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Systems: Endocrine AB > Management of T2DM > Flashcards

Management of T2DM Flashcards

1
Q

Who is part of the diabetes team?

A
  • The patient
  • Specialist nurse
  • Dieticians
  • Podiatrists
  • Clinical psychologists
  • GPs
  • Diabetes doctors
  • other specialists
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2
Q

What education is available for those with T2DM?

A
  • Practice Nurse/GP
  • Online education –no delays, DUK, Mydiabetesmyway,
  • Group Education session
  • Dietetic advice (not always 1 to 1 with dietician)
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3
Q

What should a T2DM patient expect from their care?

A
  • 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
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4
Q

Give an a example of what may be covered in a consultation.

A
  • Review data in SCI diabetes. Essentially gain an idea what could be looked at for health improvement – any new meds suggested etc
  • Ask patient open question – How has life/health/diabetes been?
  • Review blood glucose levels.
  • Establish what improvements the patient feels they could make.
  • Establish any challenging times ahead eg holidays, hospital admissions weddings, etc where glycaemic control may be more challenging
  • Try to set goals and come up with ‘care plan’
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5
Q

How is information shared between healthcare professionals?

A

SCI Diabetes

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6
Q

What is the aim of diabetes treatment?

A
  • Relief of primary symptoms
  • Prevention of complications
  • Preservation of quality of life
  • Damage minimalisation
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7
Q

What are the 3 possible ‘solutions’ in terms of diabetes drugs?

A
  • Increase insulin release
  • Increase excretion of glucose
  • Improve insulin action
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8
Q

What are the symptoms of uncontrolled T2DM?

A
  • Frequent urination
  • Increased thirst
  • Blurry vision
  • Increased hunger
  • Feeling drowsy or sleepy
  • Slow or improper healing of cuts and bruises
  • Tingling, pain or numbness in hands and feet
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9
Q

What other factors can contribute to the prevention of diabetic complications other than glycaemic control?

A
  • Smoking
  • Mood
  • Diet
  • Physical activity levels
  • BP
  • Cholesterol
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10
Q

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

A
  • 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
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11
Q

Who may you consider relaxing the target HbA1c for?

A
  • People who are older or frail
  • For adults with type2 diabetes:
    1. With reduced life expectancy
    2. 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.
    3. Intensive management not appropriate- multiple comorbidities.
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12
Q

Why is metformin usually first choice?

A
  • Improves outcomes
  • Well tolerated
  • Cheap
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13
Q

What is the mechanism of action of metformin?

A

Improves insulin action

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14
Q

What class of drugs does metformin belong to?

A

Biguanide

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15
Q

What does metformin act on?

A
  • Muscle

- Liver

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16
Q

How does metformin improve insulin sensitivity?

A
  • Affects glucose production, decrease fatty acid synthesis
  • Improves receptor function
  • Inhibits gluconeogenic pathways
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17
Q

What is the half life of metformin?

A

6 hours

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18
Q

What are the advantages of metformin?

A
  • Improves cardiovascular outcomes and mortality in obese T2 DM
  • Cheap
  • Efficaceous
  • Normally well tolerated
  • Not associated with weight gain
  • HbA1c by 12 – 17% reduction
  • Also used in pregnancy now
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19
Q

What are the disadvantages of metformin?

A
  • Risk of lactic acidosis by inhibiting lactic acid uptake by liver
    • Hypoxia
    • Renal failure (CI if creat<150)
    • Hepatic failure
    • Alcohol abuse
  • GI side effects 20 – 30 %
  • Risk vitamin B12 malabsorption
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20
Q

What is the mechanism of action of the sulfonylureas?

A

Increase insulin release

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21
Q

What do sulfonylureas act on/

A

Pancreas

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22
Q

How do sulfonylureas increase insulin release?

A
  • Binds to sulfonylurea receptors (SUR-1) on functioning pancreatic 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
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23
Q

Give 3 examples of sulfonylureas.

A
  • Glimepiride
  • Gliclazide
  • Glipizide
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24
Q

What are the advantages of sulfonylureas?

A
  • Used with metformin
  • Rapid improvement in control
  • Rapid improvement if symptomatic
  • Rapid titration
  • Cheap
  • Generally well tolerated
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25
Q

What are the disadvantages of sulfonylureas?

A
  • Risk of hypoglycaemia
  • Weight gain
  • Caution in renal and hepatic disease
  • CI in pregnancy and breastfeeding.
  • SE include: hypersensitivity and photosensitivity reactions, blood disorders
26
Q

What is the mechanism of action of the thiazolidinedione’s?

A

Improve insulin action

27
Q

What do the thiazolidinediones act on?

A
  • Adipose tissue
  • Muscle
  • Liver
28
Q

How do thiazolididiones improve insulin action?

A
  • Selectively stimulates thenuclear receptorperoxisome proliferator-activated receptor gamma (PPAR-gamma) and to a lesser extentPPAR - alpha
  • Modulates the transcription of theinsulin-sensitive genes involved in the control of glucose andlipid metabolismin themuscle,adipose tissue, and theliver.
  • Reduces insulin resistancein the liver and peripheral tissues;
  • Increases the expense of insulin-dependent glucose;
  • Decreases withdrawal of glucose from the liver;
  • Reduces quantity of glucose, insulin andglycated haemoglobinin the bloodstream.
29
Q

What are the advantages of Pioglitazone?

A
  • Good for people if insulin resistance significant
  • HbA1c by 0.6-1.3%
  • Cheap
  • Cardiovascular safety established
30
Q

What are the disadvantages of thiazolididiones?

