type ii diabetes diagnosis drugs n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
TYPE II DIABETES DIAGNOSIS & DRUGS PowerPoint Presentation
Download Presentation
TYPE II DIABETES DIAGNOSIS & DRUGS

Loading in 2 Seconds...

play fullscreen
1 / 53

TYPE II DIABETES DIAGNOSIS & DRUGS - PowerPoint PPT Presentation


  • 141 Views
  • Uploaded on

TYPE II DIABETES DIAGNOSIS & DRUGS. Ufaq Qazi GP ST1. OBJECTIVES. By the end of this session you will ……. Know the main diagnostic tests for type 2 diabetes in primary care and their respective cut-off values

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'TYPE II DIABETES DIAGNOSIS & DRUGS' - brilliant


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
objectives
OBJECTIVES
  • By the end of this session you will …….
    • Know the main diagnostic tests for type 2 diabetes in primary care and their respective cut-off values
    • Have some insight into the various classes of drugs used to treat type 2 diabetes (not including insulin)
    • Be familiar with the NICE guidelines pathway for treating a newly diagnosed type 2 diabetic patient
turning point
TURNING POINT
  • Electronic voting cards
    • Interactive session
    • Everyone can answer questions
    • Anonymous
    • Results for the group overall
    • Everyone has to answer!
how confident are you with diabetes diagnosis
HOW CONFIDENT ARE YOU WITH DIABETES DIAGNOSIS?
  • Grand master
  • Good
  • OK
  • Unsure
  • Clueless
how confident are you with diabetes drugs
HOW CONFIDENT ARE YOU WITH DIABETES DRUGS?
  • Grand master
  • Good
  • OK
  • Unsure
  • Clueless
diagnostic tests
DIAGNOSTIC TESTS
  • WHO guidance 2006
    • Random glucose
    • Fasting glucose
    • 2 hour oral glucose tolerance test (OGTT)
      • 75g oral glucose after 8-12 hour fast
    • ALL PLASMA VENOUS SAMPLES
    • FINGER-PRICK TESTS NOT DIAGNOSTIC
  • Amended in 2011
    • Now includes HbA1c
what is the diagnostic threshold value for hba1c
WHAT IS THE DIAGNOSTIC THRESHOLD VALUE FOR HbA1c?
  • 6.0% (42 mmol/mol)
  • 6.5% (48 mmol/mol)
  • 7.0% (53 mmol/mol)
  • 7.5% (59 mmol/mol)
  • 8.0% (64 mmol/mol)
diagnostic thresholds
DIAGNOSTIC THRESHOLDS
  • Random glucose > 11.1
  • Fasting glucose > 7.0
  • 2 hour OGTT > 11.1
  • HbA1c > 6.5% (48 mmol/mol)
rules for glucose tests
RULES FOR GLUCOSE TESTS
  • If Pt symptomatic then only 1 positive test is required
    • In practice, many GPs often do them all anyway
    • Fasting glucose up to 30% false -VE (elderly/ethnic minorities)
  • If Pt asymptomatic then a second test on a separate date is required
    • If one test negative then others done to prove diagnosis
rules for hba1c tests
RULES FOR HbA1c TESTS
  • If asymptomatic then second test on separate date needed
    • If < 6.5 then give lifestyle advice and retest at 6/12
  • In practice, laboratory glucose tests done to prove diagnosis
    • HbA1c < 6.5 does not exclude diabetes proven by glucose tests
  • HbA1c cannot be used
    • Children and young people
    • Symptoms less than 2/12
    • Patients on steroids (rapid glucose rise)
    • Haemoglobin or red cell disorders
pre diabetic states intermediate hyperglycaemia
“PRE-DIABETIC” STATES (INTERMEDIATE HYPERGLYCAEMIA)
  • Impaired Fasting Glycaemia (IFG)
    • Fasting glucose between 6.1 and 7.0
    • Diabetes UK advises OGTT to rule out diabetes
  • Impaired Glucose Tolerance
    • 2 hour glucose between 7.8 and 11.1
  • Both managed actively with education and lifestyle advice
    • High risk for developing diabetes
    • Both independent cardiovascular risk factors
which of these is not a class of diabetic drug
WHICH OF THESE IS NOT A CLASS OF DIABETIC DRUG?
  • Thiazolidinedione
  • Sulphonylurea
  • DPP-4 Inhibitors
  • GLP-1 Analogue
  • Biguanide
  • IGF-1 Inhibitor
which of these is not a reason to stop metformin
WHICH OF THESE IS NOT A REASON TO STOP METFORMIN?
  • Severe renal impairment
  • Sepsis
  • Radiological contrast
  • Chronic Heart Failure
  • Myocardial Infarction
  • Acute Hypoxia
which of these is not a reason to avoid glitazones
WHICH OF THESE IS NOT A REASON TO AVOID “GLITAZONES”?
  • Osteporosis
  • Bladder Cancer
  • Lymphoedema
  • Obesity
  • Heart Failure
  • Renal Impairment
which is the only oral drug safe in pregnancy
WHICH IS THE ONLY ORAL DRUG SAFE IN PREGNANCY?
  • Metformin
  • Sulphonylureas
  • Glitazones
