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Year 3 - Preparation for Clinical Practise > Managing type 2 diabetes in primary care > Flashcards

Managing type 2 diabetes in primary care Flashcards

1
Q

What is a target HbA1c concentration when using lifestyle and diet plus a single drug which is not associated with hypoglycaemia

A

less than 48mmol/mol - when type 2 diabetes is managed by diet and lifestyle alone

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2
Q

What happens if lifestyle and diet does not reduce the HbA1c concentration

A

HbA1c levels should be measured in three months, and if the agreed individualised HbA1c target has not been met by lifestyle modifications, offer standard-release metformin as initial drug treatment.

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3
Q

what is used to get glycemic control quickly

A
  • gliclazide is often used to get glycemic control quickly
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4
Q

What do you check in initial assessment of type two diabetes

A
  • Check smoking status
  • Check physical activity
  • Dietary assessment
  • Height, weight and waist circumference. Calculate BMI
  • Blood pressure
  • Assess cardiovascular risk
  • Assess for depression and anxiety
  • Urinalysis for ketones and proteinuria
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5
Q

What are the existing complications you should keep an eye out for when assessing type two diabetes

A
  • arrange screening for retinopathy
  • check for diabetic foot problems: inspection, pulses, neuropathy
  • check for nephropathy
  • assess for neuropathy and its associated complications including erectile dysfunction, neuropathic pain, autonomic neuropathy and gastroparesis
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6
Q

When do you refer a patient to the hospital immediately

A
  • immediate risk of DKA
  • moderate ketonuria or ketonaemia with or without hyperglycaemia and the person cannot eat or drink
  • a person treated with insulin does not improve rapidly with insulin treatment
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7
Q

name some structured education programmes for diabetes

A
  • X-PERT

- DESMOND

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8
Q

how should patients be educated on foot self care

A
  • regular inspection of feet and footwear
  • wearing well fitting shoes
  • taking care of toenails and avoiding the use of corn-removing plasters or sharp blades
  • avoid walking barefoot particularly on holiday
  • referring patients with high risk foot or ulceration early to a multidisciplinary foot service to minimise the risk of foot complications
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9
Q

When is self monitoring of blood glucose recommended

A

If the patient is:

  • using insulin
  • taking oral glucose lowering agents either singly or in a combination that can predispose to a higher risk of hypoglycaemia
  • is pregnant or planning to become pregnant
  • has suspected asymptomatic hypoglycaemia
  • enrolled in a structured education programme where knowledge of glucose values and trends can help patients understand their diabetes
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10
Q

What is the alphabet strategy

A
  • A - advice: diet, weight optimisation, smoking cessation, optimal physical activity
  • B - blood pressure: checked regularly and treated to targets
  • C - cholesterol profile: checked regularly and treated to target, CKD prevention< regular monitoring of renal function and screening for microalbuminuria
  • D - diabetes control
  • E - eye examination - yearly checked with digital retinal photography
  • F - feet examination - checked yearly
  • G - guardian drugs - ACE, ARB, aspirin, Statins
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11
Q

How much exercise should someone with type 2 diabetes do

A

150 minutes of moderate intensity activity

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12
Q

How much weight is recommended to loose In type 2 diabetes

A

a weight loss of more than 5% from baseline weight has beneficial effects on HbA1c, lipid profile and blood pressure

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13
Q

What is the national diabetes blood pressure target

A

140/80

- or 130/80 mmHg if there is kidney disease

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14
Q

What is the primary prevention of cardiovascular disease

A
  • to people who have a 10% or greater 10 year risk of developing cardiovascular disease is estimated using QRISK2
  • atorvastin 20mg for the primary prevention is used
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15
Q

What should you perform before starting statin treatment

A
  • baseline blood tests
  • clinical assessment
  • treat comorbidities and secondary causes of dyslipidaemia such as excess alcohol intake, hypothyroidism, liver disease and nephrotic syndrome
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16
Q

