Management of Type 2 Diabetes - 1

Question 1

What should a patient expect from their care?

Answer 1

• Blood glucose levels
• Blood Pressure
• Blood Lipids
• Eyes, feet + kidney check
• Weight
• Smoking Cessation Support
• Individual Care plan
• Education Course
• Emotional and psychological support

Question 2

What are four aims of management?

Answer 2

• Relief of primary symptoms
• Prevention of complication
• Preservation of QOL
• Damage minimisation

Question 3

What are the defects that occur in NIDDM?

Answer 3

Pancreas:
• Beta cell dysfunction
• Diminished incretin effect
• Excess glucagon

Periphery:
• Insulin resistance

Question 4

What are the effects of the defects in T2DM?

Answer 4

• Decreased insulin production
• Decreased insulin action

This increases BG levels

Question 5

What are possible treatment options for increased insulin release?

Answer 5

• Sulphonylureas
• Metiglinides
• Incretin mimetics
• DPPIV inhibitors

Question 6

What are possible treatment options for increased excretion of Glc?

Answer 6

SGLT2 inhibitors

Question 7

What are possible treatment options to improve insulin action?

Answer 7

• Biguanides
• Thiazolidiones
• Weight reduction

Question 8

What are the symptoms of uncontrolled T2DM?

Answer 8

• Frequent urination
• Increased thirst
• Blurry vision
• Increased hunger
• Feeling drowsy
• Tingling, pain or numbness in hands and feet
• Slow healing of cuts and bruises

Question 9

What factors that increase risk of complications?

Answer 9

• Smoking
• Mood
• Dietary change
• Statins
• BP
• Sedentary lifestyle

Question 10

Do we need to achieve tight glycaemic control in everyone?

Answer 10

Heterogeneous population
Risk of hypoglycaemia
Effect of intensive control on those with established cardiovascular disease

Question 11

What is the 5 step framework for choosing a Glc lowering drug?

Answer 11

1. Set HbA1c target
2. Are there other risk factors that need to be treated?
3. Are current treatments optimised?
4. What are the Glc lowering options?
5. Arrange review date and target for HbA1c

Question 12

What is the 1st line treatment of T2DM?

Answer 12

Metformin (or sulfonylurea - if weight loss/osmotic symptoms)

Review and if not reaching target move to 2nd line

Question 13

What is the 2nd line treatment of T2DM?

Answer 13

Sulfonylurea

Or:
• Thiazolidinedione
• DPP-IV inhibitor
• SGLT-2 inhibitor

Review and if not reaching target move to 3rd line

Question 14

What is the 3rd line treatment of T2DM?

Answer 14

In addition to lifestyle measures, adherence to medication and dose optimisation; add:

Oral:
• Thiazolidinedione
• DPP-IV inhibitor
• SGLT-2 inhibitor

Injectable:
• GLP-1 agonist
• Insulin

Question 15

Why is metformin first choice treatment option?

Answer 15

• Improves Glc control without significnt weight gain and CVS outcomes
• Well tolerated
• Cheap
• Can be used in pregnancy

Question 16

What class of drug is metformin?

Answer 16

Biguanide

Question 17

What is the action of metformin?

Answer 17

Improves insulin sensitivity
• Affects glucose production, decrease fatty acid synthesis
• Improves receptor function
• Inhibits gluconeogenic pathways

Half life is 6hrs

Question 18

What are the disadvantages of metformin?

Answer 18

• Risk of lactic acidosis by inhibiting lactic acid uptake by liver
- Hypoxia, renal/hepatic failure
• GI side effects
• Risk Vit B12 malabsorption

Question 19

What is the action of Sulphonylureas?

Answer 19

1. Binds to sulfonylurea receptors (SUR-1) on functioning pancreatic beta-cells.
2. Binding closes the linked ATP-sensitive potassium channels
3. Decreased potassium influx depolarization of the beta-cell membrane.
4. Voltage-dependent calcium channels open and result in an influx of calcium
5. Translocation and exocytosis of secretory granules of insulin to the cell surface

Question 20

What are the advantages of Sulphonylureas?

Answer 20

• Used with metformin
• Rapid improvement in control
• Rapid improvement if symptomatic
• Rapid titration
• Cheap
• Generally well tolerated

Question 21

What are the disadvantages of Sulphonylureas?

Answer 21

• Risk of hypoglycaemia
• Weight gain
• Caution in renal and hepatic disease
• CI in pregnancy and breastfeeding.

Question 22

What is the mechanism of thiazolidinediones?

Answer 22

Stimulates thenuclear receptorPPAR-gamma and to a lesser extentPPAR - alpha on liver, muscle and adipose tissue

Modulates the transcription of theinsulin-sensitive genes involved in the control of glucose andlipid metabolism

Question 23

What are the effects of thiazolidinediones?

Answer 23

• Reduces insulin resistancein the liver and peripheral tissues
• Increases the expense of insulin-dependent glucose
• Decreases withdrawal of glucose from the liver
• Reduces quantity of glucose, insulin andglycated haemoglobinin the bloodstream

Question 24

What are the advantages of pioglitazone (a thiazolidinedione)?

Answer 24

• Good for people if insulin resistance significant

* Cheap

Question 25

What are the disadvantages of pioglitazone (a thiazolidinedione)?

Answer 25

• Increase risk of bladder cancer
• Fluid retention - CCF
• Weight gain
• Fractures in females