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Endocrine > Treatment of Type 2 Diabetes > Flashcards

Treatment of Type 2 Diabetes Flashcards

1
Q

What will help you decide on treatments for a patient?

A 
History
- symptoms
- when was diabetes diagnosed 
- drug history
- family history
Examination 
- BMI and BP 
Investigations
- HbA1c
- individual BM check
- lipids
- renal function
- urine albumin creatinine ratio
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2
Q

What are the targets of treatment for glycaemic control?

A

HbA1c <53mmol/mol (<7%)

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3
Q

What are the blood pressure treatment targets?

A

<130/80mmHg

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4
Q

What are the targets for prevention of diabetic nephropathy?

A 
Microalbuminuria first sight 
- ACR >2.5mg/mmol in men
- ACR >3.5mg/mmol in women 
If microalbuminuria already present 
- put on ACEI or ARB
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5
Q

What are the targets for lipid control?

A

Statins for all patients >40 regardless of cholesterol
Aims
- total cholesterol <4mmol/l
- cholesterol:HDL <5

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6
Q

What are the 1st lines options in the SIGN guidelines of glycaemic control?

A 
Lifestyle options
Metformin
OR
Sulphonylurea 
- if intolerant to metformin 
- experience weight loss/osmotic symotoms
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7
Q

What are the 2nd line options in the SIGN guidelines of glycaemic control?

A 
1st line drug
PLUS
Sulphonylurea 
OR
Thiazolidinedione
- if hypos are a concern or there is no congestive heart failure
OR
DPP-IV inhibitor
- if hyops are a concern
- if weight gain is a concern
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8
Q

What are the 3rd line options in the SIGN guidelines in glycaemic control?

A 
1st and 2nd line options
ADD OR SUBSTITUTE WITH
Oral thiazolidine
Oral DPP-IV inhibitor 
Injectable insulin
- if osmotic symptoms or rising HbA1c
- if hypos are a concern, use a basal analogue 
- add prandial insulin as required 
Injectable GLP-1 agonist
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9
Q

What is the function of metformin?

A 
Biguanide 
Decreases hepatic glucose production 
Enhances insulin sensitivity  in peripheral tissues 
Increases peripheral glucose utilisation
Some people lose weight 
CV benefit
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10
Q

What are the side effects of metformin?

A 
GI side effects
- lower dose may be tolerated
Pre-existing hepatic and renal impairment 
- particularly eGFR <30ml/min 
Lactic acidosis
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11
Q

What is the function of Sulphonylureas?

A

Typically a second line drug
Increase insulin release from the pancreas
- block ATP sensitive potassium channels in beta cells

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12
Q

What are the problems associated with Sulphonylureas?

A

Risk of hypoglycaemia
Ineffective as beta cell burn out
Weight gain
Pre-exisiting renal failure

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13
Q

What is the function of Thiazolidenidiones?

A

Activate peroxisome proliferator-activated receptor (PPAR gamma agonsits)

  • decrease insulin resistance
  • decrease triglycerides, increase HDL and LDL
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14
Q

What are the concerns of Pioglitazone (thiazolidenidione)?

A 
Should not be used in patients with CCF or LVF
Fluid retention 
Small increased risk of bladder cancer 
Weight gain (fluid retention)
Fracture risk
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15
Q

Name the incretin therapies.

A

GLP-1 agonists

DPP-IV inhibitors

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16
Q

What is the function of DPP-IV inhibitors?

A

Increase incretin levels (GLP-1 and GIP), by preventing their inactivation by the DPP-IV enzyme
These inhibit glucagon release, which in turn increases insulin secretion

17
Q

What are the pros and cons of DPP-IV inhibitors?

A 
Pros
- weight neutral
- not associated with hypoglycaemia 
Problems
- more costly 
- affects renal function
- nasopharyngitis 
- heart failure 
- pancreatitis
18
Q

What is the function of GLP-1 agonists?

A

GLP-1 inhibits glucagon release, which in turn, increases the levels of insulin in the body
Plasma glucose decreases

19
Q

What are the pros and cons of GLP-1 agonists?

A 
Pros
- weight loss
- doesn't increase risk of hypos
- bigger effect on glycaemic control than DDP-IV inhibitors 
Cons
- high cost
- injectable
- GI side effects are common
- pancreatitis/pancreatic cancer
20
Q

What is the function of SGLT2 inhibitors?

A

Inhibit sodium-glucose transport protein 2 in the kidney

This inhibits glucose reabsorption, and the excess glucose is removed in the urine

21
Q

What are the pros and cons of SGLT2 inhibitors?

A 
Pros
- weight loss
- low risk of hypoglycaemia 
- CV benefits
Cons
- volume depletion 
- GU infections
- should not be used with loop diuretics
- can cause euglycaemic ketoacidosis
22
Q

Which groups of T2DM patients are most vulnerable?

A 
Elderly 
Co-morbidities 
Frailty regardless of age
Lack of hypoglycaemic awareness 
Drivers
- not vulnerable, but a special consideration

Endocrine (9 decks)

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