Diabetes Flashcards
For adults with T2DM who are overweight, what is the initial weight loss target?
5-10%
In adults with T2DM, measure HbA1c levels at:
- 3-6 monthly intervals until the HbA1C is stable on unchanging therapy
- 6 monthly intervals once Hba1c level and blood glucose lowering therapy are stable
HbA1c target for adults with T2DM managed by either lifestyle and diet combined with a single drug not associated with hypoglycaemia
48mmol/mol (6.5%)
HbA1C target for T2DM adults on a drug assciated with hypoglycaemia
53mmol/mol (7%)
In adults with T2DM, if HbA1c levels are not adequately controlled by a single drug and rise to 58mmol/mol (>7.5%) or higher: (3)
- Reinforce lifestyle and adherance
- Support person to aim for 53%
- Intensify drug Tx
Reasons for sudden low HbA1c
- Deteriorating renal function
- Sudden weight loss
Do NOT offer self-monitoring of blood glucose levels for adults with T2DM unless:
- The person is on insulin
- There is evidence of hypoglycaemic episodes
- The person is on oral meds that may increase their risk of hypos whilst driving/operating heavy machinery
- The person is pregnant/planning on becoming pregnant
When would you consider short-term self-monitoring of blood glucose levels in adults with T2DM?
- when starting tx with oral or IV corticosteroids
- to confirm suspected hypoglycaemia
Standard first line treatment for T2DM
- Metformin
If HbA1c rises to 58mmol/L (7.5%) on lifestyle when on metformin? (for the first time) And what would you then aim for HbA1C level?
Consider dual therapy with:
- M and DPP-4i
- M and pioglitazone
- M and an SU
- M and an SGLT-2i
Aim for 53mmol/L (7.5%)
If HbA1c rises to 58mmol/L (7.5%) on lifestyle when on metformin? (for the second time) And what would you then aim for HbA1C level?
Consider triple therapy with:
- M, DPP4-i, and an SU
- M, pioglitazone and an SU
- M, pioglitazone or an SU and an SGLT-2
Aim for 53mmol/L (7.5%)
If metformin is CI or not tolerated what would be first line in T2DM?
And what would you aim for their HbA1C?
- DPP4-i, pioglitazone or SU
- SGLT-2 inhibitor instead of DPP4-i if SU or pioglitazone inappropriate
DPP4i, pioglitazone, SGLT-2 - 48mmol/L (6.5%)
SU - 53 (7%)
If metformin is CI or not tolerated what would the treatment be if HbA1c rose to >58mmol/L on drug Tx
And what would you aim for their HbA1C?
Dual therapy with:
- DPP4i and pioglitazone
- DPP4i and an SU
- pioglitazone and an SU
Aim for 53%
If metformin is CI or not tolerated what would the treatment be if HbA1c rose to >58mmol/L on drug Tx when on dual therapy
And what would you aim for their HbA1C?
Insulin
<53mmol/L
What is MHRA safety advice for pioglitazone?
- Increases risk of heart failure, bladder cancer and bone fracture
What is the MHRA safety advice for SGLT-2 inhibitors? (2)
What should you do if it happens?
- DKA (rapid weight loss, N or V, abdo pain, fast and deep breathing, sleepiness, a sweet/metallic smell to breath, different colour urine/sweat), test for ketones
- Discontiune
- Don’t restart if DKA occured whilst on, unless another reason
- Stop when hospitalised for surgery or acute serious illness
- Fournier’s Gangrene - severe pain, tenderness, erythema, swelling in genital or peineal area, accompanied by fever or malaise
What is the MHRA safety advice for canagliflozin specifically?
- Increased risk of lower-limb amputation (mainly toes), advise to stay well hydrated
When should you stop metformin in renal impairment?
<30ml/min eGFR
When would you not offer an adult with T2DM pioglitazone?
- Heart failure or Hx of HF
- Hepatic impairment
- DKA
- current or history of bladder cancer
- uninvestigated macroscopic haematuria
If triple therapy with metformin and 2 other oral drugs not effective, CI, etc what would you consider?
sulfonylurea, metformin and GLP1 if BMI > 35 and specific psycholigcal or medical problems associated with obesity
OR BMI <35 AND for whom insulin would have significant occupational implications, weight loss would benefit other significant obestiy-related co-morbidites
You would only continue GLP-1 therapy in T2DM if
beneficial metabolic response,
at least 11mol/lmol reduction in HbA1c and weight loss of at least 3% of initial body weight in 6 months
Insulin regime for T2DM (there’s two regimes)
1) NPH (isophane insulin) OD/BD
2) NPH and short acting insulin - if HbA1C >75mmol/mol, administering either separately or pre-mixed (biphasic insulin)
When would you think of a diagnosis of gastroparesis in adults with T2DM
- Erratic blood glucose control OR unexplained gastric bloating or vomitting, taking into account possible alternate diagnoses
Treatment of vomitting caused by gastroparesis in adults with T2DM
- Consider erythromycin and metoclopramide
- Consider domperidone ONLY in exceptional circumstances