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MBChB - Y2 - Endocrine > Management of Type 2 Diabetes > Flashcards

Management of Type 2 Diabetes Flashcards

1
Q

Who is part of the MDT for diabetes?

A

Diabetes doctors

Specialist nurses

GP’s

Clinical psychologists

Podiatrists

Dieticians

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2
Q

What are the sources of education for T2DM?

A

Practice nurse / GP

Online education (DUK, mydiabetesmyway)

Group education sessions

Dietic advice

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3
Q

What are the 15 things a person with diabetes can expect from their care?

A
  1. Blood glucose levels measured
  2. Blood pressure measured
  3. Blood fats measured
  4. Eye screening
  5. Feet checked
  6. Kidney function monitored
  7. Weight checked
  8. Smoking cessation support
  9. Receive a care plan
  10. Attend an education course in the local area
  11. Care from special paediatric team if you are a child or a young person
  12. High quality care if admitted to hospital
  13. Information and specialist care if planning on having a baby
  14. See specialist diabetes healthcare professionals
  15. Get emotional and psychological support
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4
Q

What are the aims of diabetes treatment?

A
  • RELIEF OF PRIMARY SYMPTOMS
  • PREVENTION OF COMPLICATIONS
  • PRESERVATION OF QUALITY OF LIFE
  • DAMAGE MINIMALISATION
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5
Q

What aspects of diabetes result in decreased insulin production?

A

Beta cell dysfunction

Diminished incretin effect

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6
Q

What aspects of type 2 diabetes results in decreased insulin action?

A

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

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7
Q

One of the problems established was a decrease in insulin production - what are the solutions used to tackle this problem?

A
  • Sulphonylureas
  • Metiglinides
  • Incretin Mimetics
  • DPPIV inhibitors
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8
Q

What solutions improve insulin action - in response to the decerased insulin action (glucagon excess and increased insulin resistance)?

A

Biguanides

Thiazolidiones

Weight reduction

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9
Q

What are symptoms of uncontrolled type 2 diabetes?

A

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

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10
Q

What else needs to be considered apart from medical therapy in terms of controlling type 2 diabetes?

A

Smoking cessation

Mood control

Statins

Blood pressure control

Physical activity / sedenditary behaviour limited

Dietary change

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11
Q

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

A
  1. Set a target HbA1c
  2. “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)
  3. Are the current treatments optimised. Max dose? Tolerated? Taken?
  4. What are the glucose lowering options?
  • Remove any that are contraindicated
  • Of the remaining what are the pros and cons
  • Select the preferred choice.
  1. Agree a review date and the target HbA1c with the patient
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12
Q

Who might be subject to reducing the HbA1c level?

A

•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
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13
Q

Here is the summary for type 2 diabetes control and the names of the corresponding drugs

A
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14
Q

Why is metformin normally the first choice?

A

Improves outcomes

Well tolerated

Cheap

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15
Q

What type of drug is metformin? How does it work?

A

Biguanide - improves the action of insulin by:

Decreasing fatty acid synthesis

Improves receptor function

Inhibits gluconeogenic pathways

Improves glucose control without significatn weight gain

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16
Q

What are the advantages of metformin?

A

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

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17
Q

What are the disadvantages of metformin?

A

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

18
Q

Give examples of sulphonylureas

A

Glimepiride

Glicazide

Glipzide

19
Q

What is the mechanism of sulphonylureas?

A

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

20
Q

What advantages are attched to glimepiride and glicazide?

A

Glimeperide - once daily

Glicazide - less renally excreted - indicated in renal failure

21
Q

What are the advantages of sulphonylurea?

A
  • Used with metformin
  • Rapid improvement in control
  • Rapid improvement if symptomatic
  • Rapid titration
  • Cheap
  • Generally well tolerated
22
Q

What are the disadvantages of sulphonylurea?

A
  • 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
23
Q

What is the action of thiazolidinediones?

A

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

24
Q

What are the advantages of pioglitazone - a thiazolidinedione?

A
  • 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)
25
Q

What are the disadvantages of pioglitazone?

A

•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
26
Q

Here is a summary of metformin, sulphonylureas and pioglitazone

A
27
Q

What are incretins?

A

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)

28
Q

What inactivates GLP-1 and GIP?

A

Both GLP-1 and GIP are rapidly inactivated by the enzyme dipeptidyl peptidase-4 (DPP-4)

29
Q

What is the effect of a DPPIV?

A

Causes increase in insulin release

30
Q

What is the effect of gliptins (DPPIV)?

A

Delay the breakdown of incretins and thereby increase active incretin levels

31
Q

What are 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
32
Q

What is the benefit of GLP-1 anologues over the biological GLP-1?

A

injectable analogues of GLP-1 which are resistant to enzymatic degradation thus with greatly prolonged biological half-life

33
Q

Give examples of GLP-1 anologues

A

Lixisenatide - first line (although GLP-1 anologues are 3rd line)

Liraglutide

34
Q

What are advantages of GLP-1 anologues?

A

Weight loss

No risk of hypoglycaemia

3rd line agent

Can be used with basal insulin

35
Q

What are the disadvantages of GLP-1 anologues?

A
  • Injection
  • Very expensive
  • Possible increased risk of pancreatitis and pancreatic cancer
  • Contradindicated in pregnancy and breastfeeding.
  • Side effects include:
  • Nausea, vomiting
36
Q

What is the effect of SGLT 2 inhibitors?

A

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)

37
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
38
Q

What are the disadvantages of SGLT2 inhibitors?

A

•Side effects:

•UTI, fungal infections, osmotic symptoms

•Risk of digital amputation

•Risk of DKA

•CI in pregnancy and breastfeeding.

•Cannot use in renal impairment

39
Q

What are the common insulin regimens for type 2 diabetes?

A

Isophane insulin

(Humulin 1)

40
Q

Summary of all agents

A
41
Q

What are HbA1c targets?

A
  • 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.

MBChB - Y2 - Endocrine (25 decks)

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