Type 2 diabetes mellitus Flashcards
What is the diagnostic criteria for diabetes mellitus?
Either:
- Symptoms + one abnormal glucose test
- Polyuria, polydipsia, weight change, fatigue, frequent UTI or candida infections
- Two abnormal glucose tests at separate times
Glucose tests:
- Fasting >7.0mmol/L
- Random >11.1mmol/L
- HbA1c >6.5% (48mmol/mol)
Give five risk factors for T2DM
- Obesity and inactivity
- Poor diet: low fibre; high glycaemic index
- FHx
- Asian; african; black communities
- PMH of gestational diabetes
- Drugs: eg. statins; corticosteroids
- PCOS
- Metabolic syndrome
List five complications of T2DM
- Macrovascular: CVD; stroke; TIA; peripheral artery disease
- Microvascular: nephropathy; retinopathy; neuropathy
- Metabolic: dyslipidaemia; DKA; HHS
- Psychological: anxiety; depression
- Frequent infections
What is metabolic syndrome?
Three of the following:
- Increased waist circumference
- Hypertriglyceridaemia
- HTN
- Insulin resistance
- Prothrombotic state
Greatly increases the risk of developing T2DM
Outline monitoring of HbA1c and CBG in T2DM
- HbA1c monitoring
- 3-6-monthly until HbA1c stable on unchanging therapy
- 6-monthly thereafter
- CBG self-monitoring, only offer if any of:
- On insulin
- Evidence of hypoglycaemic episodes
- Oral medication that increases risk hypoglycaemia while driving or operating machinery
- Pregnant, or planning to become pregnant
What are the targets for HbA1c, BP, total cholesterol, and LDLs in diabetes mellitus?
- HbA1c 48-59 mmols/mol (6.5-7.5%)
- BP <140/80
- <130/80 if end organ damage present
- Total cholesterol <4 mmol/L
- LDL <2 mmol/L
What HbA1c targets are given for T2DM?
- 48 mmol/mol (6.5%)
- Monotherapy not associated with hypoglycaemia
- 53 mmol/mol (7.0%)
- Sulfonylurea monotherapy: risk of hypoglycaemia
- Not adequately controlled by single drug
State three pieces of lifestyle management for diabetes mellitus
- Diet:
- High fibre
- Low-glycaemic index carbohydrates
- Low saturated and trans fatty acids
- Weight loss (5-10% target)
- Increase exercise: improves insulin sensitivity
Outline patient education courses for diabetes mellitus
Offer structured education with annual reinforcement and review
- T1DM: DAFNE course
- Education on glycaemic index of food, and insulin doses
- T2DM: DESMOND course
What is the DVLA guidance for diabetes mellitus?
All patients must be able to:
- Produce CBG >5 mmol/L
- At least 45 minutes prior to driving
What medications are considered if a person is symptomatically hyperglycaemic?
Insulin or sulfonylurea
Review treatment once blood glucose control is achieved
Outline the initial drug treatment options for T2DM
- Metformin
- Started once HbA1c rises to 48 mmol/mol on lifestyle
- Consider modified release if not tolerated
- DPP-4i; pioglitazone; sulfonylurea; or SGLT-2i
- If metformin not tolerated
Outline the first intensification of drug treatment for T2DM who can take metformin
If HbA1c >58 mmol/mol (7.5%) whilst taking monotherapy, consider:
- Metformin, plus:
- DPP-4i
- Pioglitazone
- Sulfonylurea
- SGLT-2i
Outline the second intensification of drug treatment for T2DM who can take metformin
If HbA1c rises to 58 mmol/mol (7.5%) on dual therapy, consider:
- Triple therapy:
- Metformin + DPP-4i + SU
- Metformin + pioglitazone + SU
- Metformin + pioglitazone/SU + SGLT-2i
- Insulin-based treatment
What is the indication for GLP-1 mimetics in T2DM?
All of:
- Triple therapy not effective/tolerated, or contraindicated
- BMI 35+, and
- Obesity-associated psychological or medical problems
- BMI <35, and either
- Contraindications to insulin therapy
- Weight loss will benefit other obesity-related problems
Describe the mechanism of action of Metformin
- Decreases hepatic glucose production
- Decreases glucose absorption
- Increases insulin-mediated glucose uptake
Name two side-effects of Metformin?
