T2DM

Question 1

When / how to screen for T2DM?

Answer 1

AUSDRISK every 3 years after 40yo

vs FG or A1c annually if ATSI after 18yo

vs FG or A1c every 3 years if known to be high risk

Question 2

What are the 10 components of AUSDRISK?

Answer 2

1. Age (increasing)
2. Gender (male)
3. Ethnicity - ATSI/PI/Maori or Asian/Indian/Middle Eastern/North African/Southern European
4. FHx diabetes
5. PHx elevated glucose
6. HTN on medication
7. Smoking
8. Low fruit/vegetable intake
9. Low physical activity
10. Waist circumference >110cm for men or 100cm for women

Question 3

Who is at high risk of T2DM and when should they be screened?

Answer 3

Age ≥40 + BMI ≥25
AUSDRISK ≥12
PHx CVD event/GDM/PCOS
Pt on anti-psychotics

FG or A1c every 3 years

Question 4

What are the diagnostic criteria for impaired glucose tolerance and impaired fasting glucose?

When should these people be screened?

Answer 4

2hr glucose 7.8-11 and/or FG 6.1-6.9

Annually w FG or A1c

Question 5

Cut-offs for diabetes diagnostic tests (FG, A1c, OGTT)

Answer 5

FG <5.5 = diabetes unlikely
FG 5.5-6.9 = diabetes possible
FG ≥7 or RBG ≥11.1 = diabetes likely, repeat test

A1c <6 = diabetes unlikely
A1c ≥ 6.5% = diabetes

OGTT FG ≥7 or 2hr ≥11.1 = diabetes
FG 6.1-6.9 = impaired fasting glucose
2hr 7.8-11 = impaired glucose tolerance
2hr <7.8 = normal

Question 6

What is the difference between diagnosing diabetes in asymptomatic vs symptomatic patients?

Answer 6

Single diagnostic result required for symptomatic pts (vs. repeat test required for ASx pts)

Question 7

When should we consider DDx T1DM?
(think of 6)

Answer 7

Ketosis/ketonuria
Polyuria / polydipsia
Acute weight loss (>5% in <4/52)
<50yo
PHx or FHx auto-immune disease
Acute onset of Sx

Question 8

Name 6 self-management goals for T2DM

Answer 8

1. Balanced diet per the Australian Dietary Guidelines
2. 150mins aerobic exercise + 2-3 resistance training sessions (totalling ≥60mins) per week
3. At least 5-10% LoW if BMI ≥25
4. 0 cigarettes per day
5. ≤2 std drinks per day
6. FG 4-7; post-prandial 5-10

Question 9

When is self-monitoring of blood glucose recommended in T2DM?

Answer 9

Pt on insulin or SU
Pts having difficulty achieving glycaemic control
For monitoring of BGL arising from intercurrent illness
During pre-pregnancy and pregnancy Mx
When clinical need requires monitoring

ie. NOT routinely if low risk

Question 10

What are clinical management targets for T2DM?
A1c
ACR
Lipids
BP

Answer 10

A1c - ≤7 usually, ≤6.5 if young, >7 if elderly/comorbid - check every 3-12 months

ACR ≤2.5 for men and ≤3.5 for women - check yearly

Lipids TC <4, TG <2, LDL <2 (1.8 if existing CVD), HDL ≥1 - check yearly

BP ≤140/90, lower if younger and tolerated - check each visit

Question 11

What health checks should people w T2DM have? How often?

