Type 2 Diabetes

Question 1

Type 2 Diabetes:

Answer 1

Waist measurements in caucasians

• Men ≤102cm
• Women ≤88cm

High Diabetes Risk

• AUSDRISK ≥12
• ≥40 years who are overweight or obese
• people of any age with IGT or IFG
• people with a first-degree relative with diabetes
• all patients with a history of a cardiovascular event
• high-risk ethnicity/background (eg Pacific Islands, Indian subcontinent)
• women with a history of GDM
• women with polycystic ovary syndrome (PCOS)
• people taking antipsychotic medication

Diagnosis:

• single fasting BSL ≥7 mmol/L (repeated for confirmation)
• single HbA1c ≥6.5% (above this there is an increased risk of macrovascular complications) (repeated for confirmation)
• single random BSL ≥11.1 mmol/L

IF unlikely diabetes (fasting BSL <5.5 or HbA1c <6%) = retest in 3 years

IF possible diabetes = retest in 1 year

a) Fasting BSL ≥5.5 AND OGTT impaired
b) HbA1c 6.0 - 6.4%

Goals:
-5 -10% weight loss if ≥overweight (if BMI ≥35 with comorbidities or ≥40 then more drastic weight loss measures are required)

-adults should do 150min aerobic activity PLUS 2 - 3 (≥1hr total time) resistance exercise sessions per week

Targets:
-BSL 4 - 7 mmol/L fasting (self monitoring of glucose if on insulin or risk of hypoglycaemia)

• HbA1c ≤7% (53mmol/L)
• BP ≤140/90 UNLESS have albuminuria also ≤130/80
• total cholesterol ≤4.0, HDL ≥1.0, Triglycerides ≤2.0, LDL ≤2.0 (unless CVD then ≤1.8)

Medication:

• Algorithm as per PBS subsidy*
  1) Metformin (low and slow, slow release preparations tend to be better tolerated) OR Sulfonylurea (SU)

ADD

2) SU OR Metformin OR Dipeptidyl peptidase 4 inhibitor (DPP4i) OR Glucagon Like Peptide 1 Receptor Antagonist (GLP1RA) OR Sodium Glucose coTransporter 2 inhibitor (SGLT2i) OR Thiazolidinedione (TZD) OR insulin

ADD (possibly at the same time as taking away an ineffective second line agent)

3) SGLT2i OR SU OR GLP1RA OR insulin OR TZD
* DPP4i not on PBS as 3rd line

4)

a) if on 3 agents - switch ≥1 agent to GLP1RA OR insulin
b) if on GLP1RA - switch to insulin
c) if on insulin - intensify therapy

CONSIDERATIONS (in no order of importance):
1) Cost
Cheapest options = metformin, SU and TZD
Intermediate cost = SGLT2i and DPP4i 
Most expensive = GLP1RA and insulin

2) Atherosclerotic cardiovascular disease = GLP1RA (liraglutide>semaglutide>exenatide XR) OR SGLT2i (empaglifozin>canaglifozin)
3) Heart failure or Chronic Kidney Disease = SGLT2i OR GLP1RA (as per above) AVOID TZD and Saxagliptin in heart failure
4) Promote weight loss/minimise gain = GLP1RA (semaglutide>liraglutide>dulgaglutide>exenatide>lixisenatide) OR SGLT2i THEN DPP4i
5) Avoid hypoglycaemia = AVOID SU and insulin THEN if need SU use slow release and later generations (gliclazide)

6) HbA1c reduction contribution
DPP4i (Gliptin) 0.6%
SGLT2i (Glifozin) 0.8%
TZD (Gitazone) 0.8%
GLP1RA (Tide) 1%
SU(Ide) 1%
Metformin 1 - 2%

The Review Rule:
IF glycaemic targets are no being met after 3 -6 months review;
-medication understanding and dosing regimen
-assess adherence to medication and lifestyle interventions
-exclude confounders like infections, medication interactions
-consider alternative diagnosis like LADA, MODY
-assess tolerability/safety related to hypoglycaemia

Peripheral neuropathy screening:

1) Pinprick sensation
2) vibration sensation
3) 10g monofilament plantar surface of great toes and metatarsal region
4) ankle reflexes

Wound classification system:
SINBAD
Site
-mid or hind foot = 1
Ischaemia
-clinical evidence of reduced pedal blood flow = 1
Neuropathy
-Protective sensation lost (10g) = 1
Bacterial infection
-present = 1
Area
-Ulcer ≥1cm = 1
Depth
-reaching muscle, tendon or deeper = 1

Sick Day Management:
*SGLT2i have a risk of euglycaemic diabetic ketoacidosis
Principles
1) increase self monitoring of Blood glucose
2) diet controlled DMT2
-may need medication introduction when ill
-dehydration via osmotic diuresis is common
3) Non insulin treated DMT2
-may need insulin therapy in hospital when ill
-Nausea/Vomiting/diarrhoea - consider stopping metformin and GLP1RA as they can aggravate these symptoms leading to dehydration
-Dehydration from gastroenteritis as a concern should lead to cessation of SGLT2i, GLP1RA and metformin
4) Insulin treated DMT2
-alert GP if more than 2 readings above 15mmol/L
-may need to increase basal insulin by 10 -20% and adjust bolus insulin as a result of the change
-if only on basal insulin then bolus insulin may need to be temporarily introduced
-if not eating but remaining active may need go reduce doses to avoid hypoglycaemia

Question 2

Type 1 Diabetes:

Answer 2

glutamic acid decarboxylase (GAD) and
or insulinoma antigen-2 (IA-2) antibodies. These will be present in 90% of patients with type 1 diabetes.

Can consider non fasting C-peptide levels (diagnostic accuracy is variable depending on stage of Type 1 Diabetes development)

monogenic diabetes

• dominant inherited mutation OR de novo mutation
• diagnosis prior to age 25yo
• include Maturity Onset Diabetes of the Young (MODY)

Latent Autoimmune Diabetes of Adults (LADA)