Diabetes

Question 1

what is type 1 DM?

autoimmune destruction of?

Answer 1

insulin deficiency due to autoimmune destruction of insulin secreting pancreatic beta cells

Question 2

in type 1 DM does diet and medications help?

Answer 2

no - persistent hyperglycaemic state

Question 3

when do you tend to develop T1DM?

Answer 3

childhood and adulthood

Question 4

which type of DM is more prone to DKA?

Answer 4

T1DM

Question 5

which type requires insulin more?

Answer 5

T1DM

Question 6

what is T2DM?

Answer 6

body isn’t responding to insulin due to excess adipose tissue

Question 7

which type of DM has a HLA association?

what is it?

Answer 7

T1DM - HLA D3 + D4 association

Question 8

which pts is T2DM found commonly in?

Answer 8

Asians
elderly
men

Question 9

what is prediabetes?

Answer 9

for those that don’t meet criteria for a formal diagnosis.

Question 10

what is gestational diabetes?

Answer 10

pregnant women have a raised blood glucose

Question 11

what is maturity onset diabetes of young? (MODY)

Answer 11

Autosomal dominant
affecting insulin production in young
presents like T2DM

Question 12

what is latent autoimmune diabetes of adults (LADA)?

how does patient present?

Answer 12

adults who present with auto-immune related diabetes

think of patients who are ketotic and respond poorly to oral hypoglycaemics

Question 13

how would you expect a T1DM patient to present?

Answer 13

polydipsia (thirst)
polyuria
weight loss
nausea and vomiting

may present with DKA:
abdo pain
vomiting
reduced consciousness

Question 14

how would you expect a T2DM patient to present?

Answer 14

polydipsia (thirst)
polyuria 
Blurred vision 
Candidal (vaginal/penile infections) 
Skin infections (cellulitis)

Question 15

why do you get polydipsia and polyuria?

Answer 15

water being dragged out following excess glucose being excreted in urine (glycosuria)

Question 16

RF for T2DM

Answer 16

Old age 
obesity 
HTN 
FHx 
Gestational Diabetes 
black, hispanic 
CVS disease

Question 17

what are the four ways of checking your blood glucose?

Answer 17

1. Finger-prick bedside glucose monitor
2. One-off blood glucose (fasting or non-fasting)
3. HbA1c (measures amount of glycosylated Hb + represents average blood glucose over past 3 months.
4. Glucose tolerance test – fasting glucose is taken and then 75g glucose load is taken. Then 2hrs later a second blood glucose is taken.

Question 18

why is HbA1c good?

Answer 18

represents average blood glucose over 3 months

Question 19

what is the criteria for diagnosing DM in a symptomatic patient with regards to:

• fasting glucose
• glucose tolerance test/random glucose

Answer 19

fasting glucose >7 mmol/L

random glucose/glucose tolerance test >11.1 mmol/L

Question 20

what is the criteria for diagnosing DM if someone is asymptomatic with regards to:

• fasting glucose
• glucose tolerance test/random glucose
• HbA1c

Answer 20

• fasting glucose >7
• random/glucose tolerance test >11.1

BUT Both have to be above on two separate occasions

• HbA1c >48 mmol/mol or >6.5%.

Question 21

what is the criteria for pre-diabetes

• fasting glucose
• HbA1c

Answer 21

fasting glucose = 6.1 - 6.9

HbA1c = 42 - 48

Question 22

why is HbA1c sometimes misleading?

Answer 22

increased if there is an increase in red cell turnover

Question 23

in general for DM what sort of conservative measures can a patient take to help control their diabetes?

Answer 23

exercise - increases insulin sensitivity

food - high fibre and low glycaemic index sources of carbs, low sat fat and fat dairy products.

Question 24

Tx for T1DM (Managing mesurements)

HbA1c - how often should it be measured and what is the target?

Self monitoring of blood glucose:

• how often?
• when?
• when should you increase frequency of measurements?
• target?

Answer 24

HbA1c

• every 3-6 months
• target of 48 or less than 6.5%

blood glucose

• 4 times a day
• before each meal and once before bed
• if hypoglycaemic episodes
• target of 5-7 mmol/Lon waking and 4-7 mmol/L during the day

Question 25

Tx for T1DM (insulin) - what is the insulin regimen of choice + how often do you take it? - if you wanted just a once daily insulin injection - what is it? how does it work? - when do you offer Novorapid and why? - when would Metformin be indicated in a T1DM patient?

Answer 25

- basal-bolus Detemir twice daily - basal-bolus Glargine - long acting so good for overnight - before meals - rapid acting - if patient has BMI over 25

Question 26

Tx for T2DM - how often do you check for HbA1c? what is the target? - what does metformin do? - when do you avoid metformin? - SE of metformin?

Answer 26

- every 3-6 months, target is 48 mmol/l - increases insulin sensitivity - if patient has a low GFR due to risk of lactic acidosis - diarrhoea

Question 27

Tx for T2DM Alongside metformin: there are four classes of drugs that can be given adjunct to metformin, explain the following four classes: DPP4-inhibitors? Glitazone? Sulfonylurea? SGLT-2 inhibitor?

Answer 27

``` DPP4 inhibitors (DPP4 enzyme inactivates GLP-1 which stimulates insulin secretion - therefore they increase insulin secretion) i.e. Gliptin/Sitagliptin ``` Glitazone increases insulin sensitivity but SE: osteoporosis, CCF, fluid retention i.e. Pioglitazone Sulfonylurea increases insulin secretion but increases weight + appetite, + risk of hypoglycaemia i.e. Glicazide SGLT-2 inhibitors block reabsorption of glucose in kidneys promoting excretion i.e. Empagliflozin

Question 28

Tx for T2DM what is GLP-1 mimetic? example? who is it indicated in?

Answer 28

glucagon-like-peptide 1 Exenatide indicated if BMI >35 or if BMI <35 and triple therapy was ineffective /insulin is contraindicated

Question 29

Tx for T2DM if starting insulin: what do NICE recommend and how often?

Answer 29

Human NPH insulin (isophane) BD or at bedtime

Question 30

Tx for T2DM (metformin is tolerated) 1) Metformin if HbA1c is >58 2) Metformin + 1 out of 4 (DPP4 inhibitor, sulfonylurea, glitazone, SGLT2 inhibitors) if HbA1c is >58 3) Metformin + (2 out of 4 OR insulin) if triple therapy not effective or insulin is contraindicated: 4) Metformin + sulfonylurea + GLP-1 mimetic

Answer 30

for those that metformin is tolerated

Question 31

Tx for T2DM (metformin not tolerated) 1) 1 out of 3 (DPP4 inhibitor, sulfonylurea, glitazone) if HbA1c >58 2) 2 out of 3 if HbA1c >58 3) insulin

Answer 31

Tx for T2DM (metformin not tolerated)