Type 2 diabetes management

Question 1

If someones A1C is 1.5% above target what do you start

Answer 1

Metformin plus a second agent

Question 2

What is first line therapy if healthy behaviour interventions don’t work?

Answer 2

Metformin

Question 3

If someone presents with symptomatic hyperglycemia and/or metabolic decompensation, what do you start?
What symptoms do you look for?

Answer 3

Symptoms
- Polyuria (pee a lot)
- Polydipsia (thirst)
- Weight loss
- Volume depletion

Start insulin +/- metformin

Question 4

What is the starting dose for metformin? Titrate? MDD?
Adjust in CKD?

Answer 4

250mg once daily titrated q3-7 days.
Max daily dose 2550mg/day

Question 5

How do you adjust metformin dose based on kidney function?

Answer 5

eGFR 45+ = no dose adjustment
eGFR under 45 = decrease dose
eGFR under 30 = DO NOT USE

Question 6

What are common or serious ADRs of metformin

Answer 6

• GI N/V/D
• Metallic taste
• Lactic acidosis

Question 7

How much does metformin lower A1C by?

Answer 7

1-1.5%

Question 8

What is lactic acidosis?
Which type of patients is it most commonly seen in?

Answer 8

Metformin accumulation
- metformin shuts down enzyme that converts lactate to pyruvate
- impaired gluconeogenesis

Most common in
- renal insufficiency
- liver disease (excessive alcohol)
- cardiac failure

Question 9

Which is the best agent in lowering A1C effect when added to merformin?

Answer 9

1. SC semaglutide and other GLP1 receptor agonists

Question 10

Which agent has the highest hypoglycemic risk in addition to metformin

Answer 10

Premixed insulin

Question 11

Which SGLT2 inhibitor should be taken before the first meal of the day?

Answer 11

Canaglifozin

Question 12

What is the expectation of eGFR when you start an SGLT2i

Answer 12

eGFR will drop a bit

Question 13

What should you monitor for pre-treatment assessment when starting SGLT2i

Answer 13

Renal function
- Do not start if eGFR under 20
- Volume status including BP and electrolytes (correct first)
- Signs of decreased BP
- Assess for risk of amputation, fracture, DKA

Question 14

What are ADRs of GLP-1 receptor agonists? Hypo risk? Contraindications? ongoing monitoring what value?

Answer 14

• GI side effects N/V/D
• Acute pancreatitis
• Risk of thyroid c-cell tumours

Low hypo risk

CI: family history of medullary thyroid cancer and multiple neoplasia syndrome type 2

Monitor: SCr

Question 15

Which DPP4 does not need renal dose adjustment

Answer 15

Linagliptin (trajenta)

Question 16

Which DPP4 is CI in HF?

Answer 16

Saxagliptin

Question 17

What are ADRs of DPP4i? Weight gain?

Answer 17

Headache
Nasopharyngitis
Rash (rare)

Weight neutral
Low hypo risk

Question 18

Which lab value are DPP4i known for improving

Answer 18

Post-prandial control

Question 19

How much does DPP4i lower A1C by?

Answer 19

0.7%

Question 20

What are the ADRs of TZD

Answer 20

• Edema
• Heart failure
• Weight gain
• Bladder cancer
• Fractures (women)

Question 21

How long does it take for full effect of TZD

Answer 21

6-12 weeks

Question 22

How much does sulfonylurea lower A1C by?

Answer 22

0.8% with metformin
1-2% in monotherapy

Question 23

Which drug class is better at lowering A1C, sulfonylurea or meglitinide

Answer 23

sunflonylurea

meglitinide = 0.7% w metformin
1% with monotherapy

Question 24

What lab value might increase a high doses when on acarbose, alpha-glucosidase inhibitor?

Answer 24

LFTs may increase

Question 25

How much does acarbose lower A1C by?

Answer 25

0.6%

Question 26

Acarbose, risk of hypoglycemia? Weight gain?

Answer 26

risk of hypoglycemia? No Weight gain? Neutral

Question 27

What group is the evidence of benefit for acarbose? Which lab value is it good at controlling

Answer 27

Prediabetes Post-prandial glucose

Question 28

If experiencing hypoglycemia on acarbose what should you take?

Answer 28

Only use glucose tabs - other sugars may not be absorbed

Question 29

If you're over 60 and have 2 CV risk factors and your A1C was 1.5% over target, and you had a major adverse cardio event, what drug you start? What do the CV risk factors include?

Answer 29

GLP1-RA Risk factors - Tobacco - Dyslipidemia - hypertension - central obesity

Question 30

Which drugs have PROVEN cardiorenal benefit in high risk populations

Answer 30

GLP1-RA - dulaglutide - liraglutide - semaglutide SGLT2i - Canagliflozin - Dapaglifozin - Empagliflozin (eGFR >20)

Question 31

Which drugs have safe CV but NO proven benefit

Answer 31

GLP1-RA - exenatide ER - lixisenatide DPP4i - sitagliptin - linagliptin - alogliptin Sulfonylurea Meglitinides Insulin

Question 32

Which drug have risk of HF

Answer 32

TZDs

Question 33

What insulin do you start of symptomatic hyperglycemia? What dose?

Answer 33

Basal insulin 10 units

Question 34

If basal insulin does not work and GLP1-RA and SGLT2i are CI, what is the next option

Answer 34

Add bolus insulin

Question 35

Which factors should be considered when recommending different anti-hyperglycemic drugs?

Answer 35

1. Comorbidities 2. Hypoglycemia risk 3. Effects on body weight 4. Adverse effects 5. Cost 6. Patient preference

Question 36

How do you assess the effectiveness of AHA?

Answer 36

A1C

Question 37

Which drugs can you give with eGFR <15 or on dialysis

Answer 37

GLP1-RA maybe Linagliptin 5mg Sitaglitpin 25mg Insulins - dose reduction Gliclazide - dose reduction

Question 38

What renal function do we not initiate SGLT2

Answer 38

eGFR <20 or dialysis