DIABETES

Question 1

What is type 2 diabetes?

Answer 1

Type 2 diabetes is a chronic metabolic condition characterised by insulin resistance and insufficient pancreatic insulin production, resulting in high blood-glucose levels.

Question 2

What are the aims of treatment for type 2 diabetes?

Answer 2

The aims of treatment for type 2 diabetes are to minimise the risk of long-term microvascular and macrovascular complications by effective blood-glucose control and maintenance of glycated haemoglobin (HbA1c) at or below the target value set for each individual patient.

Question 3

What lifestyle modifications can help manage type 2 diabetes?

Answer 3

Lifestyle modifications such as weight loss, eating a healthy diet, smoking cessation, and regular exercise can help manage type 2 diabetes.

Question 4

How should drug treatment for type 2 diabetes be chosen?

Answer 4

Drug treatment for type 2 diabetes should be chosen based on the patient’s preference and clinical circumstances, and the effectiveness, safety, tolerability, and monitoring requirements of the treatment.

Question 5

What factors should be considered when reviewing or changing treatment for type 2 diabetes?

Answer 5

When reviewing or changing treatment for type 2 diabetes, factors such as managing side-effects, supporting adherence, and reinforcing lifestyle advice should be considered, as well as discussing stopping treatment that has had no impact on glycaemic control or weight, unless there is an additional clinical benefit from continued treatment.

Question 6

What are the 1st targets for controlling blood-glucose in type 2 diabetes?

Answer 6

The targets for controlling blood-glucose in type 2 diabetes depend on the patient’s clinical circumstances, but generally, a target HbA1c level of 48 mmol/mol (6.5%) is recommended when type 2 diabetes is managed by diet and lifestyle alone, or when combined with a single antidiabetic drug not associated with hypoglycaemia. (such as metformin hydrochloride)

Question 7

What is the recommended HbA1c level for patients managed by diet and lifestyle alone?

Answer 7

The recommended HbA1c level for patients managed by diet and lifestyle alone is 48 mmol/mol (6.5%).

Question 8

What HbA1c level is recommended for patients prescribed a single drug associated with hypoglycaemia ?

what drugs are associated with hypoglycaemia in the bnf example

Answer 8

Patients prescribed a single drug associated with hypoglycaemia should usually aim for an HbA1c level of 53 mmol/mol (7.0%).

(sulfonylureas i.e. gliclazide, Tolbutamide)

Question 9

Should the target HbA1c level be relaxed on a case-by-case basis in type 2 diabetes?

Answer 9

Yes, the target HbA1c level should be relaxed on a case-by-case basis in type 2 diabetes, with particular consideration for patients who are older or frail, those unlikely to achieve longer-term risk-reduction benefits, or where tight blood-glucose control is not appropriate or poses a high risk of the consequences of hypoglycaemia.

Question 10

What is metformin hydrochloride and what is its effect on blood-glucose levels?

Answer 10

Metformin hydrochloride is an antidiabetic drug that has an anti-hyperglycaemic effect, lowering both basal and postprandial blood-glucose concentrations.

Question 11

Which antidiabetic drug class is associated with hypoglycaemia?
Sulfonylureas, such as gliclazide, glimepiride, glipizide, and tolbutamide, are associated with hypoglycaemia.

Question 12

What is acarbose and how does its anti-hyperglycaemic effect compare to other antidiabetic drugs?

Answer 12

Acarbose is an antidiabetic drug with a poorer anti-hyperglycaemic effect than many other antidiabetic drugs.

Question 13

What is the advantage of meglitinides over sulfonylureas?

Answer 13

The advantage of meglitinides, such as repaglinide, over sulfonylureas is their rapid onset of action and short duration of activity, which allows for flexibility around mealtimes and can be adjusted to fit individual eating habits.

Question 14

What is the risk associated with thiazolidinedione, pioglitazone?
Thiazolidinedione, pioglitazone, is associated with weight gain and several long-term risks, and its ongoing benefit to the patient should be reviewed regularly and treatment stopped if response is insufficient.

Question 15

What are dipeptidylpeptidase-4 (DPP-4) inhibitors and how do they compare to sulfonylureas in terms of weight gain and hypoglycaemia?

Answer 15

Dipeptidylpeptidase-4 (DPP-4) inhibitors, such as alogliptin, linagliptin, sitagliptin, saxagliptin, and vildagliptin, do not appear to be associated with weight gain and have less incidence of hypoglycaemia than sulfonylureas.

Question 16

What is the advantage of sodium glucose co-transporter 2 (SGLT2) inhibitors over other antidiabetic drugs?

Answer 16

Sodium glucose co-transporter 2 (SGLT2) inhibitors, such as canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin, can lower blood-glucose levels, promote weight loss, and improve cardiovascular outcomes in certain patients.

