T2DM treatment and complications

Question 1

What is the cornerstone of therapy in T2DM

Answer 1

The cornerstone of therapy for all patients with type 2 diabetes is a personalised management programme that includes pharmacotherapy and ongoing self-management education by a diabetes education nurse or nutritionist.[61][62][63] Diabetes self-management education promotes diabetes self-care and supports beneficial lifestyle changes on an ongoing basis.[2] This requires general nutrition and health lifestyle knowledge and an individualised nutrition and exercise plan based on an initial assessment and treatment goals. Interventions that enhance self-management can significantly reduce diabetes distress

Question 2

Describe some key characteristics of patients with T2DM

Answer 2

About 80% of adults with type 2 diabetes have concurrent dyslipidaemias or hypertension, 70% are overweight or obese, and around 15% are current smokers.[9] On average, adults with type 2 diabetes are up to twice as likely to die of stroke or myocardial infarction (MI) compared with those without diabetes, and they are more than 40 times more likely to die of macrovascular than microvascular complications of diabetes.[65][66][67] However, data indicate that adults with type 2 diabetes who optimally manage glucose, blood pressure, lipids, smoking, and weight have a risk of major cardiovascular events that is not significantly above the risk of age and sex-matched non-diabetes peers.

Question 3

Describe the multi-faceted managements of patients with T2DM

Answer 3

Therefore, care of adults with type 2 diabetes must include management of all major cardiovascular risk factors to individualised targets. In addition to glucose control, this includes smoking cessation, blood pressure control, lipid control, antiplatelet use for patients with known coronary heart disease, and ACE inhibitors or angiotensin-II receptor antagonists for patients with chronic kidney disease or proteinuria.[2][41][70] In addition, use of antihyperglycaemic agents that reduce cardiovascular or overall mortality or cardiovascular events may be especially beneficial in those who have type 2 diabetes and established cardiovascular disease

Question 4

Describe the importance of managing diet in T2DM

Answer 4

Nutrition therapy involves limiting caloric intake to achieve recommended weight, while offering a diversified and appealing menu of food choices.[72] Nutrition advice needs to be tailored to the needs of each individual patient, preferably by a nutritionist.[2][29] The optimal mix of carbohydrate, fats, and protein depends upon renal status, achieved lipid levels, body mass index (BMI), and level of glycaemic control, among other factors. Low-carbohydrate diets appear to be beneficial for glycaemic control in type 2 diabetes management.[73] Saturated fat should be limited to <10% of calories.[29] Reducing sugary beverage consumption (including milk, fizzy drinks, energy drinks, and fruit juice) is of benefit to many patients.[29] Weight loss management programmes with a healthy eating and physical activity plan resulting in an energy deficit have the potential for type 2 diabetes remission.[29][74][75] The Diabetes Remission Clinical Trial (DiRECT) of supported weight loss management for people diagnosed with type 2 diabetes within the previous 6 years, and a BMI of 27kg/m² to 45 kg/m², found that almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs at 12 months.[74] At 2 years, more than a third of people with type 2 diabetes had sustained remission

Question 5

Describe the importance of monitoring exercise and sleep in patients with T2DM

Answer 5

To improve glycaemic control, assist with weight maintenance, and reduce cardiovascular risk, moderate physical activity is recommended as tolerated. The ACC/AHA has recommended that, in general, adults should engage in 3 to 4 sessions of aerobic physical activity per week, with each session lasting on average 40 minutes, and involving moderate- to vigorous-intensity physical activity.[77] Walking frequently in proper footwear is a recommended activity.[2]
In addition, gentle strength training that targets all major muscle groups may be beneficial if done for 20 minutes 2 to 3 times per week on non-consecutive days. Patients with severe or symptomatic heart disease may require evaluation before increasing levels of physical activity.[2]
People should be encouraged to limit the amount of time they spend being sedentary by avoiding extended amounts of time spent sitting.
Older adults may benefit from flexibility training and balance training 2-3 times/week (e.g., with yoga or tai chi).
An assessment of sleep duration and quality should be considered. Obesity, diabetes, hypertension, atrial fibrillation, and male sex are risk factors for sleep apnoea, and inadequate sleep may affect glycaemic control

Question 6

What are the BP targets in patients with T2DM

Answer 6

Blood pressure guidelines differ regarding recommended targets for those with diabetes.

The 2017 American College of Cardiology/American Heart Association guideline for management of high blood pressure (BP) in adults recommends BP <130/80 mmHg for people with diabetes, and classifies BP using the following categories:[78]
normal (<120/80 mmHg)
elevated (120-129/<80 mmHg)
stage 1 (130-139/80-89 mmHg)
stage 2 hypertension (≥140/90 mmHg).
The American Diabetes Association Standards of Medical Care in Diabetes recommends goal BP <140/90 mmHg for people with diabetes, with consideration of a goal BP <130/80 mmHg for those with established hypertension and diabetes and who have established cardiovascular disease or 10-year cardiovascular risk greater than 15%

Question 7

Describe how we treat HTN in diabetics

Answer 7

Regardless of specific blood pressure goal, initial treatment with an ACE inhibitor, an angiotensin-II receptor antagonist, a calcium-channel blocker, or a thiazide (or thiazide-like) diuretic is preferred. Black people may benefit most from a thiazide diuretic or a calcium-channel blocker.[79] ACE inhibitors may reduce mortality and cardiovascular events more than angiotensin-II receptor antagonists.[70] Combination drug therapy (with ACE inhibitor/angiotensin-II receptor antagonist, calcium-channel blocker, thiazide diuretic) is often required to reach blood pressure goals. Combined use of an ACE inhibitor and an angiotensin-II receptor antagonist is not recommended due to increased risk of adverse events.[80] However, most people with chronic kidney disease (CKD) should receive an ACE inhibitor or an angiotensin-II receptor antagonist as part of their antihypertensive regimen.[79] CKD is defined as (a) age <70 years with glomerular filtration rate (GFR) <60 mL/minute/1.73 m², or (b) people of any age with albuminuria >30 mg albumin/g of creatinine at any level of GFR.

Question 8

Are beta blockers contra-indicated in diabetics?

Answer 8

Beta-blockers are not contraindicated in people with diabetes but are less-preferred antihypertensive agents[79] and may mask symptoms of hypoglycaemia. ACE inhibitors may increase risk for hypoglycaemia in conjunction with insulin or an insulin secretagogue (e.g., sulfonylurea or meglitinide).

