Diabetes Flashcards
(65 cards)
1
Q
What is the definition of type 2 diabetes?
A
a metabolic disorder where persistent hyperglycaemia is caused by insulin resistance and hence a relative insulin deficiency
the body is still making insulin, but this insulin does not work as well
2
Q
How is the definition of type 1 diabetes different to type 2?
A
In type 1, there is an actual insulin deficiency
the pancreas is not producing the required amount of insulin, but the insulin present is normal
3
Q
What is the prevalence of diabetes?
What proportion of this is type 2?
A
- 4.9 million people in the UK have diabetes
- 90% of these have type 2
- there are nearly 1 million people with undiagnosed type 2 diabetes
4
Q
Why are there so many cases of undiagnosed type 2 diabetes?
A
it can present with no or very minimal symptoms that have a gradual onset over a long period of time
5
Q
How are the vast majority of cases of type 2 diabetes identified?
A
- through annual health reviews for other long-term conditions (e.g. HTN, heart conditions)
- an HbA1c test is performed
- patients with many risk factors are screened regularly or on a one-off basis
6
Q
What are the 7 main risk factors for developing type 2 diabetes?
A
- obesity (80-85% overall risk)
- family history
- ethnicity
- history of gestational diabetes
- certain medications
- polycystic ovary syndrome
- metabolic syndrome
7
Q
How does family history increase the risk of diabetes?
A
lifetime risk is 15% if one parent has diabetes
or 75% if both parents have diabetes
the risk may be even higher if other RFs are present
8
Q
How does ethnicity affect chances of developing diabetes?
A
the risk is 2 to 4 times higher in someone of Asian, African or Afro-Caribbean descent
9
Q
What medications can increase the risk of diabetes?
A
- corticosteroids
- beta-blockers
- statins
- thiazides
10
Q
What measures are in place to monitor someone who had gestational diabetes?
A
- this is diabetes that develops during pregnancy but completely resolves afterwards
- the risk is 7 times higher in these individuals
- they are monitored with annual screening
11
Q
Why might polycystic ovary or metabolic syndrome increase risk of diabetes?
A
they both cause insulin resistance
12
Q
What are the symptoms that someone with type 2 diabetes may present with?
A
- they are similar to type 1 diabetes, but much more mild and gradual onset
- urinary frequency, especially nocturia
- fatigue
- constant thirst
- genital itching / recurrent thrush
- prolonged healing of cuts / wounds
13
Q
What signs might someone with type 2 diabetes present with?
A
- acanthosis nigricans
- weight loss (might prompt you to think of something more serious)
14
Q
When would you consider referring urgently to a diabetes specialist?
A
- if symptoms have developed rapidly (within 2 months)
- there are no risk factors for type 2 diabetes
- the person is young (< 40)
15
Q
What is acanthosis nigricans?
A
hyperpigmentation associated with insulin resistance
- the skin will feel thicker
- can occur anywhere on the body, but usually axillae, neck or groin
16
Q
How is type 2 diabetes diagnosed?
A
there must be persistent hyperglycaemia in an adult
- in the presence of RFs and/or mild symptoms
- no features of type 1 diabetes
- not acutely unwell
test is repeated in 2 weeks to confirm diagnosis
in primary care, HbA1c is used
17
Q
What tests can be used to determine if someone has persistent hyperglycaemia?
A
- HbA1c > 48 mmol/mol
this is a better indicator of glucose exposure than random blood glucose readings
- fasting glucose > 7.0 mmol/l
- random glucose > 11 mmol/l
18
Q
In what 2 situations can HbA1c NOT be used for diagnosis?
A
- if someone has had rapid changes in their blood glucose levels
- if someone has abnormalities of their haemoglobin
this is because HbA1c looks at glucose storage by RBCs over the last 3 months
rapid changes are associated with type 1 diabetes - HbA1c cannot be used
19
Q
In what individuals can HbA1c not be used for diagnosis?
A
- suspected type 1 diabetes
- children / young people
- pregnancy
- symptoms for less than 2 months
- certain medications (ARVs, steroids, olanzapine)
- recent pancreatic surgery / damage
- kidney failure
- anaemia / haemoglobinopathies, recent transfusion
these are all likely to involve rapid changes in glucose
20
Q
Can type 2 diabetes be diagnosed in young people and children?
A
- it needs specialist assessment as type 1 is far more likely
- but T2DM can exist in children - particuarly Asian, Black and Afro-Carribean descent
21
Q
What is pre-diabetes?
