Type 2 diabetes Flashcards
Microvascular complications
retinopathy, neuropathy, nephropathy
Macrovascular complications
cerebrovascular disease, cardiovascular, peripheral vascular disease
HbA1C level to initiate treatment
48 mmol
Target HbA1C when on 2 or more antidiabetic drugs
53 mmol
HbA1C level that would provoke intensification of treatment
58 mmol
First line treatment
Metformin or if GI disturbances -> Metformin MR
When to start SGLT2-inhibitor (-‘flozins’)
(1)Established atherosclerotic CVD
(2) Chronic heart failure
(3) Qrisk2 of 10% or higher (high risk of CVD)
-> as soon as metformin tolerability is confirmed
advantage of SGLT2- inhibitor
proven cardiovascular benefit
If metformin contraindicated and there is CVD risk or heart failure?
offer SGLT2 inhibitor alone
When would pioglitazone not be suitable
History of bladder cancer, heart failure, ketoacidosis and univestigated macroscopic haematuria
These can cause weight gain
Pioglitazone, sulfonylureas, insulin
Antidiabetic with moderate hypoglycaemia risk, high risk in elderly
Sulfonylurea
sulfonylureas to avoid in acute porphyrias
Gliclazide, tolubutamide
These drugs are well known to cause volume depletion and hypotension - avoid in elderly
The flozins
contraindicated in ketoacidosis
gliptins, pioglitazone, flozins, sulfonylureas
gliptin that does not need dose reduction or caution in renal impairment
Linagliptin
Gliptins to reduce dose or avoid in hepatic impairment
All gliptins except linagliptin and sitagliptin
contraindicated in metabolic acidosis
metformin
not associated with hypoglycaemia risk
metformin
increased osteoporosis risk
dapagliflozin
patient has renal impairment and is on gliptin?
reduce dose or caution (Except lingaliptin)
patient has hepatic impairment ans is on gliptin?
caution or avoid (except linagliptin and sitagliptin)
patient has renal impairment and is on GLP-1?
Reduse dose or caution or avoid based on eGFFR
patient has hepatic impairment ans is on GLP-1?
Caution or avoid (except dulaglutide, exenatide and lixisenatide)
second line treatment in the absence of CVD
dual therapy with either DPP-4 inhibitor (‘gliptins’), sulfonylureas or pigoglitazone
risk of hypoglycemia with gliptins is higher with?
long-acting e.g. glibenclamide
when to offer GLP-1 mimetic
1) triple therapy ineffective, contraindicated, not tolerated
2) BMI 35 kg/m2 or more
3) BMI lower than 35 kg/m2 and insulin therapy not appropriate or would beenfit more from weight loss
when to offer insulin in type 2 diabetes?
after triple therapy has failed
HbA1c definition
measure of average plasma blood glucose levels over 2-3 months
Avoid these whilst on insulin
ACE inhibitors
oral antidiabetic medication
GLP-1 mimetics (reports of DKA)
These drugs increase insulin requirements
Thyroid medications
oral contraceptives
corticosteroids
