Management of Type 2 Diabetes Flashcards
For a type 2 diabetic - what line of treatment should always always always be used first?
Diet and exercise
Lifestyle changes
A must!
Is medication for type 2 diabetes useful if diet and exercise fails?
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
When are tablets considered then?
When there ins’t good metabolic control with the use of diet and exercise
What is the 1st line medication?``
Metformin (Biguanide)
How does metformin work?
Improves insulin sensitivity by improving receptor function
Reduces gluconeogenesis rate
Decreases fatty acid synthesis
Advantages of metformin?`
Improves CV outcomes Cheap Effective at reducing blood glucose and HbA1c Not associated with weight gain Can be used in pregnancy
Disadvantages of metformin?
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
if HbA1c is not well controlled what 2nd line medication’a can be added? What level of HbA1c would this be used at?
HbA1c - over 53 mmol/mol
Sulphonylurea or Thiazolidinediones/Glitazones or DPP‑4 inhibitor
How does Sulphonylurea work?
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
Advantages of Sulphonylurea’s?
When used with metformin = rapid improvement in control
Rapid improvement if symptomatic
Cheap
Well tolerated
Disadvanatges of sulphonylurea’s?
Risk of hypos
Weight gain
Cautions in renal and hepatic disease
Contraindicated in pregnancy and breatfeeding
Why do sulphoylurea’s cause hypos?
They release insulin
Why can sulphonylurea’s not be used on type 1 patients?
Needs functioning B-cells
How do thiazolidinediones/glitazones work?
- Stimulates the nuclear receptor PPAR-gamma = transcription of insulin sensitive genes
- This increases insulin sensitivity
- Increases glucose uptake in muscle, fat and liver cells
- Increases lipogenesis and FFA uptake
- Decreases hepatic production of glucose (glycogenolysis and gluconeogensis)
What is the most commonly used glitazone?
Pioglitazone
Advantages of pioglitazone?
Good for patients with significant insulin resistance
Cheap
CV safety established
Disadvantages of pioglitazone?
Increase of bladder cancer
Fluid retention
Weight gain
Fractures in females
What are incretins?
A group of metabolic hormones that stimulate a decrease in blood glucose levels
How does DPP‑4 inhibitor work?
DPP-4 enzyme rapidly degrades incretins
So the inhibitor - known as gliptins - delay the breakdown of incretins
Advantages of DPP‑4 inhibitors?
Well tolerated Can be used as 2nd or 3rd line Can be used in renal impairment No risk of hypos Weight neutral
Disadvantages of DPP‑4 inhibitors?
Data shows small effect on glycemic control
Contraindicated in pregnancy and breastfeeding
Possible increased risk of pancreatitis and pancreatic cancer
Causes nausea
What should be done if 2nd line treatment fails?
Triple therapy with metformin and any 2 of the 2nd lines
or starting insulin based treatment
What should be done if triple therapy is not tolerated or is contraindicated?
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
How does GLP-1 work?
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
Advantages of GLP-1?
Weight loss
No risk of hypos
Can be used with basal insulin
Disadvantages of GLP-1?
Injection
Expensive
Increased risk of pancreatic cancer and pancreatitis
CI’d in pregnancy and breastfeeding
Causes nausea and vomiting
When would an SGLT-2 inhibitor be used?
If hypos and weight gain was a concern
How does a SGLT-2 inhibitor work?
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
Advantages of SGLT-2?
Weight loss
No risk of hypos
Disadvantages of SGLT-2?
Expensive
Side effects: UTIs Osmotic symptoms Risk of DKA CI'd in pregnancy and breastfeeding Can't use in renal impairment
If an adult is being managed with type 2 with diet, exercise and a non-hypo associated drug what should be the target HbA1c?
48 mmol/mol
If an adult is being managed with a hypo associated drug what should be the target HbA1c?
53 mmol/mol
What should you do if HbA1c isn’t controlled well and rises to 58 or above?
Reinforce diet and exercise advice
Reinforce adherance to drug treatment
Intensify drug treatment
Should you consider relaxing HbA1c targets?
Yes, look at it by a case by case basis
When should a review be done? What should be done if treatment is not working?
3-6 months
Stop the treatment if not working
