Clinical (Weeks 1 + 2 - Diabetes) Flashcards Preview

Year 2 - Endocrinology (DP) > Clinical (Weeks 1 + 2 - Diabetes) > Flashcards

Flashcards in Clinical (Weeks 1 + 2 - Diabetes) Deck (115):
1

What antibodies might be present in T1DM?

Anti-GAD
Anti-islet cell

2

When is a person though to have T2DM?

When they don't have:
- T1DM
- Monogenic DM
- Other condition/Treatment causing secondary DM

3

What are some risk factors for T2DM?

Central obesity
FHx
Gestational DM
Age
Ethnicity:
- Asian
- African
- Afro-Caribbean
PMHx of MI/CVA
Medications
IGT/IFG

4

What are some symptoms of DM?

Thirst
Polyuria
Thrush
Weakness
Blurred vision
Infections
Weight loss

5

What pancreatic diseases can cause secondary DM?

Chronic/Recurrent pancreatitis
Haemochromatosis
CF

6

What endocrine diseases can cause secondary DM?

Cushing's
Acromegaly
Phaeochromocytoma
Glucogonoma

7

What drugs can induce DM?

Glucocorticoids
Diuretics
β-blockers

8

What genetic disorders can result in DM?

CF
Monogenic dystrophy
Turner's

9

What are the principles of T2DM treatment?

Alleviate hyperglycaemia symptoms
Improve glycaemic control
Minimise:
- Hypoglycaemia
- Weight gain
Reduce complications

10

What do biguanides do?

Increase insulin sensitivty

11

What dose of biguanide do we usually start with?

500mg once/twice daily

12

Give an example of a biguanide

Metformin

13

Does metformin cause weight loss/no change/weight gain?

No change

14

How much can metformin reduce a patient's HbA1c?

15-20 mmol/L

15

Does metformin cause hypoglycaemia?

Not if used as monotherapy

16

What effect does metformin have on a patient's lipid status?

Decreased triglycerides and LDL

17

Is metformin safe in pregnancy?

Yes

18

What are some side effects of metformin?

Anorexia
Nausea/Vomiting/Diarrhoea/Abdo. pain
Anaemia
Lactic acidosis:
- If in renal failure
- If in cardiac/liver failure

19

In what patient's should metformin be stopped?

Renal failure:
- If eGFR 150 micromol/L
Liver:
- Advanced cirrhosis
- Liver failure

20

When might metformin be beneficial?

NAFLD

21

In what patient's should metformin be used with caution due to the increased risk of lactic acidosis?

Acute CHF
Sepsis
Acute MI
Respiratory failure
Hypotension

22

How do sulphonylureas work?

Insulin secretagogues

23

Give examples of SUs

Glicazide
Glipizide
Glimeparide

24

What complications can metformin prevent?

Microvascular
Macrovascular

25

What complications can SUs prevent?

Microvascular

26

How do SUs manage hyperglycaemia?

Decrease HbA1c by 15-20 mmol/mol
Increased insulin secretion
More rapid action than metformin

27

When are SUs used?

1st line in underweight T2DM
2nd line as add-on to metformin/intolerant to metformin

28

What are some side effects of SUs?

Hypoglycaemia:
- Caution in elderly/alcoholics/liver disease
GI upset
Headache

29

What is the only available thiazolidinedione?

Pioglitazone

30

How do TZDs work?

They are PPARγ agonists - Increase insulin sensitivity

31

What effect do TZDs have on weight?

Increase is common:
- Due to increased S/C fat and fluid retention

32

Why can TZDs increase the risk of CHF?

Fluid retention

33

What other effects do TZDs have?

Improve microalbuminaemia
Prevent macrovascular complications
Increase hip fracture risk

34

How dies Dapaglifozin work?

Act on the incretin pathway:
- SGLT2 inhibitor

35

What are the incretins?

Stimulate intestinal secretion of insulin:
- GIP from K cells
- GLP-1 from L cells

36

What type of drug is exenatide?

