Management of T2DM Flashcards
Who is part of the diabetes team?
- The patient
- Specialist nurse
- Dieticians
- Podiatrists
- Clinical psychologists
- GPs
- Diabetes doctors
- other specialists
What education is available for those with T2DM?
- Practice Nurse/GP
- Online education –no delays, DUK, Mydiabetesmyway,
- Group Education session
- Dietetic advice (not always 1 to 1 with dietician)
What should a T2DM patient expect from their care?
- 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
Give an a example of what may be covered in a consultation.
- 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’
How is information shared between healthcare professionals?
SCI Diabetes
What is the aim of diabetes treatment?
- Relief of primary symptoms
- Prevention of complications
- Preservation of quality of life
- Damage minimalisation
What are the 3 possible ‘solutions’ in terms of diabetes drugs?
- Increase insulin release
- Increase excretion of glucose
- Improve insulin action
What are the symptoms of uncontrolled T2DM?
- 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
What other factors can contribute to the prevention of diabetic complications other than glycaemic control?
- Smoking
- Mood
- Diet
- Physical activity levels
- BP
- Cholesterol
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
Who may you consider relaxing the target HbA1c for?
- 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.
Why is metformin usually first choice?
- Improves outcomes
- Well tolerated
- Cheap
What is the mechanism of action of metformin?
Improves insulin action
What class of drugs does metformin belong to?
Biguanide
What does metformin act on?
- Muscle
- Liver
How does metformin improve insulin sensitivity?
- Affects glucose production, decrease fatty acid synthesis
- Improves receptor function
- Inhibits gluconeogenic pathways
What is the half life of metformin?
6 hours
What are the advantages of metformin?
- 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
What are the disadvantages of metformin?
- 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
What is the mechanism of action of the sulfonylureas?
Increase insulin release
What do sulfonylureas act on/
Pancreas
How do sulfonylureas increase insulin release?
- 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
Give 3 examples of sulfonylureas.
- Glimepiride
- Gliclazide
- Glipizide
What are the advantages of sulfonylureas?
- Used with metformin
- Rapid improvement in control
- Rapid improvement if symptomatic
- Rapid titration
- Cheap
- Generally well tolerated
What are the disadvantages of sulfonylureas?
- Risk of hypoglycaemia
- Weight gain
- Caution in renal and hepatic disease
- CI in pregnancy and breastfeeding.
- SE include: hypersensitivity and photosensitivity reactions, blood disorders
What is the mechanism of action of the thiazolidinedione’s?
Improve insulin action
What do the thiazolidinediones act on?
- Adipose tissue
- Muscle
- Liver
How do thiazolididiones improve insulin action?
- 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.
What are the advantages of Pioglitazone?
- Good for people if insulin resistance significant
- HbA1c by 0.6-1.3%
- Cheap
- Cardiovascular safety established
What are the disadvantages of thiazolididiones?
-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)
Give an example of thiazolididione.
Pioglitazone
What is the usual approach to T2DM management?
- Lifestyle
- Metformin
- Sulfonylureas
- 3rd line agents
Give examples of DPPIV inhibitors.
- Sitagliptin
- Saxagliptin
- Vildagliptin
Where are DPPIV inhibitors suggested in the approach to T2DM management?
- 2nd line option
- Third live option
What is the mechanism of action of DPPIV inhibitors?
Increase insulin release
What are incretin hormones?
Hormones that stimulate insulin secretion in response to meals.
How do DPPIV inhibitors increase insulin release?
- 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.
What are 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
Give examples of GLP-1 analogues.
- Lixisenatide
- Liraglutide
- Exenatide
- Bydureon
Where are GLP-1 analogues suggested in the approach to T2DM management?
-Third line injectable option
What is the mechanism of action of GLP-1 analogue?
Increase insulin release
How do GLP-1 analogues increase insulin release?
- 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
What is a common side effect of incretin mimetics?
Nausea
How should GLP-1 analogues be used according to SIGN?
- 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 are the advantages of GLP-1 analogues?
- Weight loss
- No risk of hypoglycaemia
- 3rd line agent
- Can be used with basal insulin
What are the disadvantages of GLP-1 analogues?
- Injection
- Very expensive
- Possible increased risk of pancreatitis and pancreatic cancer
- CI in pregnancy and breastfeeding.
- SE: Nausea, vomiting
Give examples of SGLT2 inhibitors.
- Canaglifolzin
- Empagliflozin
- Dapagliflozin
Where should SGLT2 inhibitors be used in the management of T2DM?
- 2nd line option
- 3rd line option
What is the mechanism of action of SGLT-2 inhibitors?
Increase excretion of glucose
How do SGLT2 inhibitors increase the excretion of glucose?
- 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
What are the SGLT2 inhibitor effects?
- 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)
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
Where is insulin used in the approach to T2DM management?
3rd line injectable
Why is insulin used in T2DM?
- There may be progressive relative insulin deficiency
- Use may become inevitable
How is isophane insulin used?
- Once daily injection
- Usually at bedtime
What should be done if HbA1c rise to 58mmol/mol (7.5%) when on a single drug?
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.
What HbA1c target should be set for an adult on a drug associated with hypoglycaemia?
Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).
What HbA1c target should be set for an adult managed by diet and lifestyle +/- a single drug not associated with hypoglycaemia?
Support the person to aim for an HbA1c level of 48 mmol/mol (6.5%).
How should someone be managed when a new treatment is initiated?
- 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
