Diabetes

Question 1

Exposure to __1__ and __2__ makes the cells in the body become resistant to the effects of __3__. With an increased __4__ requirement, beta cells in the pancreas have to work harder and become fatigued, therefore produce less.

Answer 1

1. glucose
2. insulin
3. insulin
4. insulin

Question 2

True or false: In type 2 diabetes, pancreatic fatigue leads to chronic hypoglycaemia.

Answer 2

False.

In type 2 diabetes, pancreatic fatigue leads to chronic hypERglycaemia.

Question 3

What risk factors are associated with type 2 diabetes?

Answer 3

Non-Modifiable:

• Older age
• Ethnicity (black, chinese, South Asian)
• Family History (genetics)

Modifiable:

• Obesity
• Sedentary lifestyle
• High carb diet

Question 4

How does Type 2 Diabetes present?

Answer 4

Consider type 2 diabetes in any patient fitting the risk factors.

Additional features:

• Fatigue
• Polydipsia and polyuria
• Unintentional weight loss
• Opportunistic infections (e.g. oral candida)
• Slow healing wounds
• Glucose in urine (dipstick)

Question 5

What is an Oral Glucose Tolerance Test (OGTT)?

Answer 5

Performed in the morning prior to breakfast (fasting).

Take a baseline fasting plasma glucose, then give the patient a 75g glucose drink. 2 hours later, check the plasma glucose again to see how the body coped with the carbohydrate meal.

Question 6

What studies might suggest a patient has ‘pre-diabetes’?

Answer 6

Raised HbA1c: 42-47 mmol/mol

Impaired fasting glucose: 6.1-6.9 mmol/L

Impaired glucose tolerance: OGTT plasma glucose of 7.8-11.1 after 2 hours.

Question 7

What studies can diagnose a patient with diabetes?

Answer 7

HbA1c > 48 mmol/mol

Random Glucose > 11 mmol/l

Fasting Glucose > 7 mmol/l

OGTT 2 hour result > 11 mmol/l

Question 8

What is the general approach towards treatment and management of type 2 diabetes?

Answer 8

1. Lifestyle modification
   - Diet, exercise, smoking cessation, optimise comorbidities.
2. Monitoring for complications:
   - Diabetic retinopathy, kidney function, diabetic foot
3. Medical management:

First line: Metformin

Second line:
Add second drug: sulfonylurea, pioglitazone, DPP-4 inhibitor, SGLT-2 inhibitor.

Third line:
Add third drug (metformin + 2 second-line drugs OR metformin + insulin)

Question 9

What effect does metformin have on weight?

Answer 9

Metformin is ‘weight neutral’ - it may help prevent weight gain, but doesn’t cause weight loss.

Question 10

How does metformin help patients with type 2 diabetes?

Answer 10

Increases insulin sensitivity and decreases both intestinal absorption and liver production of glucose.

Question 11

Which diabetes drug is a biguanide?

Answer 11

Metformin

Question 12

What are the notable side effects of metformin?

Answer 12

GI problems: diarrhoea and abdo pain (reducing dose often resolves the problem)

Lactic acidosis (high lactate may show on ABG)

*Does not cause hypoglycaemia

Question 13

Which diabetes drug is a thiazolidinedione?

Answer 13

Pioglitazone

Question 14

How does pioglitazone help patients with type 2 diabetes?

Answer 14

Pioglitazone increases insulin sensitivity and decreases liver production of glucose.

Question 15

What are the notable side effects of pioglitazone?

Answer 15

Weight gain

Fluid retention

Anaemia

Heart failure

*extended use may increase risk of bladder cancer

**does NOT cause hypoglycaemia

Question 16

Which common diabetes drug is a sulfonylurea?

Answer 16

Gliclazide

Question 17

How does gliclazide work?

Answer 17

Sulfonylureas stimulate insulin release from the pancreas

Question 18

What are the notable side effects of gliclazide?

Answer 18

Weight gain

Hypoglycaemia

*Increased risk of CV disease and MI when used as monotherapy

Question 19

What is the most common DPP-4 inhibitor?

Answer 19

Sitagliptin

Question 20

How do DPP-4 inhibitors help patients with type 2 diabetes

Answer 20

DPP-4 stands for dipeptidyl peptidase-4, an enzyme that inhibits incretins (such as GLP-1). Incretins (GLP-1) are released in response to a large meal and cause insulin secretion, inhibit glucagon production and slow absorption by the GI tract.

By inhibiting DPP-4, sitagliptin increases the activity of GLP-1.

Question 21

What are the notable side-effects of DPP-4 inhibitors?

Answer 21

GI upset

Symptoms of URTI

Pancreatitis

Question 22

What type of diabetes drug is ‘exanatide’?

Answer 22

GLP-1 mimetic

Exenatide and liraglutide are two commonly-used GLP-1 mimetics.

Question 23

How do GLP-1 mimetics help patients with type 2 diabetes?

Answer 23

Incretins (GLP-1) are released in response to a large meal and cause insulin secretion, inhibit glucagon production and slow absorption by the GI tract.

These drugs work by mimicking the action of GLP-1.

Question 24

What are the notable side effects of GLP-1 mimetics?

Answer 24

GI upset

Weight LOSS

Dizziness

*low risk of hypoglycaemia

Question 25

What type of drug is dapagliflozin?

Answer 25

SGLT-2 inhibitors

SLGT-2 inhibitors end with the suffix “-gliflozin”.

Examples include empagliflozin, canagliflozin and dapagliflozin.

Question 26

What is one of the main cardiovascular benefits of SGLT-2 inhibitors?

Answer 26

SGLT-2 inhibitors (empagliflozin, cangliflozin and dapagliflozin) have been shown to have cardio-protective effects, reducing the risk of MI, stroke and hospitalisation with heart failure.

Question 27

What are the notable side effects of SGLT-2 inhibitors?

Answer 27

Glycosuria

More frequent UTI’s

Weight LOSS

DKA, rare complication

Increased risk of lower limb amputation

Question 28

Which diabetes medications cause weight gain?

Answer 28

Pioglitazone

Sulfonylureas (gliclazide)

Insulin

Question 29

Which diabetes medications cause weight loss?

Answer 29

GLP-1 analogues

SGLT-2 inhibitors

Question 30

Which diabetes medications are weight neutral?

Answer 30

Metformin

DPP-4 inhibitors