TREATMENTS FOR TYPE 2 DIABETES Susan Henry Diabetes Specialist Nurse
How can we improve outcomes in Type 2 diabetes? Earlier diagnosis Better patient education Stress central role of lifestyle management Identify and treat all risk factors Use pharmacological therapy in treating hyperglycaemia
Treating Type 2 diabetes Traditional approach Diagnosis made opportunistically or when patient presents with symptoms Lifestyle management and patient education Add oral therapies. Traditionally Metformin first line adding in Gliclazide, then insulin.
Lifestyle Interventions Encourage and discuss lifestyle interventions Offer referral to dietician at diagnosis Offer DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) structured education programme at diagnosis
Lifestyle Interventions Cont Discuss with patient, may commence metformin at diagnosis and have HBA1c rechecked in 12 weeks time or Lifestyle interventions and have HBA1c checked in 12 weeks time, commence metformin if HBA1c 48mmols or above
Oral Hypoglycaemic agents First Line therapy in all patients diagnosed with type 2 diabetes Metformin (Glucophage) 500mg initially (max. dose 2g daily) Titrate dose on a weekly basis to reduce side effects bloating, diarrhoea, abdominal pain. (If not able to tolerate standard release Metformin, try Metformin MR)
How Metformin works Reduces liver glucose production Reduces absorption of glucose by gut Improves insulin sensitivity
DPP-4 Benefits cont Well tolerated No risk of hypoglycaemia unless combined with insulin or sulphonylurea Can be added in with insulin
DPP-4 medication Linagliptin (Trajenta) 5mg daily (renal friendly) Sitagliptin (Januvia) 100mg daily (Caution in renal impairment) Saxagliptin (Onglyza) 5mg daily (Cautions in renal and hepatic impairment) Vidagliptin (Galvus) 50mg twice daily (Monitor liver function, caution in renal impairment
How DPP-4 inhibitors work Extends the life of GLP-1 (not as great glucose lowering effect as GLP-1s) Increases insulin production but only when blood sugars raised therefore no risk of hypoglycaemia Reduces glucose output by liver
SGLT-2 (Sodium-glucose co-transporter 2 inhibitors) Newer Agents Stops reabsorption of glucose from the kidney back into the blood, leading to increase glucose in urine and reducing blood glucose
Cont Monotherapy if metformin not tolerated Can be added in with insulin Cautions in volume depletion, (75 + years increased risk of volume depletion) Can reduce weight
SGLT-2 Cont No risk of hypoglycaemia unless combined with insulin or sulphonylurea Side Effects can be vulvovaginal candidiasis and balanitis Empagliflozin (Jardiance) 10mg/25mg daily (avoid if EGFR<60) discontinue if EGFR drops <45 Canagliflozin 100mg-300mg daily before breakfast (avoid if EGFR <60) Dapagliflozin (Forxiga) 10mg daily (avoid if EGFR<60)
SGLT-2 IMPORTANT SAFETY INFORMATION RISK OF DIABETIC KETOACIDOSIS (DKA) - RARE Potential life threatening cases of DKA have been reported in patients taking SGLT-2 inhibitors To minimise the risks: Advise patient how to recognise signs & symptoms of DKA such as nausea, abdominal pain, excessive thirst, difficulty in breathing, fatigue, sleepiness and to seek prompt medical attention if symptoms develop Test for ketones if patient presents with symptoms (could have near normal blood glucose levels)
Sulphonylureas How they work Stimulate insulin secretion Require preserved beta cell function to achieve this Reduces HBA1c by 1-2% Always take just before or with food
Sulphonylureas Cont Side Effects Weight gain side effect, can gain 2-4kgs in weight and some patients gained as much as 10kgs. Hypoglycaemia Inform patient of symptoms and treatment. Give leaflet and teach blood glucose monitoring. Inform of driving regulations and blood glucose above 5 to drive
Sulphonylureas cont Gliclazide 40mg-80mg daily adjusted to response every 4 weeks (2 weeks if no decrease if blood glucose) Increasing up to 160mgs BD Glimepiride 1mg OD titrated to 4mgs OD Gliclizide MR start at 30mgs OD at breakfast and titrate to 120mgs OD associated with lower risk of hypos than generic gliclizide
Sulphonylureas Cont Avoid in the Frail elderly, and those with poor cognitive function, deteriorating renal function, dementia, poor eating habits HBA1c should be no lower than 53mmols if on sulphonylureas due to risk of hypoglycaemia (NICE ) Consider that falls and feeling unwell could be a result of hypoglycaemia, if patient on sulphonyurea
GLP-1 Glucagon Like Peptides The incretin hormone GLP-1 is secreted from the GI tract during food intake GLP-1 responds by stimulating release of insulin from pancreas It reduces liver output of glucose
GLP-1 Cont Slows gastric emptying and increases satiety Reduces HBA1c 0.5-1.5% Reduces Weight
NICE Guidelines Adding GLP-1 mimetic for adult patients with BMI of 35kg/m² or higher Or Have a BMI lower than 35m² for whom insulin would have significant occupational implications or weight loss would be benefit other significant obesity- related comorbidities NICE Guideline NG28, updated April 2017
All GLP-1 agents contraindicated in gastro-intestinal disease and if previous history of pancreatitis Advise patient to stop GLP-1 and seek medical help if develops any severe abdominal pain with or without vomiting Patients should be counselled about potential side effects prior to starting GLP-1 agents. NICE recommend discontinuing GLP-1 after 6 months if HbA1c not improved by 1% and weight loss of at least 3%
Cont Available in Daily and weekly injections Victoza (Liraglutide) Lyxumia (Lixisenatide) Trulicity (Dulaglutide)
DPP-4 Inhibitors And GLP-1
GLP-1 Injections
The stepwise treatment of Type 2 diabetes Healthy eating and exercise - HbA1c 48mmol/mol (6.5%) + Structured Education + Metformin First Intensification- if HbA1c rises to 58mmol/mol (7.5%) Consider adding a DPP-4/ SGLT-2/ Sulphonylurea (Rotherham guidelines GLP-1) NICE Guideline NG28, updated April 2017
Points to Consider Many different glucose lowering agents available Optimal blood glucose control is not always obtained due to limitations and action of the medication and factors which affect blood glucose control Remember timing of oral medications can be important
Cont Remember to stop any diabetes medication that has not been effective in reducing HBA1c Legacy effect Positive long term effects on cardiovascular outcomes and mortality rates of good glycaemic control early on in the course of type 2 diabetes (UKPDS)
Any Questions?