Type 2 Diabetes Managemnt And Guidelines

Question 1

Overview of type 2 diabetes treatment

Answer 1

1)Metformin (immediate release or modified release)
2) if Metformin is contraindicated - no CVD risk - Gliptins or puioglitazones or Sulphonylureas or SGLT2i as last line

If CV risk assessment/status CHF,CVD>10%

YES- add an SGLT2i only after Metformin tolerability is checked, DKA risk, illness,low carb or keto

No- continue with metformin/intensity treatment if needed

Question 2

Intensification treatment options if further treatment is needed

Answer 2

So we have already started off with metformin monotherapy

Then we have our dual therapy -

Metformin + Gliptins or pioglitazone or Sulphonylureas or SGLT2i

Then we have our Triple Therapy

Question 3

What are the options for triple therapy

Answer 3

1) metformin + Gliptins, pioglitazone, Sulphonylureas or SGLT2i (2 so 3 all together) or 1,1 and then insulin (which could also be on its own)

Or

1) Insulin + Gliptins, pioglitazone, Sulphonylureas or SGLT2i, if metformin is contraindicated

Or

1) Metformin + Gliptins, pioglitazone, Sulphonylureas or SGLT2i + GLP1 mimetic
BM1 over 35 or BMI under 35 and can take insulin or need to lose weight

Question 4

When do we need to give GLP-1 mimetic

Answer 4

• if triple therapy with metformin and 2 other oral drugs are not effective or tolerated then consider triple therapy by switching one drug for a GLP-1 mimetic for adults with T2DM and….
• Body mass over 35
• where weightloss would be beneficial for the patient
• only continue GLP-1 therapy if the adult with type 2 diabetes has had a beneficial response and reduced HbA1c of at least 11mmol/mol

Question 5

First line treatment of Type 2 diabetes and CKD

Answer 5

Offer Ace or Arb

Titrate to the highest licensed dose which they can tolerate and then add

An SGLT2i eg. Dapagliflozin

Question 6

Before starting an SGLT2i

Answer 6

• before starting an SGLT2i you need to check whether or not the patient is at risk of diabetic ketoacidosis (DKA)

Address modifiable risks for DKA before starting an SGLT2i for example if they follow a very low carb diet they may need to delay treatment until patient changes their diet

Advise patients on SGLT2 inhibitors about the need to minimise their risk of DKA by not starting a low keto diet and the possible risks