Type 2 Diabetes Flashcards
1
Q
What is type 2 diabetes?
A
relative deficiency of insulin due to an excess of adipose tissue - not enough insulin to go around all excess fatty tissue, so blood glucose creeps up
2
Q
What is MODY?
A
Group of inherited disorders affecting the production of insulin
young patients who get symptoms similar to T2DM - asymptomatic hyperglycaemia with progression to more severe complications such as DKA
3
Q
What is the way that T2DM is often detected?
A
routine blood tests
also polydipsia, polyuria
4
Q
What are 9 risk factors for T2DM?
A
- Obesity and inactivity
- Family history
- Ethnicity - Asian, African, Black communities
- History of gestational diabetes
- Poor dietary habits - high GI, low fibre
- Drug treatments e.g. statins, corticosteroids, thiazide+beta blocker
- Polycystic ovarian syndrome
- Metabolic syndrome
- Low birth weight for gestational age/prematurity
5
Q
What are the 3 macrovascular and 3 microvascular complications of T2DM?
A
Macrovascular:
- Ischaemic heart disease
- Cerebrovascular events
- Peripheral arterial disease
Microvascular:
- Nephropathy
- Retinopathy
- Peripheral neuropathy
6
Q
What are 2 forms of neuropathy that can be a complication of T2DM?
A
- Chronic painful neuropathy
- Autonomic neuropathy - skin, blood vessels, GI tract, heart, bladder, sexual function affected, blunting of hypo perception
7
Q
What are 6 complications of T2DM in addition to the microvascular and macrovascular complications?
A
- Metabolic complications - dyslipidaemia and DKA
- Psychological complications - anxiety and depression
- Reduced quality of life - self monitoring, self-management, planning activities
- Infectiosn - UTIs and skin
- Reduced life expectancy
- Dementia - 1.5-2.5x risk
8
Q
What test is usually used to diagnose T2DM?
A
HbA1c of 48 mmol/mol (6.5%) or more
9
Q
When might the use of HbA1c be inappropriate to diagnose T2DM, and what can be used in this instance?
A
Fasting plasma glucose level of 7.0 mmol/L or greater
10
Q
What is an example of evidence of insulin resistance on examination?
A
acanthosis nigricans
11
Q
If a patient is asymptomatic, how does this influence the way a diagnosis of T2DM is made?
A
should never be based on single abnormal HbA1c or fasting plasma glucose level; at least one additional abnormal HbA1c or plasma glucose level is essential
if second test result normal, arrange regular review of person
12
Q
How is T2DM diagnosed in a symptomatic person?
A
More confidence with single abnormal HbA1c or fasting plasma glucose level (although second test may be prudent still)
13
Q
What are 3 causes of severe transient hyperglycaemia?
A
- Acute infection
- Trauma
- Circulatory
14
Q
When should HbA1c not be used to diagnose diabetes? 8 situations
A
- Children and young people (<18)
- Pregnant women/ 2 months postpartum
- Symptoms of diabetes for <2 months
- People at high diabetes risk who are acutely ill
- People taking medication that may cause hyperglycaemia (e.g. corticosteroids)
- People with acute pancreatic damage, including pancreatic surgery
- People with end-stage chronic kidney disease
- People with HIV infection
15
Q
What are 4 situations when HbA1c should be interpreted with caution?
A
- Altered haemoglobin
- Anaemia (any cause)
- Altered red cell lifespan (e.g. post-splenectomy)
- Recent blood transfusion
16
Q
What can be said about the symptoms of T2DM and how it often presents?
A
thirst, polyuria, blurred vision, weight loss, recurrent infections, tiredness: not usually severe, may be absent
17
Q
In addition to diabetes type 1, what are 5 other causes of diabetes to rule out when diagnosis T2DM?
A
- Monogenic diabetes
- Secondary to pathological condition or disease
- Secondary to drug treatment
- Secondary to trauma
- Secondary to pancreatic surgery
18
Q
If you suspect T2DM in a child and young person what should be done?
A
immediately refer (on the same day) to a multidisciplinary paediatric diabetes care team with the competencies need to confirm the diagnosis and provide immediate care
19
Q
What is DKA?
A
metabolic state characterised by triad of hyperglyceamia, ketonaemia and acidosis
medical emergency as it leads to dehydration and electrolyte imbalances
20
Q
What is usually the cause of DKA?
