QuestionSBA
QuestionChoice
This is an incorrect answer. In persons with classic diabetic symptoms such as fatigue, polydipsia, polyuria, and blurred vision, a single abnormal blood test result, either HbA1c or fasting plasma glucose, is reliable. However, as this patient is asymptomatic, a second abnormal test on another day is required to confirm the diagnosis.
62319
b
Confirm diagnosis of T2DM after an abnormal HbA1c result
QuestionChoice
This is an incorrect answer. Random plasma glucose ≥11.1 mmol/L is a significant indication of underlying hyperglycaemia which should be further investigated. Moreover, the presence of risk factors (obesity and family history) increases the chance of developing T2DM in this scenario.
62322
e
Reassure as no further action required
QuestionChoice
This is an incorrect answer. Diagnosing T2DM based on a single abnormal test result in an asymptomatic patient is inappropriate as it depends on various other factors. Although metformin is considered the first-line agent, a confirmed diagnosis is mandatory first.
62320
c
Confirm diagnosis of T2DM and commence treatment with metformin
QuestionChoice
This is an incorrect answer. Diagnosing T2DM based on a single abnormal test result is inappropriate as it depends on various other factors. Insulin therapy is initiated if either oral hypoglycaemics are unsuitable or fail to control blood sugar levels despite maximum doses or there is an immediate risk of hyperglycaemia-associated complications.
62321
d
Confirm diagnosis of T2DM and commence treatment with insulin
QuestionChoice
This is the correct answer. NICE guidelines advise repeating, preferably with the same test, within two weeks in asymptomatic people. As in some cases, hyperglycaemia may be transient due to stress, infection, trauma, or recent surgery, which subsides spontaneously without further intervention. Additionally, HbA1c is more reliable and convenient as the patient does not need to fast before the test.
62318
a
Confirm diagnosis of T2DM after an abnormal HbA1c result on two different days
QuestionComment
The abnormal test is random plasma glucose and "all blood test results" doesn't specify including HbA1C, so a repeat blood test finding an abnormal HbA1C would fulfill the "two abnormal separate tests". That's confusing because assuming the first bloods were result 1/2, it implies "Confirm diagnosis of T2DM after an abnormal HbA1c result" is the answer (it being results 2/2), not "Confirm diagnosis of T2DM after an abnormal HbA1c result on two different days"
25056
QuestionComment
Shut up you got it wrong 

27648
User
subscriber
Painless diarrhoea 
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Yellow Nightshift
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# Summary

Type 2 Diabetes Mellitus is a chronic metabolic disorder characterized by pancreatic beta-cell insufficiency and insulin resistance. The primary signs and symptoms include hyperglycaemia and associated sequelae. Key investigations include random and fasting blood glucose, 2-hour glucose tolerance, and HbA1C tests. Management of type 2 diabetes primarily revolves around lifestyle modifications, hypoglycaemic agents, and insulin therapy when necessary. Major complications involve the gastrointestinal system, nervous system, peripheral arteries, foot infections, sexual dysfunction, and cardiac system. 

# Definition

Type 2 Diabetes Mellitus (T2DM) is a chronic metabolic condition characterized by inadequate insulin production from pancreatic beta cells, resulting in insulin resistance. This leads to an elevation in blood glucose levels, causing hyperglycaemia.

# Epidemiology

T2DM generally manifests in adults, and it is often associated with a strong familial predisposition. It accounts for approximately 90-95% of all diagnosed cases of diabetes.

# Aetiology

T2DM results from a combination of genetic and environmental factors. Known contributors include:

- Poor dietary habits
- Lack of physical activity
- Obesity

# Signs and symptoms

Individuals with T2DM may initially be asymptomatic, but over time, they may develop:

- Polyuria
- Polydipsia
- Unexplained weight loss
- Blurry vision
- Fatigue

# Differential diagnosis

The primary differentials for T2DM include Type 1 Diabetes Mellitus, Maturity Onset Diabetes of the Young (MODY), and Secondary Diabetes Mellitus. The main distinguishing features of these differentials are:

- Type 1 Diabetes Mellitus: Early onset (typically in childhood or adolescence), often presents with ketoacidosis, and requires insulin therapy from diagnosis.
- MODY: Early onset (typically before 25 years), non-insulin dependent, and often has a strong family history.
- Secondary Diabetes Mellitus: Often presents with other signs of pancreatic disease (e.g., pancreatitis, cystic fibrosis), or due to certain medications (e.g., glucocorticoids, antipsychotics).

