Treatment of type 2 diabetes

Question 1

what are the aspects of management?

Answer 1

education
lifestyle changes 
medications
treatment targets 
monitoring for complications

Question 2

lifestyle advice

Answer 2

dietary changes
exercise
physical activity 
reduce alcohol consumption 
smoking cessation 
weight loss

Question 3

most commonly used antidiabetic medication

Answer 3

metformin

Question 4

what is metformin?

Answer 4

biguanide

Question 5

contraindications for metformin

Answer 5

CKD
risk of lactic acidosis
poorly tolerated

Question 6

how many steps of treatment algorithm are there?

Answer 6

4

Question 7

step 1 of treatment algorithm

Answer 7

metformin
increase dose if needed
monitor renal function
consider modified release preparations if develop adverse GI effects

Question 8

HBA1c aim on metformin alone

Answer 8

<48mmol/L

Question 9

step 2 of treatment algorithm

Answer 9

dual therapy

Question 10

when should step 2 be commenced?

Answer 10

if HBA1c >58mmol/L

Question 11

dual therapy

Answer 11

metformin + sulfonylurea, DPP-4 inhibitor, pioglitazone or SGLT-2 inhibitor

Question 12

HBA1c aim for dual therapy

Answer 12

<53mmol/L

Question 13

when to move on to step 3 of treatment algorithm?

Answer 13

if HBA1c >58mmol/L

Question 14

step 3 of treatment algorithms

Answer 14

triple therapy or insulin based regimen

Question 15

triple therapy

Answer 15

metformin, DPP-4 inhibitor and sulfonylurea
metformin, pioglitazone and sulfonylurea
metformin, pioglitazone and SGLT-2 inhibitor

Question 16

step 4 of treatment algorithm

Answer 16

metformin, sulfonylurea and GLP-1 agonist - strict criteria for GLP-1 agonist

Question 17

treatment algorithm if metformin is contraindicated

Answer 17

3 steps

Question 18

step 1 if metformin contraindicated

Answer 18

DPP-4 inhibitor or pioglitazone or sulfonylurea

Question 19

HBA1c aim for step 1 if metformin contraindicated

Answer 19

<48mmol/L or <53mmol/L if sulfonylurea used

Question 20

step 2 if metformin contraindicated

Answer 20

sulfonylurea and pioglitazone or
sulfonylurea and DPP-4 inhibitor or
pioglitazone and DPP-4 inhibitor

Question 21

when to move on to step 2 if metformin contraindicated

Answer 21

> 58 mmol/L HBA1c

Question 22

step 3 if metformin contraindicated

Answer 22

consider insulin based regimen if HBA1c >58mmol/L

Question 23

what are the type of insulin regimes?

Answer 23

once/twice daily intermediate acting insulin
intermediate acting insulin and short-acting insulin as separate injections or pre-mixed formula
once daily long-acting insulin therapy
basal-bolus regimes

Question 24

intermediate acting insulin

Answer 24

NPH

Question 25

long-acting insulin therapy

Answer 25

glargine

determir

Question 26

which insulin regime is used first?

Answer 26

intermediate

Question 27

when is mixed intermediate and short acting insulin used?

Answer 27

after intermediate alone if HBA1c >75mmol/L

Question 28

when is long acting insulin used?

Answer 28

patients with hypoglycaemia issues with intermediate insulin or when the patient relies on carers for injections

Question 29

when are basal-bolus insulin regimes used?

Answer 29

patients with poor glucose control on pre-mixed regimes

Question 30

HBA1c target for management with higher intensification regimes

Answer 30

<53mmol/L

Question 31

what to do if HBA1c >58mmol/L

Answer 31

intensify medical therapy and reinforce dietary advice, lifestyle changes and drug adherence