Case 6 - Control, complications and risks T2DM

Question 1

What systemic risk is closely related to diabetes?

Answer 1

Cardiovascular risk

Question 2

Calculating CVD risk

Answer 2

• QRISK3
• Takes into account FH, systolic BP, BMI, diabetes, CKD, ethnicity, postcode

Question 3

What does NICE recommend treatment wise for someone with T2DM and high CVD risk (more than 10% if over 40 and 1 CVS risk factor if under 40)?

Answer 3

• Start on Metformin
• Then add SGLT2 inhibitor eg Dapagliflozin

Question 4

Targets for glucose levels in T2DM

Answer 4

• Measure every 3-6 months
• Every 6 months once on target

If lifestyle and diet, or lifestyle diet and one drug with no risk of hypoglycaemia:
* Target should be 48mmol/mol

If drug associated with hypoglycaemia:
* Target should be 53mmol/mol

If reach 58mmol/L on single drug intensify drug treatment

Question 5

When do we relax HbA1C targets?

Answer 5

• Reduced life expectancy or unlikely to get longer time risk reduction benefit
• Tight control would put them at increased risk of hypoglycaemia eg if risk of falling, hypoglycaemia unawareness or operate machinery
• Significant co-morbidities

Question 6

What to do if patient inquires aboit diet using meal replacement shakes curing diabetes?

Answer 6

• Diet is very important in managing diabetes
• Important to be balanced and meet nutritional needs
• Short term this may be beneficial for weight loss but could cause some increased side effects from medication
• Not suitable long term - not healthy or sustainable

Question 7

Structured education course for T2DM patients

Answer 7

• DESMOND
• For people newly diagnosed with T2DM
• f2f or video
• Helps people understand diabetes and glucose, monitoring, medication, risk factors, diet education and exercise
• MyDesmond is platform for each user with videos and educational content

Question 8

Pharmacotherapeutic therapies offered for T2DM management

Answer 8

• Metformin
• DPP-4 inhibitors eg Sitagliptin
• Pioglitazone
• SGLT2 inhibitors eg Dapagliflozin
• Sulfonylureas eg Glicazide
• GLP1 agonists eg Semaglutide

Question 9

How does each drug work for T2DM

Answer 9

1. DPP4 inhibitors - prevent breakdown of incretins eg GLP1
2. Metformin - decreased hepatic gluconeogensis, supress appetite
3. Pioglitazone - increase insulin sensitivity, increase glucose utilisation in muscle and adipose, decrease hepatic output glucose by activiating PPAR gamma in adipose
4. SGLT2 - decreased glucose reabsorption in kidney
5. Sulfonylureas - stimulata pancreatic beta cells to produce insulin
6. GLP1 - stimulate glucose dependent synthesis of insulin, weight loss

Question 10

How does CKD and microalbuminaemia increase risk of complications

Answer 10

• CKD = problems removing toxins = inflammation = increase CVD risk
• Impaired juxtoglomerular apparatus response - increase BP
• Protein loss - loss oncotic pressure, oedema –> decreased mobility
• Endothelial dysfunction - inflammation vessels = CVD risk