Management of Type 2 Diabetes Mellitus 2

Question 1

What is the mechanism by which Metformin improves hyperglycaemia?

Answer 1

Improves sensitivity to insulin

Question 2

What is the mechanism by which Sulphonylureas improves hyperglycaemia?

Answer 2

Stimulate pancreatic insulin release

Question 3

What is the mechanism by which Thiazolidinediones improve hyperglycaemia?

Answer 3

Improve insulin sensitivity

Question 4

What is the mechanism by which alpha-glucosidase inhibitors improve hyperglycaemia?

Answer 4

Prevent intestinal sugar absorption

Question 5

List some examples of DPPIV inhibitors

Answer 5

• Saxagliptin
• Sitagliptin
• Vildagliptin

Question 6

Describe the mechanism of DPPIV inhibitors

Answer 6

• The mechanism of DPP-4 inhibitors is to increase incretin levels (GLP-1 and GIP)
• Incretins inhibit glucagon release, which in turn increases insulin secretion, decreases gastric emptying, and decreases blood glucose levels.

Question 7

Advantages of DPPIV inhibitors?

Answer 7

• Can be used as second or third line treatment
• Can be used in renal impairment
• No risk of hypoglycaemia

Question 8

Disadvantages of DPPIV inhibitors?

Answer 8

• Contraindicated in pregnancy and breastfeeding

- Can make patients nauseas

Question 9

What are incretins?

Answer 9

• GLP-1 & GIP

- Incretins are a group of metabolic hormones that stimulate a decrease in blood glucose levels

Question 10

List some of the commonly used GLP-1 analogues

Answer 10

• Exenatide
• Liraglutide
• Lixisenatide

Question 11

Mechanism of GLP-1 Analogues?

Answer 11

• Mimic the incretin GLP-1

- Cause a decrease in glucagon and subsequently an increase in insulin. Lowers blood [glc]

Question 12

Advantages of GLP-1 Analogues?

Answer 12

• Weight loss (usually)
• No risk of hypoglycaemia
• 3rd line agent
• Can be used with basal insulin

Question 13

Disadvantages of GLP-1 Analogues?

Answer 13

• taken by injection & expensive
• Contraindicated in pregnancy and breastfeeding
• Can cause nausea and vomiting

Question 14

List some commonly used SGLT2-inhibitors

Answer 14

• Canaglifozin
• Dapaglifozin
• Empaglifozin

Question 15

What is the mechanism of SGLT2-inhibitors?

Answer 15

• Increase excretion of glucose
• SGLT2 (sodium glucose transporter 2) is responsible for around 90% of glucose reabsorption in the proximal tubule of the kidney, inhibition of this greatly reduces glucose reabsorption

Question 16

List the effects of SGLT2-inhibitors

Answer 16

• Excretion of glucose: lowers HbA1c
• Water excretion increased: hypotension / dehydration
• Excretion of glucose: lose weight
• Sodium excretion: lowers systolic BP
• Increases risk of urogenital infection

Question 17

When should SGLT2-inhibitors not be started?

Answer 17

• If eGFR is below 60

- Renal impairment

Question 18

Advantages of SGLT2 inhibitors?

Answer 18

• Weight loss / no hypoglycaemia
• May be beneficial in CVS morbidity
• 2nd or 3rd line agent
• Can be used alongside insulin regimen

Question 19

Disadvantages of SGLT2 inhibitors?

Answer 19

• Side effects: UTI, fungal infections, osmotic symptoms
• Risk of DKA / digital amputation
• Contraindicated in pregnancy and breastfeeding
• Contraindicated in renal impairment

Question 20

What are the preferred 2nd and 3rd line agents if the patient already has established CVS disease?

Answer 20

GLP-1 analogues OR SGLT2 inhibitors

Question 21

What is usually the first insulin regimen that type 2 diabetics are put on? What type of insulin do they use?

Answer 21

• One daily injection usually before bedtime

Using Isophane Insulin:

• Humulin I
• Humulin Insulatard

Question 22

What should your HbA1c target be for a type 2 diabetic patient?

Answer 22

• 48 mmol/mol in a patient managing the condition with lifestyle and a single drug NOT associated w hypoglycaemia
• 53 mmol/mol in a patient managing the condition with a drug associated w hypoglycaemia

Question 23

When should a new drug being taken for diabetic control be reviewed? If not working what action should be taken?

Answer 23

• Review at 3 - 6 months

- If HbA1c target not being met (usually 5 mmol/mol reduction) stop the drug