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Endocrinology > Clinical Topic 5: Diabetes > Flashcards

Clinical Topic 5: Diabetes Flashcards

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1
Q

When does Type 1 Diabetes commonly present? What sort of onset is associated with the disease?

A

< 25 year old patients

Sudden onset with a short history

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2
Q

What HLAs are associated with Type 1 Diabetes?

A

HLADR3

HLADR4

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3
Q

What antibodies are associated with Type 1 Diabetes?

A
  • Glutamic acid decarboxylase (GAD)
  • Insulin antibodies
  • Islet cell antibody
  • ZnT8
  • IA2
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4
Q

What are the three classic features of Type 1 Diabetes?

A

Polydypsia
Polyuria
Weight loss

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5
Q

Which skin condition is characteristic of Type 1 and 2 Diabetes? What does it look like?

A

Necrobiosis Lipiodica

Shiny red / yellow patches on skin

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6
Q

What HbA1c value is diagnostic for Diabetes? How many values are required?

A

48 mmol (6.5%)
If symptomatic -> 1 value required
If asymptomatic -> 2 values required from 2 different days

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7
Q

What is the diagnostic value of one-off glucose measurements for Diabetes? How many values are required?

A

Fasting glucose - more or equal to 7
Random glucose - more or equal to 11

If symptomatic -> 1 value required
If asymptomatic -> 2 values required

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8
Q

What conditions are associated with reduced cell survival, leading to a falsely low HbA1c?

A

Haemoglobinopathies
Splenomegaly
Blood loss
Blood transfusion

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9
Q

What conditions are associated with increased cell survival, leading to a falsely high HbA1c?

A

Splenectomy

B12 / folic acid / iron deficiency

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10
Q

What is the pre-diabetes range for HbA1c and fasting glucose in diabetes?

A

HbA1c: 42 - 47

Fasting glucose: 6 - 7

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11
Q

How is impaired fasting glucose defined?

A

A fasting glucose between 6 and 7

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12
Q

How is impaired glucose tolerance defined?

A

Fasting glucose more or equal to 7

OGTT 2-hour value between 7.8 and 11.1

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13
Q

What is the C-peptide result in Type 1 and Type 2 Diabetes?

What does the c-peptide test tell you?

A

Type 1: Low
Type 2: High

Whether there is endogenous insulin production

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14
Q

1 ml of Insulin = how many units?

A

100 units

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15
Q

What is the initial target HbA1c for Type 1 Diabetics?

A

48

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16
Q

What are the recommended day to day values for blood glucose in Type 1 Diabetic?

A

During the day, 4-7 mmol/L
Bedtime 6-10mmol/L

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17
Q

What is recommended number of times a Type 1 Diabetic patient should check their blood glucose a day?

A

Check glucose 4x day, including before each meal and before bed

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18
Q

What is the first-line recommendation of Insulin for Type 1 Diabetes?

A

Basal isophane Insulin

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19
Q

What is the main side effect of Insulin administration?

A

Lipoatrophy and lipohypertrophy

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20
Q

What patients may require Insulin pumps? What does the infusion comprise of?

A

Suitable for those with total insulin deficiency

Comprises a continuous basal infusion + patient activated bolus at meal times

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21
Q

What rate of fixed-rate insulin is administered to DKA patients?

A

0.1 unit / kg / hr

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22
Q

What is the initial management of DKA, and what are the risks of it?

A

IV saline 0.9%

Risk -> Cerebral oedema

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23
Q

What is a the normal range of Ketones?

A

1.3 - 3

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24
Q

What auto-immune diseases are associated with Type 1 Diabetes?

