Management of Type 2 Diabetes Mellitus

Question 1

What should be looked at during a diabetes management consultation?

Answer 1

• Blood glucose levels
• Eyes screened (funsocopy)
• Feet checked
• Kidney function
• Weight changes

Question 2

How beneficial is BP control in diabetes management?

Answer 2

• Slide shows BP control in diabetics had 24% reduction in diabetes related morbidity

Question 3

Describe the 5 step framework for choosing a glucose lowering drug? (as outlined in slides)

Answer 3

1. Set a target HbA1c
2. Are there other risk factors to be treated first?
3. Are current treatments optimized? At max. dose? Compliance?
4. Choose glucose lowering agents (make sure not contraindicated)
5. Agree on review date and target HbA1c with patient

Question 4

What is usually the first choice treatment for type 2 diabetes? Why?

Answer 4

• Metformin

- Improves outcomes, is cheap and well tolerated

Question 5

What are the actions of metformin?

What’s its half life?

Answer 5

Improves insulin sensitivity:

• Improves glucose transport & reduces fatty acid synthesis
• Improves insulin receptor function
• Inhibits gluconeogenic pathways
• 6 hours

Question 6

How efficient is metformin?

Answer 6

• Used alone can decrease fasting blood glucose by 22-26%
• Can decrease HbA1c 12-17%

Improves CVS complications and mortality in T2DM

Question 7

Can metformin be used in pregnancy?

Answer 7

Yes

Question 8

Disadvantages of metformin?

Answer 8

• GI side effects in 20-30%
• Risk of lactic acidosis by inhibiting lactic acid uptake by liver
• Risk of vitamin B12 malabsorption

Question 9

List some sulphonylureas

Answer 9

• Glimeperide
• Gliclazide
• Glipizide

Question 10

What is the action of sulphonylureas?

Answer 10

• Increase insulin release

Question 11

Mechanism by which sulphonylureas increase insulin release?

Answer 11

• Bind sulfonlyurea receptors (SUR-1) on functioning pancreatic beta-cells
• Binding closes linked ATP-sensitive K channels
• Decreased K influx = depolarization of cell
• Voltage dependent Ca channels open, Ca influx
• Ca influx causes exocytosis of secretory granules containing insulin

Question 12

Advantages of sulphonylureas?

Answer 12

• Can be used with metformin
• Rapid improvement in [BG] control
• Rapid improvement if symptomatic
• Generally well tolerated

Question 13

Disadvantages of sulphonylureas?

Answer 13

• Risk of hypoglycaemia
• Weight gain
• Need to be cautious with renal / hepatic disease
• Side effects can include hypersensitivity and photosensitivity / blood disorders

Question 14

Can sulphonylureas be used in pregnancy?

Answer 14

Contraindicated in pregnancy and breastfeeding

Question 15

What is the main thiazolidinedione used?

Answer 15

Pioglitazone

Question 16

What is the action of thiazolidinediones?

Answer 16

Improve insulin action

• Reduces insulin resistance in liver and peripheral tissues
• Decreases withdrawal of glucose from liver
• Reduce glucose, insulin and HbA1c in bloodstream

Question 17

What are the advantages of pioglitazone (thiazolidinediones)?

Answer 17

• Good at reducing insulin resistance
• HbA1c reduction of 0.6 - 1.3%
• CVS safety established

Question 18

What are the disadvantages of pioglitazone (thiazolidinediones)?

Answer 18

• Increased risk of bladder cancer
• Fluid retention common
• Weight gain
• Increased in fracture risk in females