Answer 11

Maintain immunisations: Influenza, Pneumococcal, dTpa +/- Hep B (if travelling) and Herpes Zoster

Eyes: retinopathy check at Dx then 1-2yrly

Peripheral neuropathy: 10g monofilament (small fibres) + vibration sense (large fibres) at Dx then yearly

Kidneys: eGFR + ACR at least annually

Question 12

T2DM management algorithm:
First line
Dual therapy
Multiple therapies

Answer 12

First line:
- Weight loss ≥10%
- Metformin (SU is not preferred)

Dual:
- SGLT2i or GLP1 preferred for CVD/CKD risk reduction
vs. DPP4i (if SGLT2i or GLP1 not tolerated / CI)
vs. SU (not preferred due to risk of hypoglycaemia) or insulin

Multiple:
- Options inc. SGLT2i, GLP1, DPP4i, SU and insulin
- Review meds that haven’t reduced A1c by ≥0.5%
- SGLT2i + GLP1 cannot both be covered by PBS
- Cannot use GLP1 + DPP4i together

Question 13

Metformin - class, MoA, CI, AEs, dosing, cost

Answer 13

Class - Biguanide
MoA - Reduces hepatic glucose output + lowers FG
CI - eGFR <30, severe hepatic impairment
AEs - GI upset, lactic acidosis
Dosing - Start at low dose and up-titrate, available in slow release
Cost - PBS general schedule

Question 14

Gliclazide - class, MoA, CI, AEs, dosing, cost

Answer 14

Class - Sulfonylurea
MoA - Triggers insulin release independent of glucose
CI - Severe renal or hepatic impairment
AEs - Weight gain
Dosing - Start at low dose and up-titrate, available in slow release
Cost - PBS general schedule

Other drugs inc. glibenclamide, glimepiride, glipizide

Question 15

Gliptins - class, MoA, CI, AEs, dosing, cost

Answer 15

Class - Dipeptidylpeptidase-4 (DPP-4) inhibitors
MoA - Increases availability of GLP1 (which stimulates B-cell insulin release)
CI - Pancreatitis
AEs - GI upset, rash, pancreatitis
Dosing - Reduce dose in renal impairment (except for linagliptin)
Cost - PBS subsidised for use w metformin, SU or insulin; DPP4i + metformin allows SGLT2i subsidy

Examples: alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin

Question 16

Gliflozins - class, MoA, CI, AEs, dosing, cost

Answer 16

Class - Sodium-glucose co-transporter-2 (SGLT2) inhibitor
MoA - Increases urinary glucose excretion + decreases BGLs
CI - Caution with diuretics, very low carbohydrate intake, bowel prep, perioperatively. Note glycaemic benefits lost at eGFR <45 but cardiac + kidney benefits persist to eGFR <25
AEs - dehydration, dizziness, genituourinary infections, ketoacidosis, weight loss
Dosing -
Cost - PBS subsidised for use w metformin +/- SU or insulin; SGLT2i + metformin allows DPP4i subsidy

Examples: dapagliflozin, empagliflozin, ertugliflozin

Question 17

-tides - class, MoA, CI, AEs, dosing, cost

Answer 17

Class - Glucagon-like-peptide-1 (GLP-1) receptor agonists
MoA - Stimulates B-cell insulin release + slows gastric emptying
CI - PHx pancreatitis or pancreatic Ca
AEs - N&V, weight loss, tachycardia
Dosing - Sub-cut injection. Dose reduce in mod-sev renal impairment
Cost - PBS subsidised for use w metformin +/- SU or insulin. NOT PBS subsidised as monotherapy, w DPP4i, glitazone or SGLT2i

Examples: semaglutide, exenatide, dulaglutide, liraglutide

Question 18

Pioglitazone - class, MoA, CI, AEs, dosing, cost

Answer 18

Class - Thiazolidinediones (TZD)
MoA - Lowers BGL through insulin sensitisation
CI -
AEs - Fluid retention, heart failure, weight gain, increased risk of bladder Ca/#s
Dosing - Caution in symptomatic heart failure
Cost - PBS subsidised for use w metformin and SU, or insulin

Question 19

Acarbose - class, MoA, CI, AEs, dosing, cost

Answer 19

Class - Alpha-1 glucosidase inhibitors
MoA - Slows intestinal CHO absorption + reduces post-prandial glucose
CI - Severe renal impairment
AEs - Bloating, flatulence
Dosing - Take w meals. Caution if malabsorption
Cost - PBS general schedule