  • Gliptins
type ii diabetes drugs
TYPE II DIABETES DRUGS
  • 1stor 2ndline
    • Biguanides (Metformin)
    • Insulin Secretagogues
      • Sulphonylureas
      • Meglitinides
    • Acarbose
  • 2nd or 3rd line
    • Thiazolidinediones (“Glitazones”)
    • DPP-4 inhibitors (“Gliptins”)
  • 3rd line only
    • GLP-1 Analogues
metformin
METFORMIN
  • Mode of action
    • Reduces hepatic gluconeogenesis
    • Increases peripheral glucose uptake
  • Particularly helpful for
    • Overweight
  • Side effects
    • GI (diarrhoea!)
    • Lactic acidosis
  • Avoid/withhold in
    • Severe hepatic impairment
    • Renal Impairment (eGFR < 30), reduce dose if eGFR < 45
    • Tissue hypoxia (e.g. sepsis/shock)
    • Pre-radiological contrast
    • Acute Heart Failure (actually beneficial in CHF)
insulin secretagogues sulphonylureas
INSULIN SECRETAGOGUES –SULPHONYLUREAS
  • Mode of action
    • Stimulate pancreatic beta cells to release insulin
  • Long-acting
    • Glibenclamide
      • Avoid in elderly due to hypoglycaemia
  • Short-acting
    • Gliclazide, Tolbutamide, Glipizide
  • Particularly helpful for
    • Not overweight
    • Hyperglycaemia
    • Metformin intolerant
    • Can be added to Metformin
sulphonylureas cont
SULPHONYLUREAS (cont.)
  • Side effects
    • HYPOGLYCAEMIA!
    • Weight gain
    • More rarely
      • Cholestatic hepatitis
      • Hypersensitivity (erythema multiforme)
  • Avoid in
    • Severe hepatic impairment
    • Severe renal impairment
      • But Gliclazide probably ok as mainly liver metabolism
      • Low dose and monitor glucose carefully
  • Watch out for
    • Drugs which affect cytochrome p450 metabolism
      • Rifampicin, Phenytoin, Carbamazepine, Erythromycin
insulin secretagogues meglitinides
INSULIN SECRETAGOGUES –MEGLITINIDES
  • Repaglinide / Nateglinide
  • Mode of action
    • Broadly the same as sulphonylureas
  • Particularly helpful in
    • Erratic lifestyles (because rapid-acting)
    • Can be skipped if meal skipped
  • Side effects
    • As for sulphonylureas (less risk of hypoglycaemia)
acarbose
ACARBOSE
  • Mode of action
    • Inhibits alpha-glucosidase(gut enzyme – digests carbohydrate)
    • Combine with other drugs or insulin for good glycaemic control
  • Particularly helpful in
    • Intolerance of other oral drugs
    • Impaired glucose tolerance
  • Side effects
    • Weight loss (can be beneficial)
    • Flatulence!
glitazones thiazolidinediones
“GLITAZONES” (THIAZOLIDINEDIONES)
  • Pioglitazone
    • Only one with a licence
    • Rosiglitazone withdrawn due to cardiac side effects
  • Mode of action
    • Complicated! Affects multiple gene transcriptions for glucose metabolism and insulin sensitivity
    • Better use of glucose by cells
  • Particularly helpful in
    • Recurrent hypos on sulphonylureas (elderly, operating machinery)
    • Poor response to 1st/2nd line Rx
    • Severe renal impairment (though risk of fluid overload)
glitazones cont
“GLITAZONES” (cont.)
  • Side effects
    • Weight gain
    • Increased risk of heart failure
    • Increased risk of fracture
    • Hepatotoxicity (monitor LFTs every 3/12 for first year)
  • Avoid in
    • Heart Failure / Oedema
    • Osteopenia/Osteoporosis
    • Obesity
    • Bladder Ca or undiagnosed haematuria
gliptins dpp 4 inhibitors
“GLIPTINS” (DPP-4 INHIBITORS)
  • Sitagliptin, Vildagliptin, Saxagliptin
  • Mode of action
    • Inhibit breakdown of GLP-1, a gut hormone which stimulates insulin release and inhibits glucagon release
  • Particularly helpful in
    • Recurrent hypos on sulphonylureas
    • Poor response to 1st/2nd line Rx
    • Can’t use “glitazone” (overweight, contraindication, intolerance)
  • Side effects
    • Relatively few common (GI mainly)
  • Avoid in
    • Severe hepatic impairment
    • Caution in severe renal impairment ( low dose)
glp 1 analogues
GLP-1 ANALOGUES
  • Exenatide / Liraglutide
    • s/c injection
  • Mode of action
    • Stimulates insulin release and inhibits glucagon release
    • Decrease gastric motility
  • Particularly helpful in
    • Overweight (BMI >35)
    • 3rd line Rx if insulin not acceptable
    • Weight loss would benefit other comorbidites
  • Side effects
    • Weight loss!
    • GI, particularly nausea and reduced appetite
  • Avoid in
    • Severe GI disorders
    • Severe renal impairment (eGFR < 30)
