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Diabetes

Tom Rustom 25/09/2013 TYPE 2 DIABETES AND ITS MANAGEMENT (ALL THE BORING BITS THAT EVERYONE ALWAYS FORGETS, ESPECIALLY THE DRUGS)

BLOOD GLUCOSE LOWERING THERAPY  Metformin (Glucophage, Glumetza, Riomet)  1st line in treatment of T2DM (after lifestyle change)  Suppresses appetite (useful in overweight patients)  Does not cause hypoglycaemia  S/Es – gastrointestinal, lactic acidosis  Contraindicated in renal failure  Review if creatinine >130, stop if >150  Patients should not drink alcohol and stop metformin before iodinated contrast  Start at 500mg OD, increased to 2g OD or 1g BD  Increase doses no more than weekly to reduce risk of side

BLOOD GLUCOSE LOWERING THERAPY  Sulfonylureas  Glibenclamide, Glimeparide, Gliclazide and  Consider in patients who are not overweight or for who metformin is not tolerated or contraindicated  Possible hypoglycaemia, higher risk in renal failure, uncommon, usually due to excessive dosage, needs hospital treatment  S/Es – gastrointestinal distrubances,

BLOOD GLUCOSE LOWERING THERAPY  DPP-4 Inhibitors  Sitagliptin, Vildagliptin  If on metformin + sulfonylurea and not tolerated, can substitute either drug with DPP4, or add in DPP4 if insulin not tolerated  Continue only if HbA1c concentration is reduced by at least 0.5 percentage points within 6 months of starting  S/Es: gastrointestinal, pancreatitis  If risk of hypoglycaemia then a DPP-4 inhibitor should be considered rather than a sulfonylurea

BLOOD GLUCOSE LOWERING THERAPY  Thiazolidinediones  Pioglitazone, Rosiglitazone  Alternative to DPP-4 inhibitors  Continue only if HbA1c concentration is reduced by at least 0.5 percentage points within 6 months of starting  Avoid in heart failure and osteoporosis  S/Es: Weight gain, fluid retention, liver dysfunction,  If risk of hypoglycaemia then a thiazolidinedione should be considered rather than a sulfonylurea

BLOOD GLUCOSE LOWERING THERAPY  Subcutaneous injection  Consider adding to metformin/sulf if BMI >35 and/or DPP/thiaz not tolerated  Continue only if reduction of >1.0% HbA1c and >3% initial body weight in 6 months  S/Es: severe pancreatitis  Also used if insulin therapy failed  Consider if no other oral agents are tolerated  Avoid in IBD or if at risk of bowel obstruction

BLOOD GLUCOSE LOWERING THERAPY  Insulin therapy  Consider starting when HbA1c >7.5% despite other  Start with human insulin ON or BD depending on  Can use bi-phasic or long acting insulin as well

