CP9-3 Diabetes

Question 1

What is the epidemiology of diabetes type 1?

Answer 1

Approx 400,000 people in UK
Most common in Europe globally

Question 2

What is the epidemiology of diabetes type 2?

Answer 2

More than 4.5 million people in UK
Rising globally

Question 3

How many premature deaths per week are attributed to diabetes?

Answer 3

700

Question 4

What percentage of NHS budget is spent on diabetes?

Answer 4

10%

Question 5

What is diabetes mellitus?

Answer 5

A group of disorders characterised by hyperglycaemia

Question 6

What organ is involved in diabetes?

Answer 6

Pancreas

Question 7

What endocrine cells are found in the pancreas?

Answer 7

Islets of Langerhans
Pancreatic exocrine acini

Question 8

What are the types of pancreatic islet cells? What do they produce?

Answer 8

Alpha cells = glucagon
Beta cells = insulin
Delta cells = somatostatin
F cells = pancreatic polypeptide

Question 9

How is insulin produced?

Answer 9

From proinsulin using prohormone convertase 3 and carboxypeptidase

Question 10

What affects insulin action?

Answer 10

Metabolic changes
Paracrine effects
Vascular growth
Cancer

Question 11

When is diabetes diagnosed?

Answer 11

When fasting glucose =/> 7 mmol/L
Random glucose =/> 11.1 mmol/L
HbA1c =/> 48 mmol/L
Two hour reading post OGTT =/> 11.1 mmol/L

Question 12

What is an OGTT?

Answer 12

Oral glucose tolerance test done if fasting glucose =/> 7 mmol/L. Patient given 75g of anhydrous glucose to ingest and test repeated 2 hours later

Question 13

What results of OGTT suggests although patient isn’t diabetic, they have not got healthy function?

Question 14

What is pre-diabetes?

Question 15

How is diabetes classified?

Question 16

What is type 1 diabetes?

Answer 16

Autoimmune destruction of insulin producing beta cells in the islet of Langerhans which often presents at puberty.

Question 17

What genes are associated with type 1 diabetes?

Answer 17

HLA class II coding genes like DR4-DQ8 and DR3-DQ2

Question 18

What are risk factors for type 1 diabetes?

Answer 18

Family history of autoimmune disease
Low birth weight
Viral infections
Diet high in cows milk

Question 19

What are the stages of type 1 diabetes and what happens at each stage?

Answer 19

Stage 1 = trigger of beta cell immunity but asymptomatic
Stage 2 = loss of beta cell secretory function, development of antibodies and slight glucose elevation
Stage 3 = loss of beta cell capacity causing symptoms to present

Question 20

What insulin autoantibodies are present in type 1 diabetes?

Answer 20

Glutamic acid decarboxylase autoantibodies (GAD)
Islet antigen-2 autoantibodies (IA-2)
ZnT8 transporter autoantibodies

Question 21

How do patients with type 1 diabetes present?

Answer 21

Rapid onset:
Weight loss with osmotic symptoms and low energy
Abdominal pain
Often slim
DKA

Question 22

How is type 1 diabetes managed?

Answer 22

With insulin

Question 23

How do patients with type 2 diabetes present?

Answer 23

Gradual onset (usually):
Overweight with minimal weight loss
Vision loss
Foot ulcers
Fungal infections
Hyperosmolar hyperglycaemic state (HHS)

Question 24

How is type 2 diabetes managed?

Answer 24

Lifestyle - exercise, change in diet and weight loss
Non-insulin therapy - up to 3 agents with metformin (first line) + DDP4 inhibitor, SGLT-2 inhibitor, GLP-I agonist or sulphonylureas
Insulin once a day/multiple dependening

Question 25

What is gestational diabetes?

Answer 25

Diabetes in pregnancy/hyperglycaemia first detected in pregnancy which was not present before

Question 26

How is gestational diabetes diagnosed?

Answer 26

With fasting glucose >5.6 mmol/Lor 2 hour plasma glucose level of 7.8 mmol/L

Question 27

What is not recommended in diagnosing gestational diabetes?

Answer 27

HBA1c

Question 28

Who is tested for gestational diabetes?

Answer 28

BMI > 30 Previous macrosmoic baby Previous gestational diabetes Family history of diabetes Ethnic minorities e.g. south Asian

Question 29

What are consequences of gestational diabetes?

