Managing T2DM In Adults

Question 1

What are some questions you want to ask in the history about a patient who might have diabetes in terms of HPC?

What will help differentiate between T1DM and T2DM?

Answer 1

Polyuria?
Polydipsia?
Nocturia?
Weight loss?

T2DM has a more insidious onset where these above osmotic symtpoms are absent
Normally present twitch hyperglycaemia or diabetes complications

Question 2

What are some categoreis that might indicate a cause of diabetes in the PMH?

Answer 2

Endocrinopthies

Pancreas pathology

Medications

Infections

Syndromic

Question 3

What are some endocrinopathies that can cause diabetes?

Answer 3

Acromegaly
Thyrotoxicosis,
Cushing’s Phaeochromocytoma, Glucagonoma
PCOS

Question 4

What are some pancreatic pathologies that can cause diabetes?

Answer 4

Pancreatitis
Pancreatic cancer
Pancreatectomy

Question 5

What are some medications that can cause diabetes?

Answer 5

Steroids
Levothyroxine
Thiazides
Antiretrovirals (HIV)
B-agonists

Question 6

What are some syndromes that can cause diabetes?

Answer 6

Down syndrome
Klinefelters syndrome
Turners
Huntingtons chorea

Question 7

What are you looking for on examination when you suspect a patient has diabetes?

Answer 7

BMI
BP
Signs of insulin resistance
Retinal examination
Foot examination

Question 8

What are some signs of insulin resistance?

Answer 8

Central obesity
Acanthosis nigricans
Hyperandrogenism (in females)

Question 9

What are some investigations you would do for a patient with diabetes?

Answer 9

HbA1C
Renal, liver, thyroid, lipid profile
B cell antibodies, anti GAD, anti-islet cells

Question 10

Why is it important to ask about family history for diabetes?

Answer 10

T2DM has a very strong genetic component

Question 11

What is the pathophysiology of T2DM?

Answer 11

Insulin sensitivity (inability of insulin sensitive tissue to respond to insulin) which can then lead to defective insulin secretion

Question 12

What are the steps to managing T2DM?

Answer 12

Education
Lifestyle modification
Annual reviews
Medications

Question 13

What is important to educate patients with T2DM on?

Answer 13

What is diabetes?
Why does diabetes need to be treated (complications)?

Question 14

What lifestyle modifications should patients with T2DM have?

Answer 14

Exercise
Weight loss
Dietary changes/advice
May require glucose monitoring if medications can cause hypoglycaemia

Question 15

What reviews are going to be needed with managing diabetes?

Answer 15

Blood reviews
Urine reviews
Eye screen

Individualised target HbA1c

Question 16

When would you need to inform the DVLA about your T2DM?

Answer 16

When take insulin > 3months
Taking medications like sulfonylureas like gliclazide which can cause hypoglycaemia

Question 17

What is some dietary advice you might give to a patient with T2DM?

Answer 17

High fibre
Low glycaemic index score of carbs
Low fat diary
Portion control
Alcohol reduction
Smoking cessation
Inc physical activity
Weight loss of 5%-10% target for overweight people

Question 18

What is a typical HbA1c target for a patient on a diet/single medication?

Answer 18

48mmol/mol

Question 19

What is a typical HbA1c target for a patient on a more complex regime of diets and medication with T2DM?

Answer 19

58mmol/mol

Question 20

What are some classes of medications used to manage T2DM?

Answer 20

Biguanides
Sulfonylureas
SGLT2 inhibits
GLP1 agonist
DPP4 inhibitors
Glitazones

Question 21

What is an example of a biguanide?

Answer 21

Metformin

Question 22

What is the mechanism of action of metformin?

Answer 22

Decreases Gluconeogenesis by the livier and increases insulin sensitivity

Question 23

What are the side effects of metformin?

Answer 23

Lactic acidosis
GI upset

Question 24

When do you have to alter the dose of metformin?

Answer 24

EGFR < 30

Question 25

How does metformin affect weight?

Answer 25

Either decreases or has no effect on weight

Question 26

What is an example of a sulfonylurea?

Answer 26

Gliclazide

Question 27

What is the mechanism of action of gliclazide?

