Management of T2DM 2

Question 1

When are sulfonylureas indicated as first line?

Answer 1

If patient has weight loss or osmotic symptoms

Question 2

How do you identify sulfonylureas?

Answer 2

Gli….ide

Question 3

What are the second line drugs if Metformin is used first?

Answer 3

SULFONYLUREA
Thiazolidinedione
DPP-IV/SGLT-2 inhibitors

Question 4

Third line medications are added how?

Answer 4

Adding to current regimen or substitution

Question 5

How do Sulphonylureas work?

Answer 5

Increase insulin release

Question 6

How do thiazolidiones work?

Answer 6

Improve insulin action

Question 7

How do Gliptins/ DPP-IV inhibitors work?

Answer 7

Increase insulin release

Inhibit DPP-IV and delay incretin breakdown

Question 8

Which drugs increase insulin release?

Answer 8

Sulphonylureas
Metiglinides
Incretin Mimetics
DPP-IV inhibitors

Question 9

When are DPP-IV inhibitors indicated?

Answer 9

2nd/3rd line if hypos/weight gain is a concern

Question 10

What is the function of incretins?

Answer 10

GLP-1 and GIP

Decrease blood glucose by stimulating insulin release

Question 11

How does the DPP-IV enzyme work?

Answer 11

Inhibit incretins - increase blood glucose by:
↓ insulin
↑ glucagon

Question 12

What must be taken into account when giving Gliptins?

Answer 12

Renal function/eGFR

Question 13

What are the advantages of gliptins?

Answer 13

Well tolerated
Second/third line
Can be used in renal impairment
No risk of hypo

Question 14

What are the disadvantages of gliptins?

Answer 14

Small effect on glycemic control
Cant use in pregnancy/breastfeed
Cause nausea

Question 15

What are GLP-1 analogues?

Answer 15

Injectable, enzyme resistant incretins which half a longer half life
(incretin mimetics)

Question 16

When are incretin mimetics/GLP analogues indicated?

Answer 16

BMI >35
Stop after 6/12 unless HbA1c >5mmol fall
3rd/4th line

Question 17

Which is the first line GLP-1 analogue?

Answer 17

Lixisenatide

Question 18

What is the renal dose adjustment for GLP-1 analgues?

Answer 18

Avoid if eGFR < 30

Question 19

What are the advantages of GLP-analogues?

Answer 19

Weight loss
No risk of hypo
3rd line agent
Can be used with insulin

Question 20

What are the disadvantages of GLP-analogues?

Answer 20

Injection
Very expensive
CI in pregnancy/breastfeed
Sides: N+V

Question 21

How do SGLT2 inhibitors work?

Answer 21

Inhibit SGLT2 transporter preventing reabsorption of Glucose - its peed out

Question 22

Where are the SGLT transporters located?

Answer 22

Renal proximal tubule

Question 23

What are the roles of the SGLT transporters?

Answer 23

Transport glucose from proximal tubule to blood
SGLT2 - 90%
SGLT1 - 10%

Question 24

What are the effects of SGL2 inhibitors?

Answer 24

↑ Glucose/water/Na excretion
↑ Weight loss
↓ Blood pressure
↑ Risk of urogenital infection

Question 25

How do you change SGLT2 inhibitor use in renal failure?

Answer 25

eGFR: <60 do not start <45 stop

Question 26

What are the advantages of SGLT2 inhibitors?

Answer 26

``` Weight loss No risk of hypo Good effects on glycemic control Reduce CV morb/mort Can add insulin ```

Question 27

What are the disadvantages of SGLT2 inhibitors?

Answer 27

``` Expensive Increase risk of UTI Risk of digital amputation Risk of DKA CI in pregnant/breastfeeding Cannot use in renal impairment ```

Question 28

What are the supplementary insulin regimes?

Answer 28

Isophane insulin (Humulin I, H insulatard) Once daily Usually bedime

Question 29

What are the advantages of insulin therapy for T2DM?

Answer 29

Easy to introduce | Low risk of hypoglycaemia

Question 30

What are the disadvantages of insulin therapy for T2DM?

Answer 30

Weight gain

Question 31

When is metformin contraindicated?

Answer 31

eGFR < 30

Question 32

When is Glitazone contraindicated?

Answer 32

CCF | Bladder cancer

Question 33

When are DPP-IV inhibitors contraindicated?

Answer 33

Hx Pancreatitis

Question 34

Which diabetes medications can be used safely in renal impairment?

Answer 34

Sulphonylureas Glitazone Insulin Reduced dose DDP-4 inh

Question 35

Which diabetes medications can cause weight gain?

Answer 35

Sulphonylureas Glitazone Insulin

Question 36

Which diabetes medications can cause weight loss?

Answer 36

SGLT-2 inhibitors | GLP-1 analogues

Question 37

What should the HbA1c targets be for T2D adults managing with lifestyle +/- a single drug not associated with hypos?

Answer 37

48mmol/mol

Question 38

What should the HbA1c targets be for T2D adults managing on a drug associated with hypos?

Answer 38

53mmol/mol

Question 39

What should the next line of action be for T2DM patients with HbA1c > 58 not adequately controlled by a single drug?

Answer 39

Reinforce diet, lifestyle, drug adherence Support aim for HbA1c = 53 Intensify drug treatment

Question 40

When should you consider relaxing HbA1c targets?

Answer 40

Elderly/frailty T2D with reduced life expectancy High risk consequences of hypos Multiple comorbidities

Question 41

What is the 5 step framework for choosing a glucose lowering drug?

Answer 41

1. Set target HbA1c 2. Assess for risk factors 3. Are current treatments optimised 4. What are the options 5. Agree review date and target

Question 42

Which factors should be reduced in 'take 5'?

Answer 42

``` Smoking Blood pressure Blood lipids/LDL Sugar consumption Sedentary behaviour ```

Question 43

What do you do if a drug isnt working?

Answer 43

Stop it (unless the patient has responded for many years)

Question 44

When do you review a diabetic patient?

Answer 44

3-6 months

Question 45

What is the usual target HbA1c for first review after diagnosis?

Answer 45

At least a 5mmol/mol reduction

Question 46

How can Insulin therapy in T2D be modified?

Answer 46

Start as once daily | Move to multiple (progressive therapy)