- Gastric: abdominal pain, anorexia, diarrhoea, NaV
- Vitamin-B12 deficiency
- Lactic acidosis
Name three contraindications for metformin
- CKD eGFR <30 ml/min: increased risk of lactic acidosis
- Liver failure
- Cardiac failure
Outline the first intensification of drug treatment for T2DM where metformin is contraindicated or not tolerated
If HbA1c rises to 58 mmol/mol, consider:
- DPP-4i + pioglitazone
- DPP-4i + sulfonylurea
- Pioglitazone + sulfonylurea
Outline the second intensification of drug treatment for T2DM where metformin is contraindicated or not tolerated
If HbA1c rises to 58 mmol/mol on dual therapy, consider:
- Insulin-based treatment
Name one drug in the DPP-4 inhibitors class
Outline their mechanism of action
Sitagliptin; Vildagliptin
Name two side effects of Sitagliptin (DPP-4i)?
- GI disturbances
- Hypoglycaemia (uncommon)
- Pancreatitis
What is a benefit of DPP-4i over other oral hypoglycaemic medication?
Weight neutral
Name three side effects of Pioglitazone
- GI disturbance
- Oedema
- Weight gain
- Liver impairment
- Associated with increased risk of:
- Heart failure
- Bladder cancer
- Bone fracture
Name and outline the mechanism of action of sulfonylureas
Gliclazide; Glimepiride; Tolbutamide
Stimulate insulin secretion by binding to ATP-sensitive potassium channels
Name two side-effects of sulfonylureas
- Weight gain: avoid in obese patients
- Hypoglycaemia
Name one side effect of SGLT-2 inhibitors
- Increased risk of DKA in T2DM
- Increased risk of UTI and STI
- Polyuria
- Hypoglycaemia
Outline the types of insulin analogues available
- Rapid acting (4-6hr)
- Short acting (8-10hr)
- Intermediate acting (NPH) (12-20hr)
- Long acting (24hr)
- Very long acting (50+hr)
What initial insulin regimes are recommended by NICE for T2DM?
- Intermediate (NPH) injections once or twice daily
- Consider starting NPH and short-acting insulin
- Consider long-acting insulin (Insulin Glargine) if:
- requires care assistance
- restricted by recurrent hypoglycaemia
State three side-effects of insulin
- Weight gain: inappropriate dose
- Hypoglycaemia; coma
- Hyperglycaemia
- Lipoatrophy or lipohypertrophy
- Painful injections: insufficient injection depth
- Insulin allergic reaction (exceptionally rare)
How is insulin-associated lipohypertrophy treated?
- Prevention by rotating injection sites
- Avoid injecting into affected area for 2-3 months
What advice should be given regarding insulin injections?
- Subcutaneous injections
- Abdomen
- Thighs
- Upper arm
- Needle inserted to its full length
- Rotate injection site to prevent lipohypertrophy
What is pre-diabetes?
A risk category for DM featuring:
- Elevated blood sugar
- Does not meet the criteria for DM
- HbA1c between 5.6-6.4% (38-46mmol/mol)
Define impaired glucose tolerance
Both:
- Fasting plasma glucsoe <7.0 mmol/l
- OGTT 2h value ≥7.8 mmol/l, but <11.1 mmol/l
Define impaired fasting glucose
Fasting glucose ≥6.1 mmol/l, but <7.0 mmol/l
What conditions can cause secondary diabetes?
Pancreatitis Pancreatic carcinoma Trauma Haemochromatosis Cystic fibrosis Acromegaly Cushing’s disease Hyperthyroidism Pheochromocytoma
List the other types of diabetes mellitus besides T1DM, T2DM, and GDM
Latent autoimmune diabetes of adults (LADA): T1DM occurring in adults (30-50), may not require insulin initially. Maturity onset diabetes of the young (MODY): Autosomal dominant DM in under 25s. May be of healthy BMI, and not require insulin. Drug-induced: Corticosteroids, thiazides, anti-psychotics Secondary: Pancreatitis, pancreatic carcinoma, trauma, haemochromatosis, CF, Acromegaly, Cushing’s disease, hyperthyroidism, Pheochromocytoma