Also Chronic kidney disease (incase of exams not really relevant).

Question 17

What is the risk associated with SGLT2 inhibitors?

Answer 17

SGLT2 inhibitors are associated with a risk of diabetic ketoacidosis.

symptoms are:

High blood glucose levels (hyperglycemia)
Frequent urination (polyuria)
Excessive thirst (polydipsia)
Nausea and vomiting
Abdominal pain
Rapid breathing (Kussmaul respirations)
Fruity-smelling breath (due to the presence of acetone, a byproduct of ketone breakdown)
Dry mouth and dry skin
Confusion, difficulty concentrating, or altered mental state
Fatigue and weakness
Rapid heartbeat (tachycardia) and low blood pressure (hypotension)

Question 18

When should glucagon-like peptide-1 (GLP-1) receptor agonists be prescribed?

Answer 18

GLP-1 receptor agonists, such as dulaglutide, exenatide, liraglutide, lixisenatide, and semaglutide, should be prescribed for combination therapy when other treatment options have failed.

Question 19

What is the advantage of GLP-1 receptor agonists over other antidiabetic drugs?

Answer 19

GLP-1 receptor agonists promote weight loss and may improve cardiovascular outcomes for some patients.

Question 20

What is recommended as the first choice for initial drug treatment for all patients with type 2 diabetes?

Answer 20

Standard-release metformin hydrochloride is recommended as the first choice for initial drug treatment for all patients with type 2 diabetes.

Question 21

Why is standard-release metformin hydrochloride recommended as the first choice for initial drug treatment?

Answer 21

Standard-release metformin hydrochloride has a positive effect on weight loss, reduced risk of hypoglycaemic events, and additional long-term cardiovascular benefits (just benefits!!!!!!!) associated with its use.

Question 22

How should the dose of standard-release metformin be increased?

Answer 22

The dose of standard-release metformin should be increased gradually to minimise the risk of gastro-intestinal side-effects. in steps of 500mg

Question 23

What should be offered in addition to metformin for patients with chronic heart failure or established atherosclerotic cardiovascular disease?

Answer 23

Patients with chronic heart failure or established atherosclerotic cardiovascular disease should also be offered a sodium glucose co-transporter 2 (SGLT2) inhibitor with proven cardiovascular benefit as initial drug treatment.

Question 24

When should an SGLT2 inhibitor be considered for patients with type 2 diabetes?

Answer 24

An SGLT2 inhibitor should be considered for patients who are at high risk of developing cardiovascular disease. Metformin should be initiated first, with the SGLT2 inhibitor started as soon as tolerability to metformin is confirmed.

Question 25

What should be offered to patients who develop chronic heart failure or established atherosclerotic cardiovascular disease?

Answer 25

An SGLT2 inhibitor with proven cardiovascular benefit should be offered to patients who develop chronic heart failure or established atherosclerotic cardiovascular disease.

Question 26

What should be considered if monotherapy with metformin hydrochloride does not control HbA1c to below the agreed threshold?

Answer 26

If monotherapy with metformin hydrochloride does not control HbA1c to below the agreed threshold, consider metformin hydrochloride in combination with either a dipeptidylpeptidase-4 (DPP-4) inhibitor, or pioglitazone, or a sulfonylurea.

Question 27

What should be considered when sulfonylureas are contra-indicated or not tolerated, or if the patient is at significant risk of hypoglycaemia or its consequences?

Answer 27

An SGLT2 inhibitor may be considered in combination with metformin, when sulfonylureas are contra-indicated or not tolerated, or if the patient is at significant risk of hypoglycaemia or its consequences.

Question 28

What should be added in if dual therapy is unsuccessful?
If dual therapy is unsuccessful, consider a triple therapy regimen by adding in either a DPP-4 inhibitor, or pioglitazone, or a sulfonylurea.

Question 29

What should be considered in the following triple therapy regimens?
An SGLT2 inhibitor may be considered in the following triple therapy regimens:
Metformin hydrochloride and a sulfonylurea, and either canagliflozin, dapagliflozin, or empagliflozin; or
Metformin hydrochloride and pioglitazone, and either canagliflozin or empagliflozin; or
Metformin hydrochloride and a DPP-4 inhibitor and ertugliflozin (only if a sulfonylurea or pioglitazone is not appropriate).

Question 30

What should be considered if dual therapy is unsuccessful?
If dual therapy is unsuccessful, it may be appropriate to start insulin-based treatment.

Question 31

What is the risk associated with sulfonylureas for elderly patients or those with renal impairment?
Elderly patients or those with renal impairment are at particular risk of hypoglycaemia if a sulfonylurea is indicated.

