T2DM Flashcards
what is GLP-1
- Secreted by L cells of the intestine in response to nutrients
- Rapidly metabolized by DPP-4
- Decreases serum glucose
–Pancreas
—Stimulates insulin secretion
—Inhibits glucagon secretion
—Increases beta cell mass
–GI tract
—Slows gastric emptying, leading to lower post-prandial glucose excursion
–CNS
—Decreases appetite through central actions on the hypothalamus
*GLP-1 analogues available as injected agents
*DPP-4 inhibitors decrease metabolism of endogenous GLP-1
Prevention of T2DM
- Breastfeeding
- Lifestyle
- Improve sleep quality and quantity
- Decrease sedentary behaviours
- Increase both light and vigorous physical activity
- Reducing sugar-sweetened beverage consumption
- Limit screen time
- In children with obesity, family-based healthy behaviour interventions
Target A1c T2DM
7%
Health lifestyle for T2DM
- 60 minutes daily of moderate-to-vigorous physical activity
limiting recreational screen time to < 2 hours per day - Limiting sedentary (motorized) transport, extended sitting and time spent indoors throughout the day
When to start insulin in T2DM
DKA
A1C ≥9.0%
symptoms of severe hyperglycemia
Once-a-day basal insulin
Complications and comorbidities of T2DM
Neuropathy
Retinopathy
Nephopathy
Dyslipidemia
Hypertension
NAFLD
PCOS
OSA
Depression
Binge eating
Dx T2DM
- FPG ≥ 7.0 mmoL/L
- OGTT 2-hour plasma glucose ≥11.1 mmoL/L
- Symptoms of diabetes and a random plasma glucose ≥11.1 mmol/L
○ Sx: polyuria, polydipsia, nocturia and unexplained weight loss - HbA1c ≥ 6.5%
HbA1C alone shouldn’t be used for screening
S/E of Metformin
- GI: nausea, diarrhea, abdo pain
- Lactic acidosis - rare, may be in context of AKI
Neuropathy screening in T2DM
- when and frequency
- screening test
yearly starting at dx
questions and exam
symptoms, vibration, touch, ankle reflex
retinopathy screening in T2DM
- when and frequency
- screening test
yearly starting at dx
7-standard field- stereoscopic-colour funds photography w interpretation by a trained reader
Nephropathy screening in T2DM
- when and frequency
- screening test
yearly starting at dx
first AM ACR (or random)
Dyslipidemia screening in T2DM
- when and frequency
- screening test
yearly starting at dx
fasting TC, HDL-C, TG, calculated LDL-C
hypertension screening in T2DM
- when and frequency
- screening test
at dx and every dm-related encounter
BP measurement with appropriate sized cuff
NAFLD screening in T2DM
- when and frequency
- screening test
yearly starting at dx
ALT and/or fatty liver on ultrasound
PCOS screening in T2DM
- when and frequency
- screening test
yearly clinical screening starting at dx for pubertal females
clinical assessment on hx and p/e for oligo/amenorrhea, acne, hirsutism
CVD prevention in T2DM
smoking cessation
activity
when to start statin in T2DM
In children with familial dyslipidemia + a positive FHx of early CV events:
start if the LDL-C level remains >4.1 mmol/L after a 3- to 6-month trial of dietary intervention
Who should be screened for T2DM?
- ≥3 risk factors in nonpubertal children beginning at 8 years of age or ≥2 risk factors in pubertal children. Risk factors include:
1) Obesity (BMI ≥95th percentile for age and gender)
2) Member of a high-risk ethnic group (e.g. African, Arab, Asian, Hispanic, Indigenous or South Asian descent)
3) First-degree relative with type 2 diabetes and/or exposure to hyperglycemia in utero
-4) Signs or symptoms of insulin resistance (including acanthosis nigricans, hypertension, dyslipidemia, NAFLD [ALT >3X upper limit of normal or fatty liver on ultrasound]) - PCOS
- IFG and/or IGT
- Use of atypical antipsychotic medications
how to screen T2DM
an A1C and a FPG or random plasma glucose
not A1C alone
What are high risk ethnic groups for T2DM
Asian
Arab
African
Hispanic
Indigenous
South Asian descent
physical activity rec
≥60 minutes of moderate-to-vigorous physical activity daily,
what is OGTT
abnormal?
