Type 2 Diabetes

Question 1

What is the pathophysiology of T2DM?

Answer 1

Central adiposity causes increased exposure and so reduced sensitivity to insulin

Over time the beta cells become fatigued and damaged so are unable to secrete the high levels of insulin required

Question 2

What are the risk factors?

Answer 2

Old age
Ethnicity
FH
Obesity
Sedentary lifestyle
High carbohydrate diet

Question 3

What blood test is used to screen for T2DM?

Answer 3

HbA1c

Question 4

What is the presentation?

Answer 4

Fatigue
Polydipsia
Polyuria
Unintentional weight loss
Slow healing
Glucose in urine dipstick

Question 5

What is the diagnosis of T2DM?

Answer 5

HbA1c>48mmol/L
Random glucose>11mmol/L
Fasting glycose>7mmol/L
Oral glucose tolerance test (OGTT) >11mmol/L

Question 6

What is OGTT?

Answer 6

Performed before breakfast
Take a baseline fasting plasma glucose
Patient drinks a 75g glucose drink
Measure plasma glucose 2 hours later

Question 7

What is pre-diabetes?

Answer 7

Patient is at risk of progressing to diabetes
Diagnosed with HbA1c (42-47mmol/L)

Question 8

What is the treatment target for HbA1c?

Answer 8

48mmol/mol for new T2DM

Question 9

What is the management of T2DM?

Answer 9

Dietary modification
Exercise and weight loss
Stop smoking
Monitor complications

Question 10

What is the medical management of T2DM?

Answer 10

1. Metformin
2. Sulfonylurea, Pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor
3. Triple therapy (metformin + 2 of second line agents)
   or
   metformin + insulin

Question 11

What is metformin?

Answer 11

Biguanide
Increases insulin sensitivity and decreases liver production of glucose
No effect on body weight

Question 12

What are the side effects of metformin?

Answer 12

Diarrhoea and abdominal pain
Lactic acidosis

Question 13

What are sulfonylureas?

Answer 13

Most common is gliclazide
Stimulate insulin release from the B cells
Benefit when needing rapid improvement in BG control

Question 14

What are the side effects of sulfonylureas?

Answer 14

Weight gain
Hypoglycaemia
Increased risk of CVD in monotherapy
Hypersensitivity reactions

Question 15

What is pioglitazone?

Answer 15

A thiazolidinedione
Increases insulin sensitivity and decreases liver production of glucose

Question 16

What are the side effects of pioglitazone?

Answer 16

Weight gain
Fluid retention
Anaemia
Heart failure
Increases risk of bladder cancer

Question 17

What are incretins?

Answer 17

Hormones produced by the GI tract that act to reduce BG:
- Increase insulin secretions
- Inhibit glucagon production
- Slow absorption by GI tract

Question 18

What are the 2 groups of incretins?

Answer 18

DPP-4 inhibitors
GLP-1 mimetics

Question 19

What is the action of DPP-4 inhibitors?

Answer 19

DPP-4 is an enzyme that inhibits incretins
GLP-1 is the main incretin
DPP4 inhibitors therefore increase GLP-1 activity

E.g. sitagliptin

Question 20

What are the side effects of DPP-4 inhibitors?

Answer 20

GI tract upset
Pancreatitis

Question 21

What is the action of GLP-1 mimetics?

Answer 21

Mimic the action of the incretin hormone GLP-1 (glucagon like peptide-1)

E.g. exenatide

Question 22

What are the side effects of GLP-1 mimetics?

Answer 22

GI tract upset
Weight loss
Dizziness

Question 23

What are SGLT-2 inhibitors?

Answer 23

Empagliflozin, canagliflozin
Block the SLGT-2 protein that is responsible for reabsorbing glucose in the proximal tubules of the kidneys
Cause glucose to be excreted in the urine

Question 24

When are SGLT-2 inhibitors used?

Answer 24

1st or 2nd line (after metformin if tolerated) in patients at high CV risk
Greatly reduce risk of cardiovascular events such as MI, stroke and death

Question 25

What are the side effects of SGLT-2 inhibitors?

Answer 25

Glucosuria
UTIs
Osmotic symptoms
Weight loss
Risk of DKA (rare)
Risk of digital amputation

Question 26

What are the groups of insulin?

Answer 26

Rapid acting e.g. novorapid
Short acting e.g. actrapid
Intermediate acting e.g. insulatard
Long acting e.g. lantus
Combination insulins (rapid + intermediate) e.g. humalog 25