Question 32

What shorter-acting sulfonylureas should be prescribed to elderly patients or those with renal impairment?
If a sulfonylurea is indicated for elderly patients or those with renal impairment, a shorter-acting sulfonylurea, such as gliclazide or tolbutamide, should be prescribed.

Question 33

What is the effect of DPP-4 inhibitors on weight gain and incidence of hypoglycaemia?
DPP-4 inhibitors do not appear to be associated with weight gain and have less incidence of hypoglycaemia than sulfonylureas.

Question 34

What is the effect of SGLT2 inhibitors on weight loss and cardiovascular outcomes?
SGLT2 inhibitors may promote weight loss and improve cardiovascular outcomes in certain patients.

Question 35

When should GLP-1 receptor agonists be considered as part of a triple therapy regimen?
GLP-1 receptor agonists should be considered when triple therapy with metformin hydrochloride and two other oral drugs is not effective or not tolerated.

Question 36

Who should GLP-1 receptor agonists be considered for?
GLP-1 receptor agonists should be considered for patients who have a BMI of 35 kg/m2 or above and have specific psychological or medical problems associated with obesity, or for those who have a BMI lower than 35 kg/m2 and for whom insulin therapy would have significant occupational implications or if the weight loss associated with GLP-1 receptor agonists would benefit other significant obesity-related comorbidities.

Question 37

When should GLP-1 receptor agonist therapies with proven cardiovascular benefit be considered?
GLP-1 receptor agonist therapies with proven cardiovascular benefit should be considered in patients with established cardiovascular disease.

Question 38

How should the efficacy of GLP-1 receptor agonist therapy be assessed?
After 6 months, the GLP-1 receptor agonist should be reviewed and only continued if there has been a beneficial metabolic response, defined as a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight.

Question 39

When should insulin be prescribed in combination with a GLP-1 receptor agonist?
Insulin should only be prescribed in combination with a GLP-1 receptor agonist under specialist care advice and with ongoing support from a consultant-led multidisciplinary team.

Question 40

What is the first-line drug treatment for patients if metformin is contra-indicated or not tolerated?
A: A sodium glucose co-transporter 2 (SGLT2) inhibitor with proven cardiovascular benefit should be offered.

Question 41

What drug treatment should be considered as an alternative option to a DPP-4 inhibitor, if neither a sulfonylurea nor pioglitazone is appropriate?
A: An SGLT2 inhibitor.

Question 42

What is repaglinide and what is its role in the treatment of type 2 diabetes?
A: Repaglinide is an effective alternative option for single therapy, but it has a limited role in treatment because, should an intensification of treatment be required, it is not licensed to be used in any combination other than with metformin hydrochloride.

Question 43

What should be offered to patients who develop chronic heart failure or established atherosclerotic cardiovascular disease, and should be considered in patients who become at high risk of developing cardiovascular disease?
A: An SGLT2 inhibitor with proven cardiovascular benefit.

Question 44

What should be considered if initial monotherapy does not control HbA1c to below the patient’s agreed threshold?
A: Adding either a dipeptidylpeptidase-4 (DPP-4) inhibitor, pioglitazone, or a sulfonylurea.

Question 45

When should insulin-based treatment be considered?
A: If dual therapy does not provide adequate glucose control.

Question 46

What is the first-line drug treatment for patients who have chronic heart failure or established atherosclerotic cardiovascular disease?
A: A sodium glucose co-transporter 2 (SGLT2) inhibitor with proven cardiovascular benefit.

Question 47

What drug treatment should be considered for all other patients if metformin is contra-indicated or not tolerated?
A: A dipeptidylpeptidase-4 (DPP-4) inhibitor, or pioglitazone, or a sulfonylurea.

Question 48

What should be reviewed after 6 months for patients on a GLP-1 receptor agonist?
A: The GLP-1 receptor agonist should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight).

Question 49

What should be prescribed in combination with a GLP-1 receptor agonist under specialist care advice and with ongoing support from a consultant-led multidisciplinary team?
A: Insulin.

Question 50

What should be continued when insulin is indicated for intensification of treatment?
Metformin hydrochloride should be continued unless it is contra-indicated or not tolerated.

Question 51

What should a structured support program for insulin therapy cover?
A structured support program should cover insulin dose titration, injection technique, self-monitoring, and knowledge of dietary effects and glucose control.

Question 52

What are the recommended insulin regimens?
Human isophane insulin injected once or twice daily, according to requirements.
A human isophane insulin in combination with a short-acting insulin.
Insulin detemir or insulin glargine as an alternative to human isophane insulin.
Biphasic preparations that include a short-acting human analogue insulin.

