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Treatment of Diabetes

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Diabetes is currently at epidemic proportions in the UK with approximately 5% of the population suffering the disorder. Consequently, it is a disease frequently encountered in primary care and constitutes a significant component of the GMS contract. This resource of 10 assessment questions is designed to test your knowledge on how to manage the condition focusing on the main problem encountered in primary care ie type 2 diabetes. As such the resource covers the main areas of treating patients according principally to NICE guidance, including oral hypoglycaemic agents and insulin.

On completion of this resource, you should

Have an improved understanding of the therapeutic strategies in the treatment of patients with diabetes

Have an improved understanding when insulin may be required in the treatment of patients with diabetes

Have an improved understanding of the contra-indications to the use of certain therapies in the treatment of diabetes

Have improved knowledge of the management of patients presenting with hypoglycaemia

Patient UK Treatments for Type 2 Diabetes

Understand the therapeutic strategies in the treatment of patients with diabetes

Understand when insulin may be required in the treatment of patients with diabetes

Understand some of the contra-indications to the use of certain therapies in the treatment of diabetes

Management of patients presenting with hypoglycaemia

A 62 year old male presents to clinic complaining of thirst associated with long-standing weight gain. He has had problems with his weight for many years and also informs you that he has a family history of diabetes. He leads a pretty sedentary lifestyle, drinks 10 pints of beer weekly but is a non-smoker.On examination, his weight is 98.8kg, his BMI 33.2kg/m

 and his waist circumference is 103cm. His fasting plasma glucose is 8.8 mmol/l and his HbA1c is 53 mmol/mol or 7% (< 42 mmol/mol or 6%). How would you initially manage this patient?

This patient has symptoms and a fasting plasma glucose above 7 mmol/l indicating a diagnosis of diabetes - most likely type 2 diabetes. The target HbA1c in this case is less than 7%/53 mmol/mol, and so the most appropriate initial approach to his management according to NICE guidance would be lifestyle intervention. In this scenario, intervention should focus on weight loss with the recommendation of a high fibre, low-glycaemic source of carbohydrate, and low calorie diet and also the suggestion of a tailored exercise programme to increase physical activity and encourage weight loss. Such an intervention could successfully reduce this patient's weight.

http://publications.nice.org.uk/type-2-diabetes-cg87/guidance#lifestyle-managementnon-pharmacological-management

Question 1

A 50 year old female is diagnosed with type 2 diabetes and has been seen by you for advice on lifestyle interventions, in particular dietary intervention and exercise. She weighs 95kg, has a BMI of 35kg/m

 and a blood pressure of 144/90 mmHg. When you ask her what she feels about the contribution of her weight to her condition, she replies that all her family are 'big boned' and that she feels that her genes contribute more to her diabetes than the weight. At what level of the Prochaska's model of behavioural change would you place this patient?

 is an important principle in understanding where the individual's beliefs lie and therefore it helps to provide information on how receptive and willing an individual is to change. In this particular case, this woman has been diagnosed with type 2 diabetes yet to a certain extent does not appear to believe that her weight is a contributory yet changeable factor. This is termed pre-contemplation and therefore the interviewer should concentrate on providing the patient with literature/communication to educate the individual so that they themselves understand and be receptive to future advice. In this scenario, a good approach to helping the patient achieve behavioural change would be to provide her with literature relating to the treatment of diabetes through weight management. Set a date for the patient to return following the provision of this data and then try to get the patient into the contemplation stage.

Question 2

A 58 year old man re-attends clinic as he has been seen regarding a recent diagnosis of type 2 diabetes for which he has received advice on lifestyle interventions including hypocaloric diet and exercise. His weight is 102 kg, his BMI is 35kg/m

 and his waist circumference is 104cm. His HbA1c at diagnosis, six months ago was 66 mmol/mol or 8.2%. He returns after 6 months of trying to stick to the prescribed interventions with a weight of 100kg and his HbA1c is 64 mmol/mol or 8% (< 42 mmol/mol or 6%). Which of the following would be the most appropriate approach concerning treatment at this stage?

In this man's case, he has tried 6 months of lifestyle intervention, which has resulted in a modest weight loss of 2kg and a sub-optimal reduction in HbA1c to 8%. However, the target HbA1c should be less than 7%. NICE guidelines recommend that metformin should be started in an overweight patient who's blood glucose is inadequately controlled by lifestyle interventions alone. This man should be therefore be started on metformin 500mg tds. This drug has a vast amount of evidence supporting its use, with data revealing reduced cardiovascular risk as well as improved glycaemic control. One would expect to roughly achieve a 1% reduction in HbA1c following introduction of metformin.

Question 3

A 66 year old female with a 5 year history of type 2 diabetes is being treated with metformin 1g bd as well as lifestyle intervention. Her last HbA1c checked 6 months ago was 57 mmol/mol or 7.4% (normal less than 42 mmol/mol or 6%)and her most recent HbA1c is 62 mmol/mol or 7.8%. Her weight has increased slightly to 90.9kg and her BMI is 32.3 kg/m

. Which of the following would be the most appropriate approach to the management of her diabetes?

In this scenario, the patient's glycaemic control has deteriorated despite the use of an optimal dose of metformin. NICE guidelines recommend the addition of a sulphonylurea such as gliclazide when monotherapy with metformin is inadequate. Pioglitazone is associated with increased fracture risk and should be avoided in the elderly female. Leaving the treatment unchanged would lead to further deterioration in this patients diabetes, therefore it is not recommended.

http://publications.nice.org.uk/type-2-diabetes-cg87/guidance#glucose-control-levels

Question 4

A 72 year old male has a ten year history of type 2 diabetes and is receiving treatment with gliclaide 160mg bd as well as metformin 1g bd. His most recent HbA1c is 73 mmol/mol or 8.8% which has deteriorated over the last year from 60 mmol/mol or 7.6%. His weight is 103kg and his BMI is 33.6kg/m

Which of the following would be the most appropriate management of this patient?