GLP-1 receptor agonist

37

How does exenatide work?

Increased insulin secretion (no hypos)
Suppress glucagon
Decrease gastric emptying -> Early satiety
Reduce appetite
Weight loss

38

What are some side effects of exenatide?

Nausea
Pancreatitis

39

Give some examples of DPP-IV inhibitors

Vildagliptin
Sitagliptin
Saxagliptin
Linagliptin

40

What drugs are less potent; GLP-1 receptor agonist, DPP-IV inhibitors?

DPP-IV inhibitors:
- Only work on what's present
- DLP-1 decreased in T2DM

41

What are some benefits of DPP-IV inhibitors?

Increase insulin secretion (no hypos)
Decrease glucagon
Weight neutral

42

How do SGLT2 inhibitors work?

Decrease sugar uptake by ~25%:
- Glycosuria (~80g/day)
- ~1lb decrease in weight/week

43

What side effects are common with SGLT2 use?

Sugar in urine:
- Thrush
- UTIs

44

What type of insulin is used in T2DM?

Basal insulin

45

When is bariatric surgery considered?

When 30

46

What is acanthosis nigricans?

Skin becomes:
- Hyperpigmented
- Velvety
Found at:
- Axilla
- Neck

47

What is acanthosis nigricans a sign of?

Insulin resistance ie T2DM

48

What are some microvascular complications of T2DM?

Retinopathy
Nephropathy
Neuropathy:
- Impotence
- Digestion/Urination problems
Amputation

49

What are some macrovascular complications of T2DM?

CVS disease:
- MI
- CHD
- CVA
- PAD
- Angina

50

How can alcohol result in hypoglycaemia?

Increases insulin activity

51

How long do rapid-acting insulin analogues last and give examples?

~5 hours
Examples:
- Humalog
- Novorapid
- Apidra

52

How long do short-acting insulin analogues last and give examples?

~8 hours
Examples:
- Humulin S (human insulin)
- Actrapid
- Insuman rapid

53

How long do intermediate-acting insulin analogues last and give examples?

~20 hours
Examples:
- Insulatard
- Humulin I
- Insuman basal

54

How long do long-acting insulin analogues last and give examples?

~24 hours:
- Lantus (Levels remain high at end of day)
- Levemir (Levels reduced at end of day)

55

How can we evaluate glucose control?

Home blood glucose monitoring
Urine testing:
- Glucose
- Ketones
HbA1c

56

What does glycated Hb give us an idea of?

Measure of blood glucose over 6-8 weeks

57

What is the ideal HbA1c target?

48 mmol/mol

58

What are the downsides to injectable insulin?

It's into the S/C tissue (instead of portal blood)
Peaks too slow -> Can't prevent post-meal hyperglycaemia
Slow clearance

59

What factors affect the absorption of injectable insulin?

Pen accuracy
Leakage
Temperature
Injection site
Exercise

60

When is IV insulin prescribed?

DKA
HSS
Acute illness
Fasting patients who cannot tolerate PO intake

61

What monitoring is important during the delivery of IV insulin?

Hourly BG (5-12 mmol/L)
Free of hypos
Ketones if BG > 12 mmol/L
U+Es daily
Transition from IV to S/C

62

What are some indications for a pancreas transplant?

Imminent/ERSD with kidney transplant
Severe hypos
Incapacitating problems

63

What are the four mains steps in islet transplantation?

1. Donation and retrieval
2. Islet isolation
- Sterility
- Pancreas digestion
- Islet purification
3. Islet culture (24 hours)
4. Transplantation

64

What are some signs and symptoms of hypoglycaemia?

Shaking
Sweating
Anxious
Dizzy
Hungry
Tachycardia
Decreased vision
Weakness + fatigue

65

What can severe hypoglycaemia lead to?

Seizures
Unconsciousness

66

What is the immediate treatment of hypoglycaemia?