Question 9

What should be done if BP remains uncontrolled on first-line therapies

Answer 9

If blood pressure remains uncontrolled on first-line therapies, discontinue or minimise interfering substances such as non-steroidal anti-inflammatory drugs (NSAIDs), evaluate for secondary causes of hypertension (including obstructive sleep apnoea), and consider the addition of a mineralocorticoid receptor agonist,[82] and/or refer to a hypertension specialist.

Question 10

What are current studies showing about BP management

Answer 10

Blood pressure goals and guidelines are evolving as more studies are carried out. The Systolic Blood Pressure Intervention Trial (SPRINT) was terminated early, as it found that a lower systolic target of 120 mmHg reduced cardiovascular complications and deaths in people aged over 50 years with high blood pressure and at least one additional risk factor for heart disease.[83] However, people with diabetes were excluded from this trial.
There is an increasing emphasis to incorporate the use of home blood pressure monitoring into the diagnosis and management of hypertension in adults, including those with diabetes.

Question 11

Summarise the management of lipids in diabetics

Answer 11

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend high-intensity statin therapy if tolerated in adults aged over 21 years if the patient has clinical atherosclerotic cardiovascular disease (ASCVD) or low-density lipoprotein (LDL)-cholesterol ≥4.9 mmol/L (≥190 mg/dL).[85] In those aged 40 to 75 years with diabetes but no ASCVD, moderate-intensity statin therapy should be considered. [ Cochrane Clinical Answers logo ] In those with diabetes and 10-year ACC/AHA cardiovascular risk greater than 20%, consider adding ezetimibe to maximally-tolerated statin therapy to reduce LDL by 50% or more.[85] In diabetes patients aged over 75 years, it is reasonable to consider and discuss with the patient advantages and disadvantages of initiation or continuation of statin therapy.[85] In those aged 20 to 39 years with diabetes, it may be reasonable to initiate statin therapy in the presence of albuminuria, estimated GFR <60 mL/minute/1.73 m², retinopathy, or neuropathy.[85] Statins are contraindicated in pregnancy.

Question 12

What is management of lipids in diabetes driven by

Answer 12

The American Diabetes Association (ADA) recommends that management of lipid abnormalities is driven by risk status rather than LDL cholesterol level.[2] Risk factors for cardiovascular disease include LDL-cholesterol >2.6 mmol/L (>100 mg/dL), high blood pressure, smoking, and overweight and obesity. Lifestyle therapy is recommended for all people. For people with diabetes and overt cardiovascular disease, high-intensity statin therapy is added to lifestyle therapy, regardless of baseline lipid values. High-intensity statin therapy is also considered for those aged over 40 years without overt cardiovascular disease, but with one or more cardiovascular disease (CVD) risk factors. For people with diabetes aged over 40 years without additional CVD risk factors, moderate-intensity statin therapy is still considered. For some patients with diabetes and established coronary heart disease who have persistently elevated LDL despite maximally-tolerated statin therapy, addition of ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor (e.g., alirocumab, evolocumab) may confer clinical benefit

Question 13

Describe the importance of smoking cessation

Answer 13

Patients who smoke should be provided with smoking cessation resources, and be provided with smoking cessation assistance such as medications and counselling as appropriate. Varenicline combined with nicotine replacement therapy may be more effective than varenicline alone.[89] The ADA does not support e-cigarettes as an alternative to smoking or to facilitate smoking cessation

Question 14

Describe the importance of anti-platelet therapy

Answer 14

Adults with cardiovascular disease should receive aspirin for secondary prevention. Clopidogrel is an alternative for patients with aspirin allergy or intolerance. Dual antiplatelet therapy is reasonable for up to 12 months after an acute coronary syndrome. The main adverse effect is an increased risk of gastrointestinal bleeding.[2][90]
The ADA recommends that aspirin therapy be considered for primary prevention in adults with type 2 diabetes aged 50 to 70 years who are at increased cardiovascular risk (family history of premature cardiovascular disease, hypertension, dyslipidaemias, smoking, chronic kidney disease/albuminuria), unless they are at high risk of serious bleeding.[2]
US Preventive Services Task Force (USPSTF) recommendations for primary prevention of heart attack or stroke in those aged 50 to 70 years are similar

Question 15

Describe the importance of individualised HbA1c targets

Answer 15

HbA1c goals should be individualised.[92][93] For many patients, the goal HbA1c <7% is appropriate. However, HbA1c 7.0% to 7.9% may be more appropriate in some patients, such as those with advanced age, limited life expectancy, known cardiovascular disease, high risk of severe hypoglycaemia, or difficulty achieving lower HbA1c goals despite use of multiple antihyperglycaemic medications and insulin.[2] Individualised HbA1c goals improve quality of life compared with uniform tight control.

Question 16

Summarise what should be done if the HbA1c is above goal

Answer 16

If HbA1c is above goal, pharmacotherapy is recommended to reduce risk of both microvascular (nephropathy, retinopathy, neuropathy) and macrovascular (myocardial infarction, stroke, peripheral vascular disease) complications.[94][95] Data suggest that preventing major cardiovascular events and renal complications of diabetes may be affected not only by HbA1c levels but also by strategic selection of specific antihyperglycaemic medications. Some specific antihyperglycaemic medications significantly reduce all-cause or cardiovascular mortality, or major cardiovascular events or renal complications in some patient subgroups, and for such patients, these agents may be preferred.[71] Among the antihyperglycaemic medications that reduce cardiovascular mortality in some patient subgroups are metformin,[96] empagliflozin, canagliflozin, and liraglutide

Question 17

Describe how antiglycaemic agents are chosen

Answer 17

In older studies such as ACCORD, ADVANCE, and the Veterans Affairs Diabetes Trial (VADT), use of multiple drugs to achieve near-normal HbA1c was either not beneficial or increased mortality in type 2 diabetes patients with CVD or high CVD risk.[97][98][99][100][101] However, sodium-glucose co-transporter 2 (SGLT2) inhibitors were not available and glucagon-like peptide-1 (GLP-1) agonists were infrequently used in those studies.