A

Coeliacs

Graves / Hashimotos

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25
What skin condition is associated with insulin resistance?
Acanthosis nigricans
26
What things may suggest a Hyperosmolar Hyperglycaemic state?
Hypovolaemia High glucose >30 Raised serum osmolality
27
What is the initial treatment for HHS?
IV fluids STAT
28
If a patient has recently been diagnosed with Type 2 Diabetes, how often should their HBA1c be checked?
Every 3-6 months until stable initially | Then when stable -> 6 monthly
29
What is the HbA1c target for a patient who is newly diagnosed Type 2 Diabetic with lifestyle treatment?
48
30
What is the HbA1c target for a patient who is newly diagnosed Type 2 Diabetic with lifestyle treatment and Metformin and has a HbA1c of 49?
48
31
What is the HbA1c target for a patient who is newly diagnosed Type 2 Diabetic (HbA1c of 49) with a drug which causes hypoglycaemia?
53
32
What is the HbA1c target for a patient who has a HbA1c of 58?
53
33
What is the MoA of Metformin?
Biguanide Increases glucose uptake Increases muscle metabolism Decreases gluconeogenesis
34
Adverse effects of Metformin?
Diarrhoea, bloating, epigastric discomfort Lactic acidosis in renal / hepatic failure DOES NOT CAUSE WEIGHT GAIN
35
What is the MoA of Sulfonyurea?
Binds to ATP dependent K channels Causing more insulin secretion
36
Example of a Sulfonyurea?
Gliclazide
37
Adverse effects of Sulfonyurea?
Weight gain | Hypoglycaemia
38
What is the MoA of DPP4i drugs? Give examples of them
Inhibit DPP4i, hence prevents breakdown of GLP-1 Examples: -Gliptin drugs
39
What is the MoA of Thiazolidinediones? Give examples of them
PPARy inhibitor, increases insulin sensitivity Examples: Pioglitazone
40
Adverse effects of Thiazolidinediones (Pioglitozone)?
Bladder cancer Osteoporosis / fractures Heart failure Weight gain
41
What is the MoA of SGLT2 inhibitors? Examples?
SGLT2 inhibitor, inhibits glucose reabsorption in kidneys Examples: -Flozin drugs
42
Adverse effects of SGLT2 inhibitors?
Increased risk of UTI due to glycosuria, WEIGHT LOSS, Fournier gangrene
43
What is the affect of DPP4i on weight?
No change in weight
44
What is the inheritance pattern of Maturity Onset Diabetes of the Young (MODY) / Monogenic Diabetes?
Autosomal Dominant
45
What two gene mutations are associated with Maturity Onset Diabetes of the Young (MODY) / Monogenic Diabetes?
Glucokinase | - HNF-1a (Human Nuclear Transcription Factor 1a)
46
What is the treatment for Maturity Onset Diabetes of the Young (MODY) / Monogenic Diabetes?
If Glucokinase mutated -> no treatment | If HNF-1a mutated -> Sulfonyureas
47
When does Gestational Diabetes commonly develop in pregnancy?
2nd / 3rd trimester
48
Why does Gestational Diabetes occur?
Increased production of growth hormone, placental oestrogen, progesterone, cortisol
49
DIABETIC KETOACIDOSIS 1. What is the pathophysiology of DKA? 2. What may precipitate DKA in a patient? 3. How is it diagnosed? 4. What is the management of DKA? 5. What are the complications of DKA?
1. Caused by lipolysis, causing excess free fatty acids which are converted to ketones 2. Missing insulin doses, infections, post-myocardial infarction 3. Hyperglycaemia (>11), ketosis (>3), acidosis (below 7.3) 4. FIG-PICK mnemonic F = Fluids: 1L NaCl in 1st hour, then 1L every 2h with potassium I = Insulin: Stop shorting acting, continue long acting, and 0.1units / kg / hour fixed rate Actrapid G = Glucose, monitor and if below 14, give dextrose P = Potassium monitoring 4 hourly, correct if required I = Treat underlying infection / sepsis C = Chart fluid balance K = Monitor ketones or bicarbonate levels 5. Cerebral oedema, arrhythmias secondary to hyperkalaemia, gastric stasis, thromboembolism, ARDS, AKI
50
What skin manifestation is associated with T1D?
Necrobiosis lipoidica
51
What are the investigations for diagnosis of T1DM?
Urine dip for glucose and ketones One of either: Fasting glucose (equal to or above 7) or random glucose (equal to or above 11.1) HbA1c equal to or above 48mmol/mol 2 hour glucose tolerance equal to or above 11mmol/L c-Peptide - low Antibodies anti-GAD, islet cell antibody
52
Signs and symptoms of T1DM?
Polyuria, polydipsia, weight loss, muscle cramps, fatigue, diabetic ketoacidosis
53
What is the management of T1DM?
Insulin therapy - short acting after meals/snacks, long-acting at night time Check HbA1c every 3-6 months - aim for 48 mmol Check glucose min 4x day with each meal and also before bed, increase monitoring if hypoglycaemic, illness, during pregnancy or breast feeding. Keep glucose targets 4-7mmol/L pre meal and 6-10mmol/L at bedtime Metformin if BMI >25 Regular screening for complications BP control
54
What is diagnostic for "high" fasting glucose?
Equal to or over 7mmol/L
55
Complications of diabetes?
Macrovascular complications: stroke hypertension coronary artery disease peripheral vascular disease Microvascular complications: diabetic retinopathy diabetic nephropathy peripheral neuropathy UTIs Oral / vaginal candidiasis Impaired wound healing Skin and soft tissue infections
