endo Flashcards
For patients with T2DM, HbA1c should be checked every 3-6 months until stable, then how often
6 monthly
What is the HbA1c target for patients with T2DM receiving management of lifestyle
48mmol/mol
6.5%
n.b. this is the same for those on metformin only
What is the HbA1c target for patients with T2DM receiving management of metformin
48mmol/mol
6.5%
n.b. this is the same for those on lifestyle only
What is the HbA1c target for patients with T2DM receiving management of any drug which may cause hypoglycaemia e.g. sulfonylureas
53mmol/mol
7.0%
What is the HbA1c target for patients with T2DM receiving management of any ONE drug, but now their HbA1c has risen to 58mmol/mol (7.5%)
53 mmol/mol
7.0%
This is the same for T2DM on sulfronyureas
Patients on ONLY metformin for T2DM (target = 48mmol/mol (6.5%), should only have a second diabetic drug added if the HbA1c rises to…
58mmol/mol
7.5%
First line drug in T2DM
Metformin
Second line drug in T2DM
After metformin established and uptitrated
(or if CVD, chronic heart failure, QRISK >10%)
SGLT-2 inhibitor
e.g. empaglifozin, canagliflozin, dapaglifozin
If metformin is contraindicated in T2DM, what medications can be given in a patient WITH risk of CVD, established CVD, or heart failure
SGLT-2 monotherapy
e.g. empaglifozin, canagliflozin, dapaglifozin
If metformin is contraindicated in T2DM, what medications can be given in a patient WITH risk of CVD, established CVD, or heart failure
SGLT-2 monotherapy
If metformin is contraindicated in T2DM, what medications can be given in a patient WITHOUT risk of CVD, established CVD, or heart failure
DPP-4 inhibitor (sitagliptin, linagliptin)
Or pioglitazone
Or sulfonylurea (gliclazide)
SGLT-2 may be used if certain NICE criteria are met.
Examples of DPP-4 inhibitors
GLIPTINS
linagliptin
sitagliptin
Examples of sulfonyureas
Glimepiride
Gliclazide
Glipizide
Tolbutamide
Examples of SGLT-2 inhibitors
empaglifozin
canagliflozin
dapaglifozin
Stepwise T2DM medications
- Metformin
- Add one of: DPP-4 inhibitors, pioglitazone, sulfonyurea, SGLT-inhibitor (if NICE criteria met of CVD/IHD/QRISK >10%)
- Add another from the list above OR start insulin treatment
- If triple therapy is not tolerated/effective then switch one for a GLP-1 mimetic if BMI >35 - specialist referral if on insulin too
If triple therapy for T2DM (metformin + two other drugs or addition of insulin) is not effective or tolerated, consider switching one of the drugs for…:
GLP-1 mimetic
e.g. liraglutide, dulaglutide, semaglutide
If triple therapy for T2DM (metformin + two other drugs or addition of insulin) is not effective or tolerated, consider switching one of the drugs for what class…?
GLP-1 mimetic
e.g. exenatide
Second-line therapy for T2DM if on metformin already, what can you add on
metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea
metformin + SGLT-2 inhibitor (if NICE criteria met - CVD/IHD/QRISK >10%)
If metformin is not tolerated e.g. due to GI side effects, what should it be switched to
Metformin modified-release
If triple therapy for T2DM (metformin + two other drugs or addition of insulin) is not effective or tolerated, consider switching one of the drugs for GLP-1 mimetics. These can only be done for patients with:
BMI >35
BMI <35 but insulin havs occupational implications
Reduction of at least 11mmol/mol (1%) in HbA1c and weight loss of >3% in 6 months
When GLP-1 mimetics are added (after triple therapy for T2DM), can this be done in primary care
ONLY add GLP-1 mimetics to INSULIN in SPECIALIST care
When GLP-1 mimetics are added (after triple therapy for T2DM), can this be done in primary care
ONLY add GLP-1 mimetics to INSULIN in SPECIALIST care
NICE recommend starting with human NPH insulin - what type and when
Isophane, intermediate-acting
Bedtime or twice daily according to need
Blood pressure targets in T2DM
SAME as people without T2DM
<80 years: clinic 140/90, home 135/85
>80 years: clinic 150/90, home 145/85