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good afternoon, everyone. Let's welcome back, Doctor Richardson, that she's going to continue talking to us about time. Two diabetes management say Doctor Richardson, 30. Great, Thank you. How I everyone I'm Holly. And when they have to use at Manchester Royal Infirmary, I've done a few and crying lectures, and this one is going to be following on from Monday's lecture eso. On Monday, we talked for a bit about type one diabetes and how insulin works. So today we're going to go through the complications of all diabetes and then specifically, management off type two and which could be quite big topics. So if we do you ever run? Then I apologize, Um, and thank you for coming in, sitting inside on such a sunny day as well. So by the end of it, I ideally, everyone on this score would be able to list six complications of diabetes and why they occur on. We're also going to talk through six drugs that are used to treat type two diabetes on. You should have an idea of what would he would give those drugs in and what kind of indications for each patient would be and this is a recap in the last week session on with some of the words out. Um, if you just have a look through it. So if you could send in some of the words but them in the chat as well, then that would be a bit of a recap to make sure that it'll sunk in. I bring in. I don't know if you got the chatter, Doctor. Yeah. Okay. I'm just assuming out we'll take a minute of able to get a three. Yeah, I definitely don't have to say all the answers in the shot give you another 20 seconds or so. Okay. I'll just move on to the ancestor. I'd hate for this is what people had in mind. Um, so diabetes mellitus is a lot of fun. Condition of chronic hyperglycemia. Type one is caused by auto immune destruction of beater cells in the pancreatic islet of longer hands, usually in childhood or adolescents. This means no insulin could be produced and glucose levels rise. Replacement incident regimes have demonstrated below. The first regime is basal bolus, which is background insulin and top ups at mealtime. And the second is a buy phasic or mixed regime which is long acting and short acting. Mix together before injection. If a diabetic patient presents with a double pain and vomiting immediately. Check of the M, which is a blood sugar on the level of ketone, is in their blood or urine. As this may be diabetic ketoacidosis, this diabetic emergency is treated first with foods, then insulin deranged electrolytes. IgI Life threatening hypokalemia may occur. Not gonna get it during treatment because it will be and see. Then you give it and does get. The laser is very accurate answers coming in, so I think twice about something. And so this time we're gonna talk about Type two diabetes, which is not caused by lack of insulin on like a vengeance and is type one. Type two is where the B cells respond poorly to insulin on. That's usually due to chronic exposure. So that's why um, obesity is a risk factor. Because of these, patients are more likely to have had lots of lots of glucose voting about for decades, Some other outdated times. You might hear some people refer to juvenile onset diabetes, Um, in terms of type one that can be inaccurate because you can get certain types of type two that that start very early, and you can have people diagnosed with type one into their forties. It's red, but those times are inaccurate, and some people call type one I D. D M. Because you're very dependent on insulin on, you have to take it to survive. Um, and they can call Type two and I D. D. And that's also inaccurate because as well see later on in this lecture, Insulin is one of the last drug works that you would use to treat type two. Once you've exhausted all of your other option and that it's inaccurate, call them non insulin dependent. The risk factors for Type two diabetes. So obesity is that large on the left but the big one on. Then you can also see male gender, uh, men or twice is likely to get it. Three miles, um, elderly, old age, that's an older man there and ethnicity. So people from South Asia or Black African or Blackerby in a more likely to get diabetes on high BP and then on the picture on the right, you can see a family, and so Type two diabetes has a really strong genetic link. Where is Type one? Diabetes does not have a strong genetic like so here's the case today. A 50 year old with every single risk factor on the previous page walks into the GP surgery. He would like some general advice on how to stay healthy and his fifties. He takes a lot of peanut only. He also shows you a callous on his left foot that his wife noticed last week. He had not noticed it himself. Um, so hopefully everyone who knows which Lecter they're sitting in is fairly constant already. That this sounds more like diabetes and but some other things to pull out from that case, um, well, while mainly with the metals, I think it's important to say that he hadn't noticed it himself because they're different times of fiddles that you have come across Arterial and Venus vessels is arterial are exquisitely painful, and Venus it usually painful. Diabetic ulcer is are very often not noticed it all because of the neuropathy that's involved in diabetes on, So that's a distinguishing factor to help you with your ulcer. Is eso the next thing you want to see? If this man is an examination. So he's dystonic Lee. Well, he has got a small area of ulceration ulceration on the weight bearing anterior pad off his foot. Um, his BP is noted to be 104 7 98 so he's still hypertensive. A random blood sugar is 13.7 on a urine dip shows two pluses of glucose on nothing else. So you arrange for an HBA one C blood test to be taken. You'll remember from last week that we said that diabetes could be diagnosed by things like random blood glucose is is and or glucose tolerance tests on. Also, fasting really goes on. The cutoff for around really goes is a one. So if a patient has got a random blood glucose of over 11.1 on the other, signs and symptoms consistent diabetes such as this man's fertile. So then you can diagnose diabetes. However, you can also diagnose type two with an HBA one C blood test. Talk about the next page so HBA one C is to do with your hemoglobin levels on. It's a marker of the last 2 to 3 months of glycemia control, so glucose sticks to red blood cells on could be detected on the blood test. But this the blood cells take out to three months to degrade. And so it means that they last a lot longer and that they can be used as a marker of how much really goes. Approximately has bean in the circulation for the last few months, which is why it is usually used to monitor glycemia control. Because it might be the type one