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Endocrine Pathology > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

Definition of DM

A

A group of metabolic diseases of multiple aetiologies characterised by hyperglycaemia together with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both

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2
Q

Types of DM

A 
Type I
Type II
Recognised genetic syndromes; MODY
Gestational diabetes
Secondary diabetes
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3
Q

What is the only hormone that lowers [BG]?

A

Insulin

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4
Q

What hormone dominates the absorptive state?

A

Insulin

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5
Q

Risk to get T1DM if monozygotic twins

A

30-50% concordance

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6
Q

Risk to get T1DM if both parents have it

A

30%

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7
Q

Risk to get T1DM with father having T1DM

A

6%

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8
Q

Risk to get T1DM if mother has it

A

1%

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9
Q

Risk to get T1DM if sibling has it

A

8%

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10
Q

Effect of insulin on adipose tissue

A

Reduced lipolysis

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11
Q

Effect of insulin on liver

A

Reduced glucose production

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12
Q

Effect of insulin on muscle

A

Increased glucose uptake

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13
Q

Risk of T2DM in identical twin

A

90-100%

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14
Q

Risk of T2DM if one parent has it

A

15%

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15
Q

Risk of T2DM if both parents have it

A

75%

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16
Q

Risk of T2DM if sibling has it

A

10%

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17
Q

Risk of T2DM if non identical twin

A

10%

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18
Q

Inheritance of MODY

A

Autosomal dominant

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19
Q

What does MODY stand for?

A

Maturity onset diabetes in the young

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20
Q

Pathology of MODY

A

single gene defect

impaired Beta-cell function

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21
Q

Two types of mutations of MODY

A

Glucokinase mutations

Transcription factor mutations

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22
Q

When is the onset of diabetes in MODY glucokinase mutations patients?

A

Birth

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23
Q

Status of hyperglycaemia in MODY glucokinase mutation patients

A

Stable

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24
Q

Treatment of MODY glucokinase mutations patients

A

Diet

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25
Q

How common are complications in MODY glucokinase mutations patients?

A

Rare

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26
Q

Examples of MODY transcription factor mutations

A

HNF-1a
HNF-1B
HNF-4a

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27
Q

Age of onset of MODY transcription factor mutations

A

Adolescence/young adult onset

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28
Q

State of hyperglycaemia in MODY transcription factor mutations patients

A

Progressive

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29
Q

Treatment of MODY transcription factor mutations patients

A

1/3 diet
1/3 OHA
1/3 insulin

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30
Q

How common are complications in patients with MODY transcription factor mutations?

A

Frequent

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31
Q

Causes of secondary DM

A 
drug therapy e.g. corticosteriods
pancreatic destruction 
- CF
- haemachromatosis 
- Chronic pancreatitis 
- Pancreatectomy 
Recognised genetic syndromes - DIDMOAD
Cushings 
Acromegaly 
Phenochromocytoma
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32
Q

What can gestational diabetes be associated with?

A

FH of type II diabetes

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33
Q

What does having gestational diabetes leave you with an increased risk of developing later in life?

A

Type II diabetes

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34
Q

What trimester does gestational diabetes develop in?

A

2nd/3rd trimester

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35
Q

Who is gestational diabetes more common in?

A

Overweight

Inactive

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36
Q

Neonatal problems related to gestational diabetes

A

Macrosomia
Respiratory distress
Neonatal hypoglycaemia

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37
Q

Symptoms of hyperglycaemia

A 
Polydipsia
Polyuria
Blurred vision 
Weight loss
Infections
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38
Q

Long term microvascular complications of hyperglycaemia

A

retinopathy
neuropathy
nephropathy

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39
Q

Long term macrovascular complications of hyperglycaemia

A

Stroke
MI
PVD

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40
Q

What group does diabetes diagnostic criteria identify?

A

Those with significantly increased premature mortality and increased risk of microvascular and cardiovascular complications

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41
Q

What is ‘normoglycaemia’ used for?

A

Glucose levels associated with low risk of developing diabetes or cardiovascular disease

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42
Q

What group does intermediate hyperglycaemia (IGT and IFG) identify?

A

A group at higher risk of future diabetes and adverse outcomes such as cardiovascular disease

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43
Q

Diagnostic level of diabetes with HbA1c

A

> _ 48 mmol/mol

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44
Q

How many lab and symptoms are needed to diagnose diabetes?

A

ONE diagnostic lab glucose PLUS symptoms
or
TWO diagnostic lab glucose WITHOUT symptoms

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45
Q

What lab values can be diagnostic of diabetes?

A

Diagnostic glucose levels (venous plasma) fasting >7.0mmol/l, random > 11.1 mmol/l
OGTT 2 hours after 75g CHO >11.1 mmol/l
Diagnostic HbA1c >_ 48 mmol/mol

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46
Q

What is HbA1c?

A

Glycosated haemoglobin

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47
Q

What does HbA1c give an indication of?

