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Endocrinology > Diabetes type 2 > Flashcards

Diabetes type 2 Flashcards

1
Q

What are the risks of SGL2 inhibitors to tell patients about?

A
  1. Genitourinary infections (warn patients re thrust/UTIs and advise how to treat if does, often settles after a few months as less glucose secreted in urine)
  2. fall in BP due to diuretic effect
  3. DKA - rare. Must discuss sick day rules (stop if acutely unwell including abdominal pain/vomiting/nausea, dehydrated, or 3 days before fasting for a procedure and 3 days after a procedure)
  4. Small increase in lower limb amputations in one trial with canagliflozin (not others) in high risk patients - steer away from use here
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2
Q

How do SGL2 inhibitors work?

A

Reduce renal resorption of glucose in the kidney

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3
Q

What is SGL2 inhibitors association with weight?

A

Results in modest weight loss

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4
Q

Which condition can be worsened by SGLT2 inhibitors?

A

Obstructive urinary tract symptoms due to increased flow

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5
Q

Which medication has benefit in established cardiovascular and renal disease (and of this class, which has the best evidence)? What is second line in renal disease/heart failure?
Is it primary or secondary prevention?

A

SGLT2 inhibitors have been demonstrated to reduce a number of cardiovascular outcomes, including death and renal outcomes. Empagliflozin. GLP-1 also in cardiovascular disease, second line for renal disease/heart failure.
SGLT2-i/GLP-1: secondary prevention for CVD. Emerging evidence that SGLT2-i provides primary prevention for HF and CKD.

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6
Q

When titrating insulin, what FBG should be aimed for?

A

6-8mmol/L

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7
Q

What does insulin mean for driving regulations?

A

Both in Australia and UK, need to inform driving authority. Must be free of hypoglycaemia and on a regimen to minimise hypoglycaemic episodes. In Australia needs yearly review by endocrinologist for commerical drivers license.

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8
Q

What is GLP-1 associated with weight?

A

Results in weight loss

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9
Q

Australian PBS requirements for GLP-1?

A

Byetta (twice daily exanatide) allowed with insulin. Weekly preparations (exanatide, duraglutide - Trulicity) with metformin and/or SU or both

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10
Q

What HBA1c target in microvascular disease?

A

= 7.0% (especially if young etc)

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11
Q

Which medication is helpful in proliferative retinopathy?

A

Fenofibrate reduces the need for laser therapy

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12
Q

Which cholesterol medication should be used in a person with established CVD and retinopathy?

A

Will need an ongoing statin, therefore statin + fenofibrate

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13
Q

What are the target lipid levels in established CVD?

A

Total cholesterol < 4.0; LDL < 1.8; TG < 2.0; HDL >1.0

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14
Q

Which dose of SLG1 to use?

A

10mg and 25mg have same outcomes and lower dose better tolerated, could increase to 25mg if tolerated
Could consider stopping diuretic BP medications if BP under control
Better tolerated if BSL is lower
Consider in high risk patients due to cardiovascular and renal outcomes e.g. AMI, microalbuminuria

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15
Q

When would SU be indicated after metformin?

A

When cost is a major issue or for marked osmotic symptoms

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16
Q

What is the target HbA1c for those on diet control measures only?

A

<48mmol/L (6.5%)

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17
Q

What did the DIRECT trial show?

A

Substantial weight loss after diagnosis (15kg) can lead to remission - good to include in initial conversation with right motivated patient

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18
Q

When do you start metformin?

A

When HbA1c rises over 48

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19
Q

Which metformin should be started initially according to NICE guidelines?

A

Standard release

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20
Q

When should dual therapy be started according to NICE guidelines and what is the target?

A

HbA1c>58 (7.5%) aiming for 53 (7.0%)

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21
Q

When should triple therapy be started according to NICE guidelines?

A

If HbA1c>58 (7.5%) while on dual therapy, aiming for 53 (7.0%)

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22
Q

What is a red flag with new onset type 2 diabetes and what do you do about it?

