Management of Type 2 Diabetes Flashcards
Who is part of the MDT for diabetes?
Diabetes doctors
Specialist nurses
GP’s
Clinical psychologists
Podiatrists
Dieticians
What are the sources of education for T2DM?
Practice nurse / GP
Online education (DUK, mydiabetesmyway)
Group education sessions
Dietic advice
What are the 15 things a person with diabetes can expect from their care?
- Blood glucose levels measured
- Blood pressure measured
- Blood fats measured
- Eye screening
- Feet checked
- Kidney function monitored
- Weight checked
- Smoking cessation support
- Receive a care plan
- Attend an education course in the local area
- Care from special paediatric team if you are a child or a young person
- High quality care if admitted to hospital
- Information and specialist care if planning on having a baby
- See specialist diabetes healthcare professionals
- Get emotional and psychological support
What are the aims of diabetes treatment?
- RELIEF OF PRIMARY SYMPTOMS
- PREVENTION OF COMPLICATIONS
- PRESERVATION OF QUALITY OF LIFE
- DAMAGE MINIMALISATION
What aspects of diabetes result in decreased insulin production?
Beta cell dysfunction
Diminished incretin effect
What aspects of type 2 diabetes results in decreased insulin action?
Excess glucagon
Insulin resistance
In summary the reason for increased glucose levels is because of a decreased insulin production in combination with a decreased insulin action
One of the problems established was a decrease in insulin production - what are the solutions used to tackle this problem?
- Sulphonylureas
- Metiglinides
- Incretin Mimetics
- DPPIV inhibitors
What solutions improve insulin action - in response to the decerased insulin action (glucagon excess and increased insulin resistance)?
Biguanides
Thiazolidiones
Weight reduction
What are symptoms of uncontrolled type 2 diabetes?
Frequent urination
Increased thirst
Blurry vision
Increased hunger
Feeling drowsy or sleepy
Slow or improper healing (cuts and bruises)
Tingling pain or numbness in hands and feet
What else needs to be considered apart from medical therapy in terms of controlling type 2 diabetes?
Smoking cessation
Mood control
Statins
Blood pressure control
Physical activity / sedenditary behaviour limited
Dietary change
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? ( I think this may be referring to high blood pressure, smoking, sedenditary lefestyle etc)
- 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 might be subject to reducing the HbA1c level?
•People who are older or frail
•For adults with type 2 diabetes:
- With reduced life expectancy
- 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.
- Intensive management not appropriate- multiple comorbidities
Here is the summary for type 2 diabetes control and the names of the corresponding drugs
Why is metformin normally the first choice?
Improves outcomes
Well tolerated
Cheap
What type of drug is metformin? How does it work?
Biguanide - improves the action of insulin by:
Decreasing fatty acid synthesis
Improves receptor function
Inhibits gluconeogenic pathways
Improves glucose control without significatn weight gain
What are the advantages of metformin?
Advantages:
Improves CVS outcomes and mortality in obese T2DM
Efficaceous - effectively lowers blood sugar levels
Well tolerated
Not associated with weight gain
Used in pregnancy
What are the disadvantages of metformin?
Risk of lactic acidosis by inhibiting lactic acid uptake by the liver:
- Hypoxia
- Renal failure
- Hepatic failure
- Alcohol abuse
GI side effects
Risk of vitamin B12 malabsorption
Give examples of sulphonylureas
Glimepiride
Glicazide
Glipzide
What is the mechanism of sulphonylureas?
Increase the release of insulin - binds to SUR - 1 (sulphonylurea receptors on functioning beta cells)
Binding closes the linked ATP - sensitive potassium channels
Decreased potassium influx depolarisation of the beta - cell membrane
Voltage dependant calcium channels open and result in an influx of calcium
Translocation and exocytosis of secretory granules of insulin to the cell surface
What advantages are attched to glimepiride and glicazide?
Glimeperide - once daily
Glicazide - less renally excreted - indicated in renal failure
What are the advantages of sulphonylurea?
- Used with metformin
- Rapid improvement in control
- Rapid improvement if symptomatic
- Rapid titration
- Cheap
- Generally well tolerated
What are the disadvantages of sulphonylurea?
- Risk of hypoglycaemia
- Weight gain
- Caution in renal and hepatic disease
- CI in pregnancy and breastfeeding.
- Side effects include
- •Hypersensitivity and photosensitivity reactions
- •Blood disorders
What is the action of thiazolidinediones?
Improve the action of insulin
They bind to nuclear receptor PPAR- gamma - in adipose tissue, the muscle and the liver
Increases lipogenesis - enhances the uptake of fatty acids and glucose
What are the advantages of pioglitazone - a thiazolidinedione?
- Good for people if insulin resistance significant
- HbA1c by 0.6-1.3%
- Cheap
- Pioglitazone 45mg od £1.50 x 0.6
- Cardiovascular safety established
- (Contrast with rosiglitazone)
What are the disadvantages of pioglitazone?
•Increase risk of bladder cancer
- Caution in those of increased risk bladder cancer (Age, industry etc)
- Fluid retention - CCF (congested heart failure) - risk in patients with heart failure
- Weight gain
- Fractures in females
- •Small increased risk
- •TZDs affect bone turnover
- •Reduced BMD (bone mineral density)
- •Initial report were of increased distal fractures in women
Here is a summary of metformin, sulphonylureas and pioglitazone
What are incretins?
Hormones that stimulate a decrease in blood sugar levels. They are released after eating.
They augment the release of insulin
They slow the rate of absorption of nutrients into the blood stream (by reducing gastric emptying and may directly reduce food intake)
Inhibit the release of glucagon
Include glucagon like peptide - 1 and gastric inhibatory peptide 1 (GLP-1 and GIP)
What inactivates GLP-1 and GIP?
Both GLP-1 and GIP are rapidly inactivated by the enzyme dipeptidyl peptidase-4 (DPP-4)
What is the effect of a DPPIV?
Causes increase in insulin release
What is the effect of gliptins (DPPIV)?
Delay the breakdown of incretins and thereby increase active incretin levels
What are 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 is the benefit of GLP-1 anologues over the biological GLP-1?
injectable analogues of GLP-1 which are resistant to enzymatic degradation thus with greatly prolonged biological half-life
Give examples of GLP-1 anologues
Lixisenatide - first line (although GLP-1 anologues are 3rd line)
Liraglutide
What are advantages of GLP-1 anologues?
Weight loss
No risk of hypoglycaemia
3rd line agent
Can be used with basal insulin
What are the disadvantages of GLP-1 anologues?
- Injection
- Very expensive
- Possible increased risk of pancreatitis and pancreatic cancer
- Contradindicated in pregnancy and breastfeeding.
- Side effects include:
- Nausea, vomiting
What is the effect of SGLT 2 inhibitors?
They increase the excretion of glucose
Normally SGLT2 is responsible for the reabsorption of 90% of blood glucose
Gliflozins selectively inhibit SGLT2 in the renal proximal tubule
Lowers HbA1C
Increases osmotic diuresis (potential for dehydration and hypotension)
Gets rid of calories (lose weight with the 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?
•Side effects:
•UTI, fungal infections, osmotic symptoms
•Risk of digital amputation
•Risk of DKA
•CI in pregnancy and breastfeeding.
•Cannot use in renal impairment
What are the common insulin regimens for type 2 diabetes?
Isophane insulin
(Humulin 1)
Summary of all agents
What are HbA1c targets?
- For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%).
- For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).
- If HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
- 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.
