Type 2 diabetes

Question 1

What HbA1c level indicates a pre-diabetic state? how many of these patients will go on to develop diabetes?

Answer 1

41-48 (<40 = normal)

4% develop diabetes

Question 2

When are most people screened for type 2 diabetes?

Answer 2

> 40yrs annual CV risk check includes HbA1c

Question 3

What investigations take place at a diabetic annual review?

Answer 3

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

Question 4

When should anti diabetic drugs be started?

Answer 4

After 3 months of reduced carbohydrate and increased exercise

Question 5

Outline the Type 2 diabetes medical management plan

Answer 5

1. Metformin (increase dose)

2. Metformin + 
Sulfonylurea (gliclazide/tolbutamide) 
OR
Gliptin 
OR
Pioglitozone

3. Triple therapy (metformin + sulfonylurea + gliptin/prioglitozone
   OR
   Insulin therapy (not started in general practice)

Question 6

What insulin type is usually used?

Answer 6

NPH - injected once or twice a day

Question 7

What insulin regime should be used if HbA1c is >75?

Answer 7

NPH + short acting

Question 8

What should be sued instead of NPH if hypoglycaemia is a problem?

Answer 8

insulin detemir / glargine (both long-acting)

Question 9

Mechanism of metformin?

Answer 9

Decreases gluconeogenesis

Increased peripheral use of glucose

Question 10

Side effects of metformin?

Answer 10

GI upset (bloating, diarrhoea)
Can cause lactic acidosis

+ve side effect = aids weight loss

Question 11

When is metformin contraindicated? What drugs should be used instead?

Answer 11

Poor renal function

1. Sulfonyurea or gliptin or piogltiazone
2. Combination of 2 drugs
3. Add GLP-1

Question 12

When is metformin particularly beneficial?

Answer 12

In overweight patients and patients with PCOS (can normalise menstrual cycle)

No risk of hypoglycaemia

Question 13

Sulfonylureas mechanism?

Answer 13

Augments insulin secretion (only works if there is residual B cell function)

Question 14

Side effects of sulfonylureas?

Answer 14

Weight gain
GI symptoms
Hypoglycaemia

Question 15

When should sulfonylureas be avoided?

Answer 15

Porphyria
Hepatic impairment
Severe renal impairment
Pregnancy/BF (give glibenclamide)

Question 16

What is the mechanism for Gliptin?

Answer 16

DPP-4 inhibitor –> increases insulin secretion and lowers glucagon secretion

Does not cause hypoglycaemia, weight neutral

Question 17

What cancer risk is associated with pioglitazone?

Answer 17

bladder cancer

Question 18

How is GLP-1 administered?

Answer 18

Injections

Question 19

GLP-1 mechanism of action?

Answer 19

Activates the GLP receptor –> increase insulin secretion
Slows gastric emptying
Suppresses glucagon

Question 20

Why should ACE-i always be given to diabetics?

Answer 20

Protects the kidneys

Question 21

What is indicated if U+Es decrease after giving ACE-i?

Answer 21

Renal artery stenosis (increased risk in DM)

Question 22

What is the prognosis once proteinuria is detected?

Answer 22

Irreversible damage to kidneys - progress to end-stage kinder disease in 5 years

Question 23

What can be used to control cholesterol?

Answer 23

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

Question 24

What additional problems should be attended to at an annual review?

Answer 24

Depression screen - PHQ-9
Flu jab
Smoking advice

Question 25

Peripheral neuropathy

Answer 25

Burning, walking on cotton wool or feel nothing

Lead to ulcers, nail infections, cellulitis - practice nurse - if infected review in 48 hrs after start of flucloxacillin

Skin will look flaky, dry, shiny with hair loss

Question 26

Incomprehensible pulses (PVD)

Answer 26

Can lead to intermittent claudication

–> urgent angiogram (if sudden onset/occurs over short distances)
25% improve with better lifestyle, 25% get worse
50% remain the same

Question 27

Charcot’s joint

Answer 27

Neuropathic joint (sensory-motor neuropathy, autonomic neuropathy, trauma and metabolic abnormalities) --> deformity and acute inflammation (hot, swollen but not pain)
Treat as acute fracture