Diabetes Mellitus: Management of Type 2

Question 1

What dietary advice should be given to patients with T2DM?

Answer 1

• Encourage high fibre, low glycaemic index sources of carbohydrates
• Include low-fat dairy products and oily fish
• Control the intake of foods containing saturated fats and trans fatty acids
• Limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
• Discourage use of foods marketed specifically at people with diabetes
• Initial target weight loss in an overweight person is 5-10%

Question 2

How often should HbA1C be checked?

Answer 2

Every 3-6 months until stable.

Then 6 monthly

Question 3

What is your HbA1C target for diet/lifestyle controlled T2DM?

Answer 3

48 mmol/mol (6.5%)

Question 4

What is your HbA1C target for Diet/lifestyle+ Metformin (or if metformin contraindicated and on gliptin or pioglitazone) controlled T2DM?

Answer 4

48 mmol/mol (6.5%)

Question 5

What is your HbA1C target for T2DM that is controlled using any sulfonylurea or Repanglinide (Lifestyle + sulfonylurea/Repanglinide )?

Answer 5

53mmol/mol (7.0%)

Question 6

If a patient is already on sulphonylurea or is in the intensification phases (Dual therapy) and above, and their HbA1C increases to 58 mmol/mol, what should their target be and what can you consider?

Answer 6

53 mmol/mol (7.0%)

You may want to consider introducing a new agent or maxing out their current medication.

Question 7

You review a patient at 6 monmths after starting Metformin. They are on 500mg BD. His HbA1C is 51 mmol/mol (6.8%). What should you do?

Answer 7

Increase his Metformin from BD to TDS and reinforce his target of 48 mmol/mol.

Question 8

Describe the Treatment Algorithm for patients who can take Metformin.

Answer 8

1. Monotherapy - Metformin
   
   • Start this if HbA1c rises to 48 mmol/mol on lifestyle.
   • Offer standard release initially but can consider modified-release if not tolerated.
   • Aim for an HbA1C of 48mmol/mol
2. First intensification (Dual Therapy)
   
   • Start this if HbA1c rises to 58 mmol/mol.
   • Add a second drug to Metformin - Sulphonylurea, Gliptin or Pioglitazone.
   • Aim for an HbA1C of 53mmol/mol (7%)
3. Second intensification (Triple Therapy or Insulin)
   
   • Start if HbA1C rises to 58mmol/mol
   • Add a third drug or consider insulin therapy.
   • Aim for an HbA1C of 53mmol/mol (7%)
4. Final Intensification - If triple therapy not effective/tolerated and they meet the strict criteria for use consider Metformin + SU + GLP-1 .
5. Insulin therapy - consider if HbA1c rises or remains above 58 mmol.mol.

Question 9

Describe the Treatment Algorithm for patients who CANNOT take Metformin.

Answer 9

1. Monotherapy - Sulphonylurea or Gliptin or Pioglitazone or Repaglinide.
   
   • Start this if HbA1c rises to 48 mmol/mol on lifestyle.
   • Aim for HbA1C of 48mmol/mol if on gliptin/pio
   • Aim for HbA1C of 53mmol/mol if on Sulphonylurea or Repaglinide.
2. First intensification (Dual Therapy)
   
   • Start this if HbA1c rises to 58 mmol/mol.
   • STOP repiglinide if using.
   • Add a second - SU+ gliptin, SU + Pio or Gliptin + Pio.
   • Aim for an HbA1C of 53mmol/mol (7%)
3. Second intensification (Triple Therapy or Insulin)
   
   • Start if HbA1C rises to 58mmol/mol
   • Consider Insulin

Question 10

What are the strict criteria for GLP-1 use?

Answer 10

1. BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity
2. BMI < 35 kg/m² and either:
   
   • Insulin therapy would have significant occupational implications
   • Weight loss would benefit other significant obesity related comorbidites.

Question 11

When starting insulin, what regime of insulin is preferable?

Answer 11

• NPH Insulin (Isophane, intermediate acting)
  
  • Injected once or twice daily according to need.
  • This is usually all that is required for T2DM.
• If HbA1c is >=75mmol/mol - Consider either:
  
  • Biphasic regime using a Biphasic insulin (Humulin M3)
  • Basal Bolus regime: Starting both NPH and short-acting insulin- as an intensified regime if glycemic control still not optimal.

Question 12

what does NICE recommend for someone switching from double or triple therapy to insulin?

Answer 12

Continue Metformin

NOTE: Sulfonylureas are often continued when introducing a basal insulin regime (once daily injection in the evening) but gradually phased out as the regime becomes more intense and switches to biphasic or basal-bolus regime.

Question 13

Why is a single daily dose of long-acting insulin preferred?

Answer 13

Good quality trials have shown this was almost as good as more complex regimes and resulted in fewer hypos and less weight gain.

Question 14

How much insulin can you start with as a single dose and how can you adjust it?

Answer 14

Start at 10 units and increase as per Frank’s guidelines.

• Initially test BM’s twice daily (before breakfast and before dinner) and take the 7 day average.
• If >14 mmol/L increase each dose by 4 units
• If 9-14 mmol/l each dose by 2 units
• If <9 mmol/l then reduce monitoring to once daily and review in 3 to 6 months.

