T2 DM Flashcards
Type 2 diabetes is a condition where a combination of insulin ____ and reduced insulin ____ cause persistently high blood sugar levels.
resistance, production
Repeated exposure to ___ and ____ makes the cells in the body resistant to the effects of insulin
glucose
insulin
More and more insulin is required to…
stimulate body cells to take up and use glucose
Overtime, the ____ becomes fatigued and damaged by producing so much insulin and the insulin output is reduced
pancreas
A high carbohydrate diet combined with insulin resistance and reduced ____ f______ leads to chronic high blood glucose levels known as…
pancreas function
hyperglycaemia
What kinds of complication can chronic hyperglycaemia lead to?
Microvascular
Macrovascular
Infectious
What are non-modifiable risk factors for T2 DM?
Older
Black African, Caribbean or South Asia
Family history
What are some modifiable risk factors for T2 DM?
Obesity
Sedentary lifestyle
High carb diet (particularly sugar)
Smoking
What are presenting features of T2 DM?
Tiredness
Polyuria
Polydipsia
Unintentional weight loss
Opportunistic infections
Slow wound healing
Glucose in urine
T2DM is a risk factor itself for hypertension, silent MI, nephrotic syndrome, CKD…
What is acanthosis nigricans?
Thickening and darkening of the skin, giving a velvety appearance, often at the neck, axilla and groin.
Associated with insulin resistance.
An HbA1c of what range indicates pre-diabetes?
42 - 47 mmol/mol
How do you diagnose T2 DM?
An HbA1c of 48 mmol/mol or above
Repeat after 1 month to confirm diagnosis
How do you manage T2 DM according to NICE?
Structured education program
Low-glycaemic-index and high-fibre diet
Exercise
Weight loss if overweight
Antidiabetic drugs
Monitoring and managing complications
What are the HbA1c treatment target for new T2DM patients?
48 mmol/mol
What are the HbA1c treatment target for T2DM patients requiring more than 1 antidiabetic med?
53 mmol/ mol
What is the first line medication for T2DM?
Metformin
If has CVD or HF, then add SGLT-2 inhibitor like dapagliflozin.
Consider it for patients with a QRISK score above 10%
What is second line medication for T2DM?
If HbA1c is 58+, add one of the below:
Sulfonylurea
Pioglitazone
DPP-4 inhibitor
SLGT-2 inhibitor
What are third line medication options for T2DM?
Triple therapy = metformin with 2 second line drugs
and last resort = giving insulin
How does metformin work?
Increases insulin sensitivity and decreases glucose production by the liver.
True or false: metformin is a biguanide
True
True or false: metformin causes weight gain
False, may cause weight loss.
What are side effects of metformin?
GI:
pain, nausea, diarrhoea
Lactic acidosis secondary to having AKI and taking metformin
What is the suffix for SGLT-2 inhibitors?
-gliflozin
eg. empagliflozin, canagliflozin, dapagliflozin
Where are SGLT2 proteins found?
Sodium-glucose co-transporter 2 protein is found in the proximal tubes of the kidneys.
How do SGLT2 proteins work?
Reabsorb glucose from the urine back into the blood.
How do SGLT-2 inhibitors work?
Block the SGLT2 proteins from reabsorbing glucose back so more is excreted in the urine, lowering HbA1c and reducing blood pressure. Also leads to weight loss and improves HF.
Risk of hypoglycaemia when used with insulin or sulfonylureas.
What are side effects of SGLT-2 inhibitors
Glycosuria
Increased urine output
UTIs
Weight loss
DKA
Fournier’s gangrene (rare but severe infection of genitals or perineum)
Name a thiazolidinedione and how it works
Pioglitazone
Increases insulin sensitivity and decreases liver production of glucose
What are some side effects of pioglitazone?
Weight gain
Heart failure
Increased risk of bone fractures
Small increase in risk of bladder cancer
Name a sulfonylurea and how it works
Gliclazide
Stimulate insulin release from pancreas
What are side effects of gliclazide
Weight gain
Hypoglycaemia
What group of hormones are produced in response to large meals to reduce blood sugar?
Incretins
How do incretins work?
Increase insulin secretion
Inhibit glucagon production
Slow absorption in GI tract
What is the main incretin, and what is it inhibited by?
Glucagon-like peptide-1 (GLP-1)
Inhibited by enzyme dipeptidyl peptidase-4 (DPP-4)
What do DPP-4 inhibitors do?
Block the action of DPP-4 , allowing increased incretin activity
What are some common DPP-4 inhibitors?
sitagliptin
alogliptin
Do not cuase hypoglycaemia
What are side effects of DPP-4 inhibitors?
Headaches
Low risk of acute pancreatitis
What are examples of GLP-1 mimetics?
exenatide
liraglutide
(SC injections)
What are side effects of GLP-1 mimetics?
Reduced appetite
Weight loss
GI symptoms: discomfort, nausea and diarrhoea
How long does it take rapid-acting insulin to start working and last?
eg NovoRapid
Takes 10 minutes
Lasts 4 hours
How long does it take short-acting insulin to start working and last?
eg Actrapid
Takes 30 minutes
Lasts 8 hours
How long does it take intermediate-acting insulin to start working and last?
eg Humulin I
Takes 1 hour
Lasts 16 hours
How long does it take long-acting insulin to start working and last?
eg Levemir and Lantus
Takes 1 hour
Lasts about 24 hours
Combination insulins contain a _____ and ______ insulin
eg Humalog 25 (25:75)
Humalog 50 (50:50)
Novomix (30:70)
rapid-acting and intermediate-acting
What are key complications of T2 DM?
Infections
Diabetic retinopathy
Peripheral neuropathy
Autonomic neuropathy
CKD
Diabetic foot
Gastroparesis
Hyperosmolar hyperglycemic state
What is 1st line treatment of hypertension in T2 DM patients?
ACE inhibitors
What med is given to T2DM patients with CKD when the albumin-to-creatinine ratio is above 3 mg/mmol
ACE inhibitor
When would you give a SGLT-2 inhibitor along with the ACE inhibitor to a T2DM patient with CKD?
When the albumin-to-creatinine ratio is above 30 mg/mmol
What are the 4 treatment options for neuropathic pain with T2DM?
Amitriptyline (tricyclic antidepressant)
Duloxetine (an SNRI antidepressant)
Gabapentin (anticonvulsant)
Pregabalin (anticonvulsant)
What is a rare but potentially fatal complication of T2DM?
hyperosmolar hyperglycemic state (HHS)
What characterises HHS?
hyperosmolality - water loss leads to very concentrated blood with high sugar levels but absence of ketones.
Polyuria, polydipsia, weight loss, dehydration, tachycardia, hypotension and confusion
How do you treat HHS?
IV fluids and careful monitoring
What is IGT?
Impaired Glucose Tolerance
Seen in prediabetics.
Sees normal FPG of less than 6 mmol/l
but 2 hours after taking set amount of glucose in Oral Glucose Tolerance Test (OGTT), the glucose levels are now 7.8-11 mmol/l
What is IFG?
Impaired Fasting Glucose
Seen in prediabetics.
FPG is between 6.1-6.9 mmol/l (greater than normal)
and
2 hours post OGTT, less than 7.8 mmol/l
What are OGTT levels in normal, pre-diabetic and diabetic patient?
Normal = less than 7.8 mmol/l
Prediabetic = 7.8-11 mmol/l
Diabetic = more than 11 mmol/l
What are FPG (fasting plasma glucose) levels in normal, pre-diabetic and diabetic patients
Normal = up to 6 mmol/l
Prediabetic = 6.1-6.9
Diabetic = 7+
