Management of Type 2 Diabetes - 1 Flashcards
What should a patient expect from their care?
- Blood glucose levels
- Blood Pressure
- Blood Lipids
- Eyes, feet + kidney check
- Weight
- Smoking Cessation Support
- Individual Care plan
- Education Course
- Emotional and psychological support
What are four aims of management?
- Relief of primary symptoms
- Prevention of complication
- Preservation of QOL
- Damage minimisation
What are the defects that occur in NIDDM?
Pancreas:
• Beta cell dysfunction
• Diminished incretin effect
• Excess glucagon
Periphery:
• Insulin resistance
What are the effects of the defects in T2DM?
- Decreased insulin production
- Decreased insulin action
This increases BG levels
What are possible treatment options for increased insulin release?
- Sulphonylureas
- Metiglinides
- Incretin mimetics
- DPPIV inhibitors
What are possible treatment options for increased excretion of Glc?
SGLT2 inhibitors
What are possible treatment options to improve insulin action?
- Biguanides
- Thiazolidiones
- Weight reduction
What are the symptoms of uncontrolled T2DM?
- Frequent urination
- Increased thirst
- Blurry vision
- Increased hunger
- Feeling drowsy
- Tingling, pain or numbness in hands and feet
- Slow healing of cuts and bruises
What factors that increase risk of complications?
- Smoking
- Mood
- Dietary change
- Statins
- BP
- Sedentary lifestyle
Do we need to achieve tight glycaemic control in everyone?
Heterogeneous population
Risk of hypoglycaemia
Effect of intensive control on those with established cardiovascular disease
What is the 5 step framework for choosing a Glc lowering drug?
- Set HbA1c target
- Are there other risk factors that need to be treated?
- Are current treatments optimised?
- What are the Glc lowering options?
- Arrange review date and target for HbA1c
What is the 1st line treatment of T2DM?
Metformin (or sulfonylurea - if weight loss/osmotic symptoms)
Review and if not reaching target move to 2nd line
What is the 2nd line treatment of T2DM?
Sulfonylurea
Or:
• Thiazolidinedione
• DPP-IV inhibitor
• SGLT-2 inhibitor
Review and if not reaching target move to 3rd line
What is the 3rd line treatment of T2DM?
In addition to lifestyle measures, adherence to medication and dose optimisation; add:
Oral:
• Thiazolidinedione
• DPP-IV inhibitor
• SGLT-2 inhibitor
Injectable:
• GLP-1 agonist
• Insulin
Why is metformin first choice treatment option?
- Improves Glc control without significnt weight gain and CVS outcomes
- Well tolerated
- Cheap
- Can be used in pregnancy
What class of drug is metformin?
Biguanide
What is the action of metformin?
Improves insulin sensitivity
• Affects glucose production, decrease fatty acid synthesis
• Improves receptor function
• Inhibits gluconeogenic pathways
Half life is 6hrs
What are the disadvantages of metformin?
• Risk of lactic acidosis by inhibiting lactic acid uptake by liver
- Hypoxia, renal/hepatic failure
• GI side effects
• Risk Vit B12 malabsorption
What is the action of Sulphonylureas?
- 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
What are the advantages of Sulphonylureas?
- Used with metformin
- Rapid improvement in control
- Rapid improvement if symptomatic
- Rapid titration
- Cheap
- Generally well tolerated
What are the disadvantages of Sulphonylureas?
- Risk of hypoglycaemia
- Weight gain
- Caution in renal and hepatic disease
- CI in pregnancy and breastfeeding.
What is the mechanism of thiazolidinediones?
Stimulates thenuclear receptorPPAR-gamma and to a lesser extentPPAR - alpha on liver, muscle and adipose tissue
Modulates the transcription of theinsulin-sensitive genes involved in the control of glucose andlipid metabolism
What are the effects of thiazolidinediones?
- 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 (a thiazolidinedione)?
- Good for people if insulin resistance significant
* Cheap
What are the disadvantages of pioglitazone (a thiazolidinedione)?
- Increase risk of bladder cancer
- Fluid retention - CCF
- Weight gain
- Fractures in females