Typically 20-30 units is all that is required as part of a basal regime. If more is required then consider switching to a biphasic regime and stopping oral hypoglycaemics. (Australian Guidelines)

Question 15

What is the rule of 15 for management of mild hypoglycaemia?

Answer 15

If BGL < 4mmol/L and the patient is symptomatic:

• Provide 15 grams of quick acting carbs.
• Wait 15 minutes and repeat blood glucose. If level not rising, repeat step 1.
• If patient’s next meal is more than 15 minutes away, provide longer-acting carbohydrate and retest blood glucose again in 2-4 hours.

Question 16

What blood pressure targets should be pursued in T2DM patients?

Answer 16

• If end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
• Otherwise < 140/80 mmHg

Question 17

When switching a patient over from a nightly bolus regime (augmentation regime) to a biphasic regime (replacement regime), how should it be done?

Answer 17

They will usually be on 20-30 units (0.3units/kg) of insulin.

Stopping oral hypoglycaemics before starting the biphasic regime will usually require another 20-30 units of insulin to replace them.

From this point follow Frank’s advise.

• Start Insulin and continue metformin (stop others)
  
  • Start with 1/2 of 1 unit/kg and then uptitrate to 1 unit/kg. (e.;g. 70 kg start at 35 and then titrate up)
• For BD insulin regime:Give 65% in AM and 35% in PM (before evening meal.)
  
  • But if evening feeder may beed adjustment to ratio.
• Initially test BM’s twice daily (before breakfast and before dinner) and take the 7 day average.
  
  • If >14 mmol/L increase each dose by 4 units
  • If 9-14 mmol/l each dose by 2 units
  • If <9 mmol/l then reduce monitoring to once daily and review in 3 to 6 months.
• When giving insulin DO NOT forget lifestyle advise of HbA1C is persistently high.
• 10% rule - 10% increase in daily insulin if persistently hyperglycaemic.
• 20% rule - for persistent hypoglycaemia - knock 20% of regime and retitrate.

Question 18

What is the first line medication for controlling BP in diabetic patients?

Answer 18

ACE Inhibitor

NOTE: A2RB if afro-carribean.

Question 19

Should antiplatelets (e.g. aspirin or clopidogrel) be given to all patients with T2DM?

Answer 19

No. Only if there is evidence of CVD risk.

Question 20

How should blood lipids be managed in T2DM?

Answer 20

1. Calculate QRISK2
2. If >10% then offer a statin.
3. Atorvastatin 20mg ON is first line.

Question 21

What are some contraindications for pioglitazone?

Answer 21

• Heart failure/risk of failure
• Fractures
• Risk of or PMH of bladder cancer
• Elderly (Because of the above factors)

Question 22

What is Frank’s advice regarding managing diabetes?

Answer 22

1. Start Metformin –> Max out to 2 grams.
2. Start Gliclazide (insulin secretagogue and will knacker the pancreas)
3. Start Sitagliptin before uptitrating Gliclazide.
4. Uptitrate Gliclazide –> Max out
5. Start Insulin and continue metformin (stop others)
   
   • Start with 1/2 of 1 unit/kg and then uptitrate to 1 unit/kg. (e.;g. 70 kg start at 35 and then titrate up)
6. For BD insulin regime:
   
   • Give 65% in AM and 35% in PM (before evening meal.)
     
     • But if evening feeder may beed adjustment to ratio.
   • Initially test BM’s twice daily (before breakfast and before dinner) and take the 7 day average.
     
     • If >14 mmol/L increase each dose by 4 units
     • If 9-14 mmol/l each dose by 2 units
     • If
7. When giving insulin DO NOT forget lifestyle advise of HbA1C is persistently high.
8. 10% rule - 10% increase in daily insulin if persistently hyperglycaemic.
9. 20% rule - for persistent hypoglycaemia - knock 30% of regime and retitrate.

Question 23

What is the insulin sensitivity factor and how do you calculate it?

NOTE: 100 rule.

Answer 23

ISF is how much your blood glucose levels will drop by each unit of insulin.

Aim is to bring blood sugar down to 10 mmol/L

Divide 100 by TDD.

100/TDD=ISF.

E.G TDD = 50 units.

100/50 = 2

Blood sugar will drop by 2mmol/L for 1 unit of insulin.

Question 24

How do you calculate how much dose to give to correct your BMs if too high?

(i.e. correction dose)

Answer 24

(Blood sugar-10) / your ISF = dose of insulin.

(minus ten because you only want to get it to 10)

E.g. BM at 17.

17-10 = 7mmol/L

ISF = 2mmol/L for 1 unit of insulin.

Therefore 7/2 = 3.5 units of insulin.

Question 25

After how long should you give another correction dose?

Answer 25

No sooner than 2 hours after previous injection.

Question 26

What is your carbohydrate ratio?

NOTE: 500 rule

Answer 26

500/TDD = carbohydrate ratio.

e.g.

500/50= 10 grams of carbs for 1 unit of insulin.

Question 27

When starting on insulin what total dose of insulin should you start with?

Answer 27

Start with 10 units

Question 28

What TDD will people eventually need on average?

Answer 28

0.5 to 1 unit per kg

Question 29

By what % should you consider decrease insulin in a patient who is persistently running low?

By what % should you decrease in a patient who is having problems with hypoglycaemia?

Answer 29

10%

20%