Type 2 Diabetes Meillitus
Type 2 Diabetes Meillitus occurs when there's repeated exposure to high levels of glucose and insulin, leading to insulin resistance. The over-worked pancreas then becomes damaged, causing chronic hyperglycaemia.
Risk factors - Elderly, Ethnicity (black, south asian, chinese), Family hx, Obesity, Lack of exercise
Presentation - Polyuria, Polydipsia, Weight loss
Investigations
Diagnosis - If symptomatic, 1 of the following is sufficient:
HbA1c of 48+ or
Fasting glucose of 7+ or
Random glucose of 11+
N.B. If asymptomatic, 2 +ve results are required from different days.
HbA1c measures the average glucose levels from last 3 months. It shouldn't be used if:
Child/Young adult
Pregnant
Haemoglobinopathy
Recent blood transfusion
Anaemic
Pre-diabetes is diagnosed if:
HbA1c between 42 - 47 or
Fasting glucose between 5.5 - 6.9
At this stage, it's known to be reversible by diet control and exercise.
Management
Lifestyle - Diet advice, regular physical activity, smoking cessation, blood pressure control
Medical:
Metformin 1st line
Pioglitazone, DPP‑4 inhibitors, Sulphonylureas or SGLT-2 inhibitors can be added on
Insulin
Aim HbA1c level is < 48 mmol/L for those with a new diagnosis and < 53 mmol/L for those past just taking metformin.
Anti-Diabetic Drugs
N.B. With SGLT2 inhibitors, they cause there to be lots of glucose in the bladder, which acts as a substrate for bacteria and fungi to grow, therefore leading to infection.
Complications
Hyperosmolar Hyperglycaemic State (HHS)
Insulin deficiency and increased counter-regulatory hormones (small amount of insulin prevents the production of ketones)
Presentation - Gradual confusion, Hypercoagulable state, VTE
Gastroparesis
Caused by nerve damage to the autonomic vagus nerve, which controls gastric muscles, leading to delayed gastric emptying
Presentation - Offensive-smelling burps, early satiety, and morning nausea
Management - Metoclopramide 1st line, Domperidone 2nd line
Postural Hypotension
Peripheral Arterial Disease
Renal Disease (aka diabetic nephropathy)
Diabetic Foot Infections
Sexual Dysfunction
Cardiac Complications
Diabetic Foot Complications
In controlled diabetes, there’s a natural progression of the disease to developing the complication of peripheral neuropathy. This tends to either lead to a:
Diabetic foot ulcer - Sensation and proprioception is lost in the foot and ankle, leading to the patient putting abnormal pressure on specific areas of the foot without feeling it. This leads to callus formation, which continue to bleed underneath after further trauma and eventually lead to ulcer formation.
Ulcerations on these specific areas of a patient’s foot + evidence of skin hardening/callusing around it should always point towards diabetes as the cause
Charcot foot - Similarly to how a diabetic foot ulcer develops, the abnormal pressure on specific areas of the foot eventually leads to an alteration in the bones and joints of the foot, leading to malignment. In Charcot’s foot, the arch is lost and the metatarsals become flat and in-line with the calcanuem.