This patient's glycaemic control has deteriorated over the last year or so as reflected by a sub-optimal HbA1c (8.8%) despite optimal dual oral hypoglycaemic agents. Thus the next step in managing this patient would be the addition of a third oral hypoglycaemic agent such as a gliptin - linagliptin. These relatively new agents are DPP-IV inhibitors which work by prolonging the half-life of the molecule Glucagon-like Peptide-1 (GLP-1), which in turn improves glucose uptake and utilisation. These class of drugs are relatively weight neutral, which is important in this obese patient. Pioglitazone may be expected to cause some weight gain, as a consequence of fluid retention.

http://www.nice.org.uk/nicemedia/pdf/CG87QuickRefGuide.pdf

Question 5

A 65 year old male attends clinic for his annual review. He has a three year history of type 2 diabetes for which he takes metformin 500 mg tds as well as adopting lifestyle interventions. His weight is 92kg and his BMI is 30.4 kg/m

. His HbA1c is 51 mmol/mol or 6.8%. Which of the following would you suggest in terms of the future management of his diabetes?

This man has achieved good glycaemic control as reflected by his HbA1c result of 51 mmol/mol or 6.8% which is below the target of 53 mmol/mol or 7% for this patient. Therefore, the patient is responding well on the metformin along with the lifestyle changes, therefore there is no need to modify his treatment; continue with the metformin and proceed with the lifestyle interventions.

Question 6

A 31 year old male attends clinic complaining of weight loss, tiredness and thirst. He has been experiencing these symptoms over the last 3 months and has lost approximately 7kg over this time. There is no family history of any medical conditions of note. He does not take any medications, drinks little alcohol and his weight is 74kg and his BMI is 22.8kg/m

. His results reveal a plasma glucose of 18.8 mmol/l (3.5-5.5) and his HbA1c is 105 mmol/mol or 11.8% (<42 mmol/mol or 6). Which of the following would be the most appropriate initial approach to managing this patient

This young man has lost weight, has a normal BMI and presents with osmotic symptoms. This together with the high glucose suggests a diagnosis of type 1 diabetes and the patient should be commenced on insulin as the initial therapy rather than oral hypoglycaemics. Type 1 diabetes describes a condition in which the pancreas is no longer able to produce sufficient insulin due to the destruction of the pancreatic β cells by an autoimmune process. Further investigation would be expected to reveal positive autoantibodies to islet cell or Glutamic Acid Decarboxylase (GAD), which are both markers of autoimmune pancreatic beta cell destruction.

Management of type 1 diabetes from Patient UK

Question 7

A 59 year old female with a two year history of type 2 diabetes presents for her annual review. She takes metformin 1g bd and also glicalzide 160mg bd. Her weight has declined over the last year, with a weight of 70kg and a BMI of 23.2 kg/m

. She also complains of some thirst and finds that she needs to get up two to three times during the night to pass urine. Her HbA1c is 77 mmol/mol or 9.2% and one year ago it was 58 mmol/mol or 7.5%.Which of the following would be the most appropriate approach to managing this woman

Despite this patient being on maximal dual oral hypoglycaemic agents, her glycaemic control is still poor and she has lost weight. Her HbA1c has increased to 9.2%, and she has persisting osmotic symptoms. This would suggest that the patient is becoming insulin deficient and so insulin would be the most appropriate treatment for her.

Insulin Therapy in Type 2 patients NICE guidance

http://www.patient.co.uk/doctor/Insulin-Regimens.htm

Question 8

A 56 year old man attends clinic for his annual review. He has a ten year history of type 2 diabetes for which he takes metformin 1g bd. He is reasonably well and is employed as a construction worker driving JCB diggers. He denies any symptoms. He does not smoke and drinks approximately 10 units of alcohol mostly on a Friday. His HbA1c is 70 mmol/mol or 8.6% (<42 mmol/mol or 6%). His weight is 94kg and his BMI is 32.3 kg/m

. Which of the following would be the most appropriate approach to managing his diabetes?

This man has poorly controlled diabetes as reflected by his HbA1c. However, its important to recognise that his work entails the use of heavy machinery and therefore hypoglycaemic episodes should be avoided. NICE suggests that sulphonylureas such as gliclazide are best avoided in such circumstances due to their increased potential for causing hypoglycaemia. NICE recommends that the addition of a DPP-IV inhibitor to metformin would offer better control whilst avoiding hypoglycaemia eg Linagliptin or Sitagliptin. This would be expected to reduce his HbA1c by 0.5 to 1% (11 mmol/mol). In addition, promotion of lifestyle changes should be pursued at each visit.

http://www.patient.co.uk/medicine/Gliclazide.htm

Question 9

You are asked to see a 25 year old male who has type 1 diabetes who has been taken ill in the reception area whilst waiting to be seen for his annual appointment. He has become rather pale and sweaty. The BM meter reads 3.2 mmol/l and he is conversant lying on the couch but is a little confused. He usually takes mixed insulin twice daily. What would you do?

This patient is having a hypoglycaemic episode and should be treated with a short acting carbohydrate such as orange juice or milk. Alternatively the patient could have a glucose gel or another good alternative is raisins. Repeat the capillary glucose in 10-15 mins and if still hypoglycaemic further glucose can be administered. In those patients who are unconscious or uncooperative glucagon can be given IM or subcutaneously, or an IVI set up. After this inital treatment, the patient should then have a meal consisting of longer acting carbohydrates.

Treatment of Diabetes

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