1. 15-20g of glucose/simple carbohydrates
2. Recheck BG after 15 minutes
3. If still hypo -> Repeat
4. Once BG normal -> Small snack if next meal >1hr away

67

Treatment of severe hypoglycaemia?

1mg glucagon injection:
- Buttock
- Arm
- Thigh

68

What is the definition of impaired hypoglycaemia awareness?

When BG

69

During DKA what hormones increase in levels?

Counter-regulatory:
- Glucagon
- Adrenaline
- Cortisol
- GH

70

What does the activation of certain hormones in DKA cause?

Increased lipolysis
Decreased glucose utilization:
-> Hyperglycaemia
Increased proteolysis:
-> Hyperglycaemia
Increased gluconeogenesis:
-> Hyperglycaemia

71

What does hyperglycaemia result in?

Glycosuria
-> Electrolyte loss
-> Dehydration
-> Dehydration and Hyperosmolar state

72

What is the biochemical diagnosis of DKA?

1. Ketonaemia > 3mmol/L OR Ketonuria > ++
2. BG > 11.0mmol/L OR Known DM
3. Bicarbonate <15mmol/L OR venous pH <7.3

73

What can commonly precipitate DKA?

Infection
Drugs/Alcohol
Non-adherence to therapy
Newly diagnosed DM

74

What signs and symptoms are caused by the following in DKA:
- Osmotic changes
- Ketone body related

Osmotic:
- Thirst
- Polyuria -> Dehydration
Ketone bodies:
- Flushing
- Vomiting
- Abdominal pain
- Kussmaul's respiration
- +/- Ketone breath

75

What other biochemical changes can be seen in DKA?

Potassim is often raise (> 5.5mmol/L)
Creatinine is often raised
Sodium is often decreased
Increased lactate
Ketones increased:
- β-hydroxybutarate in blood
- Acetoacetate in urine

76

What causes death in DKA?

Adults:
- Hypokalaemia
- Aspiration pneumonia
- ARDS
Kids:
- Cerebral oedema

77

How is DKA managed?

Replace losses:
- Fluid -> 0.9% NaCl
-> Dextrose when glucose

78

What HbA1c levels indicate the following:
1. Normal
2. Pre-diabetes
3. Diabetes

Normal:
- 48mmol/L
- >6.5%

79

What fasting glucose levels indicate the following:
1. Normal
2. Pre-diabetes
3. Diabetes

Normal:
- 7.0mmol/L

80

What 2hr OGTT levels indicate the following:
1. Normal
2. Pre-diabetes
3. Diabetes

Normal:
- 11.1mmol/L

81

What is the normal blood ketone level?

82

What is the typical biochemistry in Hyperglycaemia Hyperosmolar Syndrome?

Higher glucose than DKA
Significant renal impairment
Increased sodium
Increased osmolarity (~400)
Less acidotic

83

Where does lactate originate from?

Erythrocytes
Skeletal muscle
Brain
Renal medulla

84

How is lactate cleared?

Hepatic uptake
Aerobic conversion -> Pyruvate -> Glucose

85

What is the normal range for lactate?

0.6-1.2mmol/L

86

How do we calculate the anion gap?

[Na+ + K+] - [HCO3- + Cl-]

87

What is the normal ion gap?

10-18mmol/L

88

What causes of acidosis present with a normal ion gap?

Diarrhoea
RTA
Addison's
Reason:
- Bicarbonate is reduced
- Cl- is raised

89

What causes of acidosis present with a high ion gap?

MUDPILES
Reason:
- Bicarbonate reduced
- Replaced by sulfate, phosphate
- Cannot be replaced sufficiently

90

What is Type A lactic acidosis?

Associated with tissue hypoxia:
- Infarct
- Cardiogenic shock
- Hypovolaemic shock
> Sepsis
> Haemorrhage

91

What is Type B lactic acidosis?

