Wk 9: Diabetes in practice: Type 2

Question 1

Define Type 2 diabetes

Answer 1

Insulin resistance + relative insulin deficiency result in persistent hyperglycaemia

Question 2

What are the assessment and diagnosis of adults with T2DM?

Answer 2

• Random plasma glucose >11mol/L
• HbA1c >48mmol/mol (6.5%)
• Fasting plasma glucose >7mmol/L
• Polyuria
• Polydipsia
• Weight loss
• Tiredness
• Blurred vision
• Infections

Question 3

What are the recommendations on when to measure blood glucose levels in T2DM?

Answer 3

• Insulin therapy
• Hypo
• Antidiabetic drugs

Question 4

What is the HbA1c recommendation of a patient managed by lifestyle + diet or lifestyle, diet + drug not associated w/ hypo?

Answer 4

48mmol/mol (6.5%)

Question 5

What is the HbA1c recommendation of a patient on a drug associated w/ hypo?

Answer 5

53mmol/mol (7%)

Question 6

What is the algorithm for adults with type 2 diabetes who can take metformin?

Answer 6

• HbA1c rises to 48mmol/mol on lifestyle: offer standard-release met, 48mmol/mol
• Rises to 58mmol/mol (1st intensification: dual therapy, 53mmol/mol
• Rises to 58mmol/mol (2nd intensification): triple therapy/insulin, 53mmol/mol

Question 7

What occurs during the 1st intensification for adults w/ T2DM who can take metformin?

Answer 7

Dual therapy w/:

• Met + DPP-4i
• Met + pioglitazone
• Met + SU
• Met + SGLT-2i

Question 8

What occurs during the 2nd intensification for adults w/ T2DM who can take metformin?

Answer 8

Triple therapy w/:

• Met, DPP-4i + SU
• Met, pioglitazone + SU
• Met, pio/SU + SGLT-2i

OR

• Insulin based therapy

Question 9

What happens when the HbA1c rises to 48mmol/mol for adults who can’t take metformin?

Answer 9

Consider:

• DPP-4i, Pioglitazone or SU
• SGLT-2i if DPP-4i = not appropriate
• Aim for 48mmol/mol: DPP-4i, Pioglitazone, SGLT-2i
• Aim 53mmol/mol: SU

Question 10

What occurs during the 1st intensification for adults w/ T2DM who can’t take metformin?

Answer 10

Dual therapy:

• DPP-4i + pioglitazone
• DPP-4i + SU
• Pioglitazone + SU
• 53mmol/mol

Question 11

What occurs during the 2nd intensification for adults w/ T2DM who can’t take metformin?

Answer 11

• Insulin based treatment

- 53mmol/mol

Question 12

Metformin

Answer 12

• Dose: initially 500mg OD w/ meal. Max 2g daily
• GI related adverse effects
• Risk of lactic acidosis
• Avoid eGFR <30ml/min/1.73m2

Question 13

Sulphonylurea - Gliclazide

Answer 13

• Dose: initially 40-80mg. Max 320mg daily
• Weight gain
• Risk of hypo + inc risk of renal impairment

Question 14

Pioglitazone

Answer 14

Dose: 15-30mg OD. Max 45mg OD

Question 15

Gliptins

Answer 15

• Reduces appetite

- Pancreatitis

Question 16

SGLT2 inhibitors - Gliflozins

Answer 16

• Dose: 10mg OD, inc 25mg OD

- Inc risk of DKA + UTI