Type 2 Diabetes - Management Flashcards
What are the main aspects of management of type II diabetes?
- Lifestyle modification
- Dietary intervention
- Weight loss
- Exercise
-
Medications
- Diabetic meds
- Meds for BP and vascular risk factors
- Driving advice
What sort of dietary advice would you give someone with diabetes?
- Low in sugar (though not sugar free)
- High in starchy carbohydrate (esp. with a low glycaemic index) - slower absorption
- High in fibre
- Low in fat (especially saturated fat).
When advising on diet, who is important to involve in the discussion?
Consult dietician!!
What would be your initial approach to managing someone with diabetes?
Non-pharmacological approach - Lifestyle modification
- Diet
- Exercise
- Weight loss
What would you consider giving as first line diabetic medication for type II diabetes?
Normal approach - Metformin
If weight loss or osmotic symptoms - Sulphonylurea
When should diabetic medications be considered for implementation in type II diabetes?
Prescribed when lifestyle changes have been implemented. Tablets will however be needed if satisfactory metabolic control is not established within 4–6 weeks.
What are the main medications used in type II diabetes?
7 main groups
- Binguanides - metformin
- Sulfonylureas
- DPP-4
- Glitazones
- GLP1
- SGLT2
- Insulins
If diabetic control on metformin and lifestyle changes alone was not adequate to keep HbA1c <53mmol/L after 3-6 months, what would you consider as the next step of treatment?
Review adherence, then consider:
- Metformin, plus one of:
- Sulphonylurea
- DPP-4 inhibitor
- Pioglitazone
- SGLT2
If someone on dual drug therapy and lifestyle modification for type II diabetes’ HbA1c rose to 53 mmol/L or above after 3-6 months, what changes to their medications would you make?
Review adherence, then consider:
- Metformin, plus combination of:
- Sulphonylurea
- DPP-4 inhibitor
- Pioglitazone
- SGLT2
- GLP-1 - BMI <30
- Basal insulin - BMI > 30
When would you consider using GLP-1 therapy in someone with type II diabetes?
Step 3 - BMI <30
If someone on triple drug therapy and lifestyle modification for type II diabetes’ HbA1c rose to 58 mmol/L or above after 3-6 months, what would you do?
Seek expert advise
When would you consider basal insulin as an option in someonewith type II diabetes?
Step 3 - BMI >30
What are the main risks/side effects of using sulphonylureas?
- Hypoglycaemia
- Weight gain
- Gastro-intestinal upset
- Hepatic impairment
- Hypersensitivity reaction (rash, liver disease)
- Rarely haematological abnormalities
What are the main risks/side effects of using metformin?
- Lactic acidosis
- GI upset
- B12 malabsorption
What are the main risks/side effects of glitazones?
- Gastrointestinal upset
- Weight gain
- Oedema
- Hepatic toxicity
- Visual disturbance
- Bladder cancer (very rare)
- Can cause hypoglycaemia.
When should you avoid metformin use?
eGFR < 36 ml/min - risk of lactic acidosis
What is important to do when someone on metformin has a vomiting or diarrhoeal illness?
Stop metformin - see if metformin is the cause
What are side effects/risks of using DPP-4 inhibitors?
- Gastrointestinal upset
- Oedema
- Hepatic toxicity (vildagliptin)
- Pancreatitis
- Upper respiratory tract infection / nasopharyngitis
- Stevens-Johnson syndrome
Can cause hypoglycaemia.
What are side effects of GLP-1 agonists?
- Gastrointestinal upset
- Pancreatitis
- Injection site reactions
- Anaphylaxis
Can cause hypoglycaemia.
Tend to reduce weight, which may be beneficial, but may be problematic if too rapid.
What two diabetic medications are most commonly associated with hypo’s?
- Insulin
- Sulphonylureas
What diabetic medication can cause lactic acidosis?
Metformin
What are the main side effects of SGLT-2 inhibitors?
- Genital mycotic infections
- UTIs
- Increased urinary frequency
What are contraindications to glitazone use?
- Hepatic impairment
- History of bladder cancer
- CCF
- Pregnancy / breast feeding
What is the target HbA1c in those with diabetes?
<53 mmol/L
Under what circumstances might you use DPP-4 inhibitors?
If weight gain was a concern
When would you consider measuring blood glucose in someone who is diabetic?
- Type 2 diabetes who are using insulin
- Increased risk of hypoglycaemia
- Experiencing acute illness
- Undergoing significant changes in pharmacotherapy or fasting, for example, during Ramadan
- Those with unstable or poor glycaemic control (HbA1c>64 mmol/mol)
- Pregnant or planning pregnancy.
- Steroid therapy
What medications would you start someone on for vascular protection and BP control in type II diabetes?
- ACEi
- CCB
- Thiazide diuretics
- Statins
What target BP would you aim for in type II diabetes?
<140/80 or <130/80 if kidney, eye or CVA
Which diabetic medications increase weight?
- Sulphonylureas
- Glitazones
Which diabetic medications help reduce weight?
- GLP-1 inhibitors
- SGLT-2 inhibitors
