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Type 2 diabetes mellitus (Risk factors (Age, Male gender, Ethnicity …

- - - - Statin
        Indication: ALL patients
        E.g. simvastatin, atorvastatin
        MOA: reduce cholestrol, reduces CV risk
      - Anti-HTN
        Indication: HTN or proteinuria
        E.g. ACE-i
    - - Sulphonhylurea
        1L if metformin CI; 2L as add on therapy with metformin
        E.g. gliclazide
        MOA: promote insulin secretion
        SEs: hypos, weight gain
        CI: elderly/renal failure, obesity
      - Meglitanides
        Indication: add on therapy
        E.g. repaglinide
        MOA: promote insulin secretion, short acting
      - Biguanide
        Indication: 1L if not controlled with diet alone
        E.g. metformin
        MOA: reduced glucose production by liver,
        sensitises target organs, promotes weight loss
        NB. must monitor renal function (risk lactic acidosis)
        SEs: nausea, abdominal pain
        CI: severe heart/renal/liver disease, iodine contrast
      - DPP-4 inhibitors
        1L if metformin CI; 2L as dual therapy with metformin/another,
        3L as triple therapy with metformin plus another drug
        E.g. sitagliptin
        MOA: prevent insulin breakdown by DPP-4 enzyme
        SEs: weight loss, N+V
      - Thiazolidinediones (glitazones)
        1L if metformin CI; 2L as dual therapy with metformin/another,
        3L as triple therapy with metformin plus another drug
        E.g. pioglitazone
        MOA: PPAR-Y agonists, activating genes involved in lipid metabolism and insulin action, reduce hepatic glucose production and increase peripheral glucose uptake
        SEs: peripheral oedema, HP, anaemia, osteoporosis
        CI: HF
      - a-glucosidase inhibitors
        Indication: add on therapy
        E.g. acarbose
        MOA: acts in the small intesting,
        inhibits a-glucosidase preventing glucose abs
        SE: bloating, flatulence, diarrhoea
      - SGLT2 inhibitors
        1L if metformin CI; 2L as dual therapy with metformin/another,
        3L as triple therapy with metformin plus another drug
        E.g. dapagliflozin
        MOA: inhibit SGLT2, preventing glucose reabs
        in PCT of kidney, causes glucose loss in urine
        SEs: UTI, weight loss, polyuria, hypotension
      - GLP-1 agonists
        Indication: add on therapy 4L
        E.g. exanetide
        MOA: promote insulin release
        SEs: weight loss, N+V
        CI: renal failure (GFR<30)
    - - Indication
        Diet and 1L/2L medical tx not worked
      - Types
        
        Ultra short acting
        Indication: match endogenous insulin
        E.g. novorapid, humalog
        MOA: ultra fast onset (<15m), short duration (2-5h);
        used just before meals, match consumption
        
        Short acting soluble
        Indication: match endogenous insulin
        E.g. isophane insulin, Actrapid, Humulin S
        MOA: fast onset (15-30m), lshort duration (<8h)
        Use before meals, match to intake
        
        Intermediate acting
        Indication: mimic basal insulin
        E.g. isophane/NPH insulins, Humulin I, Insulatard
        MOA: slow onset, long duration, achieves steady-state level; mixed with retarding agents to release slowly
        
        Long acting
        Indication: mimic basal insulin, long lasting
        to prevent nocturnal/AM hypos
        E.g. insulin glargine (Lantus), insulin detemir, insulin glutadec
        MOA: slow onset, long duration, achieves steady-state level; mixed with retarding agents to release slowly
        
        Mixed combinations
        Indication: long lasting basal and endogenous
        E.g. NovoMix 30/70
        MOA: fast acting mimic endogenous, slow release mimic basal
      - Regimens
        
        Biphasic (OD, BD, TDS)
        Indication: regular lifestyle and mealtimes
        E.g. NovoMix 30/70, Humalog 25/50
        MOA: SA insulin premixed with IA insulin
        
        Basal bolus (QDS)
        Indication: flexible lifestyle (meals and exercise)
        MOA: separate injections of SA for meals and IA/LA for night
      - Side effects
        Hypoglycaemia
        Injection site (lipohypertrophy, local reactions, abscesses
        Weight gain
      - Dose adjustments
        Indcation: intermittent illness, exercise, altered intake
        MOA: titrate to target; need increased insulin when ill
        despite reduced intake; do frequent BMs (4x/d)
      - Administation
        SC via vial, pre-filled pens, cartridge fillable pens