Type 2 diabetes

• Type 2 diabetes is a condition where a combination of insulin resistance and reduced insulin production cause persistently high blood sugar levels.
• Non-modifiable risk factors:

  • older age
  • Ethnicity - black African or Caribbean, south Asian
  • Family history
• Modifiable risk factors:

  • Obesity
  • Sedentary lifestyle
  • High carbohydrate diet
• Presentation:

  • Tiredness
  • Polyuria and polydipsia (frequent urination and excessive thirst)
  • Unintentional weight loss
  • Opportunistic infections (e.g. oral thrush)
  • Slow wound healing
  • Glucose in urine (on a dipstick)
• Acanthosis nigricans is characterised by the thickening and darkening of the skin (giving a “velvety” appearance), often at the neck, axilla and groin. It is often associated with insulin resistance.
• An HbA1c of 42 – 47 mmol/mol indicates pre-diabetes
• An HbA1c of 48 mmol/mol or above indicates type 2 diabetes. 

  The sample is typically repeated after 1 month to confirm the diagnosis (unless there are symptoms or signs of complications). 
• If the patient is symptomatic of diabetes a single abnormal HbA1c or fasting glucose level > 7.0 mmol/L is sufficient to diagnose diabetes
• The NICE guidelines (updated 2022) recommendations on managing type 2 diabetes include:

  • A structured education program
  • Low-glycaemic-index, high-fibre diet
  • Exercise
  • Weight loss (if overweight)
  • Antidiabetic drugs
  • Monitoring and managing complications
• Diabetic patients should be offered immunization against influenza and pneumococcal infection
• Medical management:

  • Standard release metformin - taper dose up over several weeks
  • Once metformin tolerated add SGLT-2 inhibitor e.g dapagliflozin
  • Second line is to add a sulfonylurea, pioglitazone or DPP-4 inhibitor
  • If HbA1c still not optimal commence triple therapy with metformin and 2 other oral agents or consider insulin therapy
  • If triple therapy fails and the patients BMI is above 35 there is the option of switching one of the drugs to a GLP-1 mimetic
• HbA1c targets:

  • 48 mmol/mol for patients that are diet controlled or on one antidiabetic medication that does not cause hypoglycaemia e.g. metformin
  • 53 mmol/mol for patients on more than one antidiabetic mediation or one that causes hypoglycaemia
• ACE inhibitors are used first-line to manage hypertension in patients of any age with type 2 diabetes. 
• Patients should have their urine albumin tested at every annual diabetic review
• Key complications of type 2 diabetes are:

  • Infections (e.g., periodontitis, thrush and infected ulcers)
  • Diabetic retinopathy
  • Peripheral neuropathy
  • Autonomic neuropathy
  • Chronic kidney disease
  • Diabetic foot
  • Gastroparesis (slow emptying of the stomach)
  • Hyperosmolar hyperglycemic state
• Investigations:

  • HbA1c - 48 or higher
  • U&Es - diabetic nephropathy and metformin is nephrotoxic
  • LFTs - fatty liver disease is associated with T2DM
  • Cholesterol and lipids
  • Urine albumin-creatinine ratio - raised in diabetic nephropathy
• If urine albumin-creatinine ratio is raised, should be started on an ACE inhibitor regardless of blood pressure - reduces proteinuria