Management of Diabetes D - Type 2 Diabetes Mellitus - Part 2 Flashcards
what are the first ad second line options ofr type 2 diabetes?
first line - metformin
second line - sulfonylurea and thiazolidinedione
how does sulphonylureas help type 2 diabetes?
Increase insulin release
how does each of the following help type 2 diabetes?
- Metformin (Biguanides)
- Thiazolidiones
- Weight reduction
- And exercise
Improve Insulin Action
what are incretins?
Incretins are a group of metabolic hormones that stimulate a decrease in blood glucose levels. Incretins are released after eating and augment the secretion of insulin released from pancreatic beta cells of the islets of Langerhans by a blood glucose-dependent mechanism
what are DPPIV-inhibitors examples?
…Gliptins:
saxagliptin, sitagliptin, vildagliptin
how do DPPIV-inhibitors help diabetes?
increase insulin release
how do GLIPTINS work?
whata re the advantages of DPPIV inhibitors?
- Usually well tolerated
- Can be used as 2nd or 3rd line agent
- Can be used in renal impairment
- No risk of hypoglycaemia
- Weight neutral
what are the disadvantages of DPPIV inhibitors?
- Trial data shows relatively small effects on glycemic control
- CI in pregnancy and breastfeeding.
- Possible increased risk of pancreatitis and pancreatic cancer
- SE: nausea
Examples of GLP-1 analogues
…..tides
Exenatide, Liraglutide, Lixisenatide
how do GPL1 agonists help in type 2 diabetes?
what is the mode of action of GPL1 agonists?
how do GPL1 anaglouges affect weight?
can promote weight loss
What are the guildlines for: GLP-1 ANALOGUES: SIGN & NICE
NICE CG87:
- BMI >35; (Ethnicity; Occupation)
- Stop after 6/12 unless:
- HbA1C -1% and Weight - 3% in 6/12
SIGN 154:
- 3rd line agent; BMI > 30 kg/m2
- In combination with oral agents and/or basal insulin usually as 3rd or 4th line
- Stop after 3-6/12 unless HbA1C >5mmol/mol fall or individualized target reached
what is the first choice GLP1 analogue?
Liraglutide is the first choice one now
How are GLP1 analogues given?
pen devices
what are the advantages of GLP1 analogues?
- Weight loss
- No risk of hypoglycaemia
- 3rd line agent
- Can be used with basal insulin
what are the disadvantages of GLP1 analogues?
- Injection
- Very expensive
- Possible increased risk of pancreatitis and pancreatic cancer
- CI in pregnancy and breastfeeding.
- SE: Nausea, vomiting
what are examples of SGLT2-inhibitors?
…gliflozins
Canagliflozin, Dapagliflozin, Empagliflozin
how does SGLT2 inhibitors affect type 2 diabetes?
increase excretion of glucose
slides showing how SGLT2 inhibitors work:
SGLT2 inhibitors, also called gliflozins, are a class of medications that inhibit reabsorption of glucose in the kidney and therefore lower blood sugar. They act by inhibiting sodium-glucose transport protein 2 (SGLT2). SGLT2 inhibitors are used in the treatment of type II diabetes mellitus (T2DM)
what are the effects of SGLT2 inhibitors?
- GETS RID OF GLUCOSE / MORE GLYCOSURIA - LOWERS HbA1C
- GETS RID OF WATER/OSMOTIC DIURESIS - (POSTURAL) HYPOTENSION, DEHYDRATION
- GETS RID OF CALORIES/WASTES GLUCOSE - LOSE WEIGHT WITH SAME INTAKE
- GETS RID OF SODIUM/LESS REUPTAKE - LOWERS SYSTOLIC BLOOD PRESSURE
- GREATER RISK OF UROGENITAL INFECTION - CYSTITIS and CANDIDIASIS
When should SGLT-2 inhibitors not be used in regards to renal impairment?
what are the advantages of SGLT2 inhibitors?
- Weight loss
- No risk of hypoglycaemia
- Good effects on glycemic control
- May have beneficial effect on cardiovascular morbidity & mortality
- 2nd or 3rd line agent
- Can add to insulin regimens in T2DM
what are the disadvantages of SGLT2 inhibitors?
- Expensive
- SE: UTI, fungal infections, osmotic symptoms
- Risk of digital amputation
- Risk of DKA
- CI in pregnancy and breastfeeding
- Cannot use in renal impairment
is insulin used in T2D?
- Progressive relative insulin deficiency
- Use may become ‘inevitable’
- As many T2 as T1 on insulin
Which regimen? (4T 1yr)
What is Supplementary Insulin Therapy in T2D and the effects?
- Easy introduction to insulin
- Low risk of hypoglyceamia
- Weight gain?
- Not quite the last resort – intensification regimens (4T 2-3yr)
- Which supplementary insulin? once daily normally at bed time
table for the summary of diabetes medication:
what are HbA1c tagrets for people with T2D?
For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%)
For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%)
If HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
• reinforce advice about diet, lifestyle and adherence to drug treatment and, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and, intensify drug treatment
Consider relaxing the target HbA1c level on a case‑by‑case basis
what cases would this be in?
- People who are older or frail
- For adults with type 2 diabetes:
- With reduced life expectancy
- high risk of the consequences of hypoglycaemia- those at increased risk of falling, impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job
- intensive management not appropriate- multiple comorbidities
What is 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