A
although more common in type 1 diabetes, can also develop in type 2
21
Q
What are the 4 criteria when you should suspect DKA?
A
- Known diabetes or signiificant hyperglycaema (BM >11 mmol/L)
- Clinical features of DKA
- Precipitating factors present
- Ketones in urine or blood
22
Q
What are 5 possible precipitating factors for DKA?
A
- Infection e.g. pneumonia/UTI
- Physiological stress (trauma/surgery)
- Inadequate insulin or non-adherence with insulin treatment
- Other medical conditions e.g. hypothyroidism or pancreatitis
- Drugs e.g. corticosterioids, diuretics, sympathomimetic drugs e.g. salbutamol
23
Q
How can you test for ketonaemia suggesting DKA in adults?
A
urine or blood ketones - test if you suspect, even if plasma glucose levels are near normal
24
Q
How should you test for ketones in a child or young person with suspected DKA?
A
test for blood ketones with ketone testing meter and strips
if not possible, arrange immediate admission to a hospital with acute paediatric facilities
25
What is considered a high level of ketones from testing?
2+ in urine
\>3mmol/L in blood
26
Do low blood ketones (\<3 mmol/L) always exclude DKA?
not always
27
Is hyperglycaemia always present in DKA?
no - children and young people on insulin therapy may develop DKA with normal blood glucose levels
28
What are 6 symptoms of DKA?
1. Increased thirst and urinary frequency
2. Weight loss
3. Inability to tolerate fluids
4. Persistent vomiting and/or diarrhoea
5. Abdominal pain
6. Lethargy and/or confusino
29
What are 3 signs of DKA?
1. Fruity smell of acetone on the breath
2. Acidotic breathing - deep sighing (Kussmaul) respiration
3. Dehydration - mild, moderate, severe or shock
30
What are 4 classes of dehydration in DKA?
1. Mild - only just clinically detectable
2. Moderate - dry skin and mucus membranes, reduced skin turgor
3. Severe - sunken eyes and prolonged capillary refill time
4. Shock
31
What are 3 signs of shock in DKA?
1. Tachycardia, poor peripheral perfusion, hypotension (indicating decreased cardiac output)
2. Lethargy, drowsiness, decreased level of consciousness (indicating decreased cerebral perfusion)
3. Reduced urine output (decreased renal perfusion)
32
What is the definition of hypoglycaemia?
considered present when blood glucose levels decrease to **\<3.5 mmol/L**
33
What initial support should be offered to patients diagnosed with T2DM? 7 aspects
1. Individual **care plan**
2. Structured group education programme e.g. **DESMOND**
3. Ensure person and/or family know how to **contact diabetes team** during working hours and out of hours
4. Provide info on government and disability **benefits** if needed
5. Manage **lifestyle** issues e.g. diet, exercise
6. **Screen** for complications of type 2 diabetes
7. Provide up to date information (including written information) on diabetes support groups (local and national)
34
What are the recommened HbA1c targets for people managed by 1. lifestyle and diet 2. lifestyle + single drugs not associated with hypos 3. drug associated with hypos?
1. \<48
2. \<48
3. \<53
35
How frequently should you measure HbA1c levels in T2DM?
initially 3-6 monthly individuals, until HbA1c is stable on unchanging treatment then at 6 monthly intervals
36
What are 2 other reasons for a person with diabetes achieving a lower HbA1c, other than good control?
1. Deteriorating renal function
2. Sudden weight los
37
What is the advice re self-monitoring of blood glucose in T2DM, and what are 6 situations when you would consider it?
1. Person is on insulin therapy
2. There's evidence of hypoglycaemic episodes
3. The person is taking a drug that may increase their risk of hypoglycaemia while driving or operating machinery (such a sulfonylurea)
4. Person is pregnant or is planning to become pregnant
5. Short term: when starting steroids
6. Short term: to confirm suspected hypoglycaemia
38
What are 2 situations when adults with T2DM are at increasd risk of worsening hyperglycaemia?
1. Intercurrent illness
2. Infection
39
What support should be arranged if a patient with T2DM does require self-monitoring of blood glucose?