 No end-organ damage  < 140/80 mmHg  End-organ damage  < 130/80 mmHg  ACE inhibitors are first-line  CV risk should be reviewed anually  Start Simvastatin 40mg if:  <40 yrs with poor CV risk profile  >40 and CV risk >20%/10 yrs  >40 normal to high CV risk  Assess lipid profile and modifiable risk factors after 1-3  Aim to achieve:  Total cholesterol <4.0 or LDL <2.0  If not achieved then Simvastatin 80mg  Alternative statins can be considered as well as Ezetimibe if still  High serum TG (>4.5) then offer a fibrate ANTI-THROMBOTIC THERAPY  Offer Aspirin 75mg (or clopidogrel if intolerant)  > 50 years and BP <145/90  < 50 years and significant CV risk factors  Annual ACR, creatinine and eGFR  Abnormal ACR:  > 2.5 for men  > 3.5 for women  If ACR abnormal:  Repeat twice more within 3-4 months  Microalbuminuria if any further abnormal results  Query validity of result if significant hypertension, retinopathy, heavy proteinuria, unwell, haematuria or GFR deteriorated suddenly  If nephropathy confirmed then start ACE-I and aim BP < A 64-year-old man with type 2 diabetes mellitus is reviewed. He is currently prescribed metformin and also takes aspirin and simvastatin. There has been no change to his medication for the past 18 months. According to recent NICE guidelines, how often should his HbA1c be checked? A.
Only if new problems develop A 64-year-old man with type 2 diabetes mellitus is reviewed. He is currently prescribed metformin and also takes aspirin and simvastatin. There has been no change to his medication for the past 18 months. According to recent NICE guidelines, how often should his HbA1c be checked? A.
Only if new problems develop  NICE recommend checking the HbA1c every 6  The general target for patients is 48 mmol/mol  Individual targets should be agreed with patients to encourage motivation  HbA1c should be checked every 2-6 months Side-effects of diabetes mellitus drugs A.
Select the drug most likely to cause each one of the following side-effects: 1.
Syndrome of inappropriate ADH secretion Select the drug most likely to cause each one of the following side-effects: 1.
Syndrome of inappropriate ADH secretion 2. Lactic acidosis 3. Fluid retention Characteristic side effect GI upset Lactic acidosis Sulfonylureas (gliclazide, glimepiride) Hypoglycaemic episodes Increased appetite and weight gain SIADH Liver dysfunction (cholestatic) Glitazones (pioglitazone) Weight gain Fluid retention Liver dysfunction Fractures DPP-4 Inhibitors (Sitagliptin, Vildagliptin) GI upset Pancreatitis Diabetes mellitus: management of type 2 A.
< 130/80 mmHg < 125/75 mmHg < 120/70 mmHg 6.5% (48 mmol/mol) 6.0% (42 mmol/mol) 6.2% (44 mmol/mol) No additional treatment Choose most appropriate answer 1.
A 43-year-old man with type 2 diabetes mellitus is reviewed. His HbA1c is 6.6% (49 mmol/mol) on metformin therapy. His blood pressure is 128/78 mmHg, he is a non-smoker and is not overweight. There is no family history of note. What addition, if any, should be made to his medication? The general HbA1c target (NICE) for patients with type 2 diabetes mellitus The target blood pressure (NICE) for a 60-year-old man with type 2 diabetes mellitus and diabetic nephropathy 1. A 43-year-old man with type 2 diabetes mellitus is reviewed. His HbA1c is 6.6% (49 mmol/mol) on metformin therapy. His blood pressure is 128/78 mmHg, he is a non-smoker and is not overweight. There is no family history of note. What addition, if any, should be made to his medication? No additional treatment The general HbA1c target (NICE) for patients with type 2 diabetes mellitus 6.5% (48 mmol/mol) The target blood pressure (NICE) for a 60-year-old man with type 2 diabetes mellitus and diabetic nephropathy < 130/80 mmHg  1. May consider increasing metformin dose or adding gliclazide as HbA1c >6.5, however, depends on target agreed with patient  See nice guidance A 48-year-old man who was diagnosed with type 2 diabetes mellitus presents for review. During his annual review he was noted to have the following results: His current medication is metformin 500mg tds. According to recent NICE guidelines, what is the most appropriate action? A.
Simvastatin 40mg ON Lifestyle advice, repeat lipid profile in 3 months Total cholesterol 5.3 mmol/L Atorvastatin 40mg ON HDL cholesterol 1.0 mmol/L Increase metformin slowly to 1g TDS LDL cholesterol 3.1 mmol/L A 48-year-old man who was diagnosed with type 2 diabetes mellitus presents for review. During his annual review he was noted to have the following results: His current medication is metformin 500mg tds. According to recent NICE guidelines, what is the most appropriate action? A.
Simvastatin 40mg ON Lifestyle advice, repeat lipid profile in 3 months Total cholesterol 5.3 mmol/L Atorvastatin 40mg ON HDL cholesterol 1.0 mmol/L Increase metformin slowly to 1g TDS LDL cholesterol 3.1 mmol/L  Patients > 40 yrs should be started on Simvastatin 40mg if CV E.g. smoker, HTN, ‘high-risk' lipid profile  A high-risk lipid profile may be defined as: Total cholesterol > 4.0 mmol/L, or Low-density lipoprotein cholesterol > 2.0 mmol/L, or Triglycerides > 4.5 mmol/L  NICE recommend increasing Simvastatin to 80mg if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained  Liver function tests should be check at baseline, within 3 months and at 12 months but not again unless clinically You review a 68-year-old man who has type 2 diabetes mellitus. He was noted during recent retinal screening to have pre-proliferative changes in his right eye but is otherwise well with no history of cardiovascular disease. Following NICE guidelines, what should his target blood pressure be? A.
You review a 68-year-old man who has type 2 diabetes mellitus. He was noted during recent retinal screening to have pre-proliferative changes in his right eye but is otherwise well with no history of cardiovascular disease. Following NICE guidelines, what should his target blood pressure be? A.