Answer 27

Blocks the ATP sensitive potassium channels leading to K+ building up, depolarisation, Ca2+ influx leads to insulin effluent

Question 28

What is the side effects of gliclazide that needs to be monitored? How does it affect weight?

Answer 28

Hypoglycaemia Weight gain

Question 29

What are some SGLT2 inhibitors?

Answer 29

Dapagliflozin Empagliflozin

Question 30

What is the mechanism of action of empagliflozin or dapagliflozin?

Answer 30

Blocks SGLT2 meaning less glucose reabsorbed in the PCT so more lost in the urine

Question 31

What are some side effects/complications of SGLT2 inhibitors?

Answer 31

UTIs Euvolaemic DKA

Question 32

What is a Contraindication to SGLT2 inhibitors?

Answer 32

Hypovolaemia

Question 33

How do SGLT2 inhibitors affect weight and HbA1c?

Answer 33

Large weight loss Lowers HbA1c better than metformin. But less than gliclazide

Question 34

What are some examples of GLP1 agonists?

Answer 34

Liraglutide Semaglutide

Question 35

What are some side effects of GLP1 agonists like semaglutide?

Answer 35

DKA Inc risk of thyroid cancer Hypoglycaemia

Question 36

How does semaglutide (GLP1 agonist) affect HbA1c and weight?

Answer 36

Best for weight loss Better at reducing HbA1c than metformin but not as good as SGLT2 inhibitors like dapagliflozin

Question 37

What are some examples of DPP4 inhibitors?

Answer 37

Sitigliptin Saxagliptin

Question 38

What makes DPP4 inhibitors like saxagliptin “safe”?

Answer 38

No risk of hypoglycaemia

Question 39

What is the mechanism of action of DPP4 inhibitors like sitiglipitn and saxagliptin?

Answer 39

Prevents the breakdown of incretins So incretins stimulate and simulate insulin food is consumed so drug only has its effect when food is consumed

Question 40

How do GLP1 agonists work?

Answer 40

Increased production of incretins means more insulin is released

Question 41

How does DPP4 inhibitors like saxagliptin effect weight and HbA1c?

Answer 41

Neutral on weight gain Worse than metformin on HbA1c reduction

Question 42

What are some glitazones?

Answer 42

Pioglitzones Rosiglitazones.

Question 43

What is the mechanism of action of glitazones like pioglitazone?

Answer 43

PPAR-gamma leads to glucose differentiating to fat cells

Question 44

What are some side effects of glitazones?

Answer 44

Fluid retention (heart failure) Osteoporosis Bladder cancer

Question 45

What medication is best to reduce HbA1c?

Answer 45

Gliclazide

Question 46

What medication is best for weight loss when treating T2DM?

Answer 46

GLP1 agonists like liraglutide and semaglutide

Question 47

What is the best medication for T2DM for avoiding hypoglycaemia?

Answer 47

DPP4 inhibitors like sitagliptin and saxagliptin

Question 48

What is the order of diabetic medications in terms of best to worst for reducing HbA1c?

Answer 48

Most effective - Gliclazide, SGLT2 inhib, GLP1 (semaglutide), metformin, DPP4 inhibitors - worst

Question 49

What is the NICE guidelines for medications treating T2DM?

Answer 49

Metformin first line If Qrisk2>10% also give SGLT2 inhibitor if HbA1c doesn’t resolve Can try up to 4 antiglycaemic agents before moving to insulin

Question 50

What is the Qrisk score?

Answer 50

Chance of developing a major cardiovascular event like an MI in the next 10years

Question 51

What insulin regimes can be done for a patient with T2DM?

Answer 51

Long acting (NPH twice daily) Basal bolus Twice daily fixed mixtures Twice daily free mixing

Question 52

What is the first line drug management for T2DM?

Answer 52

Metformin (if low CVD risk) Metformin + SGLT2/Dapagliflozin (if high CVD risk)

Question 53

What is the drug management if Metformin is not tolerated in its normal or modified release form if theres a low risk of CVD?

Answer 53

DPP4 inhibitor, pioglitazone or sulfonylurea