Type 2 Diabetes Flashcards
What are the risk factors for T2DM?
Non modifiable:
- older age
- ethnicity (black, chinese, south asian)
- family history
Modifiable:
- obesity
- sedentary lifestyle
- high refined carb diet
How can a patient be screened for T2DM?
Check HbA1c
Which symptoms might be present in T2DM?
Fatigue Polydipsia + polyuria Unintentional weight loss Opportunistic infections Slow healing Glucose in urine (on dipstick)
How is T2DM diagnosed?
If symptomatic, any of:
- fasting glucose > 7
- random glucose or OGTT >/= 11.1
- HbA1c > 48 (6.5%)
If asymptomatic:
- repeat test on a separate occasion to confirm
What is pre-diabetes and how is it diagnosed?
Indication that the patient is heading towards diabetes - require good education + lifestyle advice to prevent progression Diagnosed with either: - HbA1c - impaired fasting glucose - impaired glucose tolerance
Which HbA1c results would indicate pre-diabetes?
42-47
How is impaired fasting glucose defined?
Fasting glucose 6.1 - 6.9
How is impaired glucose tolerance defined?
Plasma glucose at 2 hours on OGTT –> 7.8 - 11.1
Which dietary modifications are recommended for T2DM?
Vegetables + oily fish
Low glycemic index, high fibre diet
Which other risk factors should be modified in the management of T2DM?
Exercise + weight loss Stop smoking Optimise treatment for other illnesses: - hypertension - hyperlipidaemia - CVD
What should the target HbA1c be for T2DM?
48 for new type 2 diabetics
53 for those who have moved beyond metformin alone
What is HbA1c?
Measure of glycated haemoglobin (glucose attached to Hb)
–> reflects average glucose level over the last 3 months
What is the first line medical management for T2DM?
Metformin
- initially 500mg once daily as tolerated
What is the second line medical treatment for T2DM?
If HbA1c remains > 48, add either:
- sulfonylurea (usually first unless risk of hypo undesirable)
- pioglitazone
- DPP-4 inhibitor
- SGLT2 inhibitor
(based on individual factors + drug tolerance)
What is the third line medical treatment for T2DM?
Triple therapy with metaformin + 2 of second line drugs
OR
Metformin + insulin
(if HbA1c remains > 58 despite two drugs)
Which drugs are preferred for patients with cardiovascular disease?
SGLT2 inhibitors + GLP-1 inhibitors
What type of drug is metformin and how does it work?
Biguanide
- increases insulin sensitivity + decreases liver production of glucose
What are the side effects of metformin? What are the contraindications?
Diarrhoea + abdominal pain (dose dependent, reducing the dose often helps)
LACTIC ACIDOSIS
Doesn’t cause hypoglycaemia, weight neutral
CI:
- significant renal impairment
- those at risk of tissue hypoxia e.g. dehydration, sepsis, acute heart/liver/resp impairment
- iodine containing contrast (stop day before)
What kind of drug is pioglitazone and how does it work?
Thiazolidinedione
- increases insulin sensitivity + decreases liver production of glucose
What are the side effects of pioglitazone?
Weight gain Fluid retention (oedema, ascites) Anaemia Heart failure Bladder cancer (extended use) Raised LFTs Fractures
Doesn’t cause hypoglycaemia
How do sulfonylureas work? Give an example
Stimulate insulin release from the pancreas
- gliclazide
- glibenclamide
What are the side effects of sulfonylureas?
Weight gain
HYPOGLYCAEMIA
Increased risk of CVD + MI when used as monotherapy
SIADH
How do DPP-4 inhibitors work? Give an example
Inhibit the DPP-4 enzyme –> increase in GLP-1 activity
- sitagliptin
What are the side effects of DPP-4 inhibitors?
GI upset
Symptoms of URTI
Pancreatitis
Give an example of a GLP-1 mimetic. When are they used?
Exenatide - given as a SC injection twice daily or once weekly in MR form
Sometimes used in combination with metformin + sulfonylurea in overweight patients
What are the side effects of GLP-1 mimetic?
GI upset
Weight loss
Dizziness
Low risk of hypoglycaemia
How do SGLT-2 inhibitors work? Give some examples
Block the reabsorption of glucose in the proximal tubules of the kidney –> excretion of glucose in the urine
End with ‘gliflozin’
- empagliflozin
- dapagliflozin
- canagliflozin
What are the side effects of SGLT-2 inhibitors?
Glucosuria
Increased risk of UTIs
Weight loss
DKA (rare - notably with only moderately raised glucose)
Increased likelihood of lower limb amputation
What are the positive effects of SGLT-2 inhibitors?
Reduce the risk of CVD and hospitalisation with HF
How is control of diabetes monitored in T2DM?
HbA1c every 3-6 months initially, then every 6 months once stable
No need for finger prick glucose unless on insulin/suspected hypos
Which oral hypoglycaemics are okay for use in pregnancy?
Metformin
Glibenclamide
When must patients with diabetes inform the DVLA?
All drivers on insulin
HGV drivers on insulin OR oral hypoglycaemics (even if not known to cause hypos)
Can patients on insulin drive a HGV?
It is possible but very strict criteria regarding hypoglycaemia must be met
What are the features of hyperosmolar hyperglycaemic state (HHS)?
Old patients, first presentation of T2DM
May be precipitated by illness, dehydration
Onset over several days:
- weakness, leg cramps, visual impairment
- severe hypovolaemia
- signs of infection
- confusion, lethargy, neuro signs, seizures, rarely coma
What is the diagnostic criteria for HHS?
- glucose > 30
- serum osmolality > 320
- no significant ketosis
How is HHS managed?
IV fluids - slower rate than DKA
Insulin after 1 hour - half the rate of DKA (very sensitive to insulin)
Monitor fluid balance, U&Es, glucose
DVT prophylaxis
What are the complications of HSS?
Cerebral oedema
PE
Ischaemia: MI, stroke
Much higher mortality than DKA (due to older patients with comorbidities)
What are the secondary causes of diabetes?
SHIT PANCREAS:
- Steroids/Cushing’s
- Haemochromatosis
- Inflammation (pancreatitis)
- Thyrotoxicosis
- Phaemochromocytoma
- Antipsychotics
- Neoplasia
- CF
- anti- REtrovirals
- Acromegaly
- Surgical removal