Patients with type 2 diabetes using multiple daily insulin injections or an insulin pump should self-monitor blood glucose three or more times daily. For patients using less frequent insulin injections or non-insulin therapies, self-monitoring may be useful to guide therapy.[2]

Choice of agents should be individualised, taking into account patient values and preferences, the likelihood that an agent reduces all-cause or cardiovascular mortality, renal effects, adverse effects, costs, and other factors

Question 18

What is the first choice therapy in patients with T2DM

Answer 18

Metformin is the recommended first-choice therapy at diagnosis in the absence of contraindications because of its safety profile and likely cardiovascular benefit.[94][96] Metformin may be safely used in patients with reduced estimated glomerular filtration rates (eGFRs), but it is contraindicated if eGFR <30 mL/minute/1.73 m².[2][102] Metformin should not be initiated if the eGFR is <45 mL/minute/1.73 m², and, for patients taking metformin whose eGFR falls to within the 30-45 mL/minute/1.73 m² range, continued use can be considered with close monitoring of renal function and a dose reduction.[102][103] People who are unable to take metformin due to contraindications or intolerance can either use an alternative non-insulin agent or start insulin therapy. Basal-bolus insulin is used as initial treatment (without metformin) for those with type 2 diabetes and very high initial glucose levels (>16.6 mmol/L [>300 mg/dL]).

Question 19

When can you start to add other agents in diabetic patients who were started on metformin (but without CVD risk)

Answer 19

In patients with diabetes without diagnosed cardiovascular disease, if metformin is used as initial treatment and fails to achieve goals after 3 months, a second agent may be added based on individualised assessment of necessary clinical benefit, safety considerations, costs, and patient preference:[102]

Sodium-glucose co-transporter 2 (SGLT2) inhibitor: canagliflozin, dapagliflozin, empagliflozin, or ertugliflozin
Glucagon-like peptide-1 (GLP-1) agonist: liraglutide, exenatide, lixisenatide, semaglutide, or dulaglutide
Dipeptidyl peptidase-4 (DPP-4) inhibitor: sitagliptin, saxagliptin, linagliptin, or alogliptin
Sulfonylurea: glimepiride, gliclazide, or glipizide; meglitinides (e.g., repaglinide, nateglinide) are an alternative
Alpha-glucosidase inhibitor: acarbose or miglitol
Thiazolidinedione: pioglitazone
Insulin.

Question 20

When can you start to add other agents in diabetics (with CVD RISK)

Answer 20

In patients with diabetes and with diagnosed cardiovascular disease, if metformin is used as initial treatment and fails to achieve goals after 3 months, a second agent may be added. Addition of a SGLT2 inhibitor or GLP-1 agonist is recommended in patients with long-standing sub-optimal glycaemic control plus established cardiovascular and/or renal disease.[2][102][104]

SGLT2 inhibitor: canagliflozin or empagliflozin may be preferred.
GLP-1 agonist: liraglutide may be preferred.

Question 21

Do the 3-agent of glucose lowering agents have to include insulin?

Answer 21

There are many appropriate 3-agent combinations of glucose-lowering therapy that do not involve insulin. Choice of second and third antihyperglycaemic medications may differ depending on cardiovascular comorbidities.[102] When 2- or 3-drug non-insulin regimens fail, basal insulin can be added. Bolus insulin can be subsequently added if needed to achieve or maintain adequate glucose control. To reduce the risk of hypoglycaemia, a sulfonylurea is usually tapered if insulin is started.

Question 22

Describe a key clinical property of metformin

Answer 22

Agents are often selected based on a discussion with the patient of the pros and cons of the agents. Agents that reduce all-cause or cardiovascular mortality may be preferred.[41]

Metformin can promote weight loss and may reduce cardiovascular events and mortality.

Question 23

Describe the key clinical properties of SGLT inhibitors

Answer 23

SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) inhibit renal glucose reabsorption. The resulting increase in glycosuria improves glycaemic control, promotes weight loss, and has a diuretic effect that reduces blood pressure.[105] There is evidence that use of SGLT2 inhibitors prevents major kidney outcomes (dialysis, transplantation, or death due to kidney disease) in people with type 2 diabetes.[106] Empagliflozin and canagliflozin have been shown to reduce cardiovascular risk in people with CVD and type 2 diabetes, and may have renal benefits.[71][107][108][109][110] Empagliflozin and canagliflozin have been shown to significantly reduce cardiovascular or all-cause mortality in those with diabetes and established cardiovascular disease.[111][112][113] In one trial, treatment with dapaglifozin in patients with type 2 diabetes who had, or were at risk for, atherosclerotic cardiovascular disease did not result in a lower rate of major adverse cardiovascular events, but did report a lower rate of hospitalisation for heart failure.[114] Trials on the CVD benefits of ertugliflozin are ongoing.[115][116][117] Adverse effects for different agents have included a higher rate of genital infections, diabetic ketoacidosis, acute kidney injury, fracture, and/or amputation.[111][118][119] Notably, the US Food and Drug Administration (FDA) has confirmed an increased risk of leg and foot amputations with canagliflozin.[120] The European Medicines Agency (EMA) also warns of the potential increased risk of toe amputation with SGLT2 inhibitors.[121] For canagliflozin, the prescribing information will also list lower-limb amputation as an uncommon side effect.[122] The FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA) warn of cases of necrotising fasciitis of the perineum (also known as Fournier’s gangrene) observed in post-marketing surveillance of SGLT2 inhibitors.[123][124] Thus, SGLT2 inhibitors should be avoided in patients with conditions that increase the risk for limb amputations, and in patients prone to urinary tract or genital infections.

Question 24

Describe the key properties of GLP-1 agonists

Answer 24

GLP-1 agonists (liraglutide, exenatide, lixisenatide, semaglutide, dulaglutide) are suitable for obese patients without gastroparesis who desire weight loss, are willing to take injections, and can tolerate the common adverse effect of initial nausea.[125] In one review, GLP-1 agonist use led to loss of 1.4 kg versus placebo, and loss of 4.8 kg versus insulin.[126] As a class of drugs, GLP-1 agonist treatment has beneficial effects on cardiovascular, mortality, and kidney outcomes in patients with type 2 diabetes.[127] Liraglutide significantly reduced cardiovascular mortality and all-cause mortality in those with diabetes and cardiovascular disease or high CVD risk in one randomised trial.[128] Dulaglutide and semaglutide have both been shown to reduce major cardiovascular events, but not all-cause or cardiovascular mortality.[129][130][131] Exenatide and lixisenatide have both been shown not to reduce major cardiovascular events.[132] The MHRA warns of cases of diabetic ketoacidosis in patients with type 2 diabetes on a combination of a GLP-1 receptor agonist and insulin who had doses of concomitant insulin rapidly reduced or discontinued

Question 25

Describe the clinical properties of DPP-4 inhibitors and sulfonylureas

Answer 25

DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin, alogliptin) are well tolerated, weight-neutral, but confer no mortality benefit.
Sulfonylureas (glipizide, glimepiride, glyburide) are the subject of long clinical experience and may reduce microvascular complications, but confer no mortality benefit and may cause weight gain and hypoglycaemia.[102] Along with metformin and human insulin, these are among the more affordable antihyperglycaemic medications

Question 26

Describe the clinical properties of alpha glucosidase inhibitors

Answer 26

Alpha-glucosidase inhibitors (acarbose, miglitol) can be added to metformin in people with large postprandial glucose excursions, but increased flatus and gastrointestinal (GI) side effects are common. There is no strong evidence of a benefit on all-cause or cardiovascular mortality.