Answer 29

Macrosomia Pre-eclampsia Stillbirth Neonatal morbidity Childhood obesity of baby Mother developing type 2 diabetes

Question 30

How is gestational diabetes managed?

Answer 30

Diet of mild Limited oral options including metformin or glibenclamide Insulin (only during pregnancy as goes away once given birth)

Question 31

How is gestational diabetes managed post-birth?

Answer 31

Repeat fasting glucose of Hba1c as increased risk of type 2 diabetes and annual diabetes screening

Question 32

What are types of genetic diabetes?

Answer 32

Mature onset diabetes of the young (MODY) Maternal inherited diabetes and deafness Wolfram syndrome (DIDMOAD)

Question 33

What is secondary diabetes?

Answer 33

Diabetes secondary to pancreas damage

Question 34

What are causes of secondary diabetes?

Answer 34

Pancreatitis (due to gallstones or alcohol) Pancreatectomy (for cancer or trauma) CF Haemochromotosis

Question 35

What drugs can induce diabetes?

Answer 35

Steroids Atypical anti-psychotics Immunotherapy e.g. nivulomab Protease inhibitors (used in HIV treatment)

Question 36

What endicrinopathies can cause diabetes?

Answer 36

Cushing’s syndrome Acromegaly Somatostatin secreting tumours (somatostatinoma) Glucagon secreting tumours (glucagonoma)

Question 37

What are counter regulatory hormones?

Answer 37

Hormones that oppose the action of insulin which are secreted in response to stress

Question 38

What are counter regulatory hormones?

Answer 38

Hormones that oppose the action of insulin which are secreted in response to stress

Question 39

What are examples of counter regulatory hormones?

Answer 39

Glucagon Epinephrine/norepinephrine Glucocorticoid GH

Question 40

What are examples of stimuli for insulin release?

Answer 40

Glucose Fatty acids and ketones Vagal nerve stimulation Gut hormones Drugs that medicate diabetes Prostaglandins

Question 41

What stimuli inhibits insulin release?

Answer 41

Sympathetic stimulation Alpha adrenergic agents e.g. adrenaline Beta blockers Dopamine Serotonin Somatostatin

Question 42

Where is glucagon rapidly degraded?

Answer 42

In tissues especially liver and kidneys

Question 43

How many amino acids make up glucagon?

Answer 43

29

Question 44

What stimulated glucagon release?

Answer 44

Amino acids Beta adrenergic stimulation Fasting Hypoglycaemia Exercise Cortisol

Question 45

What stimulates inhibition of glucagon release?

Answer 45

Glucose Somatostatin Free fatty acids Ketones Insulin

Question 46

What is the action of glucagon?

Answer 46

Reduces intestinal motility and gastric acid secretion Increases glucose levels via glycogenolysis, gluconeogensis and/or lipolysis

Question 47

How does insulin work as a metabolic regulator?

Answer 47

Decreases lipolysis and glucose production but increases glucose utilisations

Question 48

How does gucagon work as a metabolic regulator?

Answer 48

Increases glucose production

Question 49

How does epinephrine work as a metabolic regulator?

Answer 49

Increases glucose production and lipolysis and decreases glucose utilisation

Question 50

How does cortisol work as a metabolic regulator?

Answer 50

Increases glucose production and lipolysis and decreases glucose utilisation

Question 51

How does GH work as a metabolic regulator?

Answer 51

Increases glucose production and lipolysis and decrees ease glucose utilisation

Question 52

How does free fatty acids work as a metabolic regulator?

Answer 52

Increases glucose production and decreases glucose utilisation

Question 53

A 23 year old man presents to the hospital with 10kg weight loss over two weeks. He feels thirsty and recently developed penile thrush. What is the most likely aetiology of his diabetes? 1. T1D 2. T2D 3. MODY 4. Cushings syndrome

Answer 53

1. T1D

Question 54

A 58 year old lady attends her GP for a routine appointment. She has blood tests taken which show a HbA1c of 45 mmol/mol. What is the diagnosis: 1. T1D 2. T2D 3. Gestational diabetes 4. Impaired glucose tolerance

Answer 54

4. Impaired glucose tolerance

Question 55

Does everybody on insulin with diabetes have type 1?

Answer 55

No - more common in type 1 but can also be used in type 2