What should your baseline assessment be before you start statin treatment

A
  • smoking status
  • alcohol consumption
  • blood pressure
  • BMI
  • HbA2c
  • renal function and eGFR
  • transaminase level
  • thyroid stimulating hormone
17
Q

before starting statin treatment what else should you measure

A
  • total cholesterol
  • HDL cholesterol
  • non-HDL cholesterol
  • triglyceride concentrations
18
Q

what should you aim for after 3 months of starting statin treatment

A
  • aim for a greater than 40% reduction in non-HDL cholesterol
19
Q

what should you do if the patient experience side effects while staking statin

A
  • stop the statin and restart it when the symptoms have resolved
  • reduce the dose of the statin
  • change the statin to a lower intensity option
20
Q

When should you use a lower dose of atrovastatin

A
  • may be drug interactions
  • high risk of adverse effects
  • patient prefers to be started on a lower dose
  • patient has chronic kidney disease
21
Q

what should the target be if blood pressure is older than 80

A
  • below 150/90 or ABPM 145/85
22
Q

if you are taking two drugs for diabetes what is your target HbA1c

A

less than 53 mmol/mol

23
Q

describe what drugs you should apply at what levels in blood glucose lowering therapy

A

HbA1c above 48mmol/mol on lifestyle and diet

  • release metformin
  • gradually increase the dose over several weeks to minimise the risk of GI side effects

HBA1C levels rise to 58 mmol/mol or higher on a single drug

  • consider metformin dual therapy with either
  • DPP4 Inhibitor, pioglitazone, sulfonylurea, SGLT-2 inhibitor

HbA1c levels are not met on dual therapy with metformin and another oral drug
- triple therapy with:
- metformin, a DPP-4 inhibitor and a sulfonylurea
- metformin, pioglitazone and a sulfonylurea
- Metformin, pioglitazone, or sulfonylurea and SGLT-2
or
- consider insulin
or
- Triple therapy with metformin, a sulfonylurea, and a glucagon‑like peptide‑1 (GLP‑1)

24
Q

what should you do if metformin is contraindicated or not tolerated

A

A dipeptidyl peptidase‑4 (DPP‑4) inhibitor, or pioglitazone, or a sulfonylurea

A sodium-glucose co-transporter (SGLT)-2 inhibitor (if DPP‑4 inhibitor would otherwise be prescribed and a sulfonylurea or pioglitazone is not appropriate)

25
Q

in what case should you do a triple therapy with metformin, a sulfonylurea, and a glucagon‑like peptide‑1 (GLP‑1)

A

If BMI is above 35 kg/m2 and specific psychological or other medical problems associated with obesity

If BMI is below 35 kg/m2 and insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity‑related comorbidities

26
Q

name two incretins

A

glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 (GLP-1)

27
Q

what do incretins do

A
  • stimulate the release of insulin and inhibit the release of glucagon
28
Q

How are incretins broken down

A
  • they are broken down by the enzyme DPP-4
29
Q

What are the advantages of DPP-4 inhibitors

A
  • usually weight neutral
  • are well tolerated
  • can be used with insulin therapy
30
Q

what is a risk for DPP-4 inhibitors

A
  • risk of acute pancreatitis
31
Q

What should you do when a DPP-4 inhibitor is combined with a sulfonylurea

A
  • it is associated with a 50% increase in risk of hypoglycaemia and may required reduction in sulfonylurea dose when used in combination therapy
32
Q

What are the side effects of GLP-1 agonists

A
  • gastrointestinal = abdominal bloating, nausea, vomiting and diarrhoea
  • usually resolve after a few weeks
33
Q

Name the side effects of SGLT-2 inhibitors

A
  • geniturinary infections
  • polyuria
  • volume depletion
  • increased LDL cholesterol
  • increased creatine
  • DKA
34
Q

What does pioglitazone do

A
  • improves insulin sensitivity in the liver, muscle and fat,
  • reduces fasting and postprandial plasma glucose
  • increases HDL cholesterol and LDL
  • lowers triglycerides
  • improves hypertension
  • reduces microalbuminuria
35
Q

What are the side effects of pioglitazone

A
  • weight gain
  • fluid retention
  • distal long bone fractures particularly in post-menopausal

Year 3 - Preparation for Clinical Practise (33 decks)

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