1.75 g/kg (max 75 g) anhydrous glucose dissolved in water
check BG at baseline and 2h later
abnormal = ≥11.1 mmoL/L
Metformin
Class:
Mech of Action
Lowers A1C by:
Weight:
SE:
Class: biguanide
Mech of Action:
- Enhance insulin sensitivity in liver and peripheral tissues by activation of AMP-activated protein kinase
- Inhibits hepatic glucose production
Lowers A1C by: 1%
Weight: Neutral
SE: GI symptoms (Nausea, diarrhea)
Lactic acidosis
Where is GLP1 secreted
What does it do
What degrades it
secreted by L-cells in the small intestine in response to food
increases insulin secretion proportionate to BG concentrations
suppresses glucagon
prolongs gastric emptying
promotes satiety.
rapidly degraded by DPP- IV
GLP1 RA
Class:
Drugs:
MOA (3):
A1C decrease:
Weight:
SE:
Class: Incretin
Drugs:
Short acting: exenatide, lizisenatide
Long acting: liraglutide, semaglutide, dulaglutide, exenatide ER
LE SLED
MOA (3):
- Increases glucose dependent insulin release
- Slows gastric emptying
- Inhibits glucagon release
A1C decrease: 0.6-1.4%
Weight: loss 1.1-4.4kg
SE: GI side effect
Pancreatitis
Thyroid C Cell malignancy**
DPP4i
Class:
Drugs:
MOA (3):
A1C decrease:
Weight:
SE:
Class: Incretin
Drugs:
Aloglipton
Linagliptin
Saxagliptin
Sitagliptin
LASS
MOA (3):
- Inhibits the enzyme that breaks down incretins,
Leads to:
- Increases glucose dependent insulin release
- Slows gastric emptying
- Inhibits glucagon release
A1C decrease: 0.5-0.7%
Weight: neutral
SE:
Risk heart failure (saxagliptin)
Pancreatitis
Severe joint pain
SGLT2i
MOA:
Drugs:
A1C Reduction:
Weight:
SE:
MOA: reduces glucose reabsorption by the kidneys
== glucosuria
Drugs:
Canagliflozin
Dapagliflozin
Empagliflozin
–>CDE
A1C Reduction: 0.5-0.7%
Weight: loss 2-3kg
Side effects:
Genital myocotic infections
UTI
DKA euglycemic (rare)
Sulfonylurea
Class:
Drugs:
MOA:
A1C reduction:
Weight:
Side effects:
Class: Insulin secretagogue
Drugs:
Gliclazide
Glimepride
Glyburide
MOA: Activates sulfonylurea receptor on B-cell to stimulate insulin secretion
A1C reduction: 0.6-1.2%
Weight: Gain 1.2-3.2kg
Side effects: Hypoglycemia
what kind of drug is liraglutide, semaglutide
GLP1-agonist
what kind of drug is Saxagliptin
DPP4i
Glimepride -what kind of drug
Sulfonylurea
Insulin secretagogue
Glyburide - what kind of drug
Sulfonylurea
Insulin secretagogue
For surgery, meds to stop before surgery, stop day or surgery, dn’t stop
Stop 3d before: SGLT2i
Stop 1d before: GLP1a
Stop day of: metformin, sulfonylurea, DPP4i
why DM ctrl is important for pregnancy
Fetal: higher A1c at the time of conception is associated with:
- Increased the risk of fetal malformations
- Increased risk of intrauterine fetal death / Spontaneous abortion
Maternal:
- pregnancy can worsen diabetes complications = retinopathy
- Improved glycemic control improves fertility
- preeclampsia
