Type 2 Diabetes

1
Type 2 Diabetes

• Emily Foley, Helen Anthony and Jenny Williamson
  GPST2s

2
Outline of afternoon

• Knowledge test- AKT questions
• Diagnosis and explaining the diagnosis
• What to do with abnormal blood tests (case based)
• Monitoring and resources for patients
• Management- including lifestyle, risk factors,
  drugs
• When to consider referral and who to
• CSA case
• Re-test knowledge with answers

3
AKT knowledge test
4

1. A patient who presents with polydipsia has a
non fasting glucose taken which is reported as
11.4 mmol/l. How should this be interpreted?

1. Normal
2. Diabetes mellitus
3. Impaired fasting glucose
4. Impaired glucose tolerance
5. Suggests diabetes but further testing needed
6. Impaired fasting glucose and impaired glucose
   tolerance

5
2. An oral glucose tolerance test is performed.
Fasting sample 6.4 mmol/l, 2-hour sample 8.4
mmol/l. What is the diagnosis?

• Normal
• Diabetes mellitus
• Impaired fasting glucose
• Impaired glucose tolerance
• Suggests diabetes but further testing needed
• Impaired fasting glucose and impaired glucose
  tolerance

6
3. After fasting overnight a patients urine
shows glucose , no ketones. How should this be
interpreted?

• Normal
• Diabetes mellitus
• Impaired fasting glucose
• Impaired glucose tolerance
• Suggests diabetes but further testing needed
• Impaired fasting glucose and impaired glucose
  tolerance

7
4. A patient is diagnosed with type 2 diabetes.
Following NICE guidelines, what target should be
set for the HbA1c?

• Agree target with patient but generally aim for
  7
• Agree target with patient but generally aim for
  6
• As low as possible
• Agree target with patient but generally aim for
  6.5
• 6.5

8
5. A 62 year old man presents 4 weeks after
starting metformin for type 2 diabetes. His BMI
is 27.5. Despite slowly titrating the dose up to
500mg TDS he has experienced significant
diarrhoea. He has tried to reduce the dose back
down to 500mg BD but the diarrhoea persists. What
is the most appropriate action?

1. Switch to pioglitazone 15mg OD
2. Switch to gliclazide 40mg OD
3. Start modified release metformin 500mg OD with
   evening meal
4. Add loperamide as required
5. Arrange colonoscopy

9
6. A 56 year old lady with a BMI of 27 is
reviewed in the diabetes clinic due to poor
glycaemic control. She is currently being treated
with gliclazide 160mg BD. Her latest bloods show
Na 139, K 4.1, Ur 8.4, Cr 170, ALT 25, GGT 33,
HbA1c 9.4. Which one of the following
medications should be added next?

1. Guar gum
2. Pioglitazone
3. Metformin
4. Acarbose
5. Repaglinide

10
7. Which one of the following statements
regarding metformin is false?

1. Does not cause hypoglycaemia
2. Increases insulin sensitivity
3. Decreases hepatic gluconeogenesis
4. Increases endogenous insulin secretion
5. Reduces GI absorption of carbohydrates

11
8. A 45 year old man with diabetes is reviewed.
His most recent HbA1c is 8.6. Gliclazide is
added to the metformin he already takes. What is
the minimum time period after which the HbA1c
should be repeated?

1. 6 months
2. 1 month
3. 2 weeks
4. 2 months
5. 4 months

12
9. A 60 year old man with diabetes comes for
review. He has recently had laser therapy to
treat proliferative retinopathy. What should his
target blood pressure be?