A

Age over 60 with weight loss + any GI symptoms, back pain, or new onset diabetes –> urgent upper abdominal imaging

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23
Q

What is the benefit of good glycaemic control early on?

A

Reduced microvascular and macrovascular complications in the future (legacy effect)

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24
Q

What do you need to consider if a patient has a sudden reduction in HbA1c without any intervention?

A

Check if any weight loss (?malignancy), worsening renal function

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25
Q

What is the most common SU used in the UK?

A

gliclazide (also lowest risk of hypoglycaemia)

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26
Q

Which glitazone still exists?

A

pioglitazone

27
Q

What is the best approach when considering an agent for dual therapy?

A
  1. What is the target?
    - age
    - disease duration
    - comorbidities
  2. Other factors
    - comorbidities (for e.g. CVD/HF/CKD; against e.g. BPH, genitourinary infections, renal failure)
    - body weight
    - occupation (re risk of hypos)
    - cost
    - patient preference (re mode of admin, side effects)
28
Q

When increasing drugs, don’t forget to…?

A

Check adherence and lifestyle factors! What is going on in their life? Could adjusting social factors have a bigger affect?

29
Q

What are the disadvantages of SUs?

A
  1. Hypoglycaemia
  2. Weight gain
  3. Poor durability of effect - potent initially but after a few years wears off and HbA1c likely to rise again
  4. ?Cardiovascular risk - evidence suggesting not the best option in cardiovascular disease, mixed evidence but there are safer options
30
Q

What are the advantages and disadvantages of pioglitazone?

A

Advantages:
1. Reduces insulin resistance (good in people with this feature)
2. Cost-effective and potent (like SUs)
3. Good durability of effect and low risk of hypos (unlike SUs)
Disadvantages:
1. Weight gain (more than with SU)
2. Oedema (contraindicated in heart failure)
3. Fracture risk (association, therefore not in patients high risk of this)

31
Q

What is the DDP-4s effect on weight?

A

Weight neutral

32
Q

Side effects of DDP-4s?

A

Generally well tolerated

33
Q

What is the DDP-4s effect on hypoglycaemia?

A

Low risk

34
Q

What are the disadvantages of DDP-4s?

A

Only modest risk in HbA1c and expensive (like all newer agents)

35
Q

What is SGLT2-i effect on hypoglycaemia?

A

Low risk

36
Q

Which causes a better reduction in HbA1c? DDP-4, SLGT-i, GLP-1

A

GLP-1 (potent) > SLGT2-i (moderate) > DDP-4 (modest)

37
Q

What is GLP-1 effect on hypoglycaemia?

A

Low risk

38
Q

Side effects of GLP-1?

A

GI effects

39
Q

When do NICE guidelines suggest referring someone with diabetes for bariatric surgery?

A
  • Recent onset i.e. within the last 10 years and BMI over 35
  • Consider if BMI 30-34.9
  • If Asian would consider at lower BMIs
    As long as a tier 3 service is available
40
Q

When would you switch to slow release metformin?

A

If there are GI side effects on immediate release

41
Q

If someone goes into remission should they be de-coded? What are the implications?

A

There is a code for “diabetes in remission”. This means they will still be called in for lifelong annual HbA1c checks and retinopathy screening.

42
Q

How soon after starting a new drug should HbA1c be rechecked?

A

3-6 months (depends on how high HbA1c is, changes made, shared decision making with patient)

43
Q

What is the dose of metformin in renal impairment?

A

eGFR 60-90: 2g daily; eGFR 30-60: 1g daily; eGFR <30: stop (possibly 500mg daily under specialist supervision only)

44
Q

What medical condition increases the risk of drug-induced hypoglycaemia?

A

renal impairment

45
Q

Can DDP-4i be used in CKD?

A

Yes - linagliptin only (others reduce dose if eGFR<50)

46
Q

What is a good option in frail, elderly patients with CKD and why?

