management of type 2 diabetes Flashcards
how many scots suffer from type two diabetes?
Over 300,000 Scots living with type 2 diabetes, including those yet to be diagnosed. People with type 2 diabetes 50% more likely to die prematurely.
what is the prevalence of type two diabetes in scotland?
2020: 317,128 (5.8%)
Grampian: 2002: 10,500
Grampian: 2020: 30,994 (5.3%)
(increase by nearly 200%)
how does type 2 diabetes affect males versus females?
T1DM (Men 55.7%, Women 44.3%)
T2DM (Men 56.4%, Women 43.6%)
how does weight influence prevalence of type 2 diabetes?
56% Obese (BMI>30)
31.3 % Overweight (25-29.9)
how many hours will the average person with diabetes spend with a healthcare proffessional?
The average person with diabetes will spend 3 hours with a Healthcare Professional and will take care of themselves for the remaining 8757 hours in a year
who is involved in the diabetic team?
where can type two diabetic patients get information from?
Practice Nurse/GP – Linked to consultant and DSN/community teams
Online education – DUK, Mydiabetesmyway,
Group Education session
Dietetic advice
Website and videos
what should a person with diabetes expect?
diabetes UK
what should a patient with diabetes expect from their care?
Blood glucose levels
Blood Pressure
Blood Lipids
Eyes Screened
Feet checked
Kidney function
Weight
Smoking Cessation Support
Individual Care plan
Education Course
Emotional and psychological support
how can a diabetes patient be supported to self manage?
what is mydiabetesmyway?
The My Diabetes My Way app provides secure access to your electronic personal health record. This record includes your clinic results such as HbA1c, blood pressure and cholesterol as well as allowing you to upload and view home-recorded data, see changes through time and set goals.
what is Sci diabetes care?
Diabetes Collaboration (SCI-DC) is the national suite of products designed to underpin the Managed Clinical Networks for diabetes in Scotland. It provides a shared electronic patient record to deliver IM&T in support of treatment of people with diabetes in Scotland.
how infromation is shared between healthcare proffessional - both primary and secondary care
what should be discussed in an example consultation?
Consider ‘your agenda’ - Identify ‘red flags’ that need addressed.
Ask person what matters to them?
Review results – together
Discuss what needs addressed
Consider any challenging times ahead eg holidays, hospital admissions weddings, etc where glycaemic control may be more challenging
Try to set goals and come up with ‘care plan’
what are the aims of diabetes treatment?
RELIEF OF PRIMARY SYMPTOMS
PREVENTION OF COMPLICATIONS
How else can this be addressed?
PRESERVATION OF QUALITY OF LIFE
Balance good effects against side effects
DAMAGE MINIMALISATION
Avoidance of emergencies.
what are primary symptoms of uncontrolled type two diabetes?
describe the defects of pancreas and periphery in type 2 diabetes?
what are the effects from type two diabetes?
what are the solutions of type 2 diabetes?
what else needs to be considered in prevention of complications relating to lifestyle?
what are the benefits of BP control?
what are the benefits of good diabetic control?
what is the legacy effect of earlier glucose control?
what is the 5 step framework for choosing a glucose lowering drug?
what are the NICE guidelines on relaxing the target HbA1c level on a case-by-case basis?
1.1 Individualised care
1.1.1 Adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities and risks from polypharmacy, and their likelihood of benefiting from long-term interventions. Such an approach is especially important in the context of multimorbidity. [2015, amended 2022]
1.1.2 Reassess the person’s needs and circumstances at each review and think about whether to stop any medicines that are not effective. [2015]
1.1.3 Take into account any disabilities, including visual impairment, when planning and delivering care for adults with type 2 diabetes. [2015]
why is metformin normally first choice?
Improves outcomes
Well tolerated
Cheap
what is the solution brought about by use of metformin?
imporving the action of insulin
what organs does metformin predominantly work on?
liver
muscle
what is metformin a type of?
