Diabetes Type 2

Question 1

What is type 2 diabetes?

Answer 1

where repeated exposure to glucose and insulin makes the body more resistant to the effect of glucose so more and more insulin is required to stimulate glucose uptake, eventually making the pancreas fatigued and damaged

Question 2

Give 6 risk factors for T2 diabetes:

Answer 2

1) older age
2) ethnicity (Black African, South Asian, Caribbean)
3) sedentary life style
4) family history
5) high carbohydrate diet
6) obesity

Question 3

Give 8 presentations associated with T2 diabetes:

Answer 3

1) polyuria
2) polydipsia
3) fatigue
4) unintentional weight loss
5) opportunistic infections e.g. oral thrush
6) slow wound healing
7) glucose in urine
8) acanthosis nigricans

Question 4

What is acanthosis nigricans?

Answer 4

thickening and darkening of the skin in the neck/axilla/groin, giving it a velvety appearance which is associated with insulin resistance

Question 5

What HbA1c range indicates pre-diabetes?

Answer 5

42-47mmol/mol

Question 6

What HbA1c range indicates diabetes?

Answer 6

48+ mmol/mol

Question 7

Is the genetic link stronger in type 1 or type 2 diabetes?

Answer 7

Type 2

Question 8

What is MODY?

Answer 8

MODY – maturity onset diabetes of the young – this is a rare type of type 2 diabetes. It will present in young people who have a family history of type 2 diabetes. It is dominantly inherited.

Question 9

What is the prevalence of T2DM in the Uk?

Answer 9

The overall prevalence of this disease in the UK is about 5%. This rises to 10% by the age of 70.
Excepted to double by 2030

Question 10

What can the onset of type 2 DM be accelerated by?

Answer 10

1. Stress
2. Pregnancy
3. illness
4. Certain drugs

Question 11

What is the pathology behind T2DM?

Answer 11

Initially insulin is still released normally, and will still bind to insulin receptors, but it will not cause the normal physiological changes inside the cell. This occurs in genetically susceptible individuals due to modifiable lifestyle related factors. This is known as insulin resistance
Type-2 diabetes results when a person cannot secrete enough insulin to overcome this ‘resistance’.
Muscle cells in particular show increased insulin resistance and decreased glucose uptake

The secretory failure of insulin occurs when there is increase Beta-islet cell apoptosis, and the remaining cells fail to respond to insulin signalling
Increased lipolysis with elevated free fatty acids
Alpha-cell dysfunction – elevated glucagon levels
Increased glucose reabsorption by the kidneys
Altered cerebral responses to insulin and apetite

Question 12

Why does elevated glucose production in the liver occur?

Answer 12

not only does a high blood glucose occur because normal digested glucose cant be taken up by cells, but it has a secondary effect on the liver; there is less glucose entering liver cells, and so the liver reacts as if blood glucose were low, and begins glycogenolysis, and raises blood glucose even more.

Question 13

What are the 3 methods that diagnosis can be confirmed by?

Answer 13

HbA1c >6.5% – on at least two occasions

Fasting blood glucose (FBG) >7.0 mmol/L
OR – Random blood glucose >11.0 mmol.L, with subsequent elevated FBG on a separate day

Oral glucose tolerance test (OGTT)
Initial fasting blood sugar level (BSL) >7.0 mmol/L
End of test (after 75g of oral glucose, retested at 2 hours) >11.0 mmol/L

Question 14

What is HbA1c?

Answer 14

HbA1c is a type of ‘glycated haemoglobin’ – essentially haemoglobin that has been altered due to the presence of glucose in the bloodstream.
The higher the glucose level, the greater the amount of glycated haemoglobin – or HbA1c – in the blood. And, as red blood cells have a lifespan of about 90 days, the HbA1c value is in indicator of what glucose levels have been doing for the past 90 days.

Question 15

What is the screening guidelines for T2DM?

Answer 15

Screen everyone over 40
Consider screening anyone over 25 if likely high risk – e.g. high risk ethnic group (South Asian, Chinese, African-Caribbean, Black African origin)
Use a verified screening assessment tool – for example the Diabetes Risk Assessment Tool
If low or intermediate risk, screen every 5 years
If high risk, perform HbA1c or fasting glucose

Question 17

What is the classic acute triad presentation of T2DM?

