Page 28 - World of Irish Nursing April 2018

Diabetes 47

Improving glycaemic

control in type 2 diabetes

early initiation of pharmacological therapy is associated with

improved glycaemic control and reduced long-term complications in

type 2 diabetes, writes Poochellam Muthalagu
Part two of a two-part article

PeoPle with type 2 diabetes and hyper- postprandial plasma glucose levels. failure, weight gain and hypoglycaemia. 4
tension should be treated to a systolic Metformin alters the composition of Thiazolidinediones
blood pressure goal of ≤ 140mmHg and gut microbiota and activates mucosal NICe recommends that thiazolidinediones
lower targets may be appropriate for cer- AMP-activated protein-kinase (AMPK) that (TZDs) should be considered as second-line
tain individuals. maintains the integrity of the intestinal therapy, in addition to metformin, if the
As a primary prevention strategy in people barrier. Metformin in combination with the risk of hypoglycaemia with sulphonylureas
with type 2 diabetes, in those at increased activation of AMPK decreases hepatic glu- would be unacceptable.
cardiovascular risk (10-year risk > 10%) coneogenesis. It also decreases intestinal TZDs increase insulin sensitivity by
aspirin therapy of 75mg/day should be con- absorption of glucose and improves insulin acting on muscle and adipose tissue to
sidered. Depending on risk, in most patients sensitivity by increasing peripheral glucose increase glucose utilisation and decrease
with diabetes aged 40 and above, remem- utilisation. 3 glucose production in the liver.
ber to use moderate or high dose statins. 1 Metformin reduces fasting blood TZDs act as insulin sensitisers; thus,
ADA/NICe recommends an HbA1c ≥ glucose by approximately 20% and they work in the presence of insulin. They
48mmol/mol (6.5%) as the threshold for HbA1c by 1.5%. It can be used in com- must be taken for 12-16 weeks to achieve
initiating or up-titrating therapy in general, bination with sulphonylureas, glinides, maximal effect. TZDs are associated with
while ≥ 58mmol/mol (7.5%) remains the alpha-glucosidase inhibitors, insulin, an increased fracture risk and in some
trigger for triple therapy. 2 thiazolidinediones (TZD), glucagon-like patients may lead to heart failure. There
4
Pharmacological therapy peptide-1 receptor agonists (GlP1), is also a possible increased risk of bladder
early initiation of pharmacological ther- dipeptidylpeptidase-4 inhibitors (DPP4), cancer with use of pioglitazone.
4
apy is associated with improved glycaemic and sodium-glucose co-transporter 2 Weight gain is the result of fluid reten-
control and reduced long-term complica- inhibitors (SGlT2). tion and the activation of PPAR-gamma
tions in type 2 diabetes. Metformin is contraindicated in patients in the central nervous system (which
The initial treatment is guided by the with factors that predispose to lactic increases feeding) and the up-regulation
level of HbA1c at diagnosis, the presence of acidosis, such as renal impairment, con- of genes that facilitate adipocyte lipid
osmotic symptoms, evidence of catabolic comitant liver disease or excessive alcohol storage.
state, and the presence of chronic diabetes intake, unstable or acute heart failure and Incretin-based therapy
complications that may preclude the use of hypoxia. 3 The incretin agents (GlP1 and GIP),
a particular therapeutic agent. Insulin secretagogues: sulphonylureas and secreted by intestine l cells, increase
In addition, a patient’s age, body weight, meglitinides insulin secretion and inhibit glucagon in
convenience of administration, and impact Sulphonylureas are commonly used as response to nutrient inputs. The glucor-
on work-related issues (such as driving second-line agents in patients with type egulatory effects of incretins are the basis
motor vehicles) also play a crucial role in 2 diabetes, They can act as an alternative for treatment with inhibitors of DPP4 in
determining the order of medications used. first-line treatment if the patient cannot patients with type 2 diabetes. Agents that
The efficacy and side-effect profile of each tolerate metformin and if the patient is not inhibit DPP4, an enzyme that rapidly inac-
drug in the individual patient is also taken overweight. Sulphonylureas can also be tivates GlP1, increase active levels of these
into account. added to metformin if glycaemic control is hormones and, in doing so, improve islet
Metformin inadequate. Sulphonylureas stimulate pan- function and glycaemic control in type 2
Metformin is considered the agent creatic beta cells to release insulin. diabetes. 4 WiN Vol 26 No 3 april 2018
of first-line for treatment of type 2 The glucose-lowering effect is said to be Dipeptidyl peptidase-4 inhibitors: DPP-4
diabetes in the absence of contraindi- high for sulphonylureas. The main side-ef- inhibitors (eg. sitagliptin, saxaglip-
cations. Metformin lowers basal and fects are loss of efficacy due to beta cell tin, linagliptin, vildagliptin) are a class