Endocrine Flashcards
What are diagnostic criteria for diagnosis of T2DM.
The criteria are based on HbA1c or Fasting glucose.
HbA1c <= 41 mmol/mol (5.9%) OR <= 6 mmol/l of fasting glucose (FG)- normal,
HbA1c 42 - 47 mmol/mol or FG of 6.1-6.9 mmol/l - pre-diabetes.
HbA1c >= 48 mmol/mol (6.5%) or FG of >=7 mmol/l
If random glucose or oral glucose tolerance test (OGTT) is used the cut off is >=11.1 mmol/l.
What difference does it make in diagnosis of T2DM if patient is symptomatic vs asymptomatic?
In Symptomatic person, once a test is positive, it’s diagnostic.
In asymptomatic person, the test must be repeated on two occasions.
When would HbA1c not be appropriate for diagnosing diabetes mellitus?
- Haemoglobinopathies
- haemolytic anaemia
- untreated iron deficiency anaemia.
- suspected gestational diabetes
- children
- HIV
- CKD
- Medication-induced hyperglycaemia e.g. corticosteroids use.
What are the HbA1c targets for T2DM?
- Lifestyle - 48mmol/mol (6.5%)
- Lifestyle + Metformin - 48 mmol/mol (6.5%)
- Any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea) - 53 mmol/mol (7%).
If pt already on treatment on one drug but HbA1c rises to 58 mmol/mol (7.5%) - target HbA1c in this case is 53 mmol/mol.
What dietary advice would you give to a newly diagnosed T2DM?
- high fibre, low glycaemic index source of carbohydrate (CBH).
- low-fat dairy products and oily fish.
- limit saturated fat and trans fatty acid foods.
- limited substitution of sucrose-containing food for other CBH is allowed.
- discourage use of food marketed specifically for diabetics.
- weight loss target of 5-10% for overweight pts.
For a T2DM who CAN tolerate metformin, what are the drug therapy options?
- Metformin 1st line if HbA1c rises to 48 on lifestyle measures.
- If HbA1c rises to 58, a second agent should be added from the list of:
a) Sulfonylurea
b) Gliptin
c) Pioglitazone
d) SGLT-2 inhibitor. - if despite this, HbA1c rises or remains >58, then triple therapy needed with one of these combos:
a) Metformin + gliptin + sulfonylurea
b) Metformin + Pioglitazone + sulfonylurea
c) Metformin + sulfonylurea + SGLT 2 inhibitor
d) Metformin + pioglitazone + SGLT 2 inhibitor
OR
Insulin therapy should be considered.
For a T2DM who CAN’T tolerate metformin, what are the drug therapy options?
- if HbA1c rises to 48 on lifestyle measures, consider one of teh following:
a) Sulfonylurea
b) gliptin
c) pioglitazone - if HbA1c has risen to 58 then one of these combos:
a) Sulfonylurea + gliptin
b) Sulfonylurea + Pioglitazone
c) Gliptin + Pioglitazone. - If despite this, HbA1c rises or remain >58, consider insulin therapy.
In management of T2DM, when would you consider glucagon-like peptide 1 (GLP1) mimetic (e.g exenatide)?
- if triple therapy is not effective, not tolerated or contraindicated, then can do Metformin + sulfonylurea + GLP1 mimetic if:
a) BMI => 35 + psychological or medical problems associated with obesity OR
b) BMI <35 and for whom insulin therapy would have significant occupational implications OR
c) weight loss would benefit other significant obesity-related comorbidities
- -> but only continue if there’s reduction of at least 11 mmol/mol (1%) in HbA1c and a weight loss of at least 3% of initial body weight in 6 months.
When starting insulin for T2DM, what consideration should you give to the type of insulin and other anti-glycaemic medications?
- metformin should continue,
- In terms of other drugs, review their need.
- NICE recommends starring with human NPH insulin (isophane, intermediate-acting) taken at bedtime or BD.
Re: risk factor modification for diabetic patients, what are the BP target?
- same target as non-diabetic patients:
For <80yrs (clinic BP of 140/90), (ABPM/HBPM of 135/85).
For >80 yrs (clinic 150/90), (ABPM/HBPM 145/85)
- ACEi or ARB are first line - ARB preferred in black africal or african-caribbean origin.
Re: risk factor modification for diabetic patients, what are the lipid target?
- NICE recommends statin (atorvastatin 20mg nocte) to be offered to those with 10-yr CV risk >10%.
- For primary prevention, the indications are:
1. 10-yr CV risk=> 10% OR
2. most T1DM OR
3. CKD if eGFR<60
For all above give 20mg nocte of statin, if non-HDL has not fallen by =>40% on review, then titrate up to 80mg nocte.
- For secondary prevention (known IHD or CVD or PVD) - give 80mg atorvastatin OD.
When would bariatric surgery be considered in a patient?
- NICE suggest anyone with a BMI>50 should be considered for bariatric surgery as 1st line intervention.
- Orlistat may be used while waiting for surgery.
- Consider surgery for those with BMI >40 or BMI 35-40 with significant disease(e.g. t2DM, HTN) taht could be improved by weight loss - given that non-surgical interventions for 6 moths have failed to achieve weight loss.
