Endocrine System >
Type II Diabetes

“Complex metabolic disorder characterised by persistent hyperglycaemia (insulin resistance)”

Risk Factors
  • Modifiable:
    • Obesity
    • Physical inactivity,
    • Poor diet
    • Certain drug treatments (statins, corticosteroids, a combination of thiazide diuretic plus beta-blocker)
  • Non-Modifiable:
    • Family history
    • Age
    • PMHx of gestational diabetes
    • Ethnicity (people of Asian, African, or Black communities 2-4x more likely than white communities)
    • Polycystic Ovarian Syndrome
    • Metabolic Syndrome
Aetiology
  • A combination of insulin resistance and a relative deficiency of insulin
Pathophysiology
  • Insulin resistance (obesity) plus relative insulin deficiency ® pancreas unable to produce enough insulin to overcome resistance
    • Increased hepatic glucose output
    • Decreased glucose uptake into adipocytes
    • Decreased glucose uptake in skeletal muscle
    • Decreased glycogenesis in the liver and skeletal muscle
Clinical Presentation
  • Patients may be asymptomatic and present due to complications
  • Presentation includes:
    • Polyuria and nocturia
    • Increased thirst and polydipsia
    • Weight loss
    • Blurred vision
    • Drowsiness and extreme fatigue
Investigations
  • Bloods:
    • Main test – HbA1c > 48 mmol/mol
    • Others:
      • Random plasma glucose > 11 mmol/L
      • Fasting plasma glucose > 7 mmol/L
      • Oral glucose tolerance test 2h > 11 mmol/L
  • Imaging: n/a
  • Special: n/a
Management
  • Conservative:
    • Improve diet
    • Reduce alcohol consumption
    • Smoking cessation
    • Lose weight to reach and maintain a BMI within a healthy range
  • Medical:
    • Metformin – first-line treatment
      • If metformin isn’t tolerated:
        • Sulfonylureas (gliclazide, glibenclamide, and glimepiride)
        • A DPP-4 inhibitor (gliptins: sitagliptin or linagliptin)
        • Pioglitazone
        • An SGLT-2 inhibitor (dapagliflozin or canagliflozin).
    • Combination Therapy – second-line treatment
      • Combination therapy of metformin and sulfonylurea/DPP4-inhibitor/Pioglitazone/SGLT-2
      • If metformin contraindicated, then add a gliptin with other drugs instead
    • Third line: triple therapy and consider insulin-based therapy if metformin is contraindicated
  • Surgical: n/a
Complications
  • Diabetic foot
  • Macrovascular complications:
    • Increased risk of stroke
    • Myocardial Infarction
    • Peripheral vascular disease
  • Microvascular complications:
    • Diabetic retinopathy
    • Diabetic nephropathy
    • Diabetic neuropathy
    • Erectile dysfunction

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