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4th Year Endocrinology > Type 2 Diabetes Mellitus > Flashcards

Type 2 Diabetes Mellitus Flashcards

1
Q

Pathophysiology of type 2 diabetes mellitus

A

High insulin levels over a prolonged period of time leads to insulin resistance.

Beta cells progressively become impaired leading to decreased levels of insulin. This is a relative insulin deficiency.

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2
Q

Epidemiology of T2DM

A
  • 3.5 million people with T2DM in the UK
  • 90% of patients are adults
  • 80% of total cases of diabetes
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3
Q

Risk factors for T2DM

A
  • Age: 45-64 years old
  • Family history: strong genetic predisposition
  • Ethnicity
  • Obesity
  • Drugs: cortiocosteroids
  • PCOS
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4
Q

Symptoms of T2DM

A
  • Polyuria
  • Polydipsia
  • Polyphagia
  • Weight loss
  • Fatigue
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5
Q

Signs of T2DM

A
  • Neuropathy
    • Glove and stocking sensory loss
  • Retinopathy
  • Diabetic foot disease
    • Peripheral vascular disease
    • Calluses
    • Tissue loss
  • Acanthosis nigricans (area of hyperpigmentation in axilla or skin folds - occurs due to high circulating levels of insulin)
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6
Q

Primary investigations for T2DM

A

Asymptomatic: 2 separate positive investigations

Symptomatic: 1 positive investigation

  • Random blood glucose: ≥ 11.1 mmol/L
  • Fasting blood glucose: ≥7.0 mmol/L
  • Oral glucose tolerance test: ≥ 11.1 mmol/L two hours after a 75g oral glucose load
  • HbA1c: ≥ 48 mmol/mol suggests hyperglycaemia over 3 months
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7
Q

Investigations to consider:

A
  • U&Es: screen for renal failure
  • Urine albumin:creatinine ratio: screen for renal failure
  • Fasting lipids: screen for dyslipidaemia
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8
Q

Normal results for:

Random glucose (mmol/L)

Fasting glucose (mmol/L)

OGTT (mmol/L)

HbA1c (mmol/mol)

A
  • Random glucose < 11.1 mmol/L
  • Fasting glucose < 6.1 mmol/L
  • OGTT < 7.8 mmol/L
  • HbA1c < 42 mmol/mol
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9
Q

Management of T2DM

A
  • Lifestyle (Target HbA1c = 48)

Step up therapy if HbA1c >48

  • Metformin (Target HbA1c = 48)

Step up therapy if HbA1c >58

  • Dual therapy - add in:
    1. DPP4i
    2. Sulfonylurea
    3. Pioglitazone
    4. SGLT2i
  • (Target HbA1c = 53)

Step up therapy if HbA1c > 58

  • Insulin + metformin

Or

  • Triple therapy

Step up if triple therapy is not effective and BMI >35

  • Metformin + sulfonylurea + GLP-1 mimetic
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10
Q

Metformin is in which drug class?

Mechaism of action of metformin?

A

Biguanides

Reduces gluconeogenesis and increases insulin sensitvity

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11
Q

Side effects of metformin

A
  • Nausea and vomiting
  • ​GI discomfort
  • AKI (should be avoided in patients with significant renal impairment)
  • Lactic acidosis
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12
Q

Examples of sulfonylureas

Mechanism of action

A

Gliclazide + Glibenclamide

Inhibits ATP-K+ channel on beta cells causing depolarisation and insulin release

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13
Q

Sulfonylurea side effects

A
  • Weight gain
  • Hypoglycaemia
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14
Q

SGLT-2 inhibitor examples

Mechanism of action

A

Dapagliflozin + Empagliflozin

Inhibit SGLT-2 in the proximal tubule causing urinary glucose excretion

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15
Q

SGLT-2 side effects

A

Increases risk of UTI

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16
Q

Pioglitazone mechanism of action

Side effects

A

PPAR gamma agonist reduce peripheral insulin resistance

Can cause fluid retention (contraindicated in heart failure)

17
Q

DDP-4 inhibitors examples

Mechanism of action

A

Linagliptin + Sitagliptin

Prevent degradation of incretins hence promoting insulin secretion

18
Q

GLP-1 mimetics examples

Mechanism of action

A

Liraglutide + Exanetide

Incretin mimetic which stimulates insulin secretion

19
Q

GLP-1 mimetics side effects

A

GI upset

Reduced appetite and weight loss

20
Q

Monitoring in T2DM

A
  • Glucose
    • HbA1c: measured every 3-6 months with a target or ≤48 mmol/mol
    • Self monitoring: only advised if on insulin
  • Retinopathy
    • Immediate ophthalmology referral upon diagnosis and annually thereafter
  • Diabetic foot
    • Should be assessed at least annually, refer urgently to foot protection service if at risk
  • Diabetic nephropathy
    • Annual measurement of eGFR and urinary albumin:creatinine ration
21
Q

When would an urgent opthalmology referral be required?

A
  • Acute reduction in acuity
  • Pre-proliferation or proliferative retinopathy
  • Diabetic maculopathy
22
Q

Complications of T2DM

A
  • Cardiovascular
    • Ischaemic heart disease
    • Heart failure
    • PVD
  • Neurological
    • Stroke
    • Carpal tunnel syndrome
    • Neuropathy
  • Endocrine
    • HHS
  • Renal
    • Diabetic nephropathy and CKD
  • Opthalology
    • Diabetic retinopathy
    • Macular degeneration
    • Open-angle glaucoma
    • Cataracts

4th Year Endocrinology (7 decks)

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