Type 2 Diabetes Mellitus

Question 1

Diagnostic test for T2DM
1. Fasting
2. Random
3. Asymptomatic
4. Prediabetes

Answer 1

1. Fasting glucose greater than or equal to 7mmol/l
2. Random glucose greater than or equal to 11.1 mmol/l
3. If patient is asymptomatic the above criteria must be met on two separate occasions
4. Prediabetes/Impaired Glucose Tolerance= 6.1-6.9mmol/L fasting OR 7.8-11.0 mol/L random

Question 2

HbA1c use in diagnosis of DM

Answer 2

• a HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus
• a HbAlc value of less than 48 mmol/mol (6.5%) does not exclude diabetes (i.e. it is not as sensitive as fasting samples for detecting diabetes)
• in patients without symptoms, the test must be repeated to confirm the diagnosis
• it should be remembered that misleading HbA1c results can be caused by increased red cell turnover (due to other causes)

Question 3

conditions where HbA1c cannot be used for diagnosis of DM (8)

Answer 3

• haemoglobinopathies
• haemolytic anaemia
• untreated iron deficiency anaemia
• suspected gestational diabetes
• children
• HIV
• chronic kidney disease
• people taking medication that may cause hyperglycaemia (for example corticosteroids)

Question 4

HbA1c targets for patients with DM
1. Patients managing with lifestyle measures
2. Patients managing with lifestyle measures and metformin
3. Patients managing using any drug which may cause hypoglycaemia (e.g. sulfonylureas)

Answer 4

1. 48mmol/l
2. 48mmol/l
3. 53mmol/l

Question 5

Metformin
1. Drug Class
2. Mechanism(s) of action
3. Side effects

Answer 5

1. Biguanide

2: mechanisms
1- Decreases hepatic glucose production
2- increased hepatic insulin sensitivity
3- decreased intestinal glucose absorption

3. Side effects:
   - GI upset
   - reduced B12 absorption
   - lactic acidosis

Question 6

first line drug of choice in T2DM

Answer 6

Metformin

Question 7

When should SGLT-2 inhibitors be added to metformin?

Answer 7

should be given in addition to metformin if:
- patient has high risk of developing CVD or established CVD
- patient has chronic heart failure
- if either of these two factors develop during treatment

Question 8

first line Tx when metformin is contraindicated
1. If patient has risk of CVD, established CVD or CHF
2. If patient doesn’t have a risk of CVD, established CVD or CHF

Answer 8

1. SGLT-2 mono therapy
2. DPP-4 inhibitor or pioglitazone or sulfonylurea

Question 9

SGLT-2 inhibitors
1. Examples
2. Mechanism of action
3. Side effects (3)

Answer 9

1. canagliflozin, dapagliflozin, empagliflozin
2. reversibly inhibit sodium-glucose cotransporter 2 (SGLT-2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion
3. Side effects include
   (1) urinary and genital infection (secondary to glycosuria) . Fournier’s gangrene has also been reported
   (2) normoglycaemic ketoacidosis
   (3) increased risk of lower limb amputation- feet should be closely monitored

Question 10

DPP-4 inhibitors
1. Examples
2. Mechanism of action
3. Benefit

Answer 10

1. Vildagliptin, Sitagliptin
2. increase levels of incretins (which cause increased levels of insulin release) by decreasing their peripheral breakdown
3. Benefit: Do not cause weight gain

Question 11

Thiazolidinediones
1.. Example
2. Mechanism of action
3. Side effects (4)

Answer 11

1. Pioglitazone
2. PPAR-gamma receptor agonist (reduces peripheral insulin resistance)
3. Side effects:
   - weight gain,
   - liver impairment (monitor LFTs),
   - Fluid retention (therefore contraindicated in HF)
   -increased risk of fractures

Question 12

Sulfonylureas
1. Examples
2. Mechanism of action
3. Side effects
4. Contraindication

Answer 12

1. Gliclazide, glimepiride, glyburide, gliplizide
2. increase pancreatic insulin secretion by binding to the ATP-dependent K+ channel on cell membrane of pancreatic beta cells
3. side effects
   - Hypoglycaemic episodes
   - weight gain
4. Should be avoided in breastfeeding and pregnancy

Question 13

Second line therapy if metformin alone is not effective

Answer 13

Dual therapy - add one of the following:
- metformin + DPP-4 inhibitor
- metformin + pioglitazone
- metformin + sulfonylurea
- metformin + SGLT-2 inhibitor (if NICE criteria met)

Question 14

Blood pressure target for patients with T2DM

Answer 14

140/90

Question 15

First line medications for hypertension in DM patients and why?

Answer 15

ACEis (‘-pril’) and ARBs (‘-sartan’), because they are renoprotective in DM
ARBs are preferred for black African/Afro-Caribbean DM patients