Diabetes and its treatment

Question 1

What is type 1 diabetes

Answer 1

Insulin deficiency

Question 2

What is type 2 diabetes

Answer 2

Impaired B-cell function and/or loss of insulin sensitivity (insulin resistance)

Question 3

Symptoms of diabetes

Answer 3

Glucosuria (glucose in urine)

Polyuria, thirst (increased volume and frequency of urine)

Fatigue and malaise

Blurred vision

Infections (e.g. candidiasis)

Question 4

Extra symptoms of type 1

Answer 4

Weight loss

Ketoacidosis (N&V, acetone breath)

Question 5

extra symptoms of type 2

Answer 5

Complications (secondary)

altered mental state

Question 6

What are normal glucose levels (fasting and random)

Answer 6

Fasting- <7.0mmol/L

Random <11.1mmol.L

Question 7

How is diabetes diagnosed

Answer 7

If patient is presenting with signs/symptoms and levels of plasma glucose are as below, then positive diagnosis:

• Fasting>7mmol/L
• Random>11.1mmol/L
• Plasma glucose concentration >11.1mmol/L 2h after 75g glucose in an oral glucose tolerance test
• HbA1c> 48mmol/mol

Question 8

What does the HbA1c test show

Answer 8

Shows glycated haemoglobin

-Indicator of glycemic control during the previous 2-3 months

Question 9

IF a person is asymptomatic, how is diabetes diagnosed

Answer 9

Two abnormal test results are needed (preferably using same test)

Question 10

What are the test results like when there is impaired glucose tolerance

Answer 10

Fasting<7

random or OGTT>7.8<11.1 mol/L (still under the normal range but on the higher end)

Question 11

What are the test results like when someone has impaired fasting glycaemia

Answer 11

Fasting>6.1<7mmol/L

Question 12

What is the HbA1c like for someone who is pre-diabetic

Answer 12

42-47 (do annual screening /give lifestyle advice)

Question 13

What is ketogenesis

Answer 13

Synthesis of ketone bodies by the liver from fatty acid breakdown products

Question 14

What are the ketone bodies produced during ketogenesis

Answer 14

Acetoacetate
which turns into
B-hydroxybutyrate
and
acetone 

(normally a small amount in blood)

Question 15

When is there increased ketogenesis

Answer 15

In starvation and in diabetes mellitus so there is an excess of ketones

Question 16

What does an excess of ketones do

Answer 16

cause metabolic acidosis (decrease in blood pH)

Question 17

What inhibits and stimilates hepatic ketogenesis

Answer 17

Inhibited by insulin

Stimulated by glucagon

Question 18

What are the different types of insulins and when would you use them

Answer 18

-Short acting (before meals) i.e. analogues

Intermediate-acting (isophane)

Long-acting (insulin zinc suspension and analogues)

Biphasic (pre-mixed) - mix of short and intermediate acting insulins

–> Use them depending on the patient. They are made to suit life-style of patients

Question 19

What is the basal/bolus treatment programme

Answer 19

Long acting insulin (Basal) given which lasts for 24h and short acting insulin is given prior to every meal (Bolus)

Question 20

What are the twice daily injections programme

Answer 20

Short and intermediate acting insulin injections

Question 21

Where are insulin injections given

Answer 21

outer thighs
Lower abdomen
Upper outer arms
Buttocks

Question 22

Why are patients asked to rotate injection sites of insulin

Answer 22

To avoid lipodystrophy (which is lipoatrophy and lipohypertrophy) in some sites

Question 23

What are insulin pumps and what do they do (and who can use them)

Answer 23

Type 1 only

Continuous subcutaneous insulin infusion

-Continuous basal dose, with patient activated bolus doses at meal times

Question 24

When are insulin injections given

Answer 24

(short acting soluble insulin for urgent treatment)
For fine control in serious illness

IN diabetic ketoacidosis

In surgery- peri-operative

Question 25

Secondary causes of diabetes

Answer 25

Endocrine- Cushing's, acromegaly, pheochromocytoma (excess adrenaline) Pancreatic disease- chronic pancreatitis, surgery, CF, tumour Genetic disorders- Down's syndrome, Prader-Willi Drug induced- steroids, beta blockers, diuretics

Question 26

What is the first step in the treatment of diabetes

Answer 26

Diet/ lifestyle interventions trialled for 3 months

Question 27

What is the second step in treatment of diabetes and what are the cautions

Answer 27

Metformin (first in line but caution in renal impairment) or Sulphonylurea or DDP-4 inhibitor or pioglitazone or SGLT-2 inhibitor

Question 28

What is the third step in treatment of diabetes

Answer 28

Dual therapy

Question 29

What is the fourth step in treatment of diabetes and what do you do if this dousing work

Answer 29

Triple therapy -Start insulin- then intensify insulin regime or add drugs

Question 30

action of metformin

Answer 30

Decrease gluconeogenesis and increase glucose utilisation

Question 31

Action of sulphonylureas and prandial glucose regulators

Answer 31

Stimulate insulin secretion | -Via blockade of islet B cell ATP sensitive K+ channel

Question 32

Mode of action of pioglitazone

Answer 32

PPAR y (gamma) agonists which boost the action of insulin

Question 33

What is the incretin release like in type 2 diabetes

Answer 33

Slower than a 'normal' patient

Question 34

Mode of action of GLP-1

Answer 34

Incretin mimetics

Question 35

Mode of action of DDP-4

Answer 35

Block enzyme that degrades incretins

Question 36

What do both DDP-4 and GLP-1 mimetic do (they are drugs used in incretin based therapy)

Answer 36

``` Promote insulin release reduce glucagon secretion reduce gastric emptying Promote satiety Reduce hepatic glucose production ```

Question 37

What is the sodium glucose co-transporter 2 inhibitor drug (SGLT-2) Side effects?

Answer 37

Inhibits renal glucose reabsorption by inhibits SGLT2 in renal PCT. Increases urinary glucose excretion and decreases blood glucose Urinary tract infections POlyuria Dehydration