Question 27

Describe the clinical properties of thiazoinediones

Answer 27

Thiazolidinediones (pioglitazone, rosiglitazone) lower blood sugar effectively but more than double the risk of congestive heart failure, often causing weight gain and oedema.[102] They may cause anaemia and increase fracture rates in both women and men. In addition, rosiglitazone raises LDL-cholesterol and mixed evidence suggests that rosiglitazone may increase the risk of cardiovascular events.[135] Rosiglitazone has been removed from the European market due to persistent safety concerns.[136] However, in 2013, the US Food and Drug Administration (FDA) lifted previous restrictions applied to rosiglitazone in the US, based on newer data.[137] As a result of an updated review, the FDA has concluded that use of pioglitazone may be linked to an increased risk of bladder cancer

Question 28

Describe some other oral agents that are sometimes used

Answer 28

Bromocriptine and colesevelam are oral agents approved for glucose-lowering in some countries. They have limited impact on blood glucose in many patients. Bromocriptine may cause GI side effects. Colesevelam, originally approved as a bile-acid sequestrant, requires multiple doses per day, and may bind other medications. Neither of these agents is widely used for glucose control at present.

Question 29

Summarise the use of insulin in T2DM

Answer 29

Insulin therapy is required for severe hyperglycaemia and is an option when metformin monotherapy or multi-drug regimens are inadequate. Usually this is initiated with long-acting basal insulin at bedtime. Some patients’ blood sugars can be well controlled with a combination of non-insulin therapy and one injection of basal insulin. However, some patients will need to use both a long-acting basal insulin (e.g., detemir, glargine, or degludec) injection once daily and rapid-acting insulin (e.g, lispro, aspart, or glulisine) injected before each meal. Intermediate (NPH) and short-acting (regular) insulins are other choices for basal-bolus regimens. For patients with type 2 diabetes, human insulins are as effective as analogue insulins for glucose control, serious hypoglycaemia risk, and mortality and cardiovascular events.[139] [ Cochrane Clinical Answers logo ] Human insulins are less expensive than analogue insulins. Pre-mixed insulin is available. Regimens should be individualised. Insulin delivery devices that can be programmed to administer set doses of insulin are now available and may be used by patients to help them achieve glycaemic control. As insulin doses increase, any sulfonylurea should be tapered, but metformin may be continued.

Question 30

When should you consider insulin treatment and what are the risks

Answer 30

Insulin treatment should be considered at the time of diagnosis if glucose level is ≥16.6 mmol/L (≥300 mg/dL) or if HbA1c is ≥86 mmol/mol (≥10%). For these patients with marked hyperglycaemia, metformin can be used adjunctively, in the absence of nausea, vomiting, or volume depletion.

Exogenous insulin is a very effective way to lower serum glucose and lower HbA1c, but its use must be guided in most patients by regular self-monitored blood glucose testing. Hypoglycaemia (glucose ≤3.9 mmol/L [≤70 mg/dL]) is the most serious potential complication of insulin therapy. Another significant side effect is weight gain. Less common side effects may include hunger, nausea, diaphoresis, injection site irritation, or anaphylaxis.

Question 31

Describe corrected doses of insulin

Answer 31

When basal-bolus insulin is used by motivated and knowledgeable patients, the dose of rapid-acting insulin that is administered before each meal can be based on anticipated carbohydrate content of the upcoming meal and sometimes adjusted for anticipated physical activity. Correctional doses of rapid-acting insulin can also be applied based on pre-meal blood sugar readings (correctional algorithms). One acceptable method of determining a correction algorithm is to divide 1800 by the total daily dose of insulin to yield the expected blood sugar reduction per unit of insulin. For example, for a patient taking 60 units of insulin per day, the expected blood sugar lowering of 1 additional unit of insulin would be 1800/60=30 mg/dL (1.7 mmol/L).

Question 32

Describe the potential benefits of bariatric surgery in obese diabetics

Answer 32

Randomised clinical trials have shown a benefit from bariatric surgery (also referred to as metabolic surgery) with regard to diabetes remission, glycaemic control, need for glucose-lowering medications, quality of life, and reduction in cardiovascular risk factor markers over the short term (e.g., 1-3 years) in people with type 2 diabetes as compared with medical therapy alone,[140][141][142][143][144] as well as for possible prevention of type 2 diabetes.[145] Cohort studies suggest that both Roux en Y bypass and sleeve gastrectomy procedures lead to diabetes remission that lasts a mean of about 5 years in more than half of patients, and significantly reduce mortality, stroke, myocardial infarction, and microvascular complications in those with type 2 diabetes.[146][147][148] Compared with sleeve gastrectomy, Roux en Y leads to somewhat greater weight loss and other benefits, but is a more technically challenging operation with higher re-operation and readmission rates. The benefits and risks of bariatric surgery also vary substantially across type 2 diabetes patient subgroups. In observational studies, average benefits appeared to be highest in those who are younger (age 40-50 years), those with more recent onset of type 2 diabetes, and those not on insulin therapy

Question 33

When may you consider bariatric surgery

Answer 33

Bariatric surgery may be considered for adults with BMI ≥40 kg/m² (≥37.5 kg/m² for people of Asian-family origin) with any level of glycaemic control/any complexity of glucose-lowering regimen.[2] Surgery may also be considered for adults with BMI 35.0 to 39.9 kg/m² (32.5 to 37.4 kg/m² for people of Asian-family origin) with hyperglycaemia inadequately controlled despite lifestyle and optimal medical management, and may be considered for those with BMI 30.0 to 34.9 kg/m² (27.5 to 32.4 kg/m² for people of Asian-family origin) with hyperglycaemia inadequately controlled despite optimal use of oral or injectable medications (including insulin).[2] Bariatric surgery is best done in a high-volume, specialised centre.

