Type 2 diabetes

Question 1

what causes type 2 diabetes

Answer 1

when the body becomes resistant to insulin

Question 2

why does metformin NOT cause hygoglycaemia

Answer 2

because metformin only decreases blood glucose, it does not stimulate insulin secretion (which can cause hypoglycaemia)

Question 3

how do you minimise the risk of gastrointestinal side effects associated with metformin

Answer 3

by gradually increasing the dose

- is standard release not tolerated, can give modified release

Question 4

name some examples of Sulfonylureas and side effects associated with this class on antidiabetics

Answer 4

gliclazide, glimepiride, glipizide, tolbutamide

side effects:

• may cause hypoglycaemia
• modest weight gain

Question 5

name some examples of The DPP-4 inhibitors (gliptins)

what are the advantages of this class of antidiabetics

Answer 5

linagliptin, sitagliptin, saxagliptin

advantages:

• no weight gain (weight neutral)
• less incidence of hypoglycaemia than the sulfonylureas

*note: DPP-4 = dipeptidylpeptidase-4 inhibitors *

Question 6

name examples of The SGLT2 inhibitors (end in “flozin”

what is the main disadvantages of this class of antidiabetics

Answer 6

canagliflozin, dapagliflozin, and empagliflozin

main disadvantage:
they are associated with a risk of diabetic ketoacidosis

note: SGLT2 = sodium glucose co-transporter 2 inhibitors

Question 7

what is the target HbA1c in type 2 diabetes when the patient is taking one antidiabetic not associated with hypoglycaemia (e.g metformin)

Answer 7

48 mmol/mol

Question 8

what is the target HbA1c if a type 2 diabetic is taking two or more antidiabetic drugs in combination or a single antidiabetic associated with hypoglycaemia

Answer 8

53 mmol/mol

Question 9

when do you intensify treatment and add another antidiabetic drug if treatment with metformin is insufficient

Answer 9

when the HbA1c increases to 58 mmol/mol or above

Question 10

what is the first-line drug for all type 2 diabetics

Answer 10

metformin

Question 11

what is the alternative if metformin is contraindicated in a patient

Answer 11

SGLT2 inhibitor (‘flozin’)

examples: canagliflozin, dapagliflozin, and empagliflozin

Question 12

when would you consider starting an insulin-based treatment for type 2 diabetes

Answer 12

If dual therapy is unsuccessful

• if dual therapy unsuccessful, can either start triple therapy or consider insulin

Question 13

if a type 2 diabetic start taking insulin, how does that affect their other oral antidiabetics

Answer 13

• Metformin should be continued unless it is contra-indicated or not tolerated
• Other antidiabetic drugs should be reviewed and stopped if necessary.

Question 14

what are the antidiabetic drugs that can de added/switched when treatment with one drug (metformin) is ineffective

Answer 14

• a sulfonylurea (gliclazide, glimepiride, glipizide, tolbutamide)
• Pioglitazone
• a DPP-4 inhibitor (linagliptin, saxagliptin, sitagliptin, or vildagliptin);
• a SGLT2 inhibitor (canagliflozin, dapagliflozin or empagliflozin) .
  only when sulfonylureas are contra-indicated or not tolerated, or if the patient is at significant risk of hypoglycaemia or its consequences.

Question 15

what is the main risk/side effect associated with metformin

what counselling points should be given to patients due to this

Answer 15

risk of lactic acidosis

patient should seek immediate medical attention if they get symptoms such as:

• dyspnoea (difficulty breathing)
• muscle cramps
• abdominal pain
• hypothermia (low body temp)
• asthenia (weakness/ lack of energy)

Question 16

how do you change the dose from standard-release metformin to modified-release metformin

Answer 16

if patient is taking 2g per day or less of standard-release metformin, they can start on the same dose of modified-release metformin

Question 17

what monitoring is needed for patients whilst taking metformin

Answer 17

monitor renal function

Question 18

how does renal impairment affect the dose of all oral antidiabetic

Answer 18

need to reduce the dose of all oral antidiabetics (or avoid) if a patient has renal impairment

Question 19

why may you need to discontinue sulfonylureas

Answer 19

if a patient gets symptoms of acute pancreatitis: such as persistent, severe abdominal pain

sulfonylureas (gliclazide, glimepiride, glipizide, tolbutamide)

Question 20

what needs to be monitored if treatment with SGLT2 inhibitors is interrupted

Answer 20

monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness

note: SGLT2 inhibitor = canagliflozin, dapagliflozin, empagliflozin

Question 21

which antidiabetic causes an increased risk of lower-limb amputation (mainly toes)

Answer 21

Canagliflozin (an SGLT2 inhibitor)

note: need to emphasis routine preventative foot care for diabetics + start treatment for foot problems (e.g. ulceration, infection, or new pain or tenderness) as early as possible

Question 22

why should patients taking SGLT2 inhibitors seek urgent medical attention if they experience severe pain, tenderness, redness in the genital or perianal area

Answer 22

because these are symptoms of Fournier’s gangrene, a rare but serious and potentially life-threatening infection, has been associated with the use of (SGLT2) inhibitors

*note: SGLT2 inhibitor = canagliflozin, dapagliflozin, empagliflozin *

Question 23

which antidiabetics can cause weight gain

Answer 23

• Pioglitazone

- Sulfonylureas (gliclazide, glimepiride, glipizide, tolbutamide)

Question 24

which class of antidiabetics can cause weight loss

Answer 24

SGLT2 inhibitors : canagliflozin, dapagliflozin, empagliflozin

Question 25

what are the diabetic complications

Answer 25

• nephropathy (renal impairment)
• neuropathy (nerve damage most common in legs + feet)
• retinopathy (vision loss or blindness)

to prevent all of these, ensure blood glucose and blood pressure controlled. These complications are due to damage to blood vessels caused by uncontrolled blood glucose + blood pressure

Question 26

what is the consequence if pioglitazone is combined with insulin

Answer 26

there is an increased risk of heart failure

note: if a patient is taking both, monitor them for symptoms of heart failure. it should not be used in patients with heart failure or a history of heart failure

Question 27

why should patients be assessed for risk factors of bladder cancer before starting treatment with pioglitazone

Answer 27

because pioglitazone increases the risk of bladder cancer