Question 53

What is the preferable insulin regimen for patients who cannot use the device needed to inject human isophane insulin?
Insulin detemir or insulin glargine as an alternative to human isophane insulin.

Question 54

How should the dose of bedtime basal insulin be titrated when starting insulin therapy?
Bedtime basal insulin should be initiated and the dose titrated against morning (fasting) glucose.

Question 55

What should be monitored for patients who are prescribed a basal insulin regimen?
Patients who are prescribed a basal insulin regimen should be monitored for the need for short-acting insulin before meals (or a biphasic insulin preparation).

Question 56

What should be monitored for patients who are prescribed a biphasic insulin?
Patients who are prescribed a biphasic insulin should be monitored for the need for a further injection of short-acting insulin before meals or for a change to a basal-bolus regimen with human isophane insulin or insulin detemir or insulin glargine if blood-glucose control remains inadequate.

Question 57

When is insulin detemir or insulin glargine preferable to human isophane insulin?
Insulin detemir or insulin glargine is preferable when a once daily injection would be beneficial, or if recurrent symptomatic hypoglycaemic episodes are problematic, or if the patient would otherwise need twice-daily human isophane insulin injections in combination with oral glucose-lowering drugs.

Question 58

What should be reviewed and stopped if necessary when starting insulin therapy?
Other antidiabetic drugs should be reviewed and stopped if necessary.

Question 59

What type of insulin regimen can be preferable for patients who prefer injecting insulin immediately before a meal?
Biphasic preparations that include a short-acting human analogue insulin can be preferable for patients who prefer injecting insulin immediately before a meal.

Question 60

tell a story oon all the possible escalation scenarios with the steps on how to solve?

Answer 60

start with metformin 500mg OD (aim for HbA1c of 48 (6.5%)
if HbA1c is >48 (6.5%) is then you want to gradually max out the dose of metformin in steps of 500mg (max is 2g).
if that still doesn’t control the HbA1c to 48 (6.5%) or below. then you want to intensify with another drug in this order:
Metformin + DPP-4 inhibitor
o Metformin + pioglitazone
o Metformin + sulfonylurea
o Metformin + SGLT-2 inhibitor (if sulfonylurea is contraindicated or not tolerated, or if the person is at significant
risk of hypoglycaemia or its consequences)
o Elderly pts or pts with renal impairment at risk of a hypo should be prescribed a shorter-acting sulfonylurea e.g.,
Gliclazide or Tolbutamide
Second metformin treatment intensification 8 , 9
1. Triple therapy regimens:
o Metformin + DPP-4 inhibitor + Sulfonylurea
o Metformin + Pioglitazone + Sulfonylurea
o Metformin + Pioglitazone/Sulfonylurea + SGLT-2 inhibitors canagliflozin or empagliflozin (Dapagliflozin is
recommended only in combination with metformin and a sulfonylurea, not pioglitazone)
o Metformin + DPP-4 inhibitor + SGLT-2 inhibitor ertugliflozin, only if sulfonylurea or pioglitazone is not appropriate.
2. Alternatively at this stage, may be appropriate to start insulin- based treatment
3. If triple therapy unsuccessful, glucagon-like peptide-1 receptor agonist (GLP-1) + Metformin + Sulfonylurea – but only
for pts with BMI of 35+kg/m 2 AND issues associated with obesity OR BMI lower than 35 and don’t want insulin therapy
(5mcg BD)

Now if metformin is not tolerated you want to start with a sulfonylurea (which can cause hypoglycaemia and moderate weight gain) and aim for HbA1c of 53 (7.0%). if target is not met you want to max out the dose of the sulfonylurea, if that still doesn’t get us to the target you would want to intensify in this order:
sulfonylurea + DPP-4
sulfonylurea + pioglitazone
NEVER GIVE IT WITH SGLT-2 INHIBITORS

Now lets say the patient doesn’t want to gain weight or doesn’t like the idea of hypoglycaemia then you would want to give a DPP-4 inhibitor and then aim for HbA1c of 48 (6.5%). if the aim is not met then you would want to max out the dose if possible. if that doesn’t work. you can then intensify the treatment in this order:
DPP-4 + sulfonylurea (BUT EXPLAIN TO THE PATIENT THAT THEY WILL BE GETTING ALL THOSE SIDE EFFECTS THEY DONT WANT) IF THEY SAY THEY DONT WANT SULFONYLUREA THEN YOU WANT TO

GIVE DPP-4 inhibitor + Pioglitazone

DONT GIVE WITH SGLT2 INHIBIORS.

something applies to Pioglitazones but it is rare to start with that because of the long term side effects like (Fluid retention and oedema, Bone fractures, Weight gain, Bladder cancer)

If non of these work then you want to switch to insulin therapy