Structured assessment should be covered at least annually, checking:
* self-monitoring skills, the quality and frequency of testing, and the equipment used
* that the person knows how to interpret the blood glucose results and what action to take if they are too high or too low
* impact of self-monitoring on person's quality of life and the continued benefit to the person
40
What should you offer as the initial treatment for all adults with type 2 diabetes?
standard-release **metformin** (unless contraindicated)
41
How is metformin started in T2DM?
gradually increase dose of standard-release over several weeks (to minimise risk of adverse effects) such as GI effects
42
What should you consider if GI adverse effects on standard-release metformin at intolerable?
trial of modified-release metformin
43
What monitoring should be performed on metformin?
renal function
44
What are 4 second line treatments if first-line drug treatment (e.g. metformin) is ineffective?
1. Metformin plus a **gliptin** or
2. Metformin plus **pioglitazone** or
3. Metformin plus **sulfonylurea**
4. Metformin plus an **SGLT-2i**
45
If metformin is contraindicated or not tolerated, what are 4 drug treatment options to consider?
1. Gliptin + pioglitazone or
2. Gliptin + sulfonylurea or
3. Pioglitazone + sulfonylurea
4. SGLT+2i instead of gliptin if a sulfonylurea or pioglitazone is not appropriate
46
What are 4 third-line treatment options if second-line is ineffective and metformin can be taken?
1. Triple therapy with metformin, gliptin and a sulfonylurea or
2. Triple therapy with metformin, pioglitazone, and a sulfonylurea or
3. Triple therapy with metformin, pioglitazone or a sulfonylurea and an SGLT-2i
4. Insulin-based treatment
47
What is a third-line option for management if metformin is contraindicated or not tolerated?
insulin-based treatment
48
What are 3 options for fourth line drug management of T2DM?
1. If on triple thearpy with metformin and 2 other oral antidiabetes, consider: metformin + sulfonylurea + GLP-1
1. if BMI \>35 and specific psychological or other medical problems linked to obesity or
2. BMI\<35 and insulin therapy woudl have significant occupational implications, or weight los would benefit other significant obesity-related comorbidities
2. Combination of metformin + DPP-4 inhibitor + SGLT2i ertugliflozon - only if sulfonylurea or pioglitazone not appropriate
3. if on inuslin-based traetment: seek specialist advice for consideration of treatment with GLP-1 mimetic plus insulin
49
When should you only continue GLP-1 mimetic therapy?
if person has had beneficial metabolic response (reduction of at least 11 mmol/mol in HbA1c and weight loss of at least 3% of initial body weight in 6 months)
50
What is the management in T2DM for an adult with type 2 DM with symptomatic hyperglycaemia?
consider insulin thearpy or sulfonylurea; review treatment when blood glucose control has been achieved
51
What type of diet advice should be provided in T2DM?
individualised ongoing nutritional advice from healthcare professional with specific expertise and competencies in nutrition
52
What are 5 important aspects to emphasise about diet in T2DM?
1. Plenty of fibre, low GI sources of carbohydrate (fruit, veg, wholegrain, pulses), low-fat dairy products, oily fish
2. Control intake of foods containing saturated and trans fatty acids
3. Individualise recommendations for carbohydrate and alcohol intake, meal patterns - to reduce hypo risk (esp if insulin or insulin secretagogue treatment)
4. Advise limited substitution of sucrose containing foods for other carbohydrate in meal plan allowed but avoid excess energy intake
5. Discourage use of foods marketed specifically for diabetes
53
What should you do if a patient with T2DM is overweight?
set initial body weight los target of 5-10%
consider referral to dietician
54
What should you bear in mind when giving a patient with T2DM advice about exercise?
risk of hypos
55
What are 4 pieces of advice to give in T2DM regarding alcohol?
1. Info on recommended max alcohol intake
2. Advise to avoid drinking on empty stomach (as will absorb faster) - eat snack containing carb befoer and after drinking
3. Alcohol may exacerbate or prolong hypoglycaemic effect of antidiabetic drugs - signs of hypo become less clear, delayed hypos may occur several hours after alcohol consumption
4. Always wear form of diabetes ID - reduced awareness of hypos may be confused with alcohol intoxicatio (MedicAlert bracelet, necklace, watch, Diabetes ID card)
56
What advice about smoking should you give in alcohol? 2 things
1. Explain smoking is risk factor for CVD; give advice on cessation and smoking cessation services. reinforce annually if don't plan to stop
2. explain general dangers of substance misuse and possible effects on blood glucose control
57
If you suspect DKA in a patient what should you, both before and after?
