Treatment of Type 2 Diabetes Flashcards
What are the treatment goals for T2DM?
- Reduce microvascular complications eg, retinopathy, nephropathy and foot disease.
- Reduce macrovascular complications eg, MI, stroke, heart failure, PVD
What are the biomedical treatment targets for T2DM?
- HbA1c of 7% or 53mmol/mol.
- BP <130/80,
- Cholesterol <5
- Healthy body weight
These aims depend on age, duration of diabetes, complications, co-morbidities, current lifestyle.
What are the different class of glucose lowering drugs?
Metformin,
- Sulphonylureas,
- Glitazones,
- Insulin,
- DPP-4 inhibitors (gliptins),
- GLP1-receptor agonists (tides)
- SGLT2 inhibitors (flozins)
What is first, second and third line therapy for T2DM
First = Metformin +/- empagliflozin if they have CV risks
Second line = Add sulphonylureas, pioglitazone, DPP-4 inhibitor or SGLT2 inhibitor if HbA1c > 58mmol/l
Third line = Metformin + 2 other second line drugs or metformin + insulin/GLP-1 (both injectables).
Fourth line = Metformin + oral + swap an oral drug for injectible
What are the glucose lowering drugs preferred for patients who also have CV disease?
- SGLT2 inhibitors or GLP-1 inhibitors
What is the mechanism of metformin and its main side effects
- Suppresses hepatic gluconeogensis (hepatic glucose production) and increases peripheral insulin sensitivity (increasing glucose uptake)
- Side effects: Lactic acidosis, diarrhoea and abdo pain.
- Contraindicated if eGFR <30ml/min
- Does not cause hypoglycaemia but only moderately affective
Name an example of sulphonylureas, its function and side effects
- Gliclazide.
- Increases stored insulin in beta cells by closing potassium channels. Increases cellular glucose uptake.
- Side effects include high risk of hypoglycaemia, weight gain and increase CV risk.
- However these are highly effective
S for Sponge as they squeeze the insulin out of the pancrease
Name an example of a DPP-4 inhibitors, the mechanism of action and side effects
- Sitgliptin
- They inhibit DPP-4 (enzyme which degrades incretins) which enhances effects of endogenous incretins. They also increase insulin secretion and decrease glucagon secretion
- May cause GI side effects and pancreatitis but few side effects
- Low risk of hypos
siting on my Dairyair (arse)
Name an example of a SGLT2 inhibitor, the mechanism of action and side effects
- Empagliflozin
- They inhibit the SGLT2 in the proximal convoluted tubule to decrease renal reabsorption of glucose.
- Side effects include UTIs, DKA or hypovolaemia.
- Cardiovascular benefit and renal benefit, weight loss and low hypo risk
Name an example of a Thiazolidinediones, the mechanism of action and side effects
- Pioglitazone
- PPAR gamma receptor agonist. Increases sensitivity of fat, muscles and liver to endogenous/exogenous insulin. Decreases liver production of glucose
- Causes weight gain, fluid retention and fractures so AVOID in heart failure and osteoporosis
NOT IN HEART FAILURE
Name an example of a GLP-1 receptor agonist, the mechanism of action and side effects
- Exenatide
- Mimic function of GLP-1. Increases insulin secretion, decreases glucagon secretion and decreases appetite.
- Injectable and may have GI side effects but has high efficacy
CV PROTECTION
Where are the sites of action for insulin?
- Increases glucose uptake and utilisation in skeletal muscle,
- reduced hepatic glucouse production
- decreases lipolysis
- Decreases gluconeogenesis
- Side effects are weight gain, injectable and highest hypo risk
What are the prescribing considerations for the elderly?
- Polypharmacy
- Likely to have reduced eGF|R,
- Increased liklihood of hypo
What are the prescribing considerations in renal disease
- Stop metformin when eGFR is below 30ml/min.
- Caution with sulphonylureas
- Dose reduction with DDP-4 inhibitors and GLP-1 agonists
- SGLT2 inhibitors less effective with reduced eGFR
What are the prescribe considerations in heart failure?
- DO NOT USE Pioglitazone
- FLozins can improve outcomes in patients with/without diabetes
- Metformin can be used in CHF but should be withheld in acute attacks
