Management of Type 2 Flashcards
What should a patient expect from their care?
- BG levels
- BP
- Blood lipids
- Eyes screened
- Feet checked
- Kidney function
- Weight
- Smoking cessation support
- Individual care plan
- Education course
- Emotional + psychological support
What sort of questions should be asked in a type 2 consultation?
- How has life/health/diabetes been? (open Q)
- What improvements patient feels they could make
- Establish challenging times for glycaemic control ahead e.g. hols, weddings
- Review BG levels
What are the 4 main aims of diabetes treatment?
Relief of primary symptoms
Prevention of complications
Preservation of quality of life
Damage minimalisation
What are the 3 pancreatic defects found in type 2 and what are their effects?
BETA CELL DYSFUNCTION
DIMINISHED INCRETIN EFFECT
= decreased insulin production
EXCESS GLUCAGON
= decreased insulin action
What is the defect found in the periphery in type 2 and what is its effect?
INSULIN RESISTANCE
= insulin resistance
Name 4 meds which increase insulin release
Sulphonylureas
Metiglinides
Incretin Mimetics
DPPIV inhibitors
What med increases excretion of glucose?
SCLT2 inhibitors
Name 3 meds/methods which improve insulin action
Biguanides
Thiazolidiones
Weight reductions
Give 7 signs of type 2 DM
Thirst
Blurry vision
Drowsiness/sleepiness
Increased hunger
Frequent urination
Slow/improper healing of cuts and bruises
Tingling, pain or numbness in hands + feet
Other than meds, what else needs considered in type 2 to prevent complications?
Smoking Mood Statins Blood pressure Physical activity Diet
Step 1 of framework for choosing glucose lowering drug
Set a target HbA1c
Step 2 of framework for choosing glucose lowering drug
‘Take 5’ - are there other risk factors to be treated first
Step 3 of framework for choosing glucose lowering drug
Are the current treatments optimised; max dose, tolerated, taken?
Step 4 of framework for choosing glucose lowering drug
What are the glucose lowering options?
- remove any contraindicated
- of remaining what r pros n cons
- select preferred choice
Step 5 of framework for choosing glucose lowering drug
Agree a review date and target HbA1c with patient
In who should the target HbA1c level be relaxed?
People who r older/frail
Adults with reduced life expectancy
Adults at high risk of the consequences of hypo (falling, impaired awareness of it, those who drive/operate machinery)
People in whom intensive management is not appropriate - multiple comorbidities
What is the usual first line oral treatment for type 2?
Metformin
What is the first line is there are osmotic/weight loss symptoms?
Sulfonylurea
What is added as the usual 2nd line oral treatment for type 2?
Sulfonylurea
What other 3 meds can be 2nd line if contraindications to Sulfonylurea (for all - if hypos a concern)?
Thiazolidinedione(if no CCF)
DPP-IV inhibitor (if weight gain a concern)
SGLT-2 inhibitor (if weight gain a concern)
Then review 2nd line meds, if not reaching target then move to 3rd line and add/substitute - give the 3 oral 3rd line agents?
Thiazolidinedione
DPP-IV inhibitor
SGLT-2 inhibitor
Give the 2 injectable 3rd line meds, and the indications for each?
GLP-1 agonist (if BMI>30kg/m2; if desire to lose wt; usually <10 yrs from diagnosis)
Insulin (if osmotic symptoms/rising HbA1c)
Continue medication if either…
glycaemic target acheived or HbA1c falls >5mmol/mol in 3-6 months
Give the 3 common names for Sulfonylureas
GLIMEPIRIDE
GLICLAZIDE
GLIPIZIDE
(the ‘gli…ides’)
Give the common name for Thiazolidinedione
PIOGLITAZONE
Give the common name for DPP-IV inhibitor
SITAGLIPTIN
Give the common name for SGLT-2 inhibitor
EMPAGLIFLOZIN
Give the common name for GLP-agonist
LIXISENATIDE
What type of drug is metformin?
A biguanide
What is the action of metformin?
Improves insulin sensitivity
How does metformin improve insulin sensitivity?
Affects glucose production, decreases FA synthesis
Improves receptor function
Inhibits gluconeogenic pathways
What are some advantages of metformin?
Improves CVS outcomes + mortality in obese T2 DM Cheap Efficaceous Well tolerated No weight gain Used in pregnancy HbA1c by 12-17% reduction
What are 3 possible disadvantages of metformin?
Risk of lactic acidosis (by inhibiting lactic acid uptake by liver)
GI side effects 20-30%
Risk vitamin B12 malabsorption
How do sulfonylureas work?
By increasing insulin release
What is the mechanism by which sulfonylureas increase insulin release?
Binds to its receptor Closes of ATP sensitive potassium channels Decrease potassiun Depolarisation Influx of calcium Insulin is exocytosed
What are some advantages of sulphonylureas?
Used with metformin Rapid improvement in control/symptoms Rapid titration Cheap Genereally well tolerated
What are some disadvantages of sulphonylureas?
Risk of hypo Weight gain Caution in renal/hepatic disease CI in pregnancy and breastfeeding SE include hypersensitivity/photosensitivity reactions; blood disorders
What is the action of thiazoliinedione?
really only pioglitazone
Improve insulin action/reduces insulin resistance by sensitising liver and muscle to increase glucose uptake
Give some advantages of thiazoliinedione
Good for people if insulin resistance significant
HbA1c by 0.6-1.3%
Cheap
CVS safety established in pioglitazone
Give some disadvantages of thiazoliinedione
Increase risk of bladder cancer
Fluid retention - CCF
Weight gain
Fractures in females (small risk)
