Management of Type 2 diabetes Flashcards
HbA1c targets and reference points?
It’s worthwhile thinking of the average patient who is taking metformin for Type 2 diabetes, you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%)
so target is 48 mmol/mol but only add 2nd drug if 58 mmol/mol
Dietary advice: Type 2
encourage high fibre, low glycaemic index sources of carbohydrates
include low-fat dairy products and oily fish
control the intake of foods containing saturated fats and trans fatty acids
limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
discourage the use of foods marketed specifically at people with diabetes
initial target weight loss in an overweight person is 5-10%
How often should HbA1c be checked?
Every 3-6 months until stable, then 6 monthly
Individual targets should be agreed with patients to encourage motivation
a patient is newly diagnosed with HbA1c and wants to try lifestyle treatment first. You agree on a target of:
48 mmol/mol
a patient is newly diagnosed with HbA1c and wants to try lifestyle + metformin treatment first. You agree on a target of:
48 mmol/mol
you review a patient 6 months after starting metformin. His HbA1c is 51 mmol/mol (6.8%). You …
You increase his metformin from 500mg bd to 500mg tds and reinforce lifestyle factors
HbA1c target: lifestyle + a drug which may cause hypoglycaemia (eg sulfonylurea)?
53 mmol/mol
CI of Metformin?
if the patient has a risk of CVD, established CVD or chronic heart failure:
- SGLT-2 monotherapy
if the patient doesn’t have a risk of CVD, established CVD or chronic heart failure:
- DPP‑4 inhibitor or pioglitazone or a sulfonylurea
- SGLT-2 may be used if certain NICE criteria are met
Metformin remains the first-line drug of choice in ?
Type 2 diabetes
metformin should be titrated up slowly, why?
to minimise the possibility of GI upset
if standard-release metformin is not tolerated then modified-release metformin should be trialled
When can SGLT-2 inhibitors be given?
should also be given in addition to metformin if any of the following apply:
- the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
- the patient has established CVD
- the patient has chronic heart failure
metformin should be established and titrated up before introducing the SGLT-2 inhibitor
SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure
If triple therapy is not effective or tolerated consider switching one of the drugs for a GLP-1 mimetic:
BMI ≥ 35 kg/m² and specific psychological or other medical problems associated with obesity or
BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities
only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
GLP-1 mimetics should only be added to insulin under specialist care
Risk factor modification: hypertension
blood pressure targets are the same as for patients without type 2 diabetes
ACE inhibitors or angiotensin II receptor blockers (ARB) are first-line
- an ARB is preferred if the patient has a black African or African–Caribbean family origin
Age < 80 years: clinic BP 140/90 mmHg, ABPM/HMPM 135/85
Age>80 clinic: 140/90mmHg, ABPM/HMPMP 145/85 mmHg
Lipids: lifestyle
following the 2014 NICE lipid modification guidelines only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg
Secondary prevention (known IHD or cerebrovascular disease OR peripheral arterial disease) - Atorvastatin 80mg od
Antiplatelets: lifestyle
should not be offered unless a patient has existing cardiovascular disease