Answer 17

1. Polyuria
2. Thirst
3. Weight loss

Question 18

What are the common subacute presentation of a T2DM patient?

Answer 18

1. Lack of energy
2. Polyuria, polydipsia
3. Vision blurring
4. Frequent fungal/ bacterial infections - often of the genitals
5. Loss of sensation

Question 19

Give 3 non-pharmaceutical interventions for T2 diabetes:

Answer 19

1) exercise
2) weight loss
3) low glycaemia, high fibre diet

Question 20

What is the first line drug for T2 diabetes treatment?

Answer 20

metformin
with a SGLT-2 inhibitor if patient has existing CVD

Question 21

List 4 second line diabetes drugs:

Answer 21

1) sulfonylurea
2) pioglitazone
3) DPP-4 inhibitor
4) SGLT-2 inhibitor

Question 22

What is the third line drug management for T2 diabetes?

Answer 22

1) triple therapy (metformin and 2 second line drugs)
OR
2) insulin therapy

Question 23

When are GLP-1 mimetics indicated?

Answer 23

where triple therapy for T2 diabetes fails and the patient’s BMIi is over 35 kg/m^2

Question 24

Describe the action of metformin:

Answer 24

it increases insulin sensitivity and decreases glucose production in the liver

Question 25

Give 4 side effects of metformin:

Answer 25

1) abdominal pain
2) nausea
3) diarrhoea
4) lactic acidosis secondary to AKI

Question 26

Give 3 examples of SGLT-2 inhibitors:

Answer 26

1) dapagliflozin
2) empagliflozin
3) canagliflozin

Question 27

Describe the action of SGLT-2 inhibitors:

Answer 27

they block the action of sodium-glucose contransporter-2 proteins found in the proximal tubules of the kidney which act to reabsorb glucose, meaning SGLT-2 inhibitors cause increased glucose to be excreted in urine

Question 28

Give 4 side effects of SGLT-2 inhibitors:

Answer 28

1) increased urine output
2) UTIs
3) diabetic ketoacidosis
4) genital thrush

Question 29

What type of drug is pioglitazone?

Answer 29

Thiazolidinedione

Question 30

Describe the action of pioglitazone:

Answer 30

it increases insulin sensitivity and decreases glucose production in the liver

Question 31

Give 3 side effects of pioglitazone:

Answer 31

1. Weight gain
2. Heart failure
3. Increased risk of bone fractures

Question 32

Give an example of a sulfonylureas:

Answer 32

gliclazide

Question 33

Describe the action of sulfonylureas?

Answer 33

stimulate insulin release

Question 34

Give 2 side effects of sulfonylureas:

Answer 34

1) weight gain
2) hypoglycaemia

Question 35

Describe the action of DPP-4 inhibitors:

Answer 35

they inhibit DPP-4 which acts to inhibit incretins (hormones produced by the GI tract after eating to increase insulin secretion and inhibit glucagon production), therefore increasing incretin activity

Question 36

Give two examples of DPP-4 inhibitors:

Answer 36

1) sitagliptin
2) alogliptin

Question 37

Give 2 side effects of DPP-4 inhibitors:

Answer 37

1) headaches
2) low risk of acute pancreatitis

Question 38

Describe the action of GLP-1 mimetics:

Answer 38

the mimic the action of glucagon-like peptide-1 (the main incretin which acts to increase insulin secretion and inhibits glucagon production)

Question 39

Give two examples of GLP-1 mimetics:

Answer 39

1) exenatide
2) liraglutide

Question 40

Give 4 side effects of GLP-1 mimetics:

Answer 40

1) reduced appetite
2) weight loss
3) nausea
4) vomiting

Question 41

True or false: T2 diabetics on insulin have to pass a strict criteria in order to drive

Answer 41

True

Question 42

Give 8 complications of type 2 diabetes:

Answer 42

1) CKD
2) infection
3) gastroparesis
4) diabetic retinopathy
5) diabetic foot
6) autonomic neuropathy
7) peripheral neuropathy
8) hyperosmolar hyperglycaemic state

Question 43

What is the step wise approach for treatment of T2DM patients?

Answer 43

Lifestyle
Lifestyle + metformin
Lifestyle + metformin + secondary drug agent &laquo_space;start here if HbA1c >8.5% at diagnosis
Lifestyle + metformin + secondary drug agent + insulin (+/- third line agent – most commonly GLP-1 agonists)