Type 2 Diabetes Management

TYPE 2 DIABETES (T2DM)

  • Estimated 4.5 million people with diabetes in the UK; over 3 million in England.
  • 5 million people at high risk of developing T2DM.
  • Prediction: 1 in 3 people will be obese by 2034; 1 in 10 to develop T2DM.

CHARACTERISTICS OF T2DM

  • Accounts for approximately 90% of diabetic patients, primarily between ages 40 and 80.
  • Polygenic condition with no HLA associations; no immune disturbance.
  • Insulin resistance in peripheral tissues; insulin levels can be normal or high.
  • Hyperglycaemia may also arise from insufficient insulin secretion.
  • Obesity is a common feature, acting as a trigger in genetically susceptible individuals.
  • Rising incidence of T2DM in younger populations due to obesity.

CLINICAL FEATURES

  • Symptoms resemble Type 1 Diabetes Mellitus (T1DM) like thirst and polyuria, but are less severe and develop over months.
  • Additional complaints: lack of energy, visual issues, recurrent fungal infections (e.g. candidiasis).

PATHOPHYSIOLOGY OF SYMPTOMS

  • Polyuria: Caused by osmotic diuresis when blood glucose exceeds renal capacity for reabsorption.
  • Thirst: Resulting from fluid loss and electrolyte imbalance.

DIAGNOSIS OF DIABETES MELLITUS

  • Fasting plasma glucose ≥ 7.0 mmol/L (after 8 hours of fasting).
  • Random plasma glucose ≥ 11.1 mmol/L (meal timing irrelevant).
  • HbA1c ≥ 48 mmol/mol (6.5%) indicates chronic hyperglycaemia.

MANAGEMENT OF T2DM

  • First-line approach: Lifestyle modifications:
    • Weight loss, balanced diet, smoking cessation, regular exercise.
    • Careful monitoring of carbohydrate intake and balanced nutrient distribution throughout the day.
    • For overweight adults, an initial weight loss target of 5–10%.

ORAL ANTIDIABETIC DRUGS (OADs)

  • Prescribed if lifestyle changes don’t suffice after 3 months.
  • Used to supplement diet and exercise, not replace them.
Main Classes of OADs:
  1. Biguanides (e.g., Metformin) - 1st line treatment, reduces glucose output, increases utilization.
    • Side effects: gastrointestinal issues, rare lactic acidosis.
  2. Sulphonylureas (e.g., Glipizide) - Stimulate insulin secretion, risk of hypoglycaemia.
    • Avoid in obesity and severe hepatic/renal impairment.
  3. DPP-4 Inhibitors (e.g., Sitagliptin) - Increase insulin secretion and lower glucagon secretion.
  4. Thiazolidinediones (e.g., Pioglitazone) - Enhance insulin receptor sensitivity but risk of heart failure.
  5. SGLT-2 Inhibitors (e.g., Dapagliflozin) - Improve glycaemic control via increased glucose excretion in urine, associated with risks such as Fournier’s gangrene and DKA.
  6. Alpha-Glucosidase Inhibitors (e.g., Acarbose) - Impair carbohydrate digestion but limited use due to side effects.
  7. Post-prandial Regulators (e.g., Repaglinide) - Stimulates insulin release shortly before meals.

MONITORING T2DM

  • Every 3 to 6 months until stable; then biannual monitoring.
  • HbA1c targets:
    • 48 mmol/mol (6.5%) for diet/lifestyle or single OAD.
    • 53 mmol/mol (7.0%) if using combination therapies or OADs associated with hypoglycaemia.

DIABETES AS A RISK FACTOR FOR CVD

  • Diabetes significantly increases cardiovascular disease risk; needs concurrent management of hypertension and lipid levels.
  • Lifestyle interventions are crucial to reduce additional risks from smoking and obesity.
Blood Pressure Targets:
  • <140/90 mmHg (<80 years).
  • <150/90 mmHg (≥80 years).

STEP-WISE MANAGEMENT

  1. Start with metformin unless contraindicated.
  2. Add SGLT2 inhibitors if high CVD risk.
  3. Intensify drug therapy if HbA1c not under control to targeted thresholds.
  4. Consider GLP-1 receptor agonists or insulin if other options are ineffective.

EDUCATIONAL PROGRAMS

  • Programs like DESMOND and X-PERT help manage T2DM effectively.