A

DDP4i (linagliptin) - well tolerated (no increased risk of UTI/diarrhoea etc), low risk of hypoglycaemia, linagliptin ok in CKD, non injectable, modest effect on HbA1c but goal is higher in elderly

47
Q

Can SGL2-i be used in CKD?

A

No. Need eGFR>60 to initiate. Avoid ongoing use if eGFR persistently <45

48
Q

Elderly lady with symptomatic hyperglycaemia on metformin and gliclazide - when adding in new agent would you stop or switch the SU?

A

Stop and monitor (risk of hypos, durability of effect, ongoing concerns about cardiovascular risk).

49
Q

What do the IDF guidelines suggest as the HbA1c goal for the elderly?

A

53-58 if functionally independent (7-7.5%); 58-64 if functionally dependent (7.5-8%); if frail or dementia up to 69 (8.5%) - don’t go higher than 8.5-9% as will become symptomatic and will induce immune system impairment

50
Q

GLP-1 vs insulin?

A

Newer guidelines suggest GLP-1 preferable. No cardiovascular benefits with insulin.

51
Q

Which specific SLGT2i and GLP1i have proven cardiovascular benefits?

A

empagliflozin, canagliflozin; liraglutide

52
Q

How would you start metformin? (in normal renal function)

A

Take four weeks to titrate to 1g bd. Consider switching to 2g XR nocte if SEs become an issue

53
Q

Which drugs should be continued with insulin? What are the benefits of continuing some of these drugs?

A

Metformin: always (unless problems with tolerability or renal contraindications)
SU: stop with rapid acting or pre-mixed, can be continued if only basal insulin is being used (brings down post-prandial BGL while basal insulin brings down overall background level)
DDP4: not much added benefit, but can continue
SLG2i: should be continued
GLP-1: should be continued, however only bd exanetide available to be taken with insulin on the PBS

Helps reach glycaemic targets and reduces overall amount of insulin required

54
Q

What are the indications for insulin?

A

In general, delay due to weight gain and risk of hypoglycaemia. Used if unresponsive to other agents or needs acute lowering of symptomatic hyperglycaemia

55
Q

What is the mechanism of action of GLP1-i?

A

Promotes insulin secretion (DPP4i does same by preventing inactivation of GLP1). Creates a gastroparesis effect which reduces glucose emptying into blood stream and reduce appetite (thereby causing weight loss) - DDP4i do not do this

56
Q

What is the main side effect of GLP1-i?

A

GI side effects esp nausea - can be mitigated by starting at half dose of exanetide before moving to full dose

57
Q

Which class may be an option in severe renal and hepatic impairment?

A

Glitazones

58
Q

How do you manage GI side effects on metformin?

A
  1. Switch to slow release

2. Down titrate dose (still get glucose lowering effect from 500mg daily)

59
Q

Should agent be titrated to maximum dose before adding a second agent? How long should you give it to work? What would indicate effectiveness?

A

Yes; 3 months; an improvement of at least 0.5% (20-30% of people are non responders) - stop if not effective

60
Q

What are the new agents effects on post prandial vs overall blood glucose control?

A

SLGT2-i overall glucose control; DDP4-i and GLP1-i more post prandial effect

61
Q

When should SLGT-2 inhibitors be stopped to prevent DKA?

A

Surgery, dehydrated, very restricted diet/fasting, intercurrent illness such as infection, bowel preparation

62
Q

How far in advance of surgery should SLGT-2 inhibitors be stopped?

A

On day of procedure for minor procedures with short (four hour) fasting time with no risk of dehydration and rapid reintroduction of food and drink following the procedure; two days before other procedures and restart the day after (when patient is eating and drinking properly and close to discharge)

63
Q

At what level of blood capillary ketones should you suspect DKA?

A

1.5mmol/L or above (or 1.0mmol/L perioperatively)

Endocrinology (5 decks)

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