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ZA - Endocrine System > Management of Type 2 Diabetes > Flashcards

Management of Type 2 Diabetes Flashcards

1
Q

For a type 2 diabetic - what line of treatment should always always always be used first?

A

Diet and exercise
Lifestyle changes

A must!

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2
Q

Is medication for type 2 diabetes useful if diet and exercise fails?

A

No, diet and exercise is a must and no amount of tablets will succeed where these have failed

Meds given in conjunction with diet and exercise

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3
Q

When are tablets considered then?

A

When there ins’t good metabolic control with the use of diet and exercise

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4
Q

What is the 1st line medication?``

A

Metformin (Biguanide)

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5
Q

How does metformin work?

A

Improves insulin sensitivity by improving receptor function

Reduces gluconeogenesis rate

Decreases fatty acid synthesis

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6
Q

Advantages of metformin?`

A 
Improves CV outcomes
Cheap
Effective at reducing blood glucose and HbA1c
Not associated with weight gain 
Can be used in pregnancy
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7
Q

Disadvantages of metformin?

A

Risk of lactic acidosis by inhibiting lactic acid uptake by liver which leads to hypoxia and renal failure

GI side effects occur in 20-30%
Risk of Vit. B12 malabsorption
Can’t use if GFR lower than 30

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8
Q

if HbA1c is not well controlled what 2nd line medication’a can be added? What level of HbA1c would this be used at?

A

HbA1c - over 53 mmol/mol

Sulphonylurea
or
Thiazolidinediones/Glitazones
or
DPP‑4 inhibitor
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9
Q

How does Sulphonylurea work?

A

Binds to sulfonylurea receptors on functioning pancreatic b-cells whihc closes the ATP-sensitive K+ channels reducing K+ entry

This depolarisation = influc of Ca2+ which stimulates exocytosis of insulin

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10
Q

Advantages of Sulphonylurea’s?

A

When used with metformin = rapid improvement in control

Rapid improvement if symptomatic

Cheap

Well tolerated

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11
Q

Disadvanatges of sulphonylurea’s?

A

Risk of hypos
Weight gain
Cautions in renal and hepatic disease
Contraindicated in pregnancy and breatfeeding

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12
Q

Why do sulphoylurea’s cause hypos?

A

They release insulin

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13
Q

Why can sulphonylurea’s not be used on type 1 patients?

A

Needs functioning B-cells

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14
Q

How do thiazolidinediones/glitazones work?

A
  1. Stimulates the nuclear receptor PPAR-gamma = transcription of insulin sensitive genes
  2. This increases insulin sensitivity
  3. Increases glucose uptake in muscle, fat and liver cells
  4. Increases lipogenesis and FFA uptake
  5. Decreases hepatic production of glucose (glycogenolysis and gluconeogensis)
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15
Q

What is the most commonly used glitazone?

A

Pioglitazone

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16
Q

Advantages of pioglitazone?

A

Good for patients with significant insulin resistance
Cheap
CV safety established

17
Q

Disadvantages of pioglitazone?

A

Increase of bladder cancer
Fluid retention
Weight gain
Fractures in females

18
Q

What are incretins?

A

A group of metabolic hormones that stimulate a decrease in blood glucose levels

19
Q

How does DPP‑4 inhibitor work?

A

DPP-4 enzyme rapidly degrades incretins

So the inhibitor - known as gliptins - delay the breakdown of incretins

20
Q

Advantages of DPP‑4 inhibitors?

A 
Well tolerated
Can be used as 2nd or 3rd line
Can be used in renal impairment
No risk of hypos
Weight neutral
21
Q

Disadvantages of DPP‑4 inhibitors?

A

Data shows small effect on glycemic control
Contraindicated in pregnancy and breastfeeding
Possible increased risk of pancreatitis and pancreatic cancer

Causes nausea

22
Q

What should be done if 2nd line treatment fails?

A

Triple therapy with metformin and any 2 of the 2nd lines

or starting insulin based treatment

23
Q

What should be done if triple therapy is not tolerated or is contraindicated?

A

Consider adding a GLP-1 injection in addition to metformin and a sulfonylurea if they have a BMI of over 35

If BMI is lower than 35 then use GLP- 1 if insulin wouldn’t fit with lifestyle/job or weight loss benefits from a GLP-1 injection would help the patient

24
Q

How does GLP-1 work?

A

GLP-1 is a gut hormone involved in the incretin effetct

So it increases insulin secretion, inhibits glucagon secretion, delays gastric emptying and has central effects on appetite

25
Q

Advantages of GLP-1?

A

Weight loss
No risk of hypos
Can be used with basal insulin

26
Q

Disadvantages of GLP-1?

A

Injection
Expensive
Increased risk of pancreatic cancer and pancreatitis
CI’d in pregnancy and breastfeeding

Causes nausea and vomiting

27
Q

When would an SGLT-2 inhibitor be used?

A

If hypos and weight gain was a concern

28
Q

How does a SGLT-2 inhibitor work?

A

SGLT-2 stands for sodium/glucose transporter 2 - it is meant to reabsorb glucose in the renal system

With this medication it causes glucose to be removed from body stopping reabsorption and also removes calories helping with weight loss

Also reduces sodium reuptake reducing systolic pressure

29
Q

Advantages of SGLT-2?

A

Weight loss

No risk of hypos

30
Q

Disadvantages of SGLT-2?

A

Expensive

Side effects:
UTIs
Osmotic symptoms
Risk of DKA
CI'd in pregnancy and breastfeeding
Can't use in renal impairment
31
Q

If an adult is being managed with type 2 with diet, exercise and a non-hypo associated drug what should be the target HbA1c?

A

48 mmol/mol

32
Q

If an adult is being managed with a hypo associated drug what should be the target HbA1c?

A

53 mmol/mol

33
Q

What should you do if HbA1c isn’t controlled well and rises to 58 or above?

A

Reinforce diet and exercise advice
Reinforce adherance to drug treatment
Intensify drug treatment

34
Q

Should you consider relaxing HbA1c targets?

A

Yes, look at it by a case by case basis

35
Q

When should a review be done? What should be done if treatment is not working?

A

3-6 months

Stop the treatment if not working

ZA - Endocrine System (21 decks)

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