1DM and T2DM?
T1DM:
- polyphagia with weight loss
- nocturnal enuresis (bed wetting )
What are the 2 risk factors for developing gestational diabetes?
Advancing age and greater pre-pregnancy BMI
What does metabolic syndrome identify?
It identifies individuals at higher risk for developing diabetes and cardiovascular disease
How is gestational diabetes screened?
Screening done between 24-28 week’s gestation with a non-fasting 50g glucose challenge test.
if BG >140 (7.8), perform a 3hr fasting 100g glucose challenge test —> Diagnostic
what is one step testing for gestational diabetes?
a single fasting 75g oral glucose tolerance test
what is two step testing for gestational diabetes?
non-fasting 50g oral glucose tolerance test, if result is 130-140 (7.2-7.8), do a 3hr fasting 100 glucose tolerance test
How is one step testing & two step testing for gestational diabetes compared to each other?
Diagnosis of gestational diabetes is more common in one step screening but two-step produces equivalent benefits and fewer harms
Your pregnant patient come in present with obesity, advanced maternal age, history of gestational diabetes, fHx of diabetes and belong to a high-risk ethnic group, what do you suggest?
gestational diabetes screening in the first trimester
When should asymptomatic pregnant patient screen for gestational diabetes?
At or after 24 weeks’ gestation
When should screening be done post partum for women who had gestational diabetes?
6-12 weeks postpartum with a fasting glucose measurement or a 74 2hr glycose tolerance test
How often should women with history of gestational diabetes be screened?
every 3 year for overt diabetes
What is the major acute complication of T2DM in youth?
- Diabetic ketoacidosis
- Hyperglycemic hyperosmolarity
Long-term morbidity of T2DM in youth is due to..?
Macrovascular (atherosclerosis)
Microvascular (retinopathy, nephropathy, neuropathy)
Is screening T2DM recommended in youth?
Insufficient evidence
Your patient is under 18 and is overweight, fHx of T2DM, high-risk ethnic group, acanthosis nigricans, hypertension, hyperlipidemia, PCOS. Is screening for T2DM recommended?
Yes
How often should you screen for at-risk patient?
T2DM/youth
every 2 years starting at age 10
or
onset of puberty if under age 10
what is MODY?
non-insulin dependent form of diabetes
When is MODY diagnosed typically?
<25yoa
x% of all patients with diabetes have MODY type.
1-5%
This patient is not obese, and were diagnosed with diabetes at a young age (<30yoa). He has a strong fHx of diabetes. Which condition should be suspected?
MODY
What type disease is MODY?
autosomal dominant disease
Which type of MODY is most common?
MODY3
What is the difference between MODY 1.2.3?
MODY 1 & MODY 3
- progressive hyperglycemia
- vascular complication
MODY 2
- mild stable fasting hyperglycemia
- low risk of diabetes-related complications
-no treatment required except during pregnancy
Is routine screening of T2DM recommended in older adults?
No while screening is dependent on whether treatment would improve overall quality of life or life expectancy.
Under which condition is screening T2DM recommended for older patients?
to prevent complications that may lead to functional impairment
what is secondary causes of diabetes?
Any disorder that damages the pancreas
Which value of fasting plasma glucose indicates increased risk of diabetes (aka pre-diabetes)?
5.6-6.9
Which value of fasting plasma glucose is diagnostic?
> 7 on more than one occasion after at least 8h fasting
what is pros and cons of Fasting Plasma Glucose?
Pros: may identify 1/3 more undiagnosed cases than A1c
cons: need fasting
Patient’s fasting plasma glucose is under 7 but diabetes is still suspected, what’s next?
perform oral glucose tolerance test
What value of oral glucose tolerance test indicates diagnostic?
126 (7) or 2hr value of 200 (11.1)
what is pros and cons of oral glucose tolerance test?
pros: identify 1/3 more undiagnosed cases than A1c
cons: require fasting. maybe false-positive
What is the diagnostic test for T1DM and T2DM?
HbA1c
How often should you repeat HbA1c?
at 3-4 month intervals
How do you interpret HbA1c value?
5.7-6.4% = pre-diabetes
6.5%= diagnostic
What’s the important of HbA1c?
reducing the average HbA1c by 0.2% could lower overall mortality by 10%
increasing 1% of HbA1c—> morality/CVD
What is the pros and cons of HbA1c
Pros:
- no fasting needed
- lower variability
- provide estimate glucose control for the preceding 2-3 months
cons:
- substantial individual variability
- affected by Hb variants
- falsely lowered by conditions that decrease RBC age
What is the normal glucose tolerance for plasma glucose 2 hours after glucose load?
<140 (7.8)
What is the DM value for plasma glucose 2 hours after glucose load?
> 200 (11.1)
what is recommendation to maintain LDL cholesterol?
<100 (2.6)
lowering to 70 infer additional benefits for T2DM
What is the characteristic of diabetic dyslipidemia?
High TG
Low HDL
presence of smaller-density LDL
what is the most common complication of diabetes, which is also a major cause of death in T1DM?
Diabetic nephropathy (kidney disease)
contribute to 1/3 of all end-stage renal disease
Is end-stage-renal disease more prevalent in T2DM or T1DM?
T2DM
What is the signs & symptoms of diabetic nephropathy?
- albuminuria
- urea & creatinine accumulation in the blood
- declined kidney function
what is the most common type of diabetic neuropathy?
Distal symmetric polyneuropathy
sign & symptoms of distal symmetric polyneuropathy
- loss of function in a ‘stocking-glove’ pattern
- sensory changes
- clawing of the toes
-altered biomechanics of the foot - calluses
-ulcerations
what is isolated peripheral neuropathy?
due to vascular ischemia/traumatic damage, involving mononeuropathy or mononeuropathy multiplex
where does isolated peripheral neuropathy commonly affected?
cranial and femoral nerves, causing motor abnormalities
Which type of diabetic neuropathy occurs primarily in patients with long-standing diabetes and affected many visceral functions?
autonomic neuropathy
- cardiovascular
- GI
- genitourinary
which condition that nearly all patients with diabetes will eventually have?
diabetic retinopathy, microangiopathy of the retina
what is the risk factor for developing diabetic retinopathy?
-long standing diabetes
- abnormal blood glucose levels
- inadequate arterial blood pressure control
how often should patient do diabetic retinopathy screening?
every year
what type of diabetic retinopathy happens in early stage?
non-proliferative retinopathy
what type of diabetic retinopathy happens in final and most severe stage?
proliferative retinopathy
(higher prevalence in T1DM)
what signs & symptoms happens in diabetic retinopathy?
- cataracts: glycosylation of lens protein
- glaucoma: increased ocular pressure damaging the optic nerve (6%)
- dry eye
- macular edema
