triple therapy of type two diabetes

Help me please?!

Ive read the NICE guidelines but I'm getting myself confused .. can anyone dumb it down for me please?

If initial diet / exercise control has failed, start off with metformin (biguanide). Monitor HbA_1c. If HbA_1c > 6.5%, add in a low-cost sulfonylurea, e.g. gliclazide (use a DPP-4 inhibitor e.g. sitagliptin instead if high risk of hypoglycaemia or if sulfonylureas are contraindicated). Monitor HbA_1c. If HbA_1c > 7.5%, consider adding in either a DPP-4 inhibitor (if not already on it) or a thiazolidinedione, e.g. pioglitazone. If HbA_1c > 7.5%, add in insulin. If HbA_1c > 7.5%, consider intensifying insulin treatment, e.g. using twice-daily biphasic human insulin, especially if HbA_1c > 9.0%.

Hope this helps!

how do you know this crap!!!!

how do you know this crap!!!!

http://www.nice.org.uk/guidance/cg87/chapter/1-guidance - There is a guideline, memorize and breakdown to the important parts

As above

I've learnt this though, it sums the NICE guidelines up very well: http://pathways.nice.org.uk/pathways/diabetes#path=view%3A/pathways/diabetes/blood-glucose-lowering-therapy-for-type-2-diabetes.xml&content=view-index

so were supposed to memories all that?! yikes:O

just for type 2 diabetes and all!

was it on a test or...

so were supposed to memories all that?! yikes:O

just for type 2 diabetes and all!

was it on a test or...

The detail you actually need to know is going to depend on which course, what stage you're at and which university. They don't all teach the same thing.

Once you become familiar with the drugs and the lab values you gradually start to piece it together through the use of the guideline.

so were supposed to memories all that?! yikes:O

just for type 2 diabetes and all!

was it on a test or...

Probably will be on the final exam this year - it was in lectures in our Type 2 DM case this year and all the lecturers seem to love including NICE guidelines in their lectures and exam questions, especially for the hypertension case we had in January.

**** we just started hypertension **** its tough

currently doing OSCE's flip theyre hard...how you finding second year yourself?

Yeah, it's going well. Just found out when I've got my OSCE this year - late May.

Hypertension is fairly straight forward initially: if the pt is under 55 or of non-Afro-Caribbean descent, start off with an ACE inhibitor, e.g. ramipril. If not tolerated, switch to an ARB, e.g. losartan. If the pt is over 55 or of Afro-Caribbean descent, start off with a dihydropyridine CCB, e.g. amlodipine. If the pt is still hypertensive, combine the two drugs. If the pt is still hypertensive, add in a thiazide-like diuretic, chlortalidone is the one recommended by NICE. If the pt has other co-morbidities, e.g. Type 2 DM, use an ACE inhibitor regardless of age. If the pt has had a previous MI or suffers from AF, consider using a rate-limiting CCB instead of a dihydropyridine one, e,g, diltiazem or verapamil, or a cardioselective beta-blocker, e.g. atenolol or metoprolol. If the pt is male and has benign prostatic hyperplasia (BPH), use an alpha-blocker, e.g. tamsulosin.

Essentially, the aim is to have the pt on as few drugs as possible, so you try to use drugs that have multiple indications / effects.

ah a while yet!

is there a flow diagram you learned that from too? were never given notes like that :I

then again you probably look up all these things anyways haha

ah.good point

This is the one that was used in lectures - a joint guideline created by the British Hypertension Society and NICE:

cheers much easier to learn when you know that

even if its not necessary for the exam!

If initial diet / exercise control has failed, start off with metformin (biguanide). Monitor HbA_1c. If HbA_1c > 6.5%, add in a low-cost sulfonylurea, e.g. gliclazide (use a DPP-4 inhibitor e.g. sitagliptin instead if high risk of hypoglycaemia or if sulfonylureas are contraindicated). Monitor HbA_1c. If HbA_1c > 7.5%, consider adding in either a DPP-4 inhibitor (if not already on it) or a thiazolidinedione, e.g. pioglitazone. If HbA_1c > 7.5%, add in insulin. If HbA_1c > 7.5%, consider intensifying insulin treatment, e.g. using twice-daily biphasic human insulin, especially if HbA_1c > 9.0%.

Hope this helps!

thank you ! The part i don't get and confuses me is the part about adding basal insulin (for dual therapy). When does that get added and what is it given in combination with?
Im a bit confused how basal insulin differs from normal insulin used in triple therapy.

Thanks for your help

thank you ! The part i don't get and confuses me is the part about adding basal insulin (for dual therapy). When does that get added and what is it given in combination with?
Im a bit confused how basal insulin differs from normal insulin used in triple therapy.

Thanks for your help

I think basal insulins are products like insulin glargine, which provide a constant supply of insulin throughout the day, mimicking physiological insulin secretion.

1.7.1.1 When starting basal insulin therapy:

- continue with metformin and the sulfonylurea (and acarbose, if used)

- review the use of the sulfonylurea if hypoglycaemia occurs.

1.7.1.2 When starting pre-mixed insulin therapy (or mealtime plus basal insulin regimens):

- continue with metformin

- continue the sulfonylurea initially, but review and discontinue if hypoglycaemia occurs.




It wouldn't be considered physiological unless it was combined with rapid acting doses as well (i.e. mimicking what the pancreas does - low dose baseline with spikes at meals.