Biguanide
how does metformin improve insulin sensitivity?
decrease fatty acid synthesis
Improves receptor function
Inhibits gluconeogenic pathways
what is the half life of metformin?
6 hours
what is the shown benefit of metformin in overweight patients?
what are the advantages of metformin?
Improves cardiovascular outcomes and mortality in obese T2 DM
Efficaceous
Used alone can decrease fasting blood glucose by 22- 26%
Normally well tolerated\
Not associated with weight gain
HbA1c by 12 – 17% reduction
Also used in pregnancy now
Cheap
what are the diasavantages of metformin?
GI side effects 20 – 30 %
Risk of lactic acidosis by inhibiting lactic acid uptake by liver
Hypoxia
Renal failure (C.I. if creat>150umol/L or eGFR <30ml/min)
Hepatic failure
Alcohol abuse
Risk vitamin B12 malabsorption
when is there risk of lactic acidosis when taking metformin?
Hypoxia
Renal failure (C.I. if creat>150umol/L or eGFR <30ml/min)
Hepatic failure
Alcohol abuse
when do you use sulphonylureas?
If osmotic symptoms or HbA1c increasing rapidly titration based on home blood glucose monitoring.
when needing rapid improvement in blood glucose levels
second line agent
how does sulphonylureas provide a solution to type 2 diabetes?
increase the release of insulin
what organs do sulphonylureas act on?
prancreas
describe the mechanism of 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
describe the dose range, frequency, metabolism, rate of renal excretion, duration of action of glimepiride?
describe the dose range, frequency, metabolism, rate of renal excretion, duration of action of gliclazide?
describe the dose range, frequency, metabolism, rate of renal excretion, duration of action of glipizide?
what drug interactions can sulphonylureas have?
what drugs ineract with sulphonylureas?
what are advantages of sulphonylureas?
Rapid improvement in control
Rapid improvement if symptomatic
Rapid titration
Cheap
Generally well tolerated
what are disadvantaged or sulphonylureas?
Risk of hypoglycaemia
Weight gain
Caution in renal and hepatic disease
CI in pregnancy and breastfeeding.
SE include
Hypersensitivity and photosensitivity reactions
Blood disorders
what are side effects of sulphonylureas?
Hypersensitivity and photosensitivity reactions
Blood disorders
what condition should avoid using sulphonylureas?
renal and hepatic disease
prgnancy and breastfeeding
what is the action of thiazolidinediones?
improve the action of insulin
what organs do thiazolidinediones act on?
liver
muscle
adipose tissue
what is the mechanism of action of pioglitazone?
selectively stimulates the nuclear
receptor peroxisome proliferator-activated
receptor gamma (PPAR-gamma) and to a lesser extent PPAR - alpha
modulates the transcription of the insulin-
sensitive genes involved in the control of
glucose and lipid metabolism in
the muscle, adipose tissue, and the liver.
reduces insulin resistance in the liver and peripheral tissues;
increases the expense of insulin-dependent glucose;
decreases withdrawal of glucose from the liver;
reduces quantity of glucose, insulin
and glycated haemoglobin in the bloodstream.
what are advanyages of pioglitazone?
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
Weight gain
Fractures in females
Small increased risk
TZDs affect bone turnover
Reduced BMD
Initial report were of increased distal fractures in women
why is there a risk of fractures in females of pioglitazone?
Small increased risk
TZDs affect bone turnover
Reduced BMD
Initial report were of increased distal fractures in women
summarise metformin, SUs and glitazone?
why is insulin used in type 2 diabetes?
Progressive relative insulin deficiency
Use may become ‘inevitable’
As many T2 as T1 on insulin
Which regimen? (4T 1yr)
what is the impact of supplimentary insulin therapy?
Easy introduction to insulin
Low risk of hypoglyceamia
Weight gain?