# Investigations

If symptomatic, one of the following results is sufficient for diagnosis:

- Random blood glucose ≥ 11.1mmol/l
- Fasting plasma glucose ≥ 7mmol/l
- 2-hour glucose tolerance ≥ 11.1mmol/l
- HbA1C ≥ 48mmol/mol (6.5%)

If the patient is asymptomatic, two results are required from different days.

# Management

Management of T2DM involves patient education, lifestyle modifications, pharmacological interventions, and close monitoring of glucose levels:

- Lifestyle modifications: Advice on diet, regular physical activity, and smoking cessation
- Pharmacological interventions: 
	- Initial drug treatment is usually metformin, with consideration of other agents like Pioglitazone, DPP‑4 inhibitors, sulphonylureas, or SGLT-2 inhibitors for those who cannot take metformin.
	- Following initial management, consider dual therapy with metformin, pioglitazone, a DPP‑4 inhibitor or a sulphonylurea (such as gliclizide).
	- If dual therapy has not controlled drug glucose, triple therapy using the above medications can be considered. Otherwise, starting insulin may be necessary.
- Close Monitoring: Measure HbA1c levels at 3-6 month intervals. If the patient is on insulin or is at risk of hypoglycaemia, self-monitoring of glucose at home is necessary.

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**Insulin Therapy**

NICE guidance recommends basal insulin therapy with isophane (NPH) insulin as the first type to be used as it is most cost effective eg. Insulatard. Quick acting insulin analogues eg. Humalog, Novorapid, may be added in with meals if there is a big post meal glucose excursion.

Long acting insulin analogues include Levemir, Lantus, Insulin Degludec and Abasaglar (a biosimilar insulin).

Mixed insulin combination which contain varying proportions of short and intermediate acting insulin such as Novomix 30 (30% short acting, 70% intermediate acting insulin) are more convenient because of fewer injections per day but may not be as successful.

**Blood Pressure targets in Diabetes**

- Blood pressure control needs to be strict in diabetes because these patients are at higher risk of macro- and microvascular complications.
- NICE Hypertension Guidance [CG136] sets the same blood pressure targets as those who do not have diabetes.

# Complications

Complications of T2DM are diverse, affecting multiple systems:

1. **Gastrointestinal Complications: Gastroparesis** - a result of poor glycaemic control leading to nerve damage of the autonomic nervous system. Characterized by delayed gastric emptying, early satiety, abnormal stomach wall movements, and morning nausea.
2. **Neurological Complications: Autonomic Neuropathy** - may lead to postural hypotension and associated symptoms like dizziness, falls, and loss of consciousness.
3. **Vascular Complications: Peripheral Arterial Disease (PAD)** - patients present with foot discolouration, gangrene, intermittent claudication, rest pain, night pain and absent peripheral pulses (confirmed on doppler).
4. **Foot Complications: Diabetic Foot Infections** - patients with vascular and neuropathic complications are at high risk for diabetic foot ulceration and subsequent infection.
5. **Sexual Dysfunction** - caused by a combination of factors including poor glycaemic control, neuropathy, microvascular complications, obesity, hypertension, depression, medication side effects, etc.
6. **Cardiac Complications** - diabetes significantly increases the risk of cardiovascular disease, contributing to major morbidity and mortality.

# References

[Click here for NICE CKS on diabetes type 2](https://cks.nice.org.uk/topics/diabetes-type-2/)

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Type 2 Diabetes mellitus
Topic
60
General Practice
Condition
220
Diabetes mellitus type 1 and 2
UkmlaTopic
10
Endocrine and metabolic
Condition
221
Diabetes mellitus type 1 and 2
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12
General practice and primary healthcare
Condition
222
Diabetes mellitus type 1 and 2
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21
Perioperative medicine and anaesthesia
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Presentation
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Weight gain
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Endocrine and metabolic
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Weight gain
UkmlaTopic
11
Gastrointestinal including liver
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Weight gain
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General practice and primary healthcare
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600
Weight gain
UkmlaTopic
15
Mental health
A 48-year-old man with no known medical history visits the GP clinic for a routine health check. His body mass index (BMI) is 27 kg/m2, and he has a family history of type 2 diabetes mellitus (T2DM). Physical examination is unremarkable. A random plasma glucose is found to be raised at 15.0 mmol/L (normal <6.1 mmol/L).


Which of the following is the most appropriate next step in management?
a