Question 34

Describe the treatment of diabetes in pregnancy

Answer 34

Good glucose control with HbA1c as close to normal as is safely possible (ideally HbA1c <6.5% [48 mmol/mol]) before conception and during pregnancy optimises maternal and fetal health outcomes.[2][150] ADA guidelines recommend the following blood glucose targets in pregnant women with pre-existing type 2 diabetes (the same as for gestational diabetes): <5.3 mmol/L (<95 mg/dL) fasting, and either ≤7.8 mmol/L (≤140 mg/dL) 1-hour postprandially or ≤6.7 mmol/L (≤120 mg/dL) 2-hour postprandially, with HbA1c goal individualised between <42-48 mmol/mol (<6% to <6.5%) or up to <53 mmol/mol (<7%) as necessary to prevent hypoglycaemia.[2] Target blood glucose values in pregnant women according to guidelines from the UK National Institute for Health and Care Excellence are, if safely achievable, a preprandial glucose 5.3 mmol/L (95 mg/dL), at 1-hour postprandial glucose below 7.8 mmol/L (140 mg/dL), and at 2- hour postprandial glucose below 6.4 mmol/L (115 mg/dL).[151][Evidence C]

In clinical practice, insulin is usually used when nutrition therapy fails to achieve these goals. NPH insulin may be combined with human short-acting or analogue rapid-acting insulin. Long-acting analogue insulins (glargine, detemir, or degludec) are not approved in pregnancy. ACE inhibitors, angiotensin-II receptor antagonists, and beta-blockers are not recommended in pregnancy and should be avoided. Statins are contraindicated in pregnancy. Retinal exam in those with diabetes prior to pregnancy should be performed prior to, during, and after pregnancy. Women with diabetes who anticipate pregnancy or are pregnant benefit from care supervision by a specialised centre whenever possible.

Question 35

Describe the importance of care delivery models in diabetes

Answer 35

Diabetes care has, on average, dramatically improved in the past 20 years, with a 50% reduction in mortality rates, cardiovascular mortality rates, and cardiovascular event rates in adults with diabetes.[13] Many factors have contributed to diabetes care improvement and better clinical outcomes for patients.[152] The principal model used to frame these strategies is the Chronic Care Model.[153] The model includes 6 core elements: delivery system design, self-management support, decision support, clinical information systems, community resources and policies, and health systems.

Evidence is generally supportive of the following care improvement strategies.

A multidisciplinary team approach to patient care, including the involvement of trained diabetes self-management educators, pharmacists, and case managers[154][155]
Advanced and integrated electronic medical record clinical decision support beyond simple reminder systems and alerts[156][157]
Simulated case-based learning interventions for clinicians.[158][159][160]
Other re-designs to the care delivery system such as alternative reimbursement methods, public policy changes to support healthier lifestyles, the patient-centred medical home, and mobile health (mHealth) technology may provide additional opportunities to improve care and are currently being evaluated.[161][162] Diabetes management decisions should be timely, rely on evidence-based guidelines, and be made collaboratively with the patient.

Question 36

Describe the importance of limiting alcohol use in diabetes

Answer 36

Alcohol use (more than 2 drinks daily for men or 1 for women) increases risk of hypoglycaemia, as well as other untoward events.

Question 37

Describe multi-dose insulin therapy

Answer 37

Multi-dose insulin therapy can be started with long-acting insulin at 0.1 to 0.2 units/kg/day in the morning or bedtime. Adjustments can be made by 2-4 units every 3 days until fasting blood sugar levels are within target range. If pre-meal sugars remain over target, rapid-acting insulin can be added at meals (approximately 4 units) and titrated by 2 units every 3 days until within the desired range. It is common to start rapid-acting insulin with the meal with the largest blood sugar excursion and add injections for other meals as needed. The need for prandial insulin becomes more likely as the total insulin doses exceed 0.5 units/kg

Question 38

Describe the use of metformin alongside insulin in the acute setting go hyperglycaemia

Answer 38

Metformin may be given adjunctively, in the absence of nausea/vomiting or volume depletion.

Metformin reduces hyperglycaemia by decreasing hepatic gluconeogenesis and glycogenolysis. At maximal effective doses, metformin may reduce HbA1c by 10-20 mmol/mol (1% to 2%). It confers a cardiovascular benefit, is rarely associated with weight gain, is inexpensive, and has a beneficial effect on low-density lipoprotein cholesterol.

The most common side effects are diarrhoea, gas, and nausea, which can be attenuated by initiating slowly 500 mg orally once a day with a meal, increasing as needed by 500 mg/day every 1 to 2 weeks until full dose of 1000 mg twice a day is reached.

Metformin is contraindicated if estimated glomerular filtration rate (eGFR) is <30 mL/minute/1.73 m². It should not be initiated if the eGFR is <45 mL/minute/1.73 m², and for patients taking metformin whose eGFR falls to within the 30-45 mL/minute/1.73 m² range, continued use can be considered with close monitoring of renal function and a dose reduction.[102][103]

Metformin should be stopped before surgery or contrast dye studies with radiographic dye injection until adequate post-event renal function is documented.

Periodic testing for vitamin B12 deficiency and B12 supplementation may be needed

Question 39

What dose of metformin is used

Answer 39

metformin: 500 mg orally (immediate-release) once daily initially, increase by 500 mg/day increments every week, maximum 1000 mg twice daily

Question 40

Outline the choice of agents that you can combine

Answer 40

Choice of agents should be tailored to account for patient values and preferences, advantages, and adverse effects. The safety of some agents is much more strongly established than the safety of other agents, and such data should be strongly considered when selecting treatments.

Metformin serves as the basis for most 3-drug combinations, in the absence of contraindications. Additional agents for 3-drug regimens are selected from the same choices as for 2-drug regimens: sulfonylureas/meglitinides, dipeptidyl-peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, alpha-glucosidase inhibitors, thiazolidinediones, basal insulin, or sodium-glucose co-transporter 2 (SGLT2) inhibitors.[102] However, evidence and guidelines do not support combining a DPP-4 inhibitor and a GLP-1 agonist in the same regimen, and they are not approved for this purpose.

The American Diabetes Association has updated its combination injectables algorithm: basal insulin plus GLP-1 agonist, basal insulin plus rapid-acting insulin, or fixed-dose insulin regimens are all alternatives.

Question 41

What can be done to reduce the risk of hypoglycaemia

Answer 41

To reduce the risk of hypoglycaemia, a sulfonylurea should be tapered if insulin is started. A reduction in dose of sulfonylurea or insulin or both may be needed when used with a GLP-1 agonist, in order to reduce the risk of hypoglycaemia. A DPP-4 inhibitor (less commonly, a thiazolidinedione, considering risks versus benefit) might be considered as an add-on to a metformin/sulfonylurea combination in people at high risk for hypoglycaemia.