Not quite the last resort – intensification regimens (4T 2-3yr)
Which supplementary insulin?
how is isophane insuline injected?
once daily ussually at bedtime
what are examples of isophane insulin?
Humulin I or H insulatard
what are examples of gliflozins?
Canagliflozin, Dapagliflozin, Empagliflozin
what is the action of gliflozins / SGLT 2 inhibitors?
increase excretion of glucose
describe normal renal glucose handling?
how do gliflozins interfere with normal renal glucose handling?
what is the inhibitors effects of SGLT2 inhibitors?
GETS RID OF GLUCOSE / MORE GLYCOSURIA
LOWERS HbA1C
GETS RID OF WATER / OSMOTIC DIURESIS
(POSTURAL) HYPOTENSION, DEHYDRATION
GETS RID OF CALORIES / WASTES GLUCOSE
LOSE WEIGHT WITH SAME INTAKE
GETS RID OF SODIUM /LESS REUPTAKE
LOWERS SYSTOLIC BLOOD PRESSURE
GREATER RISK OF UROGENITAL INFECTION
CYSTITIS and CANDIDIASIS
what is the efficacy of SGLT2 inhibitors?
what must be done for cardiovascular safety with SGLT2 inhibitors?
RCT to assess the effect of once-daily empagliflozin (at a dose of either 10 mg or 25 mg) versus placebo on cardiovascular events in adults with T2DM with established CVD.
HbA1C 7-10%
Patients with T2DM on no glucose-lowering agents or stable glucose-lowering therapy for at least 12 weeks.
The primary outcome- composite of CV death, nonfatal MI, or nonfatal stroke.
Secondary outcome - composite of the primary outcome plus hospitalization for unstable angina.
what is the primary cardiovascular outcome on SGLT2 inhibitors?
The primary outcome- composite of CV death, nonfatal MI, or nonfatal stroke.
what is the secondary cardiovascular outcome on SGLT2 inhibitors?
composite of the primary outcome plus hospitalization for unstable angina
what effect has SGLT2 inhibitors been proven to have on cardiovascular health?
what are the renal outcomes with canagliflozin?
4401 patients with a median follow-up of 2.62 years.
Primary outcome was a composite of end-stage kidney disease, a doubling of the serum creatinine level, or death from renal or cardiovascular causes
Stopped early after planned interim analysis
what effects has SGLT2 inhibitors been shown to have on renal function?
summarise the dose, frequency, renal impairement, o GIF and cost of SGLT2 inhibitors?
what can SGLT2 inhibitors increase the risk of?
diabetic ketoacidosis
what are the NICE guidelines for SGLT2 inhibitors?
2nd line therapy in those at high CV risk (started immediately after metformin tolerability established)
1st line in those at high CV risk when metformin not tolerated
Check if increased risk of DKA
Prev DKA
Unwell with intercurrent illness
Following low CHO diet
what increases a patients risk of having a DKA?
Prev DKA
Unwell with intercurrent illness
Following low CHO diet
what are advantages of SGLT2 inhibitors?
Weight loss
No risk of hypoglycaemia
Good effects on glycemic control
Beneficial effect on cardiovascular morbidity & mortality and renal outcomes
2nd or 3rd line agent
Can add to insulin regimens in T2DM
what are disadvantages of SGLT2 inhibitors?
expensive
SE:
UTI, fungal infections, osmotic symptoms
Risk of digital amputation
Risk of DKA
CI in pregnancy and breastfeeding.
Cannot use in renal impairment
what are side effects of SGLT2 inhibitors?
UTI, fungal infections, osmotic symptoms
what is the incretin effect?
the incretin effect describes the phenomenon whereby oral glucose elicits higher insulin secretory responses than does intravenous glucose, despite inducing similar levels of glycaemia, in healthy individuals.
what are examples of DPPIV-inhibitors / gliptins?
saxagliptin, sitagliptin, vildagliptin
what effect do DPPV inhibitors have on type 2 diabetes?
what is the mode of action of gliptins?
what is GLP1?
glucagon like peptide
what is GIP?
glucose-dependent insulinotropic polypeptide (GIP)
describe the dose, frequency, renal dose, on GIF of DPPIV inhibitors?
