Type 2 diabetes Flashcards
What HbA1c level indicates a pre-diabetic state? how many of these patients will go on to develop diabetes?
41-48 (<40 = normal)
4% develop diabetes
When are most people screened for type 2 diabetes?
> 40yrs annual CV risk check includes HbA1c
What investigations take place at a diabetic annual review?
Weight and BMI
BP
HbA1c - aim for <59
Urinary albumin –> albumin/creatinine ratio (ACR:
Men (normal) = <2.5mg/mmol
Women (normal) = <3.5mg/mmol
Serum creatinine - if >150micromol/L discontinue metformin
Cholesterol - aim for <5
Eye exam
Foot exam
When should anti diabetic drugs be started?
After 3 months of reduced carbohydrate and increased exercise
Outline the Type 2 diabetes medical management plan
- Metformin (increase dose)
2. Metformin + Sulfonylurea (gliclazide/tolbutamide) OR Gliptin OR Pioglitozone
- Triple therapy (metformin + sulfonylurea + gliptin/prioglitozone
OR
Insulin therapy (not started in general practice)
What insulin type is usually used?
NPH - injected once or twice a day
What insulin regime should be used if HbA1c is >75?
NPH + short acting
What should be sued instead of NPH if hypoglycaemia is a problem?
insulin detemir / glargine (both long-acting)
Mechanism of metformin?
Decreases gluconeogenesis
Increased peripheral use of glucose
Side effects of metformin?
GI upset (bloating, diarrhoea) Can cause lactic acidosis
+ve side effect = aids weight loss
When is metformin contraindicated? What drugs should be used instead?
Poor renal function
- Sulfonyurea or gliptin or piogltiazone
- Combination of 2 drugs
- Add GLP-1
When is metformin particularly beneficial?
In overweight patients and patients with PCOS (can normalise menstrual cycle)
No risk of hypoglycaemia
Sulfonylureas mechanism?
Augments insulin secretion (only works if there is residual B cell function)
Side effects of sulfonylureas?
Weight gain
GI symptoms
Hypoglycaemia
When should sulfonylureas be avoided?
Porphyria
Hepatic impairment
Severe renal impairment
Pregnancy/BF (give glibenclamide)
What is the mechanism for Gliptin?
DPP-4 inhibitor –> increases insulin secretion and lowers glucagon secretion
Does not cause hypoglycaemia, weight neutral
What cancer risk is associated with pioglitazone?
bladder cancer
How is GLP-1 administered?
Injections
GLP-1 mechanism of action?
Activates the GLP receptor –> increase insulin secretion
Slows gastric emptying
Suppresses glucagon
Why should ACE-i always be given to diabetics?
Protects the kidneys
What is indicated if U+Es decrease after giving ACE-i?
Renal artery stenosis (increased risk in DM)
What is the prognosis once proteinuria is detected?
Irreversible damage to kidneys - progress to end-stage kinder disease in 5 years
What can be used to control cholesterol?
Lipophilic statins: simvastatin, atorvastatin, lovastatin
More effective but high chance of muscle pain
Hydrophilic statins: Pravastatin
Do not give to women of child bearing age or kidney problems
What additional problems should be attended to at an annual review?
Depression screen - PHQ-9
Flu jab
Smoking advice
