Lecture 17 Management of Type 2 Diabetes Flashcards
Name professionals involved in a diabetic management team
- Diabetes doctors
- GPs
- The patient
- Clinical psychologist
- Other specialists
- Specialist nurses
- Dietitians
- Podiatrists
What should a patient expect from their care
- Blood glucose levels
- Blood Pressure
- Blood Lipids
- Eyes Screened
- Feet checked
- Kidney function
- Weight
- Smoking Cessation Support
- Individual Care plan
- Education Course
- Emotional and psychological support
What are the aims of diabetes treatment
- Relief of primary symptoms
- Prevention of complications
- Preservation of quality of life
- Damage minimalisation
Name defects of the pancreas that lead to diabetes
Beta cell dysfunction
Diminished incretin effect
Excess glucagon
Name defects of the periphery that lead to diabetes
Insulin resistance
Symptoms of uncontrolled type 2 diabetes
- Polydipsia
- Polyuria
- Blurry vision
- Increased hunger
- Feeling drowsy or sleep
- Tingling pain or numbness in hands and feet
- Slow or improper healing of cuts and bruises
What else needs to be considered to prevent complications
- Smoking
- Statins
- Mood
- Blood pressure
- Dietary change
- Physical activity
- Sedentary behaviour
Describe the 5 step framework for choosing a glucose lowering drug
- Set a target HbA1c
- “Take 5” Are there other risk factors that should be treated first?
- Are the current treatments optimised. Max dose? Tolerated? Taken?
- What are the glucose lowering options?
• Remove any that are contraindicated
• Of the remaining what are the pros and cons
• Select the preferred choice. - Agree a review date and the target HbA1c with the patient
When should the target HbA1c level be relaxed
Oder or frail people
Adults with reduced life expectancy, high risk consequences if they have hypoglycaemia
Multiple cormobidities
What is the first line treatment for type 2 diabetes
Metformin
What are the benefits of metformin
– Improves outcomes – Well tolerated – Cheap – Improves insulin action – Acts on liver and muscle Used in pregnancy
How does Metformin work
Acts on liver and muscle Biguanide Improves insulin sensitivity Improves receptor function Inhibits gluconeogenic pathways
What is the half-life of Metformin
6 hours
What are the disadvantages of Metformin
- GI side effects 20 – 30 %
- Risk of lactic acidosis by inhibiting lactic acid uptake by liver
- Hypoxia
- Renal failure (CI if creat<150)
- Hepatic failure
- Alcohol abuse
- Risk vitamin B12 malabsorption
Name 2nd line treatment for type 2 diabetes
Sulphonylureas
Thiazolidenediones- Pioglitazone,Gliatzone
GLP-1 agonist
SGLT-2 inhibitor
Whats the mechanism of Sulphonylureas
Increases insulin release
Binds to sulfonylurea receptors on functioning beta-cells
• Binding closes the linked ATP-sensitive potassium channels
• Decreased potassium influx depolarization of the beta-cell membrane.
• Voltage-dependent calcium channels open and result in an influx of calcium
• Translocation and exocytosis of secretory granules of insulin to the cell surface
Advantages of Sulphonylureas
- Used with metformin
- Rapid improvement in control
- Rapid improvement if symptomatic
- Rapid titration
- Cheap
Disadvantages of Sulphonylureas
- Risk of hypoglycaemia
- Weight gain
- Caution in renal and hepatic disease
- Hypersensitivity and photosensitivity reactions
- Blood disorders
Whats the mechanism of Thiazolidenediones
Improves insulin action
Selectively stimulates PPAR gamma and PPAR alpha
Modulates transcription of the insulin-sensitive genes
Decreases withdrawal of glucose from the liver
Reduces quantity of glucose, insulin and glycated haemoglobin in the bloodstream
Advantages of Thiazolidenediones (Pioglitazone)
- Good for people if insulin resistance significant
- HbA1c by 0.6-1.3%
- Cheap
Disadvantages of Thiazolidenediones (Pioglitazone)
- Increase risk of bladder cancer
- Caution in those of increased risk bladder cancer (Age, industry etc)
- Fluid retention - CCF
- Weight gain
- Fractures in female
What is the mechanism of SGLT-2 inhibitors
Work by preventing the kidneys from reabsorbing glucose back into the blood
Whats the mechanism of GLP-1 analogues
This type of medication works by increasing the levels of hormones called ‘incretins’. These hormones help the body produce more insulin only when needed and reduce the amount of glucose being produced by the liver when it’s not needed. They reduce the rate at which the stomach digests food and empties, and can also reduce appetite