* before: admit immediately for confirmation and emergency treatment with IV insulin and fluids
* after: discuss factors that caused, consider non-adherence, advice on reducing future risk
58
What are 5 things you should do in the case of intercurrent illness in T2DM?
1. Assess and manage; review treatment as necessary
2. Warn it may affect blood glucose control - some illnesses, especially fever, can raised BG. Vomiting and diarrhoea can lower BG and cause hypos
3. Consider need for self-monitoring of BG levels
4. Provide person with clear individualised oral and written advice (sick day rules)
5. Ensure have sick day foods and hdration supplies always readily accessible at home
59
What sick day foods and hydration supplies should be readily accessible at home for T2DM? 6 things
1. Easily digestible food and sugary drinks (provide energy, prevent further ketosis)
2. Oral rehydration salt sachets (to prevent dehydration)
3. Glucose tablets or oral gel (to prevent hypos)
4. Equipment for self-monitoring of BG and ketones
5. Additional supplies of insulin (if on insulin therapy)
6. Glucagon kit (if appropriate)
60
What are 3 situations when you should arrange immediate hospital admission in T2DM?
1. Immediate risk of DKA
2. Moderate ketonuria (2+ on dipstick) or ketonaemia (1.5-2.9) with or without hyperglyceamia and person cannot eat or drink, as risk of DKA
3. Person treated with insulin does not improve rapidly with insulin
61
When are 5 situations when you should consider arranging hospital admission or seeking urgent specialist advice in T2DM?
1. Underlying condition is unclear
2. Person dehydrated or at risk of dehydration
3. Vomiting persists beyond 2 hours
4. Person and their family/carers are unale to keep the blood glucose level about 3.5 mmol/L
5. Person and their family/carers are exhausted, or example due to repeated night-time waking
62
What are 6 pieces of advice to emphasise to a person during a period of illness that does not require admission? (sick day rules)
1. If on insulin, don't stop (seek advice frmo diabetes team if unsure how to adjust insulin doses)
2. If self-monitoring of blood glucose levels is indicated, should be done carefully and frequently (check every 3-4 hours including through night, sometimes every 1-2 hours). record
3. Consider ketone monitoring e.g. every 3-4 hours including in night. seek help if raised 2+ or \>3
4. Maintain normal meal pattern where possible if appetite reduced
5. Drink at least 3L of fluid a day to prevent dehydration
6. When feeling better, continue to monitor BG levels carefully if indicated, until returns to normal
63
What are 4 key things to regularly screen for in diabetes?
1. **Retinopathy**: once a year (starting at diagnosis)
2. **Diabetic foot problems:** once a year (starting at diagnosis)
3. **Nepropathy**: once a year
4. **Cardiovascular** **risk** **factors** (once a year
64
What are 7 things that you should perform at every review appointment for patients with T2DM (if clinically indicated) as part of surveillance?
1. Height
2. Weight
3. Waist circumference
4. Calculate BMI
5. Assess for depresison and anxiety
6. Check smoking status
7. Assess for neuropathy and its associated complications
65
What are 4 things to assess for neuropathy in T2DM at every review appointment?
1. Erectile dysfunction
2. Neuropathic pain
3. Autonomic neuropathy
4. Gastroparesis (delayed emptying of the stomach)
66
How frequently should HbA1c be measured?
3-6 monthly intervals initially
then every 6 months once stable on unchanging treatment
67
In addition to screening, what else should you check once a year in T2DM?
check injection sites and adress any injection site problems
68
When should you start screening for retinopathy in T2DM?
perform at time of diagnosis and annually thereafter
69
What are 4 situations when you should arrange emergency review by an ophthalmologist for a person with type 2 diabetes?
1. Sudden loss of vision
2. Rubeosis iridis (formation of abnormal blood vessels on anterior iris)
3. Pre-retinal or vitreous haemorrhage
4. Retinal detachment
70
When should you arrange urgent (rather than emergency) review by ophthalmologist in T2DM?
if formation of new abnormal vessels on retina
71
When should you begin screening for diabetic foot problems?
perform at diagnosis and at least once a year thereafter (sooner if problems arise)
72
What are 8 things that are assessed for during diabetic foot screening?