diabetic does really well at taking all their medicines on on the day before their appointments, they come into the clinic and they've got a great blood sugar. But they've had terrible control the last few months. That's what he's HBA one C particularly monitor monitoring, and we also use it to test for type two diabetes on those. The range is so he's definitely in the diabetic range, which is over 48 for blood. Count Waas normal on do his EKG F ah was 65 which means that he's got some level of kidney disease going on S O. It's likely that this guy has had undiagnosed diabetes for a while because he's had diabetes for enough time to get to certain complications so we can see that he's already got diabetic foot disease, which is one of the complications that we're going to talk about on. It's likely that it's his diabetes, which is also affecting his kidneys, because you can get kidney disease as a result off diabetes on. So now we're gonna talk about complications. Most of the complications that we talk out are in relation to glucose damaging blood vessels, and those could be big vessels or small blood vessels the way that glucose damages blood vessels. So with chronic exposure to hypoglycemia, you can get damage to the and the failure cells in the blood vessels. So you have really leaky vessels that are left elastic than before on that unable to regenerate themselves. So then the atherosclerosis process that you'll know about from your talks on heart disease and that you can see in this image here that's really accelerated. Um, so you ended with very prematurely after atherosclerosis vessels on, which means that wherever those vessels are leading, you have a reduced it by of blood and oxygen, which means that you can get ischemia. Um, because they're less elastic is well, it increases the risk of high BP. The diabetes can give you high BP. Um, on D, along with the damage to the blood vessels, you also get in. You know, suppression on diabetes can affect wound healing as well, so diabetics can come in with with ulcer. Is that just have have no healed given months and months of treatment because they don't have the capacity to go to get the blood spider. And then two, um, you know, do the retailing processes. And so these are, um I'm going to highlight six off the main complications of diabetes. You can see the red boxes are a lot pointing towards big blood vessels, which can be affected. So can anyone give me diseases that you might expect in those parts of the body that have got the red? The wrench textbooks is next to them. Yeah, thirst, Glory says so. If you go after the rice courses in the hot, which is about one of them is pointing yet. So I'm saying strike, which is good. Yeah, I think I'm gonna be able to get these are actually say Okay, be good. Straight heart disease. Um, claudications someone says the Claudications good. That's a sign of referral. Vascular disease. It's cramping pain. Jesus, poor blood supply in the peripheral arteries on. But we say peripheral arteries were almost always referring to the legs because those are the really long ones and the ones that have problems. People saying DVTs is no. That's because it's no. A venous problem is an arterial problem, but good guess. Okay, And now, looking at the microvascular problems. So these are very small vessels. Someone's put cataract, which is almost but retinopathy. That's what we're getting it with the eye so you can get eye disease due to damage to the small vessels that supply the retina. And then we're also getting the proper the very good On the final one bottle left, you're a fake. Perfect, um, so you can get damaged Teo all the nerves around the body, but again, because the long nerves air in the legs, you tend to notice the effects of, uh in the legs, and we call it glove and stocking Europe. The fee. So that's where you lose sensation to the parts of the body where you would wear gloves and stockings. So however you don't tend to see it in the hands very much at all, which is why I've crossed love out. Usually with diabetics, you will find that they just have very reduced sensation, kind of below the knee or in the foot. So stocking urography on then along with those you've got dental and gum disease. Diabetic foot disease, which will get onto in a minute on immunosuppression on poor wound healing. I've put a few notes here for myself, actually, so coronary artery disease is the cause of death of 80% of diabetic patients, so it's really, really important 80% to get on top of that and manage diabetic patients risk factors on also with the retinopathy. So diabetes is the leading cause of blindness in adults aged under 65. So again, really important on Drafted is some level of retinopathy affect 80% of people who've had diabetes for 20 years? Um, I've also put for anyone who's interested. People with Down Syndrome don't get diabetic retinopathy almost ever because they've got the extra chromosome 21 which gives them higher levels off substance called Endocet, in which stops the proliferation off the blood vessels in the retina. They just don't get diabetic retinopathy. Um, if anyone particularly minds looking at feeds, then I would look away. Now we're going to get some pictures. It's this is diabetic foot disease. They're lovely. Only, um, so diabetic foot disease has got multiple causes we were talking about neuropathy on. That's where you have trauma to the first on because you're lacking sensation. You don't realize that you've had trauma, eh? So any small cuts the diabetic gets, they might not realize that they've got them. And then they carry on applying pressure to that part of the foot and know giving it treatment or covering up in the plaster as that's one aspect of it. Then there's the scheme. Yeah, is also a problem supply, which inhibits wound healing. Um, on. Then that's compounded by the immune suppression that diabetics have. S O. N e ulceration that does occur is much more likely to results in infection. You can see the picture on the right is the infected one. Um, so you're more likely to get infections because they're it mean, you know, expressed anyway, um on. Uh, yes. So So when you are examining a diabetic foot. Make sure that you're pointing out some of those characteristics that are listed on the bottom rights, and they do tend to be paying less. Even though they look horrible, they tend to be on the weight bearing aspects of the foot so that particularly that one on the left on the anterior fat pads that would commonly be where it would appear on. You can see it's kind of punched out that you can see all of the layers in the rings was punched out from the inside. Um, anyone know what this is cold. This is a very specific time with diabetic foot disease. Is that