Question 42

When is basal-bolus insulin often used

Answer 42

Basal-bolus insulin is often used when basal insulin or non-insulin multi-drug regimens fail to control blood sugar. For patients already taking basal insulin, consider starting 3 to 5 units of bolus (short- or rapid-acting) insulin at 1 or more meals. Titrate doses up 2 to 3 units at each meal every few days until desired levels of pre-meal (5.0 to 7.2 mmol/L [90-130 mg/dL]) and bedtime (5.6 to 7.8 mmol/L [100-140 mg/dL]) glucoses are achieved, unless hypoglycaemia supervenes.

Question 43

Describe an emerging treatment for T2DM

Answer 43

Rapid-acting inhaled insulin delivered through the lungs has again been approved by the US Food and Drug Administration (FDA) for use in diabetes. A previous inhaled insulin product was removed from the market, with FDA-mandated screening of users of that earlier inhaled insulin product for lung cancer. Inhaled insulin is not preferred over injectable insulins with more established safety experience.

Question 44

Describe the primary prevention of T2DM

Answer 44

Lifestyle factors (obesity, physical inactivity, and stress) seem to be the main drivers of the current diabetes epidemic. With aggressive prevention of obesity in all age groups, type 2 diabetes is potentially preventable.[29][30] Several clinical trials have shown that weight loss is associated with delayed or decreased onset of diabetes in high-risk adults.[14][23][24][25][31][32] Progression to diabetes from pre-diabetic states can be reduced by 50% over 3 to 4 years through modest weight loss (7% of body weight) using diet and regular physical activity.[23] [ Cochrane Clinical Answers logo ] In addition, several pharmacological agents, including metformin, alpha-glucosidase inhibitors, orlistat, glucagon-like peptide 1 (GLP-1) receptor agonists, and thiazolidinediones, have been shown to reduce progression from pre-diabetes to diabetes.[2][26][33][34][35] Lifestyle change and/or metformin are preferred for most patients.[36][37][38][39] More aggressive multi-agent pharmacological approaches remain controversial.[40] Screening for pre-diabetes and cardiovascular risk reduction appropriate to the needs of the individual are also very important

Question 45

Describe the secondary prevention of T2DM

Answer 45

Although the risk of macrovascular complications can be reduced by over 50% using effective multifactorial interventions,[200] a US national survey found more than half of outpatients over age 50 years with diabetes and hypertension did not receive an antiplatelet agent, statin therapy, or ACE inhibitor/angiotensin-II receptor antagonist.[201]

Other preventative measures include:[2]

Annual influenza immunisations
Vaccination against pneumococcal disease
Hepatitis B vaccination for unvaccinated diabetic adults aged 19 to 59 years; considered for unvaccinated diabetic adults aged 60 years and older
Regular dental care
Tailored diabetes education.

Question 46

Describe the patient discussions in T2DM

Answer 46

Patients should be advised that frequent medication adjustments represent good care, and are not a sign of failure or a reason for self-blame or guilt.
The use of self-monitoring of blood glucose data to promptly identify loss of glucose control and proactively adjust therapy is an essential self-management skill when using multi-dose insulin regimens, and requires patient education and easy access to health team members between scheduled surgery visits. Those on multi-dose insulin regimens are often advised to use continuous glucose monitoring (CGM) equipment, or to monitor blood sugars before meals and at bedtime.
In other patients with diabetes, self-monitoring may be useful to assess the impact of changes in diet, medication regimen, and exercise, as well as to guide dietary and fluid intake and medication management during episodes of illness.[197][199]
All women of childbearing age with diabetes should be counselled about the importance of strict glycaemic control prior to conception.[2]
Patients should receive counselling on how to prevent and promptly identify eye, foot, kidney, and cardiovascular complications.

Patients should be advised that low blood sugar (glucose ≤3.9 mmol/L [≤70 mg/dL]) is often accompanied by symptoms such as tachycardia, sweating, shakiness, intense hunger, or confusion, and must be dealt with promptly by ingesting 15-20 g of carbohydrate (equivalent to 3 to 4 glucose tablets of 5 grams per tablet). After self-treatment, blood sugar should be checked if possible. Instruct patients to promptly report nocturnal hypoglycaemia or recurrent episodes of hypoglycaemia so that therapy may be adjusted. Patients should have a carbohydrate snack prior to exercise if self-monitored blood glucose is <5.6 mmol/L (<100 mg/dL) and the patient is taking insulin or an insulin secretagogue (sulfonylurea or meglitinide). Patients using alpha-glucosidase inhibitors who experience hypoglycaemia must use glucose tablets because absorption of conventional carbohydrates is slowed by the treatment.[2] Those at risk of clinically significant hypoglycaemia (glucose <3.0 mmol/L [<54 mg/dL]) should have injectable glucagon available, and a close companion should be instructed on how to inject glucagon

Question 47

What does optimal diabetes care require

Answer 47

Optimal diabetes care requires a long-term relationship with the patient, appropriate use of consultants when needed, and regular monitoring and control of blood pressure, HbA1c, tobacco use, and statin/aspirin use. Most patients require diabetes assessments every 3 to 4 months, and some patients may benefit from more frequent (monthly) visits, especially when motivated to improve their care. Use of diabetes educators is recommended, although traditional information-based diabetes patient education mandated by some professional organisations is only moderately effective in randomised studies.[194][195] A multidisciplinary team with access to nurses, educators, dieticians, clinical pharmacologists, psychologists, and other specialists as needed is recommended. Patient readiness to change is a strong predictor of improved care, and readiness to change may vary across the clinical domains of blood pressure, statin use, aspirin use, glucose, smoking, physical activity, and nutrition. Rapid assessment of readiness to change, and directing care to the domain with maximum potential to change, is advised

Question 48

When is self-management of blood glucose recommended in diabetics

Answer 48

Self-management by regular blood glucose monitoring is not routinely recommended in patients with type 2 diabetes, because it does not significantly improve glycaemic control, health-related quality of life, or hypoglycaemia rates.[2][197][198][Evidence C] However, self-monitoring of blood glucose is recommended for those who (a) are on insulin; (b) have had prior hypoglycaemic episodes; (c) drive or operate machinery and use oral medications that increase his or her risk of hypoglycaemia; or (d) are pregnant, or planning to become pregnant

Question 49

Describe the periodic monitoring for complications in diabetes

Answer 49

In addition to care required to achieve recommended levels of blood pressure, statin use, aspirin use, tobacco non-use, and glucose control, the following periodic monitoring for complications is advised:

Dilated eye examination every 1 to 2 years
Annual assessment of renal function including both a urinary albumin excretion test and a serum creatinine test with estimated glomerular filtration rate (eGFR) based on the CKD-EPI creatinine equation or equivalent[ Glomerular Filtration Rate Estimate by CKD-EPI Equation ]
Annually or more frequent foot examinations including assessment of ankle reflexes, dorsalis pedis pulse, vibratory sensation, and 10-gram monofilament touch sensation. All patients with insensate feet, foot deformities, or a history of foot ulcers should have their feet examined at every visit and are candidates for specialised footwear.