Liver disease
Leukaemia
Associated with DM:
- Metformin in illness/renal failure

92

What are the targets for each of the following in DM?
- BMI
- HbA1c
- BP
- Total cholesterol
- LDL
- Triglycerides

BMI -> 25
HbA1c -> 7% (75mmol/mol)
BP ->

93

How do we treat T2DM in the following situations:
- BMI >25
- BMI

BMI >25:
- Metformin up to 1g tds
BMI

94

What anti-lipid therapies are recommended in diabetes?

Statins:
- Increase dose to lower cholesterol
Fibrates
Ezetimibe
Cholestyramine:
- Unpleasant

95

What is peripheral neuropathy?

Pain/Loss of feeling in:
- Hands
- Feet

96

What is autonomic neuropathy?

Changes in bowel habit
Bladder function
Sexual response
Sweating
HR/BP/Hypoglycaemic unawareness

97

What is proximal neuropathy?

Pain in thigh/hips/buttocks:
- Leg weakness (Amyotrophy)

98

What factors precipitate neuropathy?

Increased length of DM
Poor glycaemic control
T1DM > T2DM
Increased cholesterol
Smoking/Alcohol/Genetics

99

A diabetic patient presents with numbness, tingling and sharp pains in their foot. It is very sensitive to touch and they have lost their balance.

Peripheral nerve damage

100

What complications can peripheral neuropathy result in?

Infections/Ulcers
Charcot foot
Deformities
Amputations

101

What is the step up treatment for painful neuropathy?

1. Simple analgesia
2. TCAs (amitryptiline at night)
3. Gabapentin
4. Oxycodone/Tramadol

102

A patient presents with constipation, nausea, bloating and a loss of appetite. He has difficulty swallowing and has known, poorly controlled DM.

Autonomic neuropathy

103

How can gastroparesis be treated?

Metoclopramide
Domperidone
Erythromycin
Gastric pacemaker

104

What is diabetic nepropathy also known as?

Kimmelsteil-Wilson Syndrome
Nodular Glomerulosclerosis

105

What can result in diabetic nepropathy?

Hypertension
Decreased renal function:
- GFR down by 1ml/min/month
Accelerated vascular disease

106

How is diabetic nephropathy screened for?

Urinary albumin creatinine ratio (ACR)
Confirm with EMU
Dipstick
U+Es -> eGFR

107

What is a normal ACR?

Male:
-

108

What is defined as microalbuminuria?

30-300mg/L of urine

109

What is macroalbuminuria?

> 300mg/L of urine

110

What can cause a false positive urinary albumin excretion rate? (UAER)

Menstruation
Vaginal discharge
UTI
Pregnancy
Illness
Renal discharge

111

What are cotton wool spots a sign of in diabetic retinopathy?

Ischaemia

112

What are hard exudates a sign of in diabetic retinopathy?

Lipid break down products

113

Which of the following drugs doesn't cause erectile dysfunction:
- Thiazides
- Beta blcoerks
- Antidepressants
- Analgesics
- NSAIDs

NSAIDs

114

Put the following steps in atheroslcersosis development in order:
- Macrophages ingest LDL to become foam cells
- Fibrous cap forms from smooth muscle migration
- Cap rupture
- Monocytes migrate into epithelium
- Smooth muscle degenerated by activated macrophages
- Cytokines produced result in smooth muscle migration
- Platelets aggregate at site of rupture and thrombus forms

1. Monocytes migrate into epithelium (become macrophages)
2. Macrophages ingest LDL to become foam cells
3. Cytokines produced result in smooth muscle migration
4. Fibrous cap forms from smooth muscle migration
5. Smooth muscle degenerated by activated macrophages
6. Cap rupture
7. Platelets aggregate at site of rupture and thrombus forms

115

How do we diagnose diabetes?

1. Symptomatic and:
- One-time fasting glucose >7.0mmol/L OR
- One-time random glucose >11.1mmol/L
OR

2. Two time results of:
- Fasting glucose >7.0mmol/L OR
- OGTT >11.1mmol/L OR
- Random glucose >11.1mmol/L

OR

3. HbA1c >48mmol/L (>6.5%)