Managing T2DM In Adults Flashcards
What are some questions you want to ask in the history about a patient who might have diabetes in terms of HPC?
What will help differentiate between T1DM and T2DM?
Polyuria?
Polydipsia?
Nocturia?
Weight loss?
T2DM has a more insidious onset where these above osmotic symtpoms are absent
Normally present twitch hyperglycaemia or diabetes complications
What are some categoreis that might indicate a cause of diabetes in the PMH?
Endocrinopthies
Pancreas pathology
Medications
Infections
Syndromic
What are some endocrinopathies that can cause diabetes?
Acromegaly
Thyrotoxicosis,
Cushing’s Phaeochromocytoma, Glucagonoma
PCOS
What are some pancreatic pathologies that can cause diabetes?
Pancreatitis
Pancreatic cancer
Pancreatectomy
What are some medications that can cause diabetes?
Steroids
Levothyroxine
Thiazides
Antiretrovirals (HIV)
B-agonists
What are some syndromes that can cause diabetes?
Down syndrome
Klinefelters syndrome
Turners
Huntingtons chorea
What are you looking for on examination when you suspect a patient has diabetes?
BMI
BP
Signs of insulin resistance
Retinal examination
Foot examination
What are some signs of insulin resistance?
Central obesity
Acanthosis nigricans
Hyperandrogenism (in females)
What are some investigations you would do for a patient with diabetes?
HbA1C
Renal, liver, thyroid, lipid profile
B cell antibodies, anti GAD, anti-islet cells
Why is it important to ask about family history for diabetes?
T2DM has a very strong genetic component
What is the pathophysiology of T2DM?
Insulin sensitivity (inability of insulin sensitive tissue to respond to insulin) which can then lead to defective insulin secretion
What are the steps to managing T2DM?
Education
Lifestyle modification
Annual reviews
Medications
What is important to educate patients with T2DM on?
What is diabetes?
Why does diabetes need to be treated (complications)?
What lifestyle modifications should patients with T2DM have?
Exercise
Weight loss
Dietary changes/advice
May require glucose monitoring if medications can cause hypoglycaemia
What reviews are going to be needed with managing diabetes?
Blood reviews
Urine reviews
Eye screen
Individualised target HbA1c
When would you need to inform the DVLA about your T2DM?
When take insulin > 3months
Taking medications like sulfonylureas like gliclazide which can cause hypoglycaemia
What is some dietary advice you might give to a patient with T2DM?
High fibre
Low glycaemic index score of carbs
Low fat diary
Portion control
Alcohol reduction
Smoking cessation
Inc physical activity
Weight loss of 5%-10% target for overweight people
What is a typical HbA1c target for a patient on a diet/single medication?
48mmol/mol
What is a typical HbA1c target for a patient on a more complex regime of diets and medication with T2DM?
58mmol/mol
What are some classes of medications used to manage T2DM?
Biguanides
Sulfonylureas
SGLT2 inhibits
GLP1 agonist
DPP4 inhibitors
Glitazones
What is an example of a biguanide?
Metformin
What is the mechanism of action of metformin?
Decreases Gluconeogenesis by the livier and increases insulin sensitivity
What are the side effects of metformin?
Lactic acidosis
GI upset
When do you have to alter the dose of metformin?
EGFR < 30
How does metformin affect weight?
Either decreases or has no effect on weight
What is an example of a sulfonylurea?
Gliclazide
What is the mechanism of action of gliclazide?
Blocks the ATP sensitive potassium channels leading to K+ building up, depolarisation, Ca2+ influx leads to insulin effluent
What is the side effects of gliclazide that needs to be monitored?
How does it affect weight?
Hypoglycaemia
Weight gain
What are some SGLT2 inhibitors?
Dapagliflozin
Empagliflozin
What is the mechanism of action of empagliflozin or dapagliflozin?
Blocks SGLT2 meaning less glucose reabsorbed in the PCT so more lost in the urine
What are some side effects/complications of SGLT2 inhibitors?
UTIs
Euvolaemic DKA
What is a Contraindication to SGLT2 inhibitors?
Hypovolaemia
How do SGLT2 inhibitors affect weight and HbA1c?
Large weight loss
Lowers HbA1c better than metformin. But less than gliclazide
What are some examples of GLP1 agonists?
Liraglutide
Semaglutide
What are some side effects of GLP1 agonists like semaglutide?
DKA
Inc risk of thyroid cancer
Hypoglycaemia
How does semaglutide (GLP1 agonist) affect HbA1c and weight?
Best for weight loss
Better at reducing HbA1c than metformin but not as good as SGLT2 inhibitors like dapagliflozin
What are some examples of DPP4 inhibitors?
Sitigliptin
Saxagliptin
What makes DPP4 inhibitors like saxagliptin “safe”?
No risk of hypoglycaemia
What is the mechanism of action of DPP4 inhibitors like sitiglipitn and saxagliptin?
Prevents the breakdown of incretins
So incretins stimulate and simulate insulin food is consumed so drug only has its effect when food is consumed
How do GLP1 agonists work?
Increased production of incretins means more insulin is released
How does DPP4 inhibitors like saxagliptin effect weight and HbA1c?
Neutral on weight gain
Worse than metformin on HbA1c reduction
What are some glitazones?
Pioglitzones
Rosiglitazones.
What is the mechanism of action of glitazones like pioglitazone?
PPAR-gamma leads to glucose differentiating to fat cells
What are some side effects of glitazones?
Fluid retention (heart failure)
Osteoporosis
Bladder cancer
What medication is best to reduce HbA1c?
Gliclazide
What medication is best for weight loss when treating T2DM?
GLP1 agonists like liraglutide and semaglutide
What is the best medication for T2DM for avoiding hypoglycaemia?
DPP4 inhibitors like sitagliptin and saxagliptin
What is the order of diabetic medications in terms of best to worst for reducing HbA1c?
Most effective - Gliclazide, SGLT2 inhib, GLP1 (semaglutide), metformin, DPP4 inhibitors - worst
What is the NICE guidelines for medications treating T2DM?
Metformin first line
If Qrisk2>10% also give SGLT2 inhibitor if HbA1c doesn’t resolve
Can try up to 4 antiglycaemic agents before moving to insulin
What is the Qrisk score?
Chance of developing a major cardiovascular event like an MI in the next 10years
What insulin regimes can be done for a patient with T2DM?
Long acting (NPH twice daily)
Basal bolus
Twice daily fixed mixtures
Twice daily free mixing
