Diabetes #2

Question 1

type 2 in untreated

Answer 1

 may be asymptomatic or have milder forms of same symptoms/signs seen in Type 1 DM.
 except ketosis and ketoacidosis much less likely in type 2.
 Unless ill, surgery, trauma.

Question 2

type 1 if untreated

Answer 2

• Hyperglycemia ->
• Glucosuria (glucose in the urine- undernormal circumstances the glucose is supposed to be reabsorbed back into the blood steam. Renal threshold- amount of glucose that can be reabsorbed by the kidney tubule. be 10mmol/L.
• >
• Polyuria : increased urine output- glucose bring water with it
• >
• Polydipsia: increase thirst
• Weight loss
• decreased protein synthesis & increased gluconeogenesis -> decreased muscle mass.
• Glucose and ketone bodies in urine = a loss of energy
• Polyphagia Increased appetite
• Sometimes fatigue
• Sometimes blurred vision: high [glucose & metabolites] in lens  exces fluid swelling.
• Excess ketone bodies accumulate in blood & are excreted in urine = ketosis.
• Uncorrected ketosis  ketoacidosis

Progression of Ketoacidosis:
 Acetone is volatile & may be excreted from the lungs  fruity odor of the breath (the acetone)
 What mechanisms try to compensate to maintain blood pH in the presence of excess acid production? Respiration (lungs), kidneys

 When no longer able to compensate  Ketoacidosis
 Blood pH   stimulates the respiratory system respiration becomes deep and rapid.
 If severe enough, acidosis causes depression of the central nervous system  patient becomes more lethargic & eventually comatose  death.

Question 3

why is weightloss a syptom in type 1

Answer 3

decrease protein synthesis & increase in gluconeogenesis. lead to decrease in muscle mass.
- Glucose and ketone bodies in urine = a loss of energy

Question 4

why is there blurred vision in type 1

Answer 4

high [glucose & metabolites] in lens  exces fluid swelling.

Question 5

 What mechanisms try to compensate to maintain blood pH in the presence of excess acid production?

Answer 5

Respiration (lungs), kidneys

stimulates the respiratory system respiration becomes deep and rapid.

Question 6

what happens in ketoacidosis

Answer 6

 Blood pH decrease. stimulates the respiratory system, respiration becomes deep and rapid. If severe enough, acidosis causes depression of the central nervous system, patient becomes more lethargic & eventually comatose, death.

Question 7

Why are pts with Type 1 DM generally prone to ketosis (and ketoacidosis), and patients with Type 2 DM are generally not?

Answer 7

• Related to hierarchy of cells in their sensitivity to insulin:
  1) adipose tissue (the most sensitive, gives the biggest response).
  2) liver
  3) muscle
• Even with reduced amounts of effective insulin available (Type 2)  this allows for lower circulation fatty acids levels, and consequently less ketosis. Lypolysis is kept not so high and therefore ketone body formation doesn’t get so high.

Question 8

Diabetic levels for:
FPG
AIC
2hPG
RANDOM PG

Answer 8

A) FPG  7.0 mmol/L (fasting plasma glucose)
OR
B) A1C > 6.5% (in adults)
OR
C) 2hPG  11.1 mmol/L in a 75g OGTT
OR
D) Random (any time of the day, without considering interval since last meal) PG  11.1 mmol/L.

• ***A or B or C or D: a (second) repeat confirmatory laboratory test must be obtained on another day to confirm the diagnosis.
• ****preferably, the same test is repeated for confirmation, EXCEPT THAT a random PG in the diabetes range in an asymptomatic person should be confirmed with an alternate test.

E) Random PG  11.1 mmol/L + symptoms of diabetes
- does not require a confirmatory test

Question 9

noraml prediabetes and diabets levels for fasting, 2hr OGTT, AIC

Answer 9

Fasting normal: 4-6 prediabetes:6.1-6.9 diabetes Greater than or equal to 7

2hr_OGTT(mmol/L) normal:5-7.7 pre: 7.8-11.0 diabetes: Greater than or equal to 11.1

AIC normal:4-5.9% pre: 6-6.4 diabetes: Greater than or equal to 6.5

Question 10

prediabetes values

recommendation, risks

go

Answer 10

a) Impaired fasting glucose (IFG)
Fasting glucose > normal but < the value to diagnose diabetes
(6.1-6.9mmol/L)
b) Impaired glucose tolerance (IGT)
2 hr value on OGTT > normal but < the value to diagnose diabetes (7.8-11.0mmol/L)

c) AIC of 6.0-6.4%

• Prediabetes: At  risk for developing diabetes, coronary heart disease
• Recommended Intervention:
• lifestyle changes (eg. Treat obesity, increase activity)
• More frequent screening

Question 11

goals of treatment in diabetes:

Answer 11

Goals of Treatment
• Relieving symptoms and enabling return to normal lifestyle. (bathroom, hungry all the time)
• Improving ability to metabolize glucose and correcting faulty metabolism so that glucose tolerance is improved and insulin resistance is decreased.
• Preventing long-term complications by good control of blood glucose.
• Assuring adequate nutritional status.