Question 50

How many patients relapse to uncontrolled states

Answer 50

Due to disease progression, comorbidities, and non-adherence to lifestyle or medication, a substantial fraction of patients who achieve recommended goals for HbA1c, blood pressure, and lipid management relapse to uncontrolled states of one or more of these within 1 year. Relapse is usually asymptomatic; frequent monitoring of clinical parameters is desirable to anticipate or detect relapse early and adjust therapy.

Question 51

Describe the factors that may lead to a loss of adequate Glycaemic control

Answer 51

Factors that may lead to loss of adequate glycaemic control include medication non-adherence, depression, musculoskeletal injury or worsening arthritis, competing illnesses perceived by the patient as more serious than diabetes, social stress at home or at work, substance abuse, occult infections, use of medications (such as corticosteroids, certain depression medications [paroxetine], mood stabilisers, or atypical antipsychotics) that elevate weight or glucose, or other endocrinopathies such as Cushing’s disease.

Question 52

Describe how loss of BP control is common too

Answer 52

Loss of control of blood pressure and lipids is also a common phenomenon. Close monitoring of patients with diabetes through frequent visits and lab work helps to maintain patients at treatment goals and proactively identify upward trends in blood pressure or HbA1c, and to reinforce the importance of statin adherence and non-smoking.

Question 53

Describe diabetic kidney disease as a low risk long-term complication

Answer 53

Chronic kidney disease occurs in about 40% of patients with type 2 diabetes over time. Prevalence of end-stage renal disease is about 1% in those with type 2 diabetes (cross-sectional data).[172] Chronic kidney disease is driven by uncontrolled blood pressure and glucose, and increases the risk of cardiovascular disease at least fourfold. An estimated glomerular filtration rate (eGFR) <60 mL/1.73m²/minute establishes a diagnosis of chronic kidney disease, and microalbuminuria or albuminuria establishes a diagnosis of nephropathy. Either of these findings should prompt increased efforts to aggressively manage systolic blood pressure, avoid non-steroidal anti-inflammatory drugs (NSAIDs), and consider use of antihyperglycaemic drugs with low risk of hypoglycaemia and pronounced renal benefits (such as sodium-glucose co-transporter 2 [SGLT2] inhibitors or glucagon-like peptide-1 [GLP-1] agonists).[106][127]
Also important are use of an ACE inhibitor or angiotensin-II receptor antagonist, and optimisation of glucose control. When eGFR is lower than 30 mL/minute/1.73m², referral to a nephrologist for expectant management of end-stage renal disease is necessary.
Renal failure predisposes patients to anaemia and hypoglycaemia; in renal failure, insulin doses may need to be reduced.

Question 54

Describe impaired vision as a low-risk long-term complication

Answer 54

In the US, approximately 25% of patients with type 2 diabetes have retinopathy at diagnosis, presumably as a consequence of unrecognised disease.[182] In a global study, prevalence of diabetic retinopathy in newly diagnosed type 2 diabetes varied from 1.5% to 31%, with higher prevalence observed in developing countries.[183] Risk of vision loss is increased by poor blood pressure and glucose control, and by failure to regularly screen for retinopathy, macular degeneration, glaucoma, and cataracts.[184][185] The risk of all of these eye conditions is increased in diabetes.

Question 55

Describe lower extremity amputation as a long-term low-risk complication

Answer 55

Incidence of lower extremity amputation (LEA) is between 2.5 and 4 per 1000 people with diabetes per year, with significant geographic variation in LEA rates within countries.[186] Incidence rates of major LEA, defined as loss of lower limb through or above the ankle, are declining in patients with diabetes; however, there is some evidence that minor LEA (loss of lower limb below the level of the ankle) incidence rates are increasing, with about half being toe or metatarsal amputations.[170]
Risk is aggravated by neuropathy and by peripheral vascular disease, and can be reduced by smoking cessation; aggressive management of glucose, blood pressure, and lipids; use of customised footwear in patients with known neuropathy or foot deformity; and prompt and aggressive management of lower extremity infections.

Question 56

Describe CVD as a high-risk complication of

Answer 56

Cardiovascular disease (CVD) and CVD-associated mortality is declining in patients with diabetes, particularly in high-income countries.[170] Adults with type 2 diabetes are twice as likely to die of stroke or myocardial infarction compared with those without diabetes, and they are more than 40 times more likely to die of macrovascular than to die of microvascular complications of diabetes.[65][66] To reduce cardiovascular risk, blood pressure, lipids, and tobacco use should be adequately managed. Use of statins, ACE inhibitors, metformin, aspirin, empagliflozin, liraglutide, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may reduce cardiovascular mortality or all-cause mortality in selected patients with type 2 diabetes. In the ACCORD and ADVANCE randomized trials, near-normal glucose control failed to decrease cardiovascular mortality or all-cause mortality in type 2 diabetes, and in one of those studies, increased all-cause mortality. However, ACCORD and ADVANCE trials did not use empagliflozin, liraglutide, or PCSK9 inhibitors. Many studies suggest that HbA1c ≥64 mmol/mol (≥8%) increases risk of major cardiovascular events.[97][98]
Increased fatigability may be an early warning sign of progressive cardiovascular disease; clinicians should have a low threshold for cardiac evaluation of any symptoms that are potentially cardiac-related in patients with type 2 diabetes.

Question 57

Describe congestive heart failure as a high risk complication

Answer 57

Diabetes is a risk factor for CHF, with poor glycaemic control associated with greater risk for the development of CHF and worsening of clinical outcomes for patients with CHF and diabetes.[174] CHF occurs in up to 10% to 15% of patients with diabetes.[175] CHF in type 2 diabetes is often related to uncontrolled hypertension, or ischaemic coronary disease, but may also occur as a microvascular complication of diabetes.
Requires management with ACE inhibitor/angiotensin-II receptor antagonist, diuretics, and other medications.
Must rule out underlying causes such as myocardial infarction, atrial fibrillation, thyroid disorders, anaemia, or structural heart disease.

