Managing type 2 diabetes in primary care Flashcards
(35 cards)
What is a target HbA1c concentration when using lifestyle and diet plus a single drug which is not associated with hypoglycaemia
less than 48mmol/mol - when type 2 diabetes is managed by diet and lifestyle alone
What happens if lifestyle and diet does not reduce the HbA1c concentration
HbA1c levels should be measured in three months, and if the agreed individualised HbA1c target has not been met by lifestyle modifications, offer standard-release metformin as initial drug treatment.
what is used to get glycemic control quickly
- gliclazide is often used to get glycemic control quickly
What do you check in initial assessment of type two diabetes
- Check smoking status
- Check physical activity
- Dietary assessment
- Height, weight and waist circumference. Calculate BMI
- Blood pressure
- Assess cardiovascular risk
- Assess for depression and anxiety
- Urinalysis for ketones and proteinuria
What are the existing complications you should keep an eye out for when assessing type two diabetes
- arrange screening for retinopathy
- check for diabetic foot problems: inspection, pulses, neuropathy
- check for nephropathy
- assess for neuropathy and its associated complications including erectile dysfunction, neuropathic pain, autonomic neuropathy and gastroparesis
When do you refer a patient to the hospital immediately
- immediate risk of DKA
- moderate ketonuria or ketonaemia with or without hyperglycaemia and the person cannot eat or drink
- a person treated with insulin does not improve rapidly with insulin treatment
name some structured education programmes for diabetes
- X-PERT
- DESMOND
how should patients be educated on foot self care
- regular inspection of feet and footwear
- wearing well fitting shoes
- taking care of toenails and avoiding the use of corn-removing plasters or sharp blades
- avoid walking barefoot particularly on holiday
- referring patients with high risk foot or ulceration early to a multidisciplinary foot service to minimise the risk of foot complications
When is self monitoring of blood glucose recommended
If the patient is:
- using insulin
- taking oral glucose lowering agents either singly or in a combination that can predispose to a higher risk of hypoglycaemia
- is pregnant or planning to become pregnant
- has suspected asymptomatic hypoglycaemia
- enrolled in a structured education programme where knowledge of glucose values and trends can help patients understand their diabetes
What is the alphabet strategy
- A - advice: diet, weight optimisation, smoking cessation, optimal physical activity
- B - blood pressure: checked regularly and treated to targets
- C - cholesterol profile: checked regularly and treated to target, CKD prevention< regular monitoring of renal function and screening for microalbuminuria
- D - diabetes control
- E - eye examination - yearly checked with digital retinal photography
- F - feet examination - checked yearly
- G - guardian drugs - ACE, ARB, aspirin, Statins
How much exercise should someone with type 2 diabetes do
150 minutes of moderate intensity activity
How much weight is recommended to loose In type 2 diabetes
a weight loss of more than 5% from baseline weight has beneficial effects on HbA1c, lipid profile and blood pressure
What is the national diabetes blood pressure target
140/80
- or 130/80 mmHg if there is kidney disease
What is the primary prevention of cardiovascular disease
- to people who have a 10% or greater 10 year risk of developing cardiovascular disease is estimated using QRISK2
- atorvastin 20mg for the primary prevention is used
What should you perform before starting statin treatment
- baseline blood tests
- clinical assessment
- treat comorbidities and secondary causes of dyslipidaemia such as excess alcohol intake, hypothyroidism, liver disease and nephrotic syndrome
What should your baseline assessment be before you start statin treatment
- smoking status
- alcohol consumption
- blood pressure
- BMI
- HbA2c
- renal function and eGFR
- transaminase level
- thyroid stimulating hormone
before starting statin treatment what else should you measure
- total cholesterol
- HDL cholesterol
- non-HDL cholesterol
- triglyceride concentrations
what should you aim for after 3 months of starting statin treatment
- aim for a greater than 40% reduction in non-HDL cholesterol
what should you do if the patient experience side effects while staking statin
- stop the statin and restart it when the symptoms have resolved
- reduce the dose of the statin
- change the statin to a lower intensity option
When should you use a lower dose of atrovastatin
- may be drug interactions
- high risk of adverse effects
- patient prefers to be started on a lower dose
- patient has chronic kidney disease
what should the target be if blood pressure is older than 80
- below 150/90 or ABPM 145/85
if you are taking two drugs for diabetes what is your target HbA1c
less than 53 mmol/mol
describe what drugs you should apply at what levels in blood glucose lowering therapy
HbA1c above 48mmol/mol on lifestyle and diet
- release metformin
- gradually increase the dose over several weeks to minimise the risk of GI side effects
HBA1C levels rise to 58 mmol/mol or higher on a single drug
- consider metformin dual therapy with either
- DPP4 Inhibitor, pioglitazone, sulfonylurea, SGLT-2 inhibitor
HbA1c levels are not met on dual therapy with metformin and another oral drug
- triple therapy with:
- metformin, a DPP-4 inhibitor and a sulfonylurea
- metformin, pioglitazone and a sulfonylurea
- Metformin, pioglitazone, or sulfonylurea and SGLT-2
or
- consider insulin
or
- Triple therapy with metformin, a sulfonylurea, and a glucagon‑like peptide‑1 (GLP‑1)
what should you do if metformin is contraindicated or not tolerated
A dipeptidyl peptidase‑4 (DPP‑4) inhibitor, or pioglitazone, or a sulfonylurea
A sodium-glucose co-transporter (SGLT)-2 inhibitor (if DPP‑4 inhibitor would otherwise be prescribed and a sulfonylurea or pioglitazone is not appropriate)
