Week 3 - Type 2 Diabetes Flashcards
What causes type 2 diabetes
- Insulin resistance / insensitivity AND slight insulin deficiency
- resisitance = body unable to respond to insulin
- deficiency = b-cells (in pancreas) unable to secrete enough insulin
Resistnance can be exacerbated by obesity, physical inactivity etc.
What are the 9 risk factors for type 2 diabetes
- Obesity
- exacerbates insulin resistance - Family history
- even higher risk if both parents have type 2 compared to only one having it - Diet
- low fibre, high glyceamic diet, keto diets ↑ risk of being obese
- high glycaemic foods cause rapid ↑ in blood glucose levels - Ethnicity
- ↑ risk if Asian, African or Afro-caribbean
- not what they eat but genetics (i.e. how body processes insulin) - Drug treatments
- e.g. statins, corticosteroids ↑ HbA1C - History of gestational diabetes
- children born to parents with a history of this type of diabets have ↑ risk - Low birth weight
- if born before 35 weeks = ↑ risk - Metabolic syndrome
- things like CVD, kidney disease can leead to dyslipidaemia + high BP can lead to diabetes - Polysicitic ovary syndrome
KEY INFO
- No insulin production leads to hyperglycaemia (high blood glucose)
- Type 2 can occur in all ages
How do we diagonse type 2 diabetes
- Blood Test: if HbA1C > 48mmol/L
- DO NOT use in CHILD (invasive)
- Fasting glucose plasma / blood conc.: if > 7mmol/L
- Random glucose plasma test: if > 11mmol/L
- Glucose plasma / blood conc. after 2 hours of eating: if > 11mmol/L
ADULT Symptoms:
- Polyuria (increased urientaion frequency)
- Blurred vision
- Unexplained weight loss
- Recurrent infections e.g. UTI
- Increased thirst
- Hyperpigmentation behind neck, armpits
CHILD symtpoms:
(same as above plus)
- Behavioral changes e.g. more irritable, reduced school performance
What are the complications for type 2 diabetes
Same as Type 1 diabetes complications
- Microvascular (neuropathy, nephropathy, retinopathy)
- Macrovascular (athersclerosis)
- Metabolic complictaions (DKA, dyslipidameia)
- Foot problems (ulcers, amputations)
- Reduced life expectancy (if not controlled well)
Dyslipidaemia - lipid levels are higher (hyperlipidaemia) or lower than usual range
DKA - diabetic ketone acidosis
List the different types of medication available for managing type 2 diabetes
- Metformin
- SGLT2 inhibitors
- DPP4 inhibitors
- Sulphonlyurea
- Insulin (type 1 treatmnet ~ if patient no loner producing insulin or completely insensitive to it)
What are the type 2 diabetes NICE guidelines for choosing medication
1st Line Treatment = Metformin / Metformin MR
- HAVE to ASSESS CV risk and KIDNEY function
- if patient has / high risk developing CVD GIVE SGLT2 inihibitor (i.e. ‘flozin’) as soon as metformin is tolerated
- add a low SGLT2 inihibitor then slowly titrate up over few months
- give MR if patient experiencing GI effects
IF Metformin CONTRAINDICATED:
- GIVE SGLT2 inihbitor alone (a cardioprotective drug)
- CVD includes athersclerosis, chronic heart failure
CONSIDER:
- DPP4 inhibitor
- Sulfonylurea
- Pioglitazone
How does metformin work
1st line treatment
Metformin lowers blood sugar levels by improving the way body handles insulin
Acts in liver
Metofrmin:
1. ↓ gluconeogenesis
2. ↓ absorption of intestinal glucose
3. ↑ insulin sensitivity
Benefits:
- doesn’t cause weight gain
- little risk of hypoglycaemia
Side effects:
- GI disturbances (= switch to metformin MR)
- Can’t be used if have renal impairment (eGFR <30)
- Can cause Vit. B12 deficiency
- Stop if unwell i.e. vomitting
How does SGLT2 inihbiotrs work
Add to metformin if have CVD / CV risk
It inhibits Sodium-GLucose co-Transporter 2
Take ONCE a day
Acts in kidneys
Suffix = -flozins
- e.g. Emapglifozin, Dapaglifozin
SGLT2 Inhibitors:
1. ↓ glucose reabsoprtion (in renal tubules)
2. ↑ urinary glucose excretion
Benefits:
