When to suspect latent autoimmune diabetes in adulthood (3)
Absence of metabolic syndrome features
Poor glycaemic control with oral agents
Other autoimmune diseases
Auto-antibodies associated with LADA?
Anti-GAD
Diabetes presenting <25 years old, often with a family history
Maturity-onset diabetes of the young (MODY)
Exclusions to using HbA1C for diagnosis? (4)
<18 years old
Pregnancy
Anaemia (or recent transfusion)
Abnormal structure Hb (e.g. sickle cell, spherocytosis)
Diagnostic cut-offs for diabetes (HbA1c)
> 48 - diabetes
42-47 - impaired glucose tolerance
<42- normal
Diagnostic cut-offs for diabetes (fasting glucose)
<6- normal
6-7- impaired fasting glycaemia; perform glucose tolerance test
>7 - diagnostic if symptomatic, needs repeated if asymptomatic
Diagnostic value for glucose tolerance test?
> 11.1
Management of pre-diabetes? (2)
Address CV risk factors Weight loss (5% weight loss reduces risk of progression to diabetes at 3yrs by 80%)
Capillary blood glucose aims a) pre-prandial b) 90 mins post-prandial
a) 4-7
b) 5-7
HbA1C targets:
a) T2DM + drug causing hypoglycaemia
b) T2DM + diet controlled/drug not causing hypoglycaemia
c) T1DM
d) T2DM when two or more antidiabetic drugs are prescribed
a) <53
b) <48
c) <48
d) <53
Maximum dose of metformin?
2g/day
Options if HbA1C not adequately controlled on metformin alone? (4)
Sulfonylurea (e.g. gliclazide, glimepiride)
Pioglitazone
DPP4 inhibitor (gliptin)
SGLT2 inhibitor (gliflozin)
First-line options if metformin is contra-indicated or not tolerated? (3)
Sulfonylurea
DPP4 inhibitor
Pioglitazone
Adverse effects of sulfonylureas?
a) common (2)
b) rare (3)
Common- Weight gain, Hypoglycaemia
Rare- cholestasis, bone marrow suppression, SIADH
Mechanism of DPP4 inhibitors (gliptins)
inhibit breakdown of glucagon-like peptide 1 (GLP1). GLP1 is an incretin (i.e. it stimulates insulin release and inhibits glucagon release)
Why are gliptins (DPP4 inhibitors) useful in renal failure?
They are excreted via the gall bladder
Mechanism of pioglitazone?
Decreases peripheral insulin resistance
Risks of pioglitazone? (4)
Increased risk of fractures
bladder cancer
Fluid retention/heart failure
Hepatotoxicity
Monitoring requirements for pioglitazone?
LFTs prior to commencing, and periodically thereafter
Under what circumstances should SGLT2 inhibitors be prescribed at the first intensification of treatment?
If a sulfonylurea is not tolerated or contraindicated, or patient is at risk of hypoglycaemia/consequences of hypoglycaemia
What is the role of GLP-1 receptor agonists e.g. liraglutide?
As part of a triple therapy regime along with metformin + sulfonylurea, only if triple therapy with metformin and two other drugs is not tolerated/contraindicated/ineffective.
Can consider in combination with metformin + SU as an alternative to insulin
What is the recommended first-line insulin regime in T2DM? (2)
Isophane (intermediate) insulin once or twice daily; consider adding short-acting insulin in addition (either separately or as a biphasic mixed insulin) if HbA1C is >75
When might a once-only long-acting insulin regime be appropriate? (3)
Usually older patients; patients who require assistance with injecting; patients with problems with recurrent hypoglycaemia.
In what circumstances should patients routinely self-monitor blood glucose? (4)
On insulin
Evidence of hypoglycaemic episodes
If taking a drug that can cause hypoglycaemia and operating a car/machinery
If pregnant/planning a pregnancy