1. lt 125/75
2. lt 130/80
3. lt 140/85
4. lt 140/90
5. lt 140/80

13
Part 1

• Diagnosing diabetes
• What to do with abnormal blood results
• Explaining the diagnosis
• What to tell patients and safety netting advice
• Who should be monitoring capillary blood glucose
  and how often?
• Useful sources of info for doctors and patients

14
Diagnosis- type 2 (WHO criteria)

• If symptoms of hyperglycaemia (polyuria,
  polydipsia, weight loss) a single fasting
  glucose 7 or random glucose of 11.1
• If asymptomatic fasting glucose 7 or random
  glucose 11.1 on two separate occasions
• Do not use HbA1c for diagnosis

15
How do you explain the diagnosis?

• Takes time
• You are not going to do it all in 10 mins
• Find out what patients understand
• Role of practice nurses- very important!
• What are the important messages to get across?
• Major morbidity/mortality risk with diabetes is
  of cardiovascular events- start early with trying
  to modify modifiable risk factors

16
Safety

• Hypoglycaemia
• Monitoring and what to do with results
• Who might benefit form keto-stix?
• What about patients with dementia?

17
6pm blood results

• A 23 year old patient who thought she might have
  a UTI drops off a urine sample- dip positive for
  glucose and ketones. No answer to repeated
  telephone calls. It is now 6pm on Friday.

18

• A 68 year old presents with some polyuria and
  polydipsia. Urine dip shows glucose and
  ketones. Capillary blood glucose is 16. They are
  not unwell. It is Friday pm. What options do you
  have?

19

• You tested a random blood glucose along with
  several other tests for a 53 year old patient who
  was tired all the time and could not produce a
  urine sample- the result comes back at 18. It is
  4pm on a Tuesday- there are no appointments left
  this afternoon.

20

• You test a fasting blood glucose for a 62 year
  old man which comes back at 7.5. A repeat test is
  6.8. Do you need to do anything about this?
• A random blood glucose for TATT comes back at
  8.1. Do you need to do a fasting glucose?

21
Self monitoring

• Costs the NHS 100 million per year
• Need to balance benefits vs. impact on quality of
  life
• Patients who self monitor should be able to
  interpret and act on results
• Should be reviewed at least annually
• Make patients aware that changes to medications
  are based on HbA1c and not CBG measurements

22
Consider self monitoring in

• Those on insulin
• Those on oral hypoglycaemics who need info about
  hypos
• To assess impact of changes to medication/lifestyl
  e
• To monitor changes during intercurrent illness
• To ensure safety e.g. driving

23
Useful sources of info and X-PERT

• Diabetes UK www.diabetes.org.uk - brilliant! Also
  run a helpline and have info in different
  languages.
• www.yorkshirediabetes.com comprehensive list of
  info leaflets and local services.
• X-PERT patient programme- 6 weekly structured
  sessions.
• Community diabetes team- can be contacted by
  email for advice.

24
Part 2- outline

• Lifestyle modifications
• Stepwise medication options
• Insulin
• Lipids/BP
• Lifestyle considerations (driving/flying)
• When to refer

25
Principles of Management

• Patient centred
• Communication is key
• Cultural needs and preferences
• Support, encouragement and continuity
• Self-monitoring glucose monitors
• Commencing insulin

26
Lets begin withLifestyle

• Group education programmes
• Dietary advice and physical encouragement
• Individualised nutritional advice
• If overweight aim for 5-10 body wt loss
• Individualised target HbA1c review 2-6m until
  stable, then 6m
• Tight blood sugar control may not be as
  beneficial as first thought

27
Oral options

• (Lifestyle)
• First step.if HbA1cgt6.5 ? metformin
• Second stepmetformin plus SU
• Third stepadd in Insulin UNLESS.
• Fourth step increase insulin/add in
  pioglitazone

28
The Simplified NICE Guidelines Insulin is added
to current oral therapy, and does not replace it
Step 5 If HbA1Cgt7.5 Intensify Insulin
regime Alternatives add insulin if hot
already on it or consider adding glitazone
Step 4 If HbA1Cgt7.5 Add Insulin Alternatives
Sitagliptin/ glitazone/ exenatide
Step 3 If HbA1Cgt6.5 Add Sulphonylurea Alterna
tives gliptins/glitazones
Step 2 If HbA1C gt6.5 Start Metformin Alternativ
es SU
Step 1 Lifestyle interventions
29
Metformin

