T2DM Flashcards
What are the risk factors for diabetes? And how can we classify them?
Non-Modifiable: Older age Ethnicity (Black, Chinese, South Asian) Family history Modifiable: Obesity Sedentary lifestyles High carbohydrate (particularly refined carbohydrate) diet
Briefly describe the pathphysiology of T2DM
Repeated exposure to glucose and insulin makes the cells in the body become resistant to the effects of insulin. It therefore requires more and more insulin to produce a response from the cells and get them to take up and use glucose. Over time, the pancreas (specifically the beta cells) becomes fatigued and damaged by producing so much insulin and they start to produce less.
How is prediabetes diagnosed and what are the ranges?
HbA1c – 42-47 mmol/mol
Impaired fasting glucose – fasting glucose 6.1 – 6.9 mmol/l
Impaired glucose tolerance – plasma glucose at 2 hours 7.8 – 11.1 mmol/l on an OGTT
How is diabetes diagnosed and what are the ranges?
HbA1c > 48 mmol/mol
Random Glucose > 11 mmol/l
Fasting Glucose > 7 mmol/l
OGTT 2 hour result > 11 mmol/l
Is it possible to cure T2DM?
yes
How is T2DM managed conservatively?
Dietary Modification- Vegetables and oily fish/Typical advice is low glycaemic, high fibre diet/ A low carbohydrate may in fact be more effective in treating and preventing diabetes but is not yet mainstream advice
Exercise and weight loss
Stop smoking
Optimise treatment for other illnesses, for example hypertension, hyperlipidaemia and cardiovascular disease
Monitoring for complications
What screening is recommended for a pt with T2DM?
Diabetic retinopathy
Kidney disease
Diabetic foot
What are the targets of treatment?
HbA1C targets:
48 mmol/mol for new type 2 diabetics
53 mmol/mol for diabetics that have moved beyond metformin alone
What medical management is available?
First line: metformin titrated from initially 500mg once daily as tolerated.
Second line add: sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor. The decision should be based on individual factors and drug tolerance.
Third line:
Triple therapy with metformin and two of the second line drugs combined, or;
Metformin plus insulin
SIGN Guidelines 2017 suggest the use of SGLT-2 inhibitors and GLP-1 mimetics (e.g. liraglutide) preferentially in patients with cardiovascular disease.
Metformin Class? Mechanism? Effect on weight? ADRs?
Biguanide
Inhibits gluconeogenesis in the liver
Weight neutral
Diarrhoea and abdo pain (dose dependent), lactic acidosis
Pioglitazone Class? Mechanism? Effect on weight? ADRs?
Thiazolidinedione
Activates PPAR-Y, gene transcription. increases insulin sensitivity.
Weight gain
Fluid retention
Anaemia
Heart failure
Extended use may increase the risk of bladder cancer
Gliclazide Class? Mechanism? Effect on weight? ADRs?
Sulfonylurea Stimulate pancreatic B cells Weight gain Hypoglycaemia Increased risk of cardiovascular disease and myocardial infarction when used as monotherapy
Sitagliptin Class? Mechanism? Effect on weight? ADRs?
DPP-4 inhibitor Prevent incretin degradation Weight loss GI upset URTI symptoms Pancreatitis
Exenatide Class? Mechanism? Effect on weight? ADRs?
GLP-1 receptor agonist Mimics incretins Weight loss GI upset Dizziness
Canagliflozin Class? Mechanism? Effect on weight? ADRs?
SGLT-2 inhibitor Reduces glucose reabsorption at the PCT Weight loss Susceptible to UTIs Glucosuria DKA