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 are disadvantages of DPPIV inhibitors?
Trial data shows relatively small effects on glycemic control
CI in pregnancy and breastfeeding.
SE:
nausea
what are examples of GLP1 analogues?
Exenatide, Liraglutide, Lixisenatide
what effect do GLP1 analogues have?
what is the mode of action of GLP1 analogues?
how does GLP1 analogues effect weight loss?
what are nausea and incretin mimics?
what is the main side effects of GLP1 analogues?
nausea
what are sign and nice guidelines ofr GLP-1 analogues?
NICE CG87
BMI >35; (Ethnicity; Occupation)
Stop after 6/12 unless:
HbA1C -1% and Weight - 3% in 6/12
SIGN 154
3rd line agent; BMI > 30 kg/m2
In combination with oral agents and/or basal insulin usually as 3rd or 4th line
Stop after 3-6/12 unless HbA1C >5mmol/mol fall or individualized target reached
describe the dose frequency reneal adjustment on gif and cost of GLP1 analogues?
what are pen devices (exenatide)?
Exenatide is an injectable diabetes medicine that helps control blood sugar levels. This medication helps your pancreas produce insulin more efficiently. Bydureon is a long-acting form of exenatide. Bydureon is used together with diet and exercise to improve blood sugar control in people with type 2 diabetes mellitus.
what are advantages of GLP-1 analogues?
Weight loss
No risk of hypoglycaemia
3rd line agent
Can be used with basal insulin
Some have benefit for CV disease
what are disadvatages of GLP1 analogues?
Injection
Expensive
CI in pregnancy and breastfeeding.
SE:
Nausea, vomiting
summarise the different drugs offered to type 2 diabetic patients?
what is the type 2 diabetics medication overveiw for patients?
what is the type 2 diabeties medication overveiw for patients with insulin?
what are the nice guidelines for choosing medications in diabetes?
what are the nice guidelines for choosing medications in diabetes P2?
what are the nice guidelines for choosing medications in diabetes P3?
what are pharmacalogical management of type 2 diabetes?
what is the 5 step framework for choosing a glucose lowering drug?
Set a goal
“Take 5” Are there other risk factors that should be prioritised over HbA1c?
Are the current treatments optimised?
Max dose? Tolerated? Taken?
What are the glucose lowering options?
Assess cardiovascular risk
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
describe the set a goal phase?
long term vs short term
HbA1c targets?
For adults whose type 2 diabetes is managed either by lifestyle and diet, or lifestyle and diet combined with a single drug not associated with hypoglycaemia, support them to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support them to aim for an HbA1c level of 53 mmol/mol (7.0%). [2015]
In adults with type 2 diabetes, 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.
what should be considered when relaxing targert HbA1c level?
Consider relaxing the target HbA1c level on a case-by-case basis and in discussion with adults with type 2 diabetes, with particular consideration for people who are older or frailer, if:
they are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
tight blood glucose control would put them at high risk if they developed hypoglycaemia, for example, if they are at risk of falling, they have impaired awareness of hypoglycaemia, or they drive or operate machinery as part of their job
intensive management would not be appropriate, for example if they have significant comorbidities. [2015, amended 2022]
“Take 5” Are there other factors that should be prioritised over HbA1c?
Are the current treatments optimised?
Maximum dose?
Tolerated?
Taken?
not on metformin why, if stopped can restart?
What are the glucose lowering options?
Remove any that are contraindicated.
Of the remaining what are the pros and cons?
Asses cardiovascular risk
Does the individual have severe albuminuria?
Select the preferred choice.
Agree a review date and the target HbA1c with the patient