• Increases insulin sensitivity
• S/E GI upset
• Cregt130 or eGFRlt45 caution
• Cregt150 or eGFRlt30 STOP!
• Renal/hepatic impairment
• Sulphonylurea (Gliclazide)
• Increases insulin secretion
• Used if not overweight
• If rapid response required
• Risk of hypoglycaemia
• Renal impairment

30
Thiazolidinediones

• Pioglitazone / Rosiglitazone
• PPAR ? agonist - ? insulin sensitivity of
  muscle and adipose tissue and ? glucagon
  secretion
• Cautions oedema,
• CCF, anaemia, wt gain
• predisposition to s
• Check LFTs

31
Drug class Examples Mode of action Side Effects
Biguanides Metformin ?insulin sensitivity Rarely lactic acidosis, GI upset
Sulphonylurea Gliclazide Glibenclamide ?insulin secretion, ?peripheral resistance Risk of hypos Weight gain
Thiazolidinediones Rosiglitazone Pioglitazone ? peripheral insulin sensitivity Weight gain, CCF, s, anaemia
DPP-4 inhibitors Sitagliptin Vildagliptin Ongoing GLP-1 effects Weight neutral
GLP-1 mimetic GLP-1 analogue Exenatide Liraglutide ? insulin secretion Nausea/Vomiting Pancreatitis

In essence exanetide if very overweight,
gliptins if cant think of anything else, never
try glitazones!!!
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Prescribing

• DPP-4 Inhibitors
• Sitagliptin / vildagliptin
• gt0.5 drop in 6m ? if not STOP!
• Consider if wt gain will be problematic
• Thiazolidinidiones
• Pioglitazone Wt gain (CCF/ risk)
• gt0.5 drop in 6m ? if not STOP!
• Consider if marked insulin insensitivity

34
Prescribing

• Exanetide
• HGV
• gt1 HbA1c and gt3 BW loss in 6/12 otherwise
  STOP!
• Preferable if BMIgt35, or lt35 with health problems
• Acarbose
• Last resort!! cant tolerate any oral meds

35
Insulin

• If oral explored and HbA1c gt7.5
• First line..human insulin o.n. or b.d. (or long
  acting if lifestyle erratic)
• Second line.pre-mixed short acting insulin

36

• Third line....bd biphasic pre-mixed insulin (gt9)
• Last resortlong acting insulin if not reaching
  targets - monitor the basal insulins for need for
  short acting pre-meals
• If unacceptable sitagliptin/exanatide/glitazone

37
Further Management-annual review

• Lipid management
• 20 / 10 yr risk
• Simvastatin 40mg ? 80mg
• Target TClt4, LDLlt2
• Consider fibrate (TG gt4.5 despite statin)
• Anti-thrombotic treatment stop aspirin
• gt50yrs high BP 75mg aspirin
• lt50yrs significant RFs 75mg aspirin

38
BP Management

• If target organ damage BPlt130/80
• Otherwise BPlt140/80
• If normotensive annual r/v
• ACE-I
• Add C or D (if pregnant give C alone)
• Add other
• Add alpha/beta/spironolactone

39
Target Organs

• 1.Kidneys
• Annual ACR/Cre/eGFR
• If EOD ACE-I and dose titrate
• 2.Eyes
• Annual retinal screening
• 3.Neuropathic Pain Management (new)
• 4.Others ED, gastroparesis and depression

40
Lifestyle limitations

• Driving
• Group 1 driver no limitations
• Group 2 unable to drive if on insulin
• Laser phototherapy contact DVLA
• Flying
• No limitations sensible dose reduction with
  hours lost
• Occupations IDDM
• Army, pilot, HGV , Navy, Police, Fireman, Postie!