1. Neuropathy - 10g monofilament for sensory examination
2. Limb ischaemia - ABPI
3. Ulceration
4. Callus formation
5. Infection and/or inflammation
6. Deformity
7. Gangrene
8. Charcot arthropathy (acute, localised inflammatory condition that may lead to varying degrees and patterns of bone desutrction, subluxation, dislocation, and deformity)
73
How are the findings of a diabetic food examination categorised? 4 categories
1. **Low risk** - no risk factors present
2. **Moderate risk** - **one** risk factor present
3. **High risk** - **previous** ulceration or amputation, on renal replacement therapy, or **more than 1** risk factor resent
4. Active diabetic foot problem
74
What should the management of diabetic foot risk be based on?
ulceration risk category
* low risk: annual foot assessments should be continued, importance of foot care emphasised etc.
* moderate-high risk: refer to foot protection service: will be seen in 2-4 weeks if high risk, 6-8 is moderate
75
How frequently should diabetic foot reassessments be performed if at low risk?
annually
76
How frequently should diabetic foot reassessments be performed if at moderate risk?
3-6 months
77
How frequently should diabetic foot reassessments be performed if at high risk if no immediate concern?
1-2 months
78
How frequently should diabetic foot reassessments be performed if at high risk if there is immediate concern?
1-2 weeks
79
What 2 things does screening for nephropathy involve?
1. Send first-pass early morning urine specimen for estimation of albumin:creatinine ratio (ACR)
2. Measure serum creatinine at same time to calculate estimated glomerular filtration rate (eGFR)
80
When is CKD diagnosed in T2DM?
tests have persistently (for at least 3 months or more) shown a reduction in kidney function or presence of proteinuria
diagnose if **eGFR persistently \<60 mL/min/1.73m3** and/or **ACR persistently \>3mg/mmol**
81
What are 8 things that should be assessed annually as part of screening for cardiovsacular risk factors?
1. Age
2. Albuminuria
3. Smoking status
4. Blood glucose control
5. Blood pressure
6. Full lipid profile (HDL, LDL, triglycerides)
7. FH of cardiovascular disease
8. Waist circumference
82
What medication should **not** be offered for primary prevention of CVD in adults with type 2 diabetes?
Antiplatelet treatment - aspirin or clopidogrel
83
When should you offer statin treatment in T2DM?
1. **offer** atorvastatin 20mg for primary prevention if \<84 years and QRISK2 is \>10% **(consider** if 85 or older)
2. If established CVD, 80mg atorvastatin for secondary prevention
84
What medication can you consider prescribing for erectile dysfunction due to neuropathy in T2DM?
phosphodiesterase-5 inhibitor (sildenafil, vardenafil, tadalafil)
if unsuccessful or contraindicated, refer man to erectile dysfunction or urology clinic
85
What are 5 things that should make you consider the possibility of autonomic neuropathy?
1. Unexplained diarrhoea, particularly at night
2. Bladder emptying diffculties
3. Impaired hypo awareness - sympathetic nervous system damage
4. Vomiting caused by gastroparesis
5. Excessive sweating
86
What are 2 aspects of management of vomiting caused by gastroparesis that may be caused by autonomic neuropathy in T2DM?
1. Small-particule size diet (mashed or pureed)
2. Referral to gastro or diabetes specialist team for consideration or treatment with prokinestic drug, e.g. erythromicin, metoclopramide, domperidone
87
What are 2 key side-effects of metformin?
1. Gastrointestinal side effects
2. Lactic acidosis
88
What are 4 side effects of sulphonylureas?
1. Hypoglycaemic episodes
2. Increased appetite and weight gain
3. SIADH
4. Liver dysfunction (cholestatic)
89
What are 5 side effects of pioglitazone?
1. Weight gain
2. Fluid retention
3. Bladder cancer
4. Liver dysfunction
5. Fractures
90
What type of drugs are gliptins and what are 2 examples?
DPP-4 inhibitors: sitagliptin, linagliptin
91
What investigation must you perform before initiating metformin? When mustn't you start metformin based on this?
renal function: do NOT start if eGFR \<30
92
What monitoring must be performed during treatment with metformin?