A

Blood glucose levels over the last 8-12 weeks

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48
Q

When can HbA1c not be used for diagnosis?

A

T1DM
All children and young people
Pregnancy - current or recent (< 2 months)
Short duration of diabetes symptoms
Patients at high risk of diabetes who are acutely ill
Patients taking medications that may cause rapid glucose rise e.g. corticosteriods
Acute pancreatic damage or pancreatic surgery
Renal failure
Iron deficiency
B12 deficiency
HIV infection

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49
Q

Presentation of T1DM

A

Short duration of

  • thirst
  • tiredness
  • polyuria/nocturia
  • weight loss
  • blurred vision
  • abdominal pain
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50
Q

Signs of DM

A 
Ketones on breath 
Dehydration 
May have increased
- RR
- tachycardia
- hypotension 
Low grade infections
- thrush/balanitis
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51
Q

Symptoms of T2DM

A 
MAY HAVE NO SYMPTOMS
thirst
tiredness
polyuria/nocturia
Sometimes weight loss
blurred vision 
symptoms of complications e.g. CVD
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52
Q

Signs of T2DM

A

NOT ketotic
Usually overweight but not always
Low grade infections; thrush/balanitis
May have microvascular or macrovascular complications at diagnosis

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53
Q

Risk factors for DM (any 2 present)

A

Overweight
FH
Over age 30 years if Maori / Asian / Pacific Island descent
Over age 40 years if European
PMH of gestational diabetes
Had a big baby (more than 4kg) - not in immediate post natal period
Inactive lifestyle, lack of exercise
Previous high blood glucose/impaired glucose tolerance

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54
Q

Does a drop in BP lead to acidosis or alkalosis?

A

Acidosis
A drop in BP leads to increased lactate
Which leads to acidosis

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55
Q

Treatment of DKA

A

Fluids - 0.9% saline

IV insulin

56
Q

What do you have to keep a close eye on when treating DKA?

A

The electrolytes

57
Q

3 things needed to diagnose DKA

A

Raised BG
Raised Ketones
Acidosis

58
Q

Would you do venous or arterial blood gas?

A

Venous

Do arterial if concerned about oxygentation

59
Q

Which is better to look at, blood or urine ketones?

A

Blood

60
Q

Which type of fluids is only used now, crystalloid or colloid?

A

Crystalloid

61
Q

What is the crystalloid of choice in DKA?

A

Saline

62
Q

What is DKA not a usual complication of?

A

T2DM

63
Q

What does LADA stand for?

A

Latent autoimmune diabetes of the adult

64
Q

What kind of disease is LADA?

A

Autoimmune

65
Q

When does LADA start?

A

Later in life, > 30 y/o

66
Q

How much family history is needed to confirm MODY?

A

FH in 3 generations

67
Q

Test for LADA

A

Autoantibodies (antiGAP)

68
Q

What does OGTT stand for?

A

Oral glucose tolerance test

69
Q

When is OGTT used?

A

Tricky cases

70
Q

What happens during OGTT?

A

The patient is asked to take a glucose drink and their BG is measured before and after the sugary drink is taken

71
Q

What cannot be used to diagnose diabetes mellitus (i.e. not a diagnostic test)?

A

Capillary blood glucose

72
Q

When HbA1c

A

T2DM is unlikely

73
Q

When HbA1c = 42-47, what does this imply?

A

Imparied/pre-diabetes

74
Q

What HbA1c > 48, what does this imply?

A

T2DM

75
Q

If cannot get the HbA1c <48, what value is preferable?

A

<53

76
Q

3rd line therapy for diabetes would be what?

A

Triple therapy

77
Q

What can progress during pregnancy and therefore must be monitored throughout?

A

Pre-proliferative retinopathy

Microalbuminuria

78
Q

Complications of DM in pregnancy

A 
Severe hypos +/- unawareness 
Progression of microvascular complications
Ketogenic state due to higher ketones leading to damage to the  baby 
Pre-eclampsia
Maternal infection 
Pre-term labour 
Miscarriage
Macrosomnia 
Hypoglycaemia (neonate)
Congenital anomaly
79
Q

Relationship between HbA1c and congenital anomaly

A

As HbA1c increases, the higher the risk of congenital anomaly increases

80
Q

What helps to prevent neonatal hypoglycaemia?

A

Breast feeding / feeding

81
Q

What happens to the insulin requirements after labour?

A

Drop almost immediately

82
Q

Why should you always ask about steroids when there is hyperglycaemia?

A

Because steroids can raise blood glucose massively.

83
Q

Under what values of ketones is negative?

A

< 0.6

84
Q

What is normal body pH?

A

7.35-7.45

85
Q

What contributes to plasma osmolarity?

A

Glucose
Urea
Electrolytes

86
Q

Equation for calculating plasma osmolarity

A

2 x (Na + K) + urea + glucose

87
Q

What does HHS stand for?

