type 2
insulin resistance and lack of insulins
prevalent factors
later in life
patients with prediabetes
hba1c of 42-47
can try and prevent with lifestyle
diabetic considered hba1c of 48
fasting - 7 or more
treatment in low CV risk
- assess HBA1c, kidney function, CV risk
treat with metformin
aim for individually agreed threshold - hb1ac above threshold
add in pioglitazone or SU -> SGLT2-2i or DPP4i
aim for threshold - hba1c above
- triple therapy by adding/swaping
-aim for the indivually agreed threshold
DPP4i - gliptins
su - sulphonurea , ‘de’ such as gliclazide
sglt2 - flozins
treatment high CVD risk
high risk - arthrosclerotic cv disease, HF, qrisk2 over 10 in adults over 40
- treat with metformin
- once tolerated - add in sglt2
- metformin not tolerated - add alone sglt2
- aim for agreed threshold
- if hba1c still above threshold
- follow guidelines for dual and triple therapy as previous
IF ANY PATIENT AT ANY POINT DEVELOPS HIGH RISK -CONSIDER SGLT2
metformin resistance
metformin contraindicated
- high risk of CV disease - SGLT2i
- low risk of CV disease - pioglitazone or SU - SGLT2 or DPP4
- aim for threshold
if HBA1C above
- additional therapy with pio, SU, sglt21 or DPPi
- aim for threshold
insulin would be next line if still not in threshold
thresholds
prediabetic - 42- 47
managed by lifestyle and diet with or w/o single drug
48 normal target
53 for hypos causing drugs such as SU , or insulin
hba1c not controlled by single drug - 58 or higher
- aim for 53
metformin - biguanide MOA
decreases glucogenesis and increases peripheral utilisation of glucose
Metformin WARNING AND SE
MHRA - reduced B12 levels
S/E
- lactic acidosis - avoid eGFR below 30, increased risk with alcohol
- GI side effects : nausea, vomiting, diarrhoea- increase slowly and give MR prep
STOP IF PATIENT DEVELOPS KIDNEY INJURY
DDP4
inhibits dipeptylpeptidase 4 to increase insulin secretion and lower glucagon secrection
warnings for DPP4i
gliptins
Avoid in ketoacidosis
caution in HF
can cause pancreatitis - discontinue in severe, persistent abdo pain
pioglitazone
not commonly seen
reduces peripheral insulin resistance
CI in HF
inc risk of bladder cancer - report haematuria, dysuria, urinary urgency
— review safety and efficacy 3-6 mnths
—- stop treatment in inadequate response
- increased risk of bone fractures
- increased risk of infections
- increased risk of liver toxicity - report nausea, vom, dark urine, fatigue
sulphonureas
augments insulin secretion
long acting: glibernclamide, glimepiride
short acting - gliclazide, tolbutamide
SE
- avoid in acute porphyria
- high risk of hypoglycaemia
- avoided in hepatic and renal failure - increased hypos
- long acting avoided in elderly, risk of hypos
- hypos may affect concentration - skilled tasks?
SGLT2 inhibitors
inhibits the sglt2 in renal proximal convoluted tubule
cana, dapa, empa, ertu
MHRA - life threatning fatal cases of DKA
MHRA - monitor ketones - if treatment interupted for surgical procedures or illness
MHRA - fourniers gangrene - necrotising fascititis of the getetalie or perineum
MHRA - cana only, risk of lower limb amputation
vol depletion - correct hypovolaemia before intiation
increased risk of UTI
monitor renal function due to renal imp
GLP 1 agonist
increase insulin secretion, suppress glucagon secretion and slows gastric emptying
GLP1 agonist MHRA
MHRA-
1. DKA risk when concomitant insulin rapidly reduced
2. reminder of SE and awareness of potential of misuse
3. risk of Pulmonary aspiration during GA or deep sedation
GLP S/E warnings
TIDEs
acute pancreatitis
GI- WEIGHT LOSS, delayed Gastric emptying, NV
dehydration - risk due to GI effects
other antidiabetics
acarbose - delayes the digestion and absorbtion of starch and sucrose , high risk of GI SE
meglatides - repaglinide
stimulates insulin secretion
exposed to stress - trauma, fever, infection, would stop and treat with insulin
Weight
GAIN - pioglitazone, SU
neutral - DPPi AND METFORMIN
LOSS - GLP1 and SGLT2i
renal function
dose reduction or avoid - metformin
dose reduction or caution - DPP-4i, SGLT2, GLP1, SU
no warning - pioglitazone
hepatic
avoid - pioglitazone
dose reduction or avoid - SGLT2, GLP, SU
dose reduction or caution - DPP4
withdraw if hypoxia likely - metformin
