Management of T2DM 2 Flashcards
When are sulfonylureas indicated as first line?
If patient has weight loss or osmotic symptoms
How do you identify sulfonylureas?
Gli….ide
What are the second line drugs if Metformin is used first?
SULFONYLUREA
Thiazolidinedione
DPP-IV/SGLT-2 inhibitors
Third line medications are added how?
Adding to current regimen or substitution
How do Sulphonylureas work?
Increase insulin release
How do thiazolidiones work?
Improve insulin action
How do Gliptins/ DPP-IV inhibitors work?
Increase insulin release
Inhibit DPP-IV and delay incretin breakdown
Which drugs increase insulin release?
Sulphonylureas
Metiglinides
Incretin Mimetics
DPP-IV inhibitors
When are DPP-IV inhibitors indicated?
2nd/3rd line if hypos/weight gain is a concern
What is the function of incretins?
GLP-1 and GIP
Decrease blood glucose by stimulating insulin release
How does the DPP-IV enzyme work?
Inhibit incretins - increase blood glucose by:
↓ insulin
↑ glucagon
What must be taken into account when giving Gliptins?
Renal function/eGFR
What are the advantages of gliptins?
Well tolerated
Second/third line
Can be used in renal impairment
No risk of hypo
What are the disadvantages of gliptins?
Small effect on glycemic control
Cant use in pregnancy/breastfeed
Cause nausea
What are GLP-1 analogues?
Injectable, enzyme resistant incretins which half a longer half life
(incretin mimetics)
When are incretin mimetics/GLP analogues indicated?
BMI >35
Stop after 6/12 unless HbA1c >5mmol fall
3rd/4th line
Which is the first line GLP-1 analogue?
Lixisenatide
What is the renal dose adjustment for GLP-1 analgues?
Avoid if eGFR < 30
What are the advantages of GLP-analogues?
Weight loss
No risk of hypo
3rd line agent
Can be used with insulin
What are the disadvantages of GLP-analogues?
Injection
Very expensive
CI in pregnancy/breastfeed
Sides: N+V
How do SGLT2 inhibitors work?
Inhibit SGLT2 transporter preventing reabsorption of Glucose - its peed out
Where are the SGLT transporters located?
Renal proximal tubule
What are the roles of the SGLT transporters?
Transport glucose from proximal tubule to blood
SGLT2 - 90%
SGLT1 - 10%
What are the effects of SGL2 inhibitors?
↑ Glucose/water/Na excretion
↑ Weight loss
↓ Blood pressure
↑ Risk of urogenital infection
How do you change SGLT2 inhibitor use in renal failure?
eGFR:
<60 do not start
<45 stop
What are the advantages of SGLT2 inhibitors?
Weight loss No risk of hypo Good effects on glycemic control Reduce CV morb/mort Can add insulin
What are the disadvantages of SGLT2 inhibitors?
Expensive Increase risk of UTI Risk of digital amputation Risk of DKA CI in pregnant/breastfeeding Cannot use in renal impairment
What are the supplementary insulin regimes?
Isophane insulin
(Humulin I, H insulatard)
Once daily
Usually bedime
What are the advantages of insulin therapy for T2DM?
Easy to introduce
Low risk of hypoglycaemia
What are the disadvantages of insulin therapy for T2DM?
Weight gain
When is metformin contraindicated?
eGFR < 30
When is Glitazone contraindicated?
CCF
Bladder cancer
When are DPP-IV inhibitors contraindicated?
Hx Pancreatitis
Which diabetes medications can be used safely in renal impairment?
Sulphonylureas
Glitazone
Insulin
Reduced dose DDP-4 inh
Which diabetes medications can cause weight gain?
Sulphonylureas
Glitazone
Insulin
Which diabetes medications can cause weight loss?
SGLT-2 inhibitors
GLP-1 analogues
What should the HbA1c targets be for T2D adults managing with lifestyle +/- a single drug not associated with hypos?
48mmol/mol
What should the HbA1c targets be for T2D adults managing on a drug associated with hypos?
53mmol/mol
What should the next line of action be for T2DM patients with HbA1c > 58 not adequately controlled by a single drug?
Reinforce diet, lifestyle, drug adherence
Support aim for HbA1c = 53
Intensify drug treatment
When should you consider relaxing HbA1c targets?
Elderly/frailty
T2D with reduced life expectancy
High risk consequences of hypos
Multiple comorbidities
What is the 5 step framework for choosing a glucose lowering drug?
- Set target HbA1c
- Assess for risk factors
- Are current treatments optimised
- What are the options
- Agree review date and target
Which factors should be reduced in ‘take 5’?
Smoking Blood pressure Blood lipids/LDL Sugar consumption Sedentary behaviour
What do you do if a drug isnt working?
Stop it (unless the patient has responded for many years)
When do you review a diabetic patient?
3-6 months
What is the usual target HbA1c for first review after diagnosis?
At least a 5mmol/mol reduction
How can Insulin therapy in T2D be modified?
Start as once daily
Move to multiple (progressive therapy)