56
What is diagnostic for "normal" fasting glucose?
Less than 6mmol/L
57
What is diagnostic for "high" HbA1c?
48mmol/L
58
What is diagnostic for "pre-diabetes" HbA1c?
42 - 47 mmol/L
59
What is diagnostic for "low" HbA1c?
<41 mmol/L
60
What is diagnostic for "high" random glucose?
>11.1
61
What is "impaired glucose tolerance" defined as?
Fasting glucose <7, and an OGTT between 7.8 and 11.1
62
MATURITY ONSET DIABETES OF YOUNG 1. What is it? 2. What is the inheritance pattern? 3. What are they PARTICULARLY sensitive to?
1. T2D which develops in patients before 25 years old 2. Autosomal dominant 3. Very sensitive to sulfonylureas
63
What is latent autoimmune diabetes in adults?
A form of diabetes commonly seen in patients with autoimmune conditions
64
What skin manifestations are associated with T2D?
Necrobiosis lipoidica, acanthosis nigricans
65
What is some advice to give patients in managing their T2DM?
High fibre diet, with low glycaemic index. Low fat dairy products, with oily fish. Initial target weight loss of 5-10%, exercise, stop smoking, optimise HTN and CVD risk
66
How may you manage complications of T2DM?
Referral to nephrology for diabetic nephropathy, referral to diabetic foot clinic / podiatry for foot checks / footwear, referral to ophthalmology / optometry for retinopathy
67
What is the initial HbA1c target for a patient with T2DM?
48 mmol/L
68
What is the HbA1c target for patients who are prescribed more than Metformin?
53mmol/l
69
A patient must go beyond what HbA1c to have a target of 53 mmol/L?
58mmol/L
70
What is the mechanism of action of Metformin? And side-effects?
Increases insulin sensitivity Side effects: GI upset, lactic acidosis
71
What is the mechanism of action of Sulfonylureas? Give examples of them? And side-effects?
Increase pancreatic cells to secrete insulin, examples: Gliclazide, Glimepiride. SE: Weight gain, hyponatraemia (due to SIADH)
72
Which medications cause weight gain?
Sulfonylureas Pioglitazones
73
Which medications cause weight loss?
SGLT-2 Inhibitors (-Flozins) GLP-1 agonists (-glutide)
74
Which medication causes risk of UTIs?
SGLT-2 inhibitors (-flozins)
75
Which medication should be avoided in heart failure patients?
Pioglitazone
76
Which medication increases risk of bladder cancer?
Pioglitazone
77
Which medication increases risk of Fournier's gangrene?
SGLT-2 Inhibitors i.e. -Flozins
78
Which medication is WEIGHT NEUTRAL?
DPP4 inhibitors (-gliptin)
79
What is the mechanism of action of Pioglitazone?
PRARy agonists, increasing insulin sensitivity
80
Which two drugs increase insulin sensitivity?
Metformin and Pioglitazone (PPARy agonist)
81
Which medication increases risk of bone fractures?
Pioglitazone
82
Which medication increases risk of acute pancreatitis?
DPP-4 inhibitors (-gliptin)
83
What kind of inheritance pattern is Maturity Onset Diabetes of the Young (MODY) What is the mutation?
Autosomal dominant Single mutation affecting beta cell function
84
Normal fasting glucose levels?
100mg/dL
85
What is Type 1 diabetes mellitus?
Chronic, progressive disease characterised by hyperglycaemia due to absolute insulin deficiency As a result of beta cell destruction Usual onset is childhood/young adulthood Prone to onset of DKA
86
Causes of Type 1 diabetes?
Unclear Cocksackie B Enterovirus Autoimmunity (GAD, IA2, ZnT8 autoantibodies)
87
Ideal blood glucose concentration?
4.4-6.1mmol/L
88
Management of T1DM during sick days?
Do not stop insulin treatment Increase blood glucose monitoring - every 3-4 hours Drink at least 3L fluids per day Check urinary ketones every 3-4 hours including overnight Seek medical advice if urine ketones >2 or blood ketones >3mmol/L Encourage normal eating patterns if appetite is reduced If unable to eat or vomiting, replace meals with sugary drinks
89
What diseases are associated with T1DM
Thyroid disease Coeliac disease
90
Sick day rules for T2DM?
If risk of dehydration -> stop metformin to reduce risk of lactic acidosis, SGLT2 inhibitors to reduce risk of euglycaemic DKA, and GLP-1 agonists to reduce risk of AKI If dietary intake is reduced -> caution sulfonylureas as may exacerbate hypoglycaemia
91
What is a fatal complication of type 2 diabetes? What is it caused by? What are the risk factors? What is the presentation? What are the investigations? What is the manegement?
Hyperosmolar hyperglycaemic state Hypersosmolarity of blood caused by water loss leading to hyperglycaemia without ketoacidosis Poor glycaemic control, advanced age, infections, medications affecting glucose metabolism Hyperglycaemia 30mmol/L, ketones <3mmol/L, no acidosis (unless HHS happening with DKA) Extreme polydipsia, polydipsia, weight loss, dehydration, tachycardia, hypotension IV fluids
92
When commencing GLP 1 agonists, how long should it be commenced and what needs to be checked?
When commencing GLP 1 agonists, give for 6 months then only continue if HbA1c is reduced by atleast 11mmol/l or 1% and weight loss of atleast 3%

Endocrinology (12 decks)

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