Question 12

how do we measure

Monitoring “Control” of Blood Glucose and Management of Diabetes

Answer 12

–Blood [glucose] testing
–Hemoglobin A1c (HbA1c) = Glycated Hemoglobin (A1C)
•Other special circumstances
•Ketone testing- when ill

Question 13

Blood glucose testing:

where is it done, when is it done, why is it done, how does it differ in type 1 and 2

Answer 13

 Venous blood (plasma glucose) - clinic
 Capillary blood – home monitoring (the one we did in lab- finger pricking)
 Day-to day –different times of the day
 Blood on reagent strip - colorimetric reaction - read by eye or blood glucose meter
 Accurate IF well-trained - technique
 Guidelines:
 Test regularly (daily)
 Test at different times
 Fasting, pre-meal, post meals, depending on type 1, typ2 or gestational
 Fasting and pre-meal are standard expectations
 Keep written records so “patterns” become obvious
 Test results are used to make insulin adjustments or changes in oral medications
 2 examples
 Tests throughout the week- type 2, only test breakfast 3 times a week, lunch only 4 times a week….more difficult to measure after a meal because you have to remember 2 hours later
 Common-blood glucose testing: type 1: have to measure every time- each meal everyday

Question 14

what is postprandial testing, why are they important

Answer 14

measuring 2 hours after a meal

Emphasis on Postprandial Blood Glucose Monitoring in Type 2 Diabetes

• Based on the evidence that:
  a) Postprandial plasma glucose results are usually better correlated with HbA1c than tests taken at other times of the day.
  b) Postprandial hyperglycemia is associated with increased cardiovascular risk.

-There has been an increasing trend to ask patients with Type 2 Diabetes to do postprandial blood glucose measuring in addition to preprandial glucose testing.

Note:

• It is difficult for patients to remember to do this (versus preprandial testing).
• Postprandial measurements are best interpreted in light of knowing what preprandial values were.

Question 15

what is Hemoglobin A1c (HbA1c)

Answer 15

 Glycated Hemoglobin (A1C) glucose attached to a Hb
 Long-term control
 Average blood [glucose] (last ~2-4-mo)
 Why the last 2-4 mo?

 AIC is formed in nonenzymatic NONREVERSIBLE reaction between HbA1c (major adult Hb) and glucose
 1c refers to position of glycation on HbA (where its located)
 Close + correlation between blood glucose concentration and HbA1c

Question 16

How does one convert from a high value to a lower value?

Answer 16



• red blood cells live 120 days, so they eventually die and as time goes on hopefully the glucose goes down in the blood so they don’t have the chance to bind to the Hb
  aic has to be done at the lab

Question 17

how to do ketone testing and why, when

what molecule are they testing for

Answer 17

Ketone testing
 Not used regularly
 Self Monitoring:
 Urinary testing- reagent dipstick
 Capillary blood - meters that quantify ketones (β- hydroxybutyric acid)
 When should patients test?
 When blood glucose concentration increase
 During illness e.g. cold or flu (tends to drive BG up)

Question 18

Recommended targets for glycemic control
aic, FPG, 2hour PG

COMMENTS ON THESE levels:

Answer 18

aic : less than7

FPG or preprandial PG: 4-7

2hr postprandial PG: 5-10mmol

Our best estimate for reducing risk of complications, but….
Should be applied to the individual – Treat the person, not the numbers.
Must be weighed against the problem of too many hypoglycemic episodes and poor quality of life……
Age must be considered –must be aware of hypoglycemic (being under 4mmol/L)(people on insulin and 2 types of drugs are at risk of hypoglycemia)symptoms
e.g. Too stringent for young children
e.g. too stringent for some elderly (might always have to have them higher for safety)

 What are reasonable targets for children
for the very young start with BG at 5-11mmol/L
as they age: 5-10mmol/L
then 5-9mmol/L
then eventually 4-7 mmol/L

Question 19

remission periode in type 1 diabetes:

honeymoon periode

Answer 19

• In general, no endogenous insulin is produced
• Execption: during initial period following diagnosis and treatment, there may be a short period of remission (Honeymoon period)
• Lasts a few months, where exogenous insulin needs (injection) decrease