A

Hyperosmolar hyperglycaemic state

88
Q

HHS vs DKA

A

HHS more dehydrated than DKA
HHS more serious than DKA due to mortality
HHS more gradual onset than DKA

89
Q

Why does HHS have a slow onset?

A

Slow dehydration

No ketones present to make you unwell

90
Q

What can HHS be the first presentation of? And especially in who?

A

T2DM

Elderly

91
Q

Risk factors for HHS

A

Illness
Dehydration
Inability to take normal diabetes medication

92
Q

What criteria is needed to diagnose HHS?

A

Increased BG
Hypovolaemia
Osmolarity > 320

93
Q

Treatment of HHS

A

IV insulin

0.9% Saline

94
Q

Speed of Tx of HHS compared to DKA

A

Treat HHS more SLOWLY than DKA to gradually improve things as it came on slower.

95
Q

Do you always have to use IV insulin the treatment of HHS? Why?

A

Often the sugar comes down with rehydration

96
Q

What can osmotic changes lead to?

A

Acute blurring of vision

97
Q

Types of retinopathies seen in DM

A

Background retinopathy
Pre-proliferative
Proliferative

98
Q

Eye problems seen in DM

A

Retinopathies
Maculopathy
Cataracts
Glaucoma

99
Q

Two groups of symptoms of hypoglycaemia

A

Autonomic symptoms

Neuroglycopenic symptoms

100
Q

Which of the two groups of hypoglycaemic symptoms come on first?

A

Autonomic

101
Q

When do neuroglycopenic symptoms come on in hypoglycaemia?

A

At a lower BG

But come on rapidly

102
Q

What is gastroparesis?

A

Delayed gastric emptying

103
Q

You are more likely to have hypo unawareness if you have had diabetes for how long?

A

> 15 years

104
Q

What must you do if you have two episodes of severe hypoglycaemia in a year?

A

Stop driving and inform the DVLA

105
Q

What happens in terms of blood levels if have gastroporesis?

A

Insulin acts before the sugar rises

106
Q

Treatment of gastroporesis

A

Prokinetics
Delayed timing of bolus of insulin after food
Liquidised or homogenised foods (absorbed more rapidly)
PEG/Jejunal feeding
Botulinum injection into pylorus
Gastric pacemaker (not always effective)

107
Q

Types of neuropathy

A

Autonomic

Peripheral

108
Q

What is the albumin:creatinine ratio more sensitive than?

A

The protein:creatinine ratio

109
Q

Which appears in the urine first, albumin or protein?

A

Albumin

110
Q

What result does microalbuminuria give on urine dipstick?

A

Negative

111
Q

What result does macroalbuminuria give on urine dipstick?

A

Positive

112
Q

Two types of dialysis

A

Haemodialysis

Peritoneal

113
Q

What is the autonomic NS effect of DM?

A

Postural hypotension

114
Q

When is HbA1c not a very accurate measurement?

A

If you are anaemic

115
Q

What should be done if you are scared of having a hypo at night?

A

Take 20% of insulin and have a snack before bed

116
Q

What type of metformin is better tolerated and why is this?

A

Slow release

Because of S/Es

117
Q

If are on testosterone and stop taking it, what can happen?

A

Can become anaemic

118
Q

What is faecal elastase a measurement of?

A

Pancreatic exocrine insufficiency

119
Q

How long does it take to develop retinopathy?

A

5 years

120
Q

Target of BG in the morning

A

5 - 8

121
Q

Effects of fight or flight on BG

A

Increase in BG

Then decrease in BG due to the adrenaline

122
Q

1 unit of insulin brings down the BG by how much?

A

4 mmol

123
Q

What antibodies are looked at in T1DM and LADA?

A

AI2 antibodies

124
Q

How many grams of CHO in 2 slices of toast?

A

30g

125
Q

Insulin ratio and what does it mean?

A

1:10

1 insulin unit for every 10g of carbs

126
Q

What should you do to your insulin after exercise?

A

Drop your insulin a bit

Because after exercise taking up glucose into muscles is easier

127
Q

How long can LADA last without insulin?

A

6 months

128
Q

What can happen to an overnight hypo?

A

It can rebound to high

129
Q

How long does it approx. take to get normal after a correction dose?

A

4 hours

130
Q

How often are patients with T1DM told to monitor their BG?

A

At least 4x a day, including before each meal and before bed

131
Q

Inheritance of MODY

A

Autosomal dominant

132
Q

T2DM BP target if NO end organ damage

A

< 140/80

133
Q

T2DM BP target if end organ damage

A

< 130/80

134
Q

What is the most important complication of fluid resus in DKA, and in who?

A

Cerebral oedema

In young patients

135
Q

HbA1c level of pre diabetes

A

42 - 47 mmol/mol

136
Q

What HLA allele is associated with T1DM?

A

HLA-DR4

Endocrine Pathology (11 decks)

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