A
- individuals with a HbA1c range 42 - 47
- they are above the normal level of 41 or below
- but they are not at the stage where they will develop complications from their diabetes (48)
22
Q
Why is it important to recognise pre-diabetes?
A
these people are likely to develop diabetes within the next 10 years
- they are offered annual monitoring and lifestyle advice to prevent the onset of diabetes
23
Q
What is the leading cause of death in T2DM?
A
cardiovascular disease including stroke and PVD
- 2.5x increased stroke risk
- 2.5x increased risk of MI / heart failure
75% of people with T2DM will die from a cardiovascular complication
24
Q
What has a more significant impact on CV risks than treating the hyperglycaemia?
A
management of blood pressure and cholesterol
- lipid profile performed annually
- blood pressure monitored every 6 months
25
How do you screen for and monitor renal disease in diabetes?
monitor **eGFR and ACR annually**
* this is performed more regularly if they have severe renal disease, HTN or risk factors for kidney disease
26
Why can diabetes lead to renal disease?
* **diabetic nephropathy** (direct damage to kidneys from raised glucose)
* **HTN**
* **renal atheroma**
* **ischaemia** (due to glucose damaging renal arterial supply)
27
Why is it important to monitor eGFR and ACR in T2DM?
T2DM is the commonest cause of CKD
but, someone is far **more likely to die from CVD** before reaching the stage of needing dialysis
**reduced eGFR** and **raised ACR** are independent risk factors for CVD
if someone has **T2DM and CKD**, their **risk of CVD is amplified**
| blood pressure & cholesterol control are as important as hyperglycaemia
28
What are the typical symptoms and signs of peripheral neuropathy?
typically associated with **pain** that is **nocturnal**, **bilateral** and in a **glove & stocking distribution**
* numbness
* burning / shooting pain
* tingling
* paraesthesia
* symmetrical
29
What causes foot complications in T2DM?
* a combination of **peripheral neuropathy** (damage to the nerve endings in the feet and hands)
* and **peripheral arterial disease**
30
What active foot conditions are associated with T2DM?
* ulceration
* ischaemia
* soft tissue / bone infection
* gangrene
a **monofilament** is used at annual screening to monitor this
31
How do foot ulcers typically present?
* tend to be seen in patients who have had **poor glucose control** over many years
* develop in **pressure areas**
* start as a haemorrhagic blister and progress
* often **painless** (neuropathy causes a lack of pain sensation in the foot)
* have a ***"punched out"*** appearance
32
What are the major risks of foot ulcers?
* they can develop into **skin infections** and **gangrene**
* they can become full-thickness and result in **bone infections**, which can result in **amputation** and progression to **sepsis**
33
What is autonomic neuropathy?
occurs when high levels of glucose **damage the nerves** of the **autonomic nervous system**
34
What are the potential symptoms of autonomic neuropathy?
* erectile dysfunction
* diarrhoea
* bladder dysfunction
* postural hypotension
* gastroparesis
* sweating abnormalities
| important to ask about these at annual review
35
Why is it important to screen annually / bi-annually for retinopathy?
* 2/3 of people will develop this within 20 years of diagnosis
* 25% of people with diabetes have retinopathy
* T2DM is the **leading cause of preventable sight loss**
36
What are some important things to mention in a consultation when making a diagnosis of T2DM?
* check the patient's **current understanding** of the condition
* explain the modifiable RFs, importance of regular check-ups and lifestyle changes
* signpost to **online resources** for further information
* organise a **follow-up** appointment to see how they are doing
37
What is a good way to explain T2DM to a patient?
*blood sugar levels are too high, which can cause serious problems in the heart, eyes, kidneys, feet and nerves*
* insulin is a hormone made by the pancreas after eating
* it helps the body to take up glucose from the blood and use it for energy
* in T2DM, the insulin does not work as well as it should or there is not enough of it
38
What other factors are important to discuss in a T2DM consultation?
* the need for an annual review & 6-monthly BP & HbA1c
* annual flu and pneumonia vaccinations
* NHS prescription exemption
* referral for retinal screening
39
What is the key lifestyle advice to offer a patient?
* **weight loss** is the single most important factor in improving glycaemic control
* consider **healthy carbohydrates** (low GI, swapping for wholegrain)
* low GI foods release glucose more slowly so avoid large post-meal rises
40
What are the HbA1c targets of someone with diabetes that takes no medication, takes metformin and a drug that can cause hypoglycaemia?