 Type 2 diabetes blood pressure target: No end organ damage - <140/80 mmHg End organ damage - <130/80 mmHg A 54-year-old obese man presents with lethargy and polyuria. A fasting blood sugar is requested: - Fasting glucose 8.4 mmol/L He is given dietary advice and a decision is made to start metformin. What is the most appropriate prescription? A.
Metformin 500mg od with food for 5 days then metformin 500mg bd for 5 days then metformin 500mg tds for 20 days then review Metformin 500mg tds with food Metformin 500mg od with food for 14 days then metformin 500mg bd for 14 days Metformin 1g tds with food Metformin 500mg tds taken at least 1 hour before meals A 54-year-old obese man presents with lethargy and polyuria. A fasting blood sugar is requested: - Fasting glucose 8.4 mmol/L He is given dietary advice and a decision is made to start metformin. What is the most appropriate prescription? A.
Metformin 500mg od with food for 5 days then metformin 500mg bd for 5 days then metformin 500mg tds for 20 days then review Metformin 500mg tds with food Metformin 500mg od with food for 14 days then metformin 500mg bd for 14 days Metformin 1g tds with food Metformin 500mg tds taken at least 1 hour before meals  Titrate Metformin slowly: allow one week before increasing dose to reduce the risk of GI side  Side effects: GI, reduced B12 absorption, lactic  Contraindications: CKD, tissue hypoxia (recent MI, sepsis, alcohol abuse, stop 2 days before GA, stop before conrast)  Metformin also used in PCOS and NAFLD A 62-year-old man is reviewed in diabetes clinic. His glycaemic control is poor despite weight loss, adherence to a diabetic diet and his current diabetes medications. He has no other past medical history of note. Which one of the following medications would increase insulin sensitivity? A 62-year-old man is reviewed in diabetes clinic. His glycaemic control is poor despite weight loss, adherence to a diabetic diet and his current diabetes medications. He has no other past medical history of note. Which one of the following medications would increase insulin sensitivity?  Thiazolidinediones  Rosiglitazone withdrawn in 2010 due to cardiovascular side effects  Adverse effects: weight gain, liver impairment, fluid retention, fractures, bladder cancer  Contraindicated in heart failure  Only continue pioglitazone if >0.5 reduction in HbA1c % in 6 months An obese 48-year-old man presents with lethargy and polydipsia. What is the minimum HbA1c that would be diagnostic of type 2 diabetes mellitus? A.
Cannot use HbA1c for diagnosis 6.0% (42 mmol/mol) 6.3% (45 mmol/mol) 6.5% (48 mmol/mol) 7.0% (53 mmol/mol) An obese 48-year-old man presents with lethargy and polydipsia. What is the minimum HbA1c that would be diagnostic of type 2 diabetes mellitus? A.
Cannot use HbA1c for diagnosis 6.0% (42 mmol/mol) 6.3% (45 mmol/mol) 6.5% (48 mmol/mol) 7.0% (53 mmol/mol)  HbA1c >6.5% diagnostic of diabetes  BUT HbA1c <6.5% doesn't exclude diabetes  HbA1c can increase red cell turnover (pregnancy, anaemia, haemaglobinopathy)  If patient symptomatic:  Fasting glucose >/= to 7.0 mmol/L  Random glucose >/= 11.1 mmol/L  If asymptomatic need 2 separate readings  IFG: Fasting glucose >/= to 6.1 but <7.0  IGT: Fasting glucose <7.0 and OGTT (2 hour) >/= 7.8 and < 11.1 A diabetic man is diagnosed as having painful diabetic neuropathy in his feet. He has no other medical history of note. What is the most suitable first-line treatment to relieve his pain? A.
Referral to pain management clinic A diabetic man is diagnosed as having painful diabetic neuropathy in his feet. He has no other medical history of note. What is the most suitable first-line treatment to relieve his pain? A.
Referral to pain management clinic  Management of diabetic neuropathy:  Neuropathic pain  1st line: Oral duloxetine (amitriptyline if CI)  2nd line: Amitriptyline or Pregabalin (or combined)  Other options: Pain clinic, Tramadol, topical  Gastroparesis (erratic BMs, bloating, vomiting)  Metoclopramide, domperidone, erythromycin A 20-year-old woman who has type 1 diabetes mellitus is found collapsed in the corridor. A nurse is already with her and has done a finger-prick glucose which is 1.8 mmol/l. On assessment you find that she is not responsive to voice, pulse 84/min. The nurse has already placed the patient in the recovery position. What is the most appropriate next step in management? A.
Smear quick-acting carbohydrate gel on the gums Give rectal dextrose Give intramuscular protamine sulphate Give intramuscular glucagon Give intramuscular dextrose A 20-year-old woman who has type 1 diabetes mellitus is found collapsed in the corridor. A nurse is already with her and has done a finger-prick glucose which is 1.8 mmol/l. On assessment you find that she is not responsive to voice, pulse 84/min. The nurse has already placed the patient in the recovery position. What is the most appropriate next step in management? A.
Smear quick-acting carbohydrate gel on the gums Give rectal dextrose Give intramuscular protamine sulphate Give intramuscular glucagon Give intramuscular dextrose  Insulin therapy side effects:  Hypoglycaemia  Signs: aggression, confusion, sweating, blurred vision,  If conscious: 10-20g of short acting carb  If unconscious: do not put anything in mouth  Reduced awareness in patients with frequent hypos, allowing glycaemic control to slip my restore awareness  Betablockers reduce awareness  Lipodystrophy  Atrophy of subcut fat  Prevent by rotating injection site PICTURE QUESTIONS Granuloma Annulaire Acanthosis Nigricans  www.passmedicine.com  www.nice.org.uk

Source: http://www.creshgp.co.uk/media/presentations/Diabetes_for_AKT.pdf