Tag: diabetes treatment second intensification

Type 2 Diabetes prevention aims to prevent or delay the onset of diabetes, or to prevent complications arising from Type 2 Diabetes. For diabetes prevention it is recommended that:

1. individuals are first assessed for the risk of prediabetes through an adequate risk assessment tool such as the German Diabetes Risk Score
2. if high risk result is achieved, the individual should be tested for prediabetes or Type 2 Diabetes
3. individuals found with prediabetes should have their blood glucose monitored every year

Diabetes Prevention and Delay

Lifestyle Changes

Type 2 Diabetes can be prevented or delayed by:

• intensive lifestyle behaviour change programmes (include a calorie-reduced diet coupled with exercise – also promote reduction of risk factors such as hypertension, hyperlipidaemia, and inflammation)
• achievement and maintenance of 7% loss of body weight
• physical activity such as brisk walking for at least 150 minutes per week

Pharmacological Therapy

Prevention of Type 2 Diabetes can also be assisted with pharmacological therapy, where individuals with a BMI of 35kg/m² AND/OR who have 60 years or more AND/OR women with past GDM (gestational diabetes mellitus) can be prescribed Metformin.

NOTE: long term use of Metformin has been associated with vitamin B12 deficiency, therefore, vitamin B12 levels should be monitored on a regular basis especially in individuals with peripheral neuropathy and/or anaemia.

Diabetes Management

Nutrition

Eating a healthy balanced diet promotes:

• weight control
• blood glucose level stabilisation
• serum lipid level decrease

A patient with diabetes should be encouraged reduce sugar intake to a minimum, to reduce carb intake, and to distribute caloric intake throughout the day in smaller meals with snacks in between. This helps to reduce the chance of experiencing a hypoglycaemic episode. Carbs which are high in fibre are a better choice.

Exercise

A 30-minute walk per day promotes better Diabetes management. Exercise:

• lowers blood glucose level
• promotes weight loss
• reduces blood lipids
• decreases the blood pressure
• promotes better circulation

Caution should be taken:

• when the individual is using insulin since hypoglycaemia can occur during exercise OR up to several hours after exercise; patient should be encouraged to check blood glucose before and after exercising
• if the individual’s urine contains ketones and blood glucose is over 14mmol/l
• if the individual has other complications such as cardiovascular disease, neuropathy and retinopathy
• patient should be encouraged to keep a blood glucose diary, listing down blood glucose values as well as when it was taken (before/after meal/exercise) so as to evaluate results and see if any changes in individualised care plan are necessary

Pharmacological Therapy

Type 1 Diabetes Management

An individual’s daily amount of needed insulin is calculated on the person’s weight: 0.4 to 1.0 units per kg per day. About 50% of the total amount of insulin needed per day is given as basal, while the other half is given in relation to food intake a.k.a. prandial.

Rapid acting insulin helps in reducing the risk of hypoglycaemia. Patient education is recommended with regards to bolus insulin dose adjustment prior to meals, based on carbohydrate intake, blood glucose, and exercise.

Lantus is long-acting, usually with no peak. It is taken ideally at bedtime or else early in the morning.

Actrapid is a short-acting insulin which works rapidly. It peaks in 2-3 hours with a duration of 5-8 hours. Actrapid is usually recommended to be administered 30 minutes before eating.

Patient on insulin should be instructed to:

• always check blood glucose after washing hands with soap and water and not use alcohol rub; to use the lancet at the side of the finger and to wipe and discard first drop of blood before testing with the 2nd drop
• check blood glucose 30 minutes before eating or 2 hours after eating
• taught how the prescribed medications work
• told when to administer insulin to self
• told to rotate injection site every time
• told to carry glucose or sugar in case a hypoglycaemic episode is experienced
• told to store opened insulin vials in a dark cupboard away from sunlight and to discard after 30 days
• told to store unopened insulin vials in the fridge
• told to discard insulin if change in colour occurs, even if still unexpired, as that could be a sign that it has been denatured

NOTE: during puberty, pregnancy, and illness, higher doses of insulin need to be administered.