pregnancy
PREGNANCY
  • Metformin is OK
  • Everything else is not OK
  • Insulin is mainstay
nice guidelines 2011
NICE GUIDELINES 2011
  • Patient education and lifestyle changes
    • Absolutely crucial alongside drug Rx
    • X-PERT programme
    • NICE gives option of trial before drug Rx
  • UK Prospective Diabetes Study (1977-2007)
    • Up to 50% have microvascular complications at diagnosis
    • Intensive glycaemic Rx superior to standard Rx (lifestyle changes)
  • So why trial lifestyle?
    • In practice, need for drug Rx almost inevitable in all Pts at 3/12
    • “Bedding in period” aids acceptance + commitment to lifestyle change
    • Meds usually started early now without formal trial period
nice guidelines 20111
NICE GUIDELINES 2011
  • 1st line is Metformin or Sulphonylurea (based on Pt and clinical characteristics)
  • Check HbA1c every 6/12
  • If remains > 6.5% on 1st line then add the other of these drugs as 2nd line
  • If intolerant of either 1st line drugs, or hypoglycaemia an issue on sulphonylureas, then add gliptin or glitazone as 2nd line
  • If HbA1c > 7.5% on 2nd line then can trial 3rd line
    • Gliptin/Glitazone if not already tried
    • At this point insulin would be considered in addition
    • Could try GLP-1 analogue if BMI >35 or insulin not acceptable
nice guidance on 2 nd 3 rd line drugs
NICE GUIDANCE ON 2ND/3RD LINE DRUGS
  • All must be reviewed at 6 months and stopped if inadequate response
    • HbA1c decrease by 0.5% (1% for GLP-1 analogues)
    • ANDweight loss of 3% with GLP-1 analogue
case study
CASE STUDY
  • 61 y.o. man with BMI 35
  • Inpatient with LRTI, now resolved
  • PMH – MI, chronic heart failure, COPD, OA
  • Meds – Aspirin, Furosemide, Bisoprolol, Ramipril, Simvastatin, Prednisolone, Salbutamol
  • Finger-prick glucose found to be raised
  • Further tests
    • Random glucose 13.5
    • Fasting glucose 7.2
case study cont
CASE STUDY (cont.)
  • Prednisolone is stopped while in hospital
  • 2 weeks later he has the following blood results with his GP
    • Fasting glucose 6.6
    • 2 hour OGTT glucose 12.4
    • eGFR 47
what treatment would you choose as 1 st line
WHAT TREATMENT WOULD YOU CHOOSE AS 1ST LINE?
  • Lifestyle changes
  • Metformin
  • Sulphonylureas
  • A+B
  • A+C
case study cont1
CASE STUDY (cont.)
  • After 6 months
    • HbA1c is 8.9%
    • eGFR 42
    • Weight increased, BMI now 37
    • Worsening OA in R knee and hip
what is the next step in rx
WHAT IS THE NEXT STEP IN Rx?
  • Add Gliclazide to current dose Metformin
  • Add Gliclazide to reduced dose Metformin
  • Add Pioglitazone to reduced dose Metformin
  • Add Sitagliptin to current dose Metformin
  • Add Exenatide to reduced dose Metformin
case study cont2
CASE STUDY (cont.)
  • Now on Gliclazide and Metformin
  • After further 6 months
    • HbA1c is 8.5%
    • eGFR is 42
    • BMI still 38
    • Severe pain and reduced mobility due to OA
what would you not go for now
WHAT WOULD YOU NOT GO FOR NOW?
  • Insulin
  • Sitagliptin
  • Pioglitazone
  • Exenatide
case study cont3
CASE STUDY (cont.)
  • He is put on Exenatide injections in addition to Gliclazide and Metformin
  • After 6 months
    • HbA1c is 8.0% (reduced by 0.5%)
    • Weight loss of 4%
    • Trouble with recurrent hypoglycaemiacausing falls and multiple A+E attendances
now what
NOW WHAT?
  • Continue with current treatment
  • Stop Exenatide and replace with Sitagliptin
  • Stop Exenatide and and replace with Insulin
  • Stop Exenatide and Gliclazide and replace with Sitagliptin
how confident are you with diabetes diagnosis1
HOW CONFIDENT ARE YOU WITH DIABETES DIAGNOSIS?
  • Grand master
  • Good
  • OK
  • Unsure
  • Clueless
how confident are you with diabetes drugs1
HOW CONFIDENT ARE YOU WITH DIABETES DRUGS?
  • Grand master
  • Good
  • OK
  • Unsure
  • Clueless
reference links
REFERENCE LINKS
  • NICE guidelines 2011 (web format)
    • http://publications.nice.org.uk/type-2-diabetes-cg87/guidance
  • NICE management pathway (interactive webpage)
    • http://pathways.nice.org.uk/pathways/diabetes/managing-type-2-diabetes#path=view%3A/pathways/diabetes/blood-glucose-lowering-therapy-for-type-2-diabetes.xml&content=close
  • WHO diagnostic guidelines (Diabetes UK page)
    • http://www.diabetes.org.uk/About_us/What-we-say/Diagnosis-prevention/New_diagnostic_criteria_for_diabetes/