Management of Type 2 DM Flashcards
Where should diabetics go for advice?
Practice nurse/GP
Online
Group education sessions
Dietetic ad
What should you ask in a consultation with a diabetic?
Review data in diabetes Review blood glucose Ask patient concerns Establish whether challenges are approaching Set goals - care plan
What are the aims of diabetes treatment?
Relief of symptoms
Prevent complications
Preserve QoL
Damage minimalisation
Which treatments improve insulin action?
Biguanides (metformin)
Thiazolidiadiones (Glitazones)
Weight loss
Which treatments improve insulin release?
Sulphonylureas (Gliclazide)
metiglinides
Incretin mimetics
DPPIV inhibitors
What is the effect of beta cell dysfunction?
Decreased insulin production
What is the action of SGLT2 inhibitors?
Increase excretion of glucose
What is the effect of decreased incretin effect?
Decreased insulin production
Which factors decrease insulin action?
Insulin resistance (periphery) Excess glucagon
What factors can be controlled to reduce the potential complications of diabetes?
Lipids Smoking HTN Mood Dietary change Sedentary behaviour
What is the 5step framework for choosing a glucose lowering drug?
- Set target HbA1c
- Are there other current risk factors needing Rx
- Are the current treatments optimised
- What Rx options are there
- Agree to review date
What factors must be taken into account in setting a target HbA1c?
Age/frailty
Reduced life expectancy
What risk would a hypo have?
Is intense management appropriate?
What is the first line management for T2D?
Metformin
Sulfonylurea if symptomatic
After metformin, what is the second line therapy for T2D?
Sulfonylurea
Thiazolidinedione
DPP-IV inhibitor
SGLT-2 inhibitor
After sulfonylurea, what is the second line therapy for T2D?
Metformin
When is Thiazolidinedione indicated for second line T2D therapy?
If hypos are a concern
If no CCF
When are inhibitors
indicated for second line T2D therapy?
If hypos are a concern
If weight gain are a concern
What are the third line therapies for T2D?
Thiazolidinedione
DPP-IV/SGLT-2 inhibitor
GLP-1 agonist
Insulin
When is insulin indicated in T2D?
Third line
If osmotic symptoms/rising HbA1c
When is GLP-1 agonist indicated in T2D?
Third line
BMI>30
Desire to lose weight
<10y from Dx
What class of drug is metformin?
Biguanides
Metformin acts on what?
Liver
Muscles
How does metformin work?
Improves Insulin Action
Decreased FA synthesis
Improve receptor function
Inhibits gluconeogenesis
What is the half life of metformin?
6hrs
What are the disadvantages of metformin?
Risk of lactic acidosis
GI side effects (20-30%)
Risk of vitamin B12 malabsorption
How does metformin cause lactic acidosis?
Inhibits lactic acid uptake by the liver
Sulphonylureas act on what?
Pancreas
What is the mechanism of Sulphonylurea action?
Bind to Sulphonylurea receptors (SUR-1) on B-cells
Closes ATP K channels
Decreases depolarisation
Ca2+ channels open
Translocation of secretory granules of insulin
Which sulphonylurea is indicated in reduced renal function?
Gliclazide
What are the disadvantages of sulphonylureas?
Risk of hypoglycaemia
Weight gain
Caution in renal/hepatic issues
Cant pregnant/breastfeeding
What side effects are associated with sulphonylureas?
Hypersensitivity
Photosensitivity
Blood disorders
What is the action of Thiazolidiones?
Improve insulin action
Modulates transcription of insulin-sensitive genes
Reduces insulin resistance
Thiazolidiones act on what?
Liver
Muscle
Adipose tissue
What are the disadvantages of Thiazolidiones?
Increased risk blader cancer
Fluid retention (NO USE IN CCF)
Weight gain
Fractures in females
When are Thiazolidiones contraindicated?
CONGESTIVE CARDIAC FAILURE
Bladder neoplasm
What is the main contraindication of metformin?
Reduced eGFR