41
In summary

• Lifestyle
• Metformin
• SU
• Insulin
• If overweight try exanetide
• If a bit clueless try a gliptin
• Never opt for a glitazone!
• Involve MDT at earliest opportunity

42
When to refer

• Motivated patients- for education and X-pert, or
  if dietician input likely to help- eg jigsaw
• Consider early referral to community MDT for any
  patient- early good education could prevent
  longterm problems
• Patients who are not tolerating many medications
  eg due to side effects/renal function etc
• If you are considering a new medication you are
  not familiar with
• ? Patients you are concerned about
  safety/compliance- may benefit from MDT approach
• Patients with lots of hypos and erratic BMs/high
  hBA1c
• Those in whom you are not sure where to go now!

43
How to refer

• Through choose and book
• See Leeds Health Pathways
• Email Elizabeth Mowatt

44
CSA practice
45
AKT questions

46

1. A patient who presents with polydipsia has a
non fasting glucose taken which is reported as
11.4 mmol/l. How should this be interpreted?

1. Normal
2. Diabetes mellitus
3. Impaired fasting glucose
4. Impaired glucose tolerance
5. Suggests diabetes but further testing needed
6. Impaired fasting glucose and impaired glucose
   tolerance

47
2. An oral glucose tolerance test is performed.
Fasting sample 6.4 mmol/l, 2-hour sample 8.4
mmol/l. What is the diagnosis?

• Normal
• Diabetes mellitus
• Impaired fasting glucose
• Impaired glucose tolerance
• Suggests diabetes but further testing needed
• Impaired fasting glucose and impaired glucose
  tolerance

48
3. After fasting overnight a patients urine
shows glucose , no ketones. How should this be
interpreted?

• Normal
• Diabetes mellitus
• Impaired fasting glucose
• Impaired glucose tolerance
• Suggests diabetes but further testing needed
• Impaired fasting glucose and impaired glucose
  tolerance

49
4. A patient is diagnosed with type 2 diabetes.
Following NICE guidelines, what target should be
set for the HbA1c?

• Agree target with patient but generally aim for
  7
• Agree target with patient but generally aim for
  6
• As low as possible
• Agree target with patient but generally aim for
  6.5
• 6.5

50
5. A 62 year old man presents 4 weeks after
starting metformin for type 2 diabetes. His BMI
is 27.5. Despite slowly titrating the dose up to
500mg TDS he has experienced significant
diarrhoea. He has tried to reduce the dose back
down to 500mg BD but the diarrhoea persists. What
is the most appropriate action?

1. Switch to pioglitazone 15mg OD
2. Switch to gliclazide 40mg OD
3. Start modified release metformin 500mg OD with
   evening meal
4. Add loperamide as required
5. Arrange colonoscopy

51
6. A 56 year old lady with a BMI of 27 is
reviewed in the diabetes clinic due to poor
glycaemic control. She is currently being treated
with gliclazide 160mg BD. Her latest bloods show
Na 139, K 4.1, Ur 8.4, Cr 170, ALT 25, GGT 33,
HbA1c 9.4. Which one of the following
medications should be added next?

1. Guar gum
2. Pioglitazone
3. Metformin
4. Acarbose
5. Repaglinide

52
7. Which one of the following statements
regarding metformin is false?

1. Does not cause hypoglycaemia
2. Increases insulin sensitivity
3. Decreases hepatic gluconeogenesis
4. Increases endogenous insulin secretion
5. Reduces GI absorption of carbohydrates

53
8. A 45 year old man with diabetes is reviewed.
His most recent HbA1c is 8.6. Gliclazide is
added to the metformin he already takes. What is
the minimum time period after which the HbA1c
should be repeated?

1. 6 months
2. 1 month
3. 2 weeks
4. 2 months
5. 4 months

54
9. A 60 year old man with diabetes comes for
review. He has recently had laser therapy to
treat proliferative retinopathy. What should his
target blood pressure be?

1. lt 125/75
2. lt 130/80
3. lt 140/85
4. lt 140/90
5. lt 140/80

55
The End