* renal function at least once a year if normal renal function
* at least twice a year if additional risk factors for renal impairment e.g. elderly or if deterioration suspected
93
What are 2 situations when you should not prescribe metformin?
1. Risk of lactic acidosis
1. DKA
2. eGFR \<30
3. acute conditions with potential to alter renal function e.g. dehydration, fasting, infection, shock
4. acute or chronic disease which amy cause tissue hypoxia
2. People about to undergo elective surgery
1. discontinue 48h before; restart no early than 48h following surgery or resumption of oral nutrition
94
What should be done if a gliptin is used in combination with sulfonylurea?
lower dose of sulfonylurea may be needed to reduce risk of hypoglcycaemia
95
What are 2 things that should be monitored before starting treatment with gliptins (DPP-4 inhibitors)?
1. Check liver function
2. Check kidney function
96
What monitoring may be required during treatment with gliptins?
liver or renal function, depending on which one (vildagliptin LFTs 3 monthly, saxagliptin renal function annually)
97
What is the mechanism of action of gliptins?
inhibit enzyme dipeptidyl peptidase 4 (DPP-4); this plays a major role in glucose metabolism by rapidly degrading incretins which stimulate postprandial insulin secretion and suppress glucagon secretion
so stop incretins from being degraded and these stimulate insulin secretion
98
What is the mechanism of action of pioglitazone?
reduces peripheral insulin resistance, thereby leading to a reduction in blood glucose concentration
doesn't directly stimulate insulin secretion
99
What are 4 things to investigate before starting treatment with pioglitazone?
1. Check LFTs
2. Measure FBC
3. Record weight
4. Check history of baldder cancer or visible blood in urine that has not been investigated - don't use if active bladder cancer
100
What monitoring should be performed during pioglitazone treatment?
LFTs periodically based on clinical judgement
101
What is a key side effect of gliptins?
pancreatitis
102
What is the mechanism of action of sulfonylureas?
insulin secretagogues: augment insulin secretion, effective only when some residual pacnreatic beta-cell activity is present
103
What are 5 examples of sulfonylureas?
1. Glibenclamide
2. Gliclazie
3. Glimepiride
4. Glipizide
5. Tolbutamide
104
What are 7 situations when you should not prescribe sulfonylureas?
1. Elderly - risk of hypos, only use short-acting ones
2. Obese - encourages weight gain
3. Acute porphyria
4. DKA
5. Severe renal impairment
6. Severe hepatic impairment
7. G6PD deficiency
105
What are the 2 types of insulin regimen recommended for people with type-2 diabetes?
1. One, two or three insulin injections a day of short-acting, rapid mixed with intermediate acting (biphasic regimen)
2. Multiple daily injection basal-bolus insulin regimens - short acting before meals, with one or more daily intermediate acting insulin or long acting to cover basal requirement
106
What is the mechanism of action of GLP-1 mimectics?
glucagon-like peptide 1 mimectics bind to and activate the GLP-1 receptor to increase insulin secrtion, suppress glucagon secretion, and slow gastric emptying
107
What are 3 examples of GLP-1 mimetics?
1. Exenatide
2. Liraglutide
3. Lixisenatide
108
What is the method of administration of GLP-1 mimectics?
subcutaneous injection in thigh, abdomen or upper arm
109
What are 6 adverse effects associted with glucagon-like peptide 1 (GLP-1) mimetics?
1. Acute pancreatitis
2. GI adverse effects
3. Hypoglycaemia
4. Headache, dizziness, drowsiess
5. Dehydration
6. Altered renal function
110
What 2 things should be monitored in treatment with GLP-1 mimetics?
check these 2 after 6 months:
1. BMI
2. HbA1c
only continue if beneficial metabolic response
111
What is the mechanism of action of SGLT-2i?
reversibly inhibit sodium-glucose co-transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion
112
What are 3 examples of SGLT-2is?
1. Dapagliflozin
2. Canagliflozin
3. Empagliflozin
113
What are 5 situations when you should avoid use of SGLT-2i?
1. DKA
2. Renal impairment
3. Hepatic impairment
4. Volume depletion
5. Lactose intolerance
114
What are 4 adverse effects of SGLT-2is?
1. Vulvovaginitis, balanitis, UTI
2. Hypoglycaemia
3. Pruritus
4. Frequency of micturition
115
What is the algorithm for the treatment of T2DM?
