[GP] Type 2 Diabetes Flashcards
what is T2DM characterised by?
insulin resistance and insufficient insulin production
how do you diagnose T2DM?
HbA1c (≥48mmol/mol or 6.5%) or fasting blood glucose (≥7mmol/L)
what do you do if a pt is asymptomatic?
repeat test and if normal, pt should be followed up
what do you do if a pt is symptomatic?
one test is sufficient, but need to rule out other causes of hyperglycaemia (e.g. trauma, infection)
what are the modifiable risk factors for T2DM?
- obesity
- inactivity
- high glycaemic diet
- drug therapy (e.g. steroids, statins)
what are the non-modifiable risk factors for T2DM?
- FHx
- hx of GDM
- black/Asian
- low birthweight
- metabolic syndrome
- PCOS
what would you start pt on if lifestyle mx fails and HbA1c ≥48mmol/mol (6.5%)?
metformin
or DDP-4i / Pioglitazone / SU
what would you do if HbA1c remains ≥58mmol/mol (7.5%) despite starting metformin?
ADD DDP-4i / Pioglitazone / SU / SGLT-2i
what would you do if HbA1c remains ≥58mmol/mol (7.5%) despite being on metformin + DDP-4i / Pioglitazone / SU / SGLT-2i?
ADD DDP-4i / Pioglitazone / SU / SGLT-2i OR commence insulin OR consider GLP-1 (with metformin and SU)
what diet and exercise advice would you give a T2DM pt?
- low glycaemic index (fruit/veg/pulses/fish)
- 2.5 hour of exercise per week
how often should you follow up a newly diagnosed T2DM pt?
HbA1c every 3-6 months – until stable on treatment then 6 monthly
what HbA1c level is aimed for if pt is on lifestyle and metformin?
48mmol/mol (6.5%)
what HbA1c level is aimed for if pt is on hypoglycaemic meds?
53mmol/mol (7.0%)
when do you offer blood sugar self-monitoring?
- on insulin
- having hypoglycaemic episodes
- high risk occupation e.g. machinery operator, driving
- pregnant
how do you screen for complications in T2DM?
annual:
- retinopathy screen
- nephropathy screen (ACR and eGFR)
- foot problems (check sensation with 10g monofilament and assess ABPI)
- cardiovascular risk (BP, smoking, lipids, FHx of CVD, BMI, glycaemic control)
what are the features of Hyperosmolar Hyperglycaemic State (HHS)?
- hypovolaemia
- hyperglycaemia (glucose ≥30mmol/L)
- NO ketosis
- NO mild acidosis
- serum osmolality >320 mosmol/kg
- usually older pt
how do you manage HHS?
- fluid replacement: IV NaCl 0.9%
- if significant ketonaemia: commence fixed rate insulin infusion (0.05unit/kg/hr) BUT if no ketones: do not commence until blood glucose ceased to fall following fluid resuscitation
- replace K+ if needed (as in DKA)
- rule out infective causes
- VTE prophylaxis
- care for pressure areas
ankle swelling, erythema, loss of foot sensation and T2DM. dx?
Charcot arthropathy
metformin and CKD. mx?
stop metformin if eGFR <30
insulin and driving. mx?
T1: DVLA must be informed and pt must be able to record CBG every 2h
when do you consider starting insulin?
if triple therapy (3x oral medication) is still not controlling HbA1c
what does HHS need to be treated with?
IV fluids and sometimes FRII