Blood glucose control depends on the technique used for insulin administration…

• short needle (4mm pen needle)
• correct dose
• rotate site
• alcohol should not be used to clean site prior to injecting insulin
• dose should be injected subcutaneously (pinch tissue and inject at a 90 degree angle)

Insulin Pen

Continuous Subcutaneous Insulin Infusion

Type 2 Diabetes Management

Initially, a newly diagnosed diabetes type 2 patient is started on a 3 month trial of diet and exercise. Following this 3 month period, if the patient’s HbA1c still increases to 48mmol/mol (6.5%), pharmacological treatment is initiated.

FIRST LINE TREATMENT

If HbA1c = 48mmol/mol (6.5%):

• Start on metformin (standard-release) morning + evening dose
• Gradually increase dose (gradually = due to GI side effects)
• In case of side effects switch to modified release metformin (evening dose)
• If metformin tolerability is confirmed in cases where patient has CHF or CVD, Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) can be introduced
• If metformin is contraindicated, SGLT-2i can be considered as a stand-alone medication

FIRST INTENSIFICATION

If HbA1c = 58mmol/mol (7.5%):

• metformin and a DPP-4i (Dipeptidyl peptidase 4 inhibitor) OR
• metformin and pioglitazone OR
• metformin and a SU (Sulfonylurea) OR
• metformin and a SGLT-2i (Sodium-glucose cotransporter 2 inhibitors)

PLUS consider introducing Insulin.

NOTE: aim for HbA1c 53mmol/mol (7%)

SECOND INTENSIFICATION

If HbA1c = 58mmol/mol (7.5%):

Triple Therapy is recommended…

• insulin-based treatment OR
• metformin + DPP-4i + SU OR
• metformin + pioglitazone + SU OR
• metformin + pioglitazone OR SU + SGLT-2i

NOTE: aim for HbA1c 53mmol/mol (7%)

If triple therapy is ineffective, not tolerated, or contraindicated, combine metformin + SU + GLP-1 mimetic.

(ideal for adults with type 2 diabetes with BMI 35kg/m² or more AND adults with same BMI experiencing significant occupational implications on insulin)

Metformin

• inhibits gluconeogenesis
• increases uptake of glucose by body tissues
• may prevent weight gain

To avoid GI disturbances, dose should be increased gradually.

DPP-4i (Dipeptidyl peptidase 4 inhibitor)

alogliptin, linagliptin, saxagliptin, sitagliptin, viltagliptin

• effects of hormones released from the intestine based on food intake are prolonged
• pancreatic insulin secretion is increased
• no known side effects

Glitazones

pioglitazone

• improves insulin sensitivity
• improves beta cell function
• does not cause GI upset
• no added risk of hypoglycaemia
• dose once daily

but…

action onset happens at 6 weeks or more; pioglitazone is also associated with an increased risk of heart failure, bone fracture, and bladder cancer.

Sulphonylureas

glicazide, glimepiride, gliplizide, tolbutamide

• stimulates secretion of pancreatic insulin

but…

increases the risk for hypoglycaemia and weight gain.

SGLT-2i (Sodium-glucose cotransporter 2 inhibitors)

canagliflozin, dapagliflozin, empagliflozin, ertugliflozin

• prevents reabsorption of glucose into the blood by the kidneys
• causes glucose excretion through urine
• promotes weight loss
• dose once daily

but…

is contraindicated for patients with renal dysfunction; increases the risk of severe genital infections and UTIs; increases risk of DKA when taken and shortly after stopping them.

GLP-1 mimetic

dulaglutide, exenatide, liraglutide, lixisennatide, semaglutide

Administered via weekly subcutaneous injection.

• inhibits glucagon secretion
• stimulates insulin secretion
• slows gastric emptying
• increases beta cell mass
• promotes weight loss

but…

commonly causes nausea (which tends to decrease by time); rarely causes acute pancreatitis.

Monitoring

• Monitor A1c and other glycaemic factors at least twice a year in patients responding to treatment (with stable glycaemic control)
• Monitor A1c and other glycaemic factors at least 4 times a year in patients who have had recent change in therapy and who are not meeting glycaemic goals

Average Glucose Estimation for HbA1c Values…

Glycaemic Targets…

Reference

NICE (2022). Type 2 diabetes in adults: management. Retrieved from https://www.nice.org.uk/guidance/ng28 on 26th March 2022

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