T2 Diabetes Flashcards
(25 cards)
What values are needed for a diagnosis of T2 Diabetes?
Persistent hyperglycemia is defined as:
- HbA1c of 48 mmol/mol (6.5%) or more
- Fasting plasma glucose level of 7.0 mmol/L or more
- Random plasma glucose of 11.1 mmol/L or more in the presence of symptoms or signs of diabetes
Pre-diabetes - 42-47 for HbA1c
When do you repeat readings to confirm the diagnosis?
If the person is symptomatic - a single abnormal HbA1c or fasting plasma glucose level can be used
If person is asymptomatic - repeat HbA1c or plasma readings - 2 separate readings needed - 2 weeks apart
What is normal plasma glucose levels (non-diabetic)
Normal fasting plasma glucose levels: 4.0 to 5.4 mmol/L
2 hours after a meal: <7.8 mmol/L
Symptoms and signs of T2 Diabetes
Symptoms: polydipsia, polyuria, blurred vision, unexplained weight loss, recurrent infections, and tiredness.
What are the risk factors?
Obesity
FH
Ethnicity
PCOS
Diet
What is DKA
More common in T1 diabetics
Life-threatening complication where there is a lack of insulin. Unable to utilise the glucose due to insufficient insulin, the body begins to breakdown fat stores rapidly - this leads to the build-up of ketones
Symptoms and signs of DKA
Symptoms:
Polydipsia and polyuria
Weight loss
Abdominal pain, nausea and/or vomiting
Shortness of breath
Lethargy, drowsiness, and/or confusion
Signs:
Fruity smell of acetone on the breath
Tachypnoea, acidotic breathing (deep sighing ‘Kussmaul respiration’)
Tachycardia, dehydration (may present with reduced skin turgor, sunken eyes, prolonged capillary refill time)
shock (tachycardia, hypotension, drowsiness, reduced urine output)
Ketones are high if urinary ketones are greater than 2+, or capillary blood ketones are above 3 mmol/L.
What is Hyperosmolar Hyperglycaemic state (HHS)
Serious complication of T2 diabetes - very high levels of blood glucose (over 30 mmol/L) typically due to illness, dehydration, or medication issues etc
When to suspect HHS?
Suspect a diagnosis of HHS if a person is unwell with severe hyperglycemia (blood glucose level typically above 30 mmol/L) for several days and:
Clinical symptoms of:
Disorientation, confusion, and/or drowsiness
Polyuria and polydipsia
Nausea
Precipitating factors for DKA and HHS
- Infection
- Inadequate insulin or non-adherence with insulin treatment
- New onset of diabetes mellitus or other physiological stress (such as trauma or surgery)
- Other medical conditions (such as hypothyroidism or pancreatitis).
- Drugs (e.g corticosteroids, diuretics, atypical antipsychotics, and sympathomimetic drugs such as salbutamol)
Macrovascular complications
Macrovascular
Atherosclerotic cardiovascular disease (CVD)
MI
Microvascular complications
Microvascular
- Diabetic kidney disease
This may be caused by diabetic nephropathy, hypertension, and renal atheroma or ischaemia
- CKD and end-stage renal disease (ESRD), which may require renal replacement therapy or kidney transplantation
- Retinopathy
- Peripheral neuropathy
Painful neuropathy may cause symptoms of numbness, burning or shooting pain, tingling and/or paraesthesia in a stocking and glove distribution, often at night. - Autonomic neuropathy
This can affect multiple systems and includes postural hypotension, gastroparesis (delayed gastric emptying), unexplained diarrhoea, inadequate bladder emptying, sexual dysfunction including erectile dysfunction, sweating abnormalities, and impaired awareness of hypoglycaemia
Foot problems
From a combination of peripheral arterial disease and peripheral neuropathy, due to loss of protective foot sensation and possible deformity leading to abnormal loading of the foot
How often do you monitor HbA1c levels?
Measure HbA1c levels at 3–6 monthly intervals until the HbA1c is stable on unchanging treatment, then at 6-monthly intervals
What is the 1st line pharmacological management for T2 Diabetes?
Offer standard-release metformin as first-line treatment - gradually increasing the dose over several weeks
If there are intolerable gastrointestinal adverse effects, consider a trial of modified-release metformin.
What is the 1st line for diabetics with CVD or high risk of CVD
Assess if they have:
chronic heart failure,
established atherosclerotic cardiovascular disease, or
Are at high risk of developing cardiovascular disease
If they are:
Add SGLT-2 Inhibitor alongside metformin - first give metformin and then add SGLT-2 inhibitor
If metformin is contraindicated - what can you offer?
- SGLT-2 inhibitors to CVD risk patients
- Otherwise:
Dipeptidyl peptidase-4 inhibitor (DPP-4 inhibitor)
Pioglitazone
Sulfonylurea
SGLT-2 inhibitor— this may be considered instead of a DPP-4 inhibitor if a sulfonylurea or pioglitazone is not appropriate
DPP-4 inhibitors work - examples, how do they work and contraindications
Examples include: Alogliptin, linagliptin, sitagliptin
DPP-4 is an enzyme that breaks down incretins. Incretins work to increase insulin secretion and decrease glucagon which ultimately leads to lowering blood glucose.
So DPP-4 inhibitors work to prevent incretin breakdown
Do not give in DKA, caution in hepatic impairment
Pioglitazone (class - glitazones)
Increases sensitivity to insulin
Do not give in HF, bladder cancer, hepatic impairment
Sulfonylureas - examples, how do they work and contraindications
E.g. gliclazide, glipizide
Stimulates insulin secretion in pancreatic beta cells - works by binding to receptors on K-ATP channels this closes channels which prevents K+ from leaving the cells.
Depolarisation occurs which triggers Ca2+ to enter and leads to exocytosis of insulin granules.
Do not prescribe to patients with Porphyria, severe renal impairment, hepatic impairemnt
SGLT-2 inhibitors - examples, how do they work and contraindications
e.g. Dapagliflozin, Empagliflozin
Works by blocking SGLT-2 channels in PCT - this causes glucose to be excreted via urine
Consider this instead of DPP-i if sulfonylureas or pioglitazone is not appropriate
Ask before starting if they have had DKA, on a low carb/ketogenic diet
Do not give in DKA, eGFR <60
What if monotherapy doesn’t work?
Can add a second med from these:
Dipeptidyl peptidase-4 inhibitor (DPP-4 inhibitor)
Pioglitazone
Sulfonylurea
SGLT-2 inhibitor - consider if sulfonylurea is contraindicated
If dual therapy doesn’t work?
For people who can take metformin, consider:
Triple therapy:
metformin + DPP-4 inhibitor + sulfonylurea
metformin + pioglitazone + sulfonylurea
metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
insulin-based treatment
NB - Can not put dapagliflozin and pioglitazone together
Those who cannot have metformin and dual therapy don’t work:
Start Insulin treatment
If triple therapy doesn’t work
Can switch one of the drugs to GLP-1 agonist for those:
- BMI of >35 + specific conditions linked to obesity OR
- BMI <35 and insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities.
GLP-1 agonists - examples, how do they work and contraindications
Glucagon-like peptide-1 receptor agonist e.g. semaglutide, exenatide
- Works by triggering pancreas to release increased insulin
- Prevents glucagon secretion
- Delays gastric emptying into intestines - causes feeling full and decreases food intake
Contraindicated: Pancreatitis, eGFR <30, GI disease
Do NOT give DPP4-i and GLP-1 agonists together