41
What are the HbA1c targets for someone who is already on diabetes treatment?
53 mmol /mol
42
How often should HbA1c targets be reviewed?
* HbA1c should be checked every ***3-6 months*** until it remains ***stable***
* following this, it is checked ***6-monthly***
43
What other lifestyle advice is relevant?
* **exercise** - ideally 150 mins mod or 75 mins a week of high intensity + strength/conditioning 2x week
* **smoking cessation** (increases CV risk)
* **alcohol** prolongs / exacerbates hypoglycaemia from medications
44
When someone is diagnosed with T2DM, when should medication be given?
* oral medications are given when glycaemic control remains suboptimal even after lifestyle changes
* usually ***metformin*** is given when **HbA1c remains > 48** mmol/mol after **3 months** of lifestyle changes
45
Why do patients with T2DM often need multiple drug treatment / changes in medication?
* most medications (other than insulin) only moderately lower HbA1c
* some people **do not respond** to certain treatments, so a change of therapy is required if there is **no change in HbA1c after 6 months**
46
What is usually the first line medication for T2DM?
**metformin**
47
What should be established prior to prescription of metformin?
What additional medication is given in this group?
**!! assess cardiovascular risk !!**
* if patient has high-risk, establised CVD or heart failure - add an **SGLT-2 inhibitor** once established on metformin
48
When should a second medication be added in addition to metformin?
* metformin is titrated up + encouraging lifestyle changes to aim for **HbA1c of 48 mmol/mol**
* a second drug is only added when **HbA1c rises ABOVE 58 mmol/mol**
49
When is metformin contraindicated?
What are the side effects?
contraindicated with **renal, hepatic or cardiac failure** due to risk of lactic acidosis
50
What are the common side effects associated with metformin?
**gastrointestinal** side effects such as:
* diarrhoea
* bloating
* epigastric discomfort
51
If metformin is not tolerated due to GI side effects, what is done?
switch to **modified-release metformin**
52
What medication is given when metformin is contraindicated?
**if high CVD risk:**
* monotherapy with SGLT-2 inhibitor
**if low CVD risk:**
* DPP-4 inhibitor OR
* pioglitazone
* OR sulfonylurea
53
If HbA1c remains >48 after 6 months of metformin, what is done?
second-line therapy is commenced
this could involve:
* **DPP-4 inhibitor**
* **pioglitazone**
* **sulfonylurea**
* SGLT-2 inhibitor (only if NICE criteria met)
## Footnote
medication choices depend on individual circumstances + patient preference
54
When are gliptins (DPP-4 inhibitors) used for management of diabetes?
* they are safe for use in **renal failure**
| e.g. sitagliptin or saxagliptin
55
When are SGLT-2 inhibitors used in the management of T2DM?
they are given when a patient has chronic heart failure, established atherosclerotic CVD or **QRISK score > 10%**
56
If at any point during treatment, CVD risk changes and QRISK becomes > 10%, what should be done?
a **SGLT-2 inhibitor** should be added
57
What happens when a patient has a HbA1c > 58 mmol/mol and they are taking metformin + another drug?
another drug from the list of second-line therapy is added
or
**insulin based treatment** starts
58
If triple therapy is not effective, what can be considered?
one of the drugs can be switched for a GLP-1 mimetic when:
* BMI > 35 with any medical problems associated with obesity
* BMI < 35 but insulin has occupational implications
59
What is the purpose of the QRISK tool?
it measures the risk that an individual will have a **heart attack** or a **stroke** in the **next 10 years**
60
When should the QRISK tool not be used?
* patients who **already have CVD**
* patients who are at high risk of CVD due to familial hypercholesterolaemia / **inherited disorders**
* patients **> 85** - they are at high risk due to age alone
61
In which groups is CVD already considered high risk and QRISK is not necessarily needed?
* type 1 diabetes
* CKD stages 3, 4, & 5
62
What should be done if someone has a QRISK score >10%?
they are offered a ***atorvastatin 20mg od*** to lower their circulating cholesterol
this reduces the risk of **atherosclerosis** + makes existing plaques more stable so **emboli** are less likely
63
What medication is given to someone with known CVD for secondary prevention?
atorvastatin 80mg od
64
What are some of the side effects of statin treatment?
* muscle tenderness
* tiredness
* abnormal LFTs
65
If someone has a QRISK score < 10%, what should be done?
* offer lifestyle advice and risk assessment in 5 years time
