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D&E Pathology > Management of T2DM 2 > Flashcards

Management of T2DM 2 Flashcards

1
Q

When are sulfonylureas indicated as first line?

A

If patient has weight loss or osmotic symptoms

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2
Q

How do you identify sulfonylureas?

A

Gli….ide

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3
Q

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

A

SULFONYLUREA
Thiazolidinedione
DPP-IV/SGLT-2 inhibitors

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4
Q

Third line medications are added how?

A

Adding to current regimen or substitution

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5
Q

How do Sulphonylureas work?

A

Increase insulin release

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6
Q

How do thiazolidiones work?

A

Improve insulin action

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7
Q

How do Gliptins/ DPP-IV inhibitors work?

A

Increase insulin release

Inhibit DPP-IV and delay incretin breakdown

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8
Q

Which drugs increase insulin release?

A

Sulphonylureas
Metiglinides
Incretin Mimetics
DPP-IV inhibitors

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9
Q

When are DPP-IV inhibitors indicated?

A

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

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10
Q

What is the function of incretins?

A

GLP-1 and GIP

Decrease blood glucose by stimulating insulin release

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11
Q

How does the DPP-IV enzyme work?

A

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

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12
Q

What must be taken into account when giving Gliptins?

A

Renal function/eGFR

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13
Q

What are the advantages of gliptins?

A

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

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14
Q

What are the disadvantages of gliptins?

A

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

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15
Q

What are GLP-1 analogues?

A

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

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16
Q

When are incretin mimetics/GLP analogues indicated?

A

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

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17
Q

Which is the first line GLP-1 analogue?

A

Lixisenatide

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18
Q

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

A

Avoid if eGFR < 30

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19
Q

What are the advantages of GLP-analogues?

A

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

20
Q

What are the disadvantages of GLP-analogues?

A

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

21
Q

How do SGLT2 inhibitors work?

A

Inhibit SGLT2 transporter preventing reabsorption of Glucose - its peed out

22
Q

Where are the SGLT transporters located?

A

Renal proximal tubule

23
Q

What are the roles of the SGLT transporters?

A

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

24
Q

What are the effects of SGL2 inhibitors?

A

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

25
Q

How do you change SGLT2 inhibitor use in renal failure?

A

eGFR:
<60 do not start
<45 stop

26
Q

What are the advantages of SGLT2 inhibitors?

A 
Weight loss
No risk of hypo 
Good effects on glycemic control
Reduce CV morb/mort
Can add insulin
27
Q

What are the disadvantages of SGLT2 inhibitors?

A 
Expensive
Increase risk of UTI 
Risk of digital amputation
Risk of DKA
CI in pregnant/breastfeeding
Cannot use in renal impairment
28
Q

What are the supplementary insulin regimes?

A

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

29
Q

What are the advantages of insulin therapy for T2DM?

A

Easy to introduce

Low risk of hypoglycaemia

30
Q

What are the disadvantages of insulin therapy for T2DM?

A

Weight gain

31
Q

When is metformin contraindicated?

A

eGFR < 30

32
Q

When is Glitazone contraindicated?

A

CCF

Bladder cancer

33
Q

When are DPP-IV inhibitors contraindicated?

A

Hx Pancreatitis

34
Q

Which diabetes medications can be used safely in renal impairment?

A

Sulphonylureas
Glitazone
Insulin
Reduced dose DDP-4 inh

35
Q

Which diabetes medications can cause weight gain?

A

Sulphonylureas
Glitazone
Insulin

36
Q

Which diabetes medications can cause weight loss?

A

SGLT-2 inhibitors

GLP-1 analogues

37
Q

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

A

48mmol/mol

38
Q

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

A

53mmol/mol

39
Q

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

A

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

40
Q

When should you consider relaxing HbA1c targets?

A

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

41
Q

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

A
  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
42
Q

Which factors should be reduced in ‘take 5’?

A 
Smoking
Blood pressure
Blood lipids/LDL
Sugar consumption
Sedentary behaviour
43
Q

What do you do if a drug isnt working?

A

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

44
Q

When do you review a diabetic patient?

A

3-6 months

45
Q

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

A

At least a 5mmol/mol reduction

46
Q

How can Insulin therapy in T2D be modified?

A

Start as once daily

Move to multiple (progressive therapy)

D&E Pathology (18 decks)

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