- ↓ CV risk (as they are cardioprotective)
- ↓ HbA1c levels
- ↑ Weight loss
- ↓ Blood pressure (need to check weekly ~ prevent hypotension)
- ↓ intestinal absorption of LDL-C
- ↑ absorption of HDL-C
↑ Risk of:
- DKA (diabetic ketoacidosis)
- SGLT2i can cause ketones
- AKI
- Infections
- Amputations
- Hypotension
How does Sulphonlyureas (Su) work
ONLY beneficial if pancreas is STILL SECRETING INUSULIN (from b-cells)
- Is a rescue medicine (only given for short period of time unless stated otherwise)
- E.g. gliclazide 80mg
- Can ONLY use if underwieght, causes hypos in overweight patients
Benefits:
- Quickly ↓ HbA1c levels (when really high)
- ↓ Blood pressure (need to check weekly ~ prevent hypotension)
- Good choice if rapid response to therapy is required
↑ Risk of:
- Hypos (hypoglycaemia)
- Weight gain (if glucose levels constantly low = ↑ desire to eat)
How does DPP4 Inhibitors work
Drug classification = gliptins
Inhibit DPP4 (a peptidase) = GIP and GLP will remain in body
Can be mono, dual or triple therapy
- mono = DPP4i
- dual = metformin + DPP4i
- triple = metformin + Su + DPP4i
E.g. Linagliptin, alogliptin
DPP4 Inhibitors:
1. ↓ glucagon secretion
2. ↑ insulin secretion
Benefits:
- Low risk of hypos (unless DPP4i is used with SU)
- ↓ HbA1c levels
- No big effects on weight
↑ Risk of:
- Joint pain = stop DPP4i
- Heart failure
- Dose changes if have reduced renal function
How does Pioglitazone work
Has too many RISKS = would NOT USE this drug
Reduces peripheral insulin resistance = ↓ blood glucose conc.
Benefits:
- Low risk of hypos (unless DPP4i is used with SU)
↑ Risk of:
MANY RISKS = would NOT USE this drug
How does GLP-1 Agoinists work
GLP-1 = Glucagon-Like Peptide-1)
GLP-1 agonist causes more insulin to be released
If previous triple therpay is ineffective, swap one of the drugs for a GLP-1 agonist only if patient is at higher risk e.g. BMI >35
GLP-1 Agonist:
1. ↑ insulin secretion
2. ↓ glucagon secretion
3. slows gastric emptying
4. ↓ appetite + food intake
Benefits:
- Low risk of hypos
- Weight loss
Cautions:
- Prgenant / breastfeeding
- Have acute pancreatitis
What are the target HbA1c Levels
48mmol/L (6.5%) = lifestyle + diet management and metformin and NOT on DRUG associated with HYPOGLYCAEMIA
53mmol/L (7.0%) = if on drug that rapidly reduces blood sugar (ON DRUG associated with HYPOGLYCAEMIA)
If not reachong target need to reinforce diet, lifestyle advice, adheanrce to drug treatment and intensify drug treatment
Give a brief overview of a management plan for a patient presenting with type 2 diabetes
Initial Considerations:
- Assess CV status / risk
- Adopt / tailor individualised diabetes care i.e. determine target HbA1C (depending on age + disease duration)
- Measure HbA1C levels every 3-6 months until stable, then every 6 months after
- Have annual / yearly review c(onsists of 9 tests):
1. HbA1c (every 6mnths, in depth check yearly)
2. BP = TARGET <140/90mmHg
3. Full lipid profile
4. BMI (18 to 24.9)
5. Smoking status (encourage cessation)
6. Urinary albumin
7. Serum creatinint
8. Eye examination (retinopthy)
9. Foot examination
10. Check if they’ve been offered vaccines
SGLT2 inhibitor monitoring:
- increases risk of DKA = monitor for symptoms
- sweet / fruity smelling breath, NV, abdominal pain, excessive thirst, confusion, unusual fatigue
- use ketone monitor
- Check body weight (BMI) - cosider drugs
- weight neutral = metformin and DPP4i (gliptins),
- weight gain = insulins, pioglitazone, sulphonylureas
- weight loss = SGLT inhibitors and GLP1 agonist - Check if they have any complications
- e.g. renal; eGFR <30 = NO METFORMIN - Diet, excercise and lifetsyle advice
- enocurage hig fibre diet, low-glycaemic diet
- control sugar, fatty acids, food high in salt intake
- control carbs + alcohol intake
- have regular meals to ↓ hypos reisk