Question 58

Describe stroke as a high risk complication

Answer 58

Related to uncontrolled blood pressure, glucose, and lipids. Lifetime risk is higher in women than in men with diabetes.[176]
Prompt hospitalisation and neurological evaluation, with possible emergency use of tissue plasminogen activator (TPA) or other therapeutic strategies, may minimise damage and maximise potential for recovery of function.

Question 59

Describe infection as a medium-risk complication

Answer 59

Hyperglycaemia compromises defence against bacterial infections by several mechanisms including impaired phagocytosis.
Normalisation of blood glucose reduces the risk of infections, especially cystitis, cellulitis, and pneumonia. Immunisation reduces the risk of serious pneumococcal, Haemophilus influenzae, and influenza infections.
Aggressive infection-specific therapy and supportive therapy including adequate glucose control are key to successful treatment.

Question 60

Describe periodontal disease as a medium risk complication

Answer 60

Type 2 diabetes is associated with periodontal disease, but causality is not established.[177] In one large epidemiological survey, periodontal disease was an independent predictor of incident diabetes.[177] Bidirectional risk has been postulated.[178]
Control of periodontal disease and hyperglycaemia are mutually beneficial. Routine preventative dental care is important for people with type 2 diabetes

Question 61

Describe treatment-related hypoglycaemia as a medium risk complication

Answer 61

Related to treatment with insulin and/or insulin secretagogues (sulfonylureas or meglitinides), alone or in combination with other drugs. [ Cochrane Clinical Answers logo ] A glucose alert value is defined as ≤3.9 mmol/L (≤70 mg/dL), requiring treatment with fast-acting carbohydrate and dose adjustment of glucose-lowering therapy. Clinically significant hypoglycaemia is defined as <3.0 mmol/L (<54 mg/dL), indicating serious, clinically important hypoglycaemia.[2] Low blood sugars are common in patients who are trying to achieve HbA1c <53 mmol/mol (<7%). Hypoglycaemia is usually associated with warning signs, such as rapid heartbeat, perspiration, shakiness, anxiety, confusion, and hunger. Hypoglycaemia unawareness (absence of symptoms during hypoglycaemia) and severe hypoglycaemia, defined as a blood sugar so low that assistance from another person or medical personnel is required to treat it, occurs in 1% to 3% of type 2 diabetes patients per year. Older people and those with comorbid heart disease, congestive heart failure, chronic kidney disease, or depression are at substantially increased risk for severe hypoglycaemia.[179]
Patients should be counselled on recognition, prevention, and treatment of hypoglycaemia and should carry with them glucose tablets or comparable 20 g fast-acting carbohydrate product. Patients using alpha-glucosidase inhibitors must use glucose tablets for hypoglycaemia because absorption of conventional carbohydrates is slowed by the medication.

Question 62

Describe depression as a medium-risk complication

Answer 62

When glycaemic goals or adherence to treatment plan are difficult to achieve, the presence of depression should be considered. Screening with a validated tool such as the Patient Health Questionnaire (PHQ)-9 may help with identification and diagnosis. The cross-sectional prevalence of depression is 10% to 25% in people with diabetes.[189] Adults with type 2 diabetes diagnosed before age 40 years have excess hospitalisations across their lifespan, which includes a large burden of mental illness in young adulthood

Question 63

Describe obstructive sleep apnoea as a medium-risk complication

Answer 63

Obstructive sleep apnoea is common among overweight and obese adults, and has been associated with insulin resistance and altered glucose metabolism. Further studies are needed to assess the effect of continuous positive airway pressure (CPAP) on glycaemic control, as results have varied.[191][192][193]
The American Diabetes Association recommends assessment of sleep pattern and duration as part of a comprehensive approach to lifestyle and glycaemic control

Question 64

Describe DKA as a low-risk complication

Answer 64

Commonly thought of in type 1 diabetes; however, can occur in type 2 diabetes and an unusual type of diabetes known as ketosis-prone diabetes. Infection and poor diabetic medication adherence are the most common reasons for developing diabetic ketoacidosis, but no precipitating factors may be apparent.[180]
Criteria of diabetic ketoacidosis is the same, regardless of type of diabetes and is potentially fatal if not properly treated.
Hydration, parenteral insulin therapy, intensive monitoring, and careful management of electrolyte imbalances and acidosis are important for successful therapy.

Question 65

Describe HHS as a low-risk complication

Answer 65

Occurs most commonly in older people with type 2 diabetes and usually evolves insidiously over days to weeks.[181] Characterised by severe hyperglycaemia, hyperosmolality, and volume depletion, in the absence of severe ketoacidosis.
Hydration, insulin therapy, and careful clinical and laboratory monitoring are the basis of successful therapy.

Question 66

Describe autonomic or peripheral neuropathy as a low-risk complication

Answer 66

Diabetic peripheral neuropathy is the most common chronic complication of diabetes, characterised by the presence of peripheral nerve dysfunction, diagnosed after the exclusion of other causes.[187] Pain is the outstanding complaint in most patients, but many patients are completely asymptomatic.
Manifestations of autonomic neuropathy may include: erectile dysfunction, diarrhoea, gastroparesis, or orthostatic hypotension.
For type 2 diabetes the effects of glycaemic control on peripheral or autonomic neuropathy are less clear than for type 1 diabetes, with early data suggesting that glucose control is beneficial if started earlier in the disease course, but later studies not confirming these findings

Question 67

Describe the prognosis in type 2 diabetics

Answer 67

Diabetes increases the likelihood of major cardiovascular events and death, but the increased risk is variable across patients depending on age at diabetes onset, duration of diabetes, glucose control, blood pressure control, lipid control, tobacco control, renal function, microvascular complication status, and other factors. The association of diabetes and increased mortality can be attenuated by cardiovascular risk factor control.[169] A HbA1c of 6% to 6.9% (42 mmol/mol to 52 mmol/mol) is associated with the lowest mortality.[169] Trends in data for complications in people with diabetes show a declining risk of cardiovascular disease (CVD) and CVD-associated mortality, particularly in high-income countries.[170] When type 2 diabetes is diagnosed at age 40, men lose an average of 5.8 years of life, and women lose an average of 6.8 years of life.[10] The overall excess mortality in those with type 2 diabetes is around 15% higher, but ranges from ≥60% higher in younger adults with poor glucose control and impaired renal function, to better than those without diabetes for those who are age 65 and over with good glucose control and no renal impairment