Type 2 diabetes lecture Flashcards
What is important to ask in history?
- Onset - long history, found on routine tests
- Osmotic symptoms? - these usually absent in T2DM
- FH
- Cushings, acromegaly, phaechromocytoma, thyrotoxicosis? - secondary cause
- Autoimmune diseases
- Exocrine pancreas function - pancreatitis? cancer? removal?
- Medications
Medications which can cause secondary diabetes
- Steroids
- Levothyroxine
- Diazoxide
- Beta agonists
- Thiazides
- ARV for HIV
- Antipsychotics too
Examination findings for T2DM
- BMI overweight
- Need to check BP
- Signs of insulin resistance
- Foot examination - neuropathy?
- Retinopathy - or refer for retinal screening
- Dysmorphic features - esp if early presentation
Signs of insulin resistance
- Central obesity
- Acanthosis nigricans - armpits or back of neck
- Hyperandrogenism in demales
Causes of dysmorphic features that can cause T2DM
- Downs
- Klinefelters
- Turners
Investigations for newly diagnosed T2DM
- HbA1C
- LFT (NAFLD?), U&Es
- Thyroid function
- Lipid profile - CVS risk
Antibody tests to rule out T1DM
- anti insulin
- Anti-GAD
- Anti-islet cell
When is OGTT used?
Gold standard
But now only really used when HbA1C is 42-48mmol/mol (pre diabetes)
Or in pregnancy
When do we check C peptide to check insulin levels?
Years into diagnosis usually
Pathophysiology of T2Dm
- Defective insulin secretion (usually normal at the start)
- Inability of insulin sensitive tissues to respond (insulin resistance)
Management of T2DM - education
- Education of condition
- Aims of treatment - WHY do we treat
- Nutrtional advice
- Target HbA1C - individualised
- Annual review info - bloods, urine, eye, foot exams etc
- Pregnancy - no pregnancy until HbA1c is 48 or less
When is home monitoring done in T2DM?
- If on hypoglycaemic agent
- If on insulin
When to infrom DVLA of T2DM?
If on insulin/hypoglycaemic oral agent
Why is HbA1c individualised in T2DM and not T1?
Older pts - need to balance risk of hypos and CVS risk
Is it worth being much stricter when no benefit of 10yr CVS risk etc
Diet/lifestyle advice for T2Dm
- High fibre, low glycaemic index
- Low fat dairy products, oily fish
- Portion control
- Reduce alcohol
- Smoking cessation
- Increase physical activity
- WEIGHT LOSS - 5-10% within first year
Glucose targets for T2Dm
- HbA1C 48mmol/mol for pts on diet/single agent
- 58 for more complex regimes
REVISE DIABETES DRUGS FROM CPT
Pls do it :))
Which drug has greatest effect on HbA1c?
Sulfonylurea - BUT problem is it has highest risk of hypoglycaemia because of this
Which drug has least effect on HbA1c?
- Dipeptidyl peptidase 4 inhibitors eg Sitagliptin
- BUT this means they have low risk of hypo - good for those at risk if need additonal agent
Best drug for weight loss - diabetes
GLP1 analogues eg Semaglutide
Dulaglutide
Treatment algorithm diabetes
If HbA1c 48mmol/mol or more on lifestyle advice:
* offer metformin
If rises to 58 consider adding:
* DPP-4 (eg sitagliptin)
* pioglitazone
* sulfonylurea (eg glicazide)
* SGLT2 (eg dapagliflozin)
If rises to 58 consider:
* metformin, DPP-4 and sulfonylurea
* metformin, pioglitazone and sulfonylurea
* metformin, pioglitazone/sulfonylurea PLUS SGLT2
* OR instead of triple therapy - insulin?
What to do if not tolerating metformin?
Try modified release
If triple therapy ineffective, what then?
- Metformin
- Sulfonylurea
- GLP-1 agonist
COMBINED
What to offer if metformin contraindicated ir not tolerated?
If rises to 48 one of:
* DPP-4
* Pioglitazone
* Sulfonylurea
* OR SGLT2
if rises to 58 dual therapy:
* DPP-4 + pioglitazone
* DPP-4 and sulfonylurea
* pioglitazone and sulfonylurea
aim for HbA1c 53
If still rises to 58:
* Consider insulin
Aim for HbA1C - 53
