T2 DM Flashcards by Jemima Solt

Type 2 diabetes is a condition where a combination of insulin ____ and reduced insulin ____ cause persistently high blood sugar levels.

resistance, production

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Repeated exposure to ___ and ____ makes the cells in the body resistant to the effects of insulin

glucose
insulin

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More and more insulin is required to…

stimulate body cells to take up and use glucose

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Overtime, the ____ becomes fatigued and damaged by producing so much insulin and the insulin output is reduced

pancreas

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A high carbohydrate diet combined with insulin resistance and reduced ____ f______ leads to chronic high blood glucose levels known as…

pancreas function

hyperglycaemia

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What kinds of complication can chronic hyperglycaemia lead to?

Microvascular
Macrovascular
Infectious

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What are non-modifiable risk factors for T2 DM?

Older
Black African, Caribbean or South Asia
Family history

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What are some modifiable risk factors for T2 DM?

Obesity
Sedentary lifestyle
High carb diet (particularly sugar)
Smoking

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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…

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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.

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An HbA1c of what range indicates pre-diabetes?

42 - 47 mmol/mol

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How do you diagnose T2 DM?

An HbA1c of 48 mmol/mol or above

Repeat after 1 month to confirm diagnosis

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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

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What are the HbA1c treatment target for new T2DM patients?

48 mmol/mol

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What are the HbA1c treatment target for T2DM patients requiring more than 1 antidiabetic med?

53 mmol/ mol

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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%

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What is second line medication for T2DM?

If HbA1c is 58+, add one of the below:
Sulfonylurea
Pioglitazone
DPP-4 inhibitor
SLGT-2 inhibitor

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What are third line medication options for T2DM?

Triple therapy = metformin with 2 second line drugs

and last resort = giving insulin

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How does metformin work?

Increases insulin sensitivity and decreases glucose production by the liver.

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True or false: metformin is a biguanide

True

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True or false: metformin causes weight gain

False, may cause weight loss.

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What are side effects of metformin?

GI:
pain, nausea, diarrhoea
Lactic acidosis secondary to having AKI and taking metformin

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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+