Type 2 diabetes lecture

Question 1

What is important to ask in history?

Answer 1

• Onset - long history, found on routine tests
• Osmotic symptoms? - these usually absent in T2DM
• FH
• Cushings, acromegaly, phaechromocytoma, thyrotoxicosis? - secondary cause
• Autoimmune diseases
• Exocrine pancreas function - pancreatitis? cancer? removal?
• Medications

Question 2

Medications which can cause secondary diabetes

Answer 2

• Steroids
• Levothyroxine
• Diazoxide
• Beta agonists
• Thiazides
• ARV for HIV
• Antipsychotics too

Question 3

Examination findings for T2DM

Answer 3

• BMI overweight
• Need to check BP
• Signs of insulin resistance
• Foot examination - neuropathy?
• Retinopathy - or refer for retinal screening
• Dysmorphic features - esp if early presentation

Question 4

Signs of insulin resistance

Answer 4

• Central obesity
• Acanthosis nigricans - armpits or back of neck
• Hyperandrogenism in demales

Question 5

Causes of dysmorphic features that can cause T2DM

Answer 5

• Downs
• Klinefelters
• Turners

Question 6

Investigations for newly diagnosed T2DM

Answer 6

• HbA1C
• LFT (NAFLD?), U&Es
• Thyroid function
• Lipid profile - CVS risk

Question 7

Antibody tests to rule out T1DM

Answer 7

• anti insulin
• Anti-GAD
• Anti-islet cell

Question 8

When is OGTT used?

Answer 8

Gold standard
But now only really used when HbA1C is 42-48mmol/mol (pre diabetes)
Or in pregnancy

Question 9

When do we check C peptide to check insulin levels?

Answer 9

Years into diagnosis usually

Question 10

Pathophysiology of T2Dm

Answer 10

• Defective insulin secretion (usually normal at the start)
• Inability of insulin sensitive tissues to respond (insulin resistance)

Question 11

Management of T2DM - education

Answer 11

• Education of condition
• Aims of treatment - WHY do we treat
• Nutrtional advice
• Target HbA1C - individualised
• Annual review info - bloods, urine, eye, foot exams etc
• Pregnancy - no pregnancy until HbA1c is 48 or less

Question 12

When is home monitoring done in T2DM?

Answer 12

• If on hypoglycaemic agent
• If on insulin

Question 13

When to infrom DVLA of T2DM?

Answer 13

If on insulin/hypoglycaemic oral agent

Question 14

Why is HbA1c individualised in T2DM and not T1?

Answer 14

Older pts - need to balance risk of hypos and CVS risk
Is it worth being much stricter when no benefit of 10yr CVS risk etc

Question 15

Diet/lifestyle advice for T2Dm

Answer 15

• High fibre, low glycaemic index
• Low fat dairy products, oily fish
• Portion control
• Reduce alcohol
• Smoking cessation
• Increase physical activity
• WEIGHT LOSS - 5-10% within first year

Question 16

Glucose targets for T2Dm

Answer 16

• HbA1C 48mmol/mol for pts on diet/single agent
• 58 for more complex regimes

Question 17

REVISE DIABETES DRUGS FROM CPT

Answer 17

Pls do it :))

Question 18

Which drug has greatest effect on HbA1c?

Answer 18

Sulfonylurea - BUT problem is it has highest risk of hypoglycaemia because of this

Question 19

Which drug has least effect on HbA1c?

Answer 19

• Dipeptidyl peptidase 4 inhibitors eg Sitagliptin
• BUT this means they have low risk of hypo - good for those at risk if need additonal agent

Question 20

Best drug for weight loss - diabetes

Answer 20

GLP1 analogues eg Semaglutide
Dulaglutide

Question 21

Treatment algorithm diabetes

Answer 21

If HbA1c 48mmol/mol or more on lifestyle advice:
* offer metformin

If rises to 58 consider adding:
* DPP-4 (eg sitagliptin)
* pioglitazone
* sulfonylurea (eg glicazide)
* SGLT2 (eg dapagliflozin)

If rises to 58 consider:
* metformin, DPP-4 and sulfonylurea
* metformin, pioglitazone and sulfonylurea
* metformin, pioglitazone/sulfonylurea PLUS SGLT2
* OR instead of triple therapy - insulin?

Question 22

What to do if not tolerating metformin?

Answer 22

Try modified release

Question 23

If triple therapy ineffective, what then?

Answer 23

• Metformin
• Sulfonylurea
• GLP-1 agonist

COMBINED

Question 24

What to offer if metformin contraindicated ir not tolerated?

Answer 24

If rises to 48 one of:
* DPP-4
* Pioglitazone
* Sulfonylurea
* OR SGLT2

if rises to 58 dual therapy:
* DPP-4 + pioglitazone
* DPP-4 and sulfonylurea
* pioglitazone and sulfonylurea
aim for HbA1c 53

If still rises to 58:
* Consider insulin
Aim for HbA1C - 53

Question 25

Insulin therapy regimes for T2Dm

Answer 25

• Basal only - UNLIKE T1DM
• Basal bolus
• Twice daily fixed mixture

Question 26

Which insulin to use in T2DM?

Answer 26

• NPH (isophane insulin) which is intermediate acting once or twice daily
• Consider NPH + short acting if HbA1c is more than 75

Question 27

When to consider analogue insulin?

Answer 27

• Persistent hypos or need assistance with injection

Question 28

Examples of isophane insulin

Answer 28

Humulin I
Insulatard

Question 29

Consequences of obesity

Answer 29

Psych:
* Depression
* Low self esteem
* Eating disorder

MSK:
* OA
* OSA
* GERD

Metabolic:
* T2DM
* HTN
* IHD

Monetary:
* Low educational achievement
* Low income
* Increased helathcare cost

Question 30

Management of obesity - diet and exercise

Answer 30

• 600kcal defecit per day
• Low carbs
• Low fat
• Increase protein
• Tier 2 - weight watchers and slimming world
• 225-300 minutes per week moderate exercise

Question 31

Behavioural management of obesity

Answer 31

• Goal setting
• Problem solving
• Assertiveness

Question 32

Questionaire for risk assessment for obesity

Answer 32

PAR-Q

Question 33

Pharmacological management of obesity

Answer 33

• Orlistat - need 5% weight loss in 12 weeks
• Liraglutide - Saxenda - need to lose 5% in 12 weeks
• Semaglutide - Wegovy for specialist weight management services

Question 34

Surgical management obesity

Answer 34

Bariatric surgery

Question 35

Criteria for starting GLP1 agonist

Answer 35

• BMI greater than 35
• Have T2DM
• Weight loss is more than 3% at 6/12
• HbA1C is more than 1% reduction at 6 months