A

-Increase risk of bladder cancer (caution in those of increased risk bladder cancer (Age, industry etc))
-Fluid retention - CCF
-Weight gain
-Fractures in females:
(Small increased risk,
TZDs affect bone turnover,
Reduced BMD,
Initial report were of increased distal fractures in women)

31
Q

Give an example of thiazolididione.

A

Pioglitazone

32
Q

What is the usual approach to T2DM management?

A
  • Lifestyle
  • Metformin
  • Sulfonylureas
  • 3rd line agents
33
Q

Give examples of DPPIV inhibitors.

A
  • Sitagliptin
  • Saxagliptin
  • Vildagliptin
34
Q

Where are DPPIV inhibitors suggested in the approach to T2DM management?

A
  • 2nd line option

- Third live option

35
Q

What is the mechanism of action of DPPIV inhibitors?

A

Increase insulin release

36
Q

What are incretin hormones?

A

Hormones that stimulate insulin secretion in response to meals.

37
Q

How do DPPIV inhibitors increase insulin release?

A
  • Incretin hormones are released by the GIT. They act on the pancreas to increase Insulin release
  • DPP-4 enzyme rapidly degrades incretins decreasing insulin release
  • DPPIV inhibitors delay the breakdown of incretins by inhibiting DPP-4 enzyme and thereby increase active incretin levels increasing insulin release.
38
Q

What are the advantages of DPPIV inhibitors?

A
  • Usually well tolerated
  • Can be used as 2nd or 3rd line agent
  • Can be used in renal impairment
  • No risk of hypoglycaemia
  • Weight neutral
39
Q

What are the disadvantages of DPPIV inhibitors?

A
  • Trial data shows relatively small effects on glycemic control
  • CI in pregnancy and breastfeeding.
  • Possible increased risk of pancreatitis and pancreatic cancer
  • SE: nausea
40
Q

Give examples of GLP-1 analogues.

A
  • Lixisenatide
  • Liraglutide
  • Exenatide
  • Bydureon
41
Q

Where are GLP-1 analogues suggested in the approach to T2DM management?

A

-Third line injectable option

42
Q

What is the mechanism of action of GLP-1 analogue?

A

Increase insulin release

43
Q

How do GLP-1 analogues increase insulin release?

A
  • Incretin hormones are released by the GIT. They act on the pancreas to increase Insulin release
  • DPP-4 enzyme rapidly degrades incretins decreasing insulin release
  • GLP-1 analogues are resistant to this degradation, thus have a greatly prolonged half life.
  • Therefore incretin activity release is increased and there is increase in insulin stimulation
44
Q

What is a common side effect of incretin mimetics?

A

Nausea

45
Q

How should GLP-1 analogues be used according to SIGN?

A
  • 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
46
Q

What are the advantages of GLP-1 analogues?

A
  • Weight loss
  • No risk of hypoglycaemia
  • 3rd line agent
  • Can be used with basal insulin
47
Q

What are the disadvantages of GLP-1 analogues?

A
  • Injection
  • Very expensive
  • Possible increased risk of pancreatitis and pancreatic cancer
  • CI in pregnancy and breastfeeding.
  • SE: Nausea, vomiting
48
Q

Give examples of SGLT2 inhibitors.

A
  • Canaglifolzin
  • Empagliflozin
  • Dapagliflozin
49
Q

Where should SGLT2 inhibitors be used in the management of T2DM?

A
  • 2nd line option

- 3rd line option

50
Q

What is the mechanism of action of SGLT-2 inhibitors?

A

Increase excretion of glucose

51
Q

How do SGLT2 inhibitors increase the excretion of glucose?

A
  • In the kidney the majority of glucose is reabsorbed by SGLT2
  • SGLT2 inhibitors inhibit SGLT2 which decreases glucose reabsorption
  • This increases secretion of glucose in the urine
52
Q

What are the SGLT2 inhibitor effects?

A
  • Gets rid of glucose/ more glycosuria (lowers HbA1c)
  • Gets rid of water/ osmotic rehydration (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)
53
Q

What are the advantages of SGLT2 inhibitors?

A
  • 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
54
Q

What are the disadvantages of SGLT2 inhibitors?

A
  • Expensive
  • SE: UTI, fungal infections, osmotic symptoms
  • Risk of digital amputation
  • Risk of DKA
  • CI in pregnancy and breastfeeding.
  • Cannot use in renal impairment
55
Q

Where is insulin used in the approach to T2DM management?

A

3rd line injectable

56
Q

Why is insulin used in T2DM?

A
  • There may be progressive relative insulin deficiency

- Use may become inevitable

57
Q

How is isophane insulin used?

A
  • Once daily injection

- Usually at bedtime

58
Q

What should be done if HbA1c rise to 58mmol/mol (7.5%) when on a single drug?

A

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.
59
Q

What HbA1c target should be set for an adult on a drug associated with hypoglycaemia?

A

Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).

60
Q

What HbA1c target should be set for an adult managed by diet and lifestyle +/- a single drug not associated with hypoglycaemia?

A

Support the person to aim for an HbA1c level of 48 mmol/mol (6.5%).

61
Q

How should someone be managed when a new treatment is initiated?

A
  • Review at 3-6 months
  • If its not working stop it
  • At the start agree a trial period (usually up to 6months) and agree a target. (Usually at least 5mmol/mol reduction in HbA1c)
  • Note this does not apply to agents that the person has responded to for many years e.g. Sulfonylureas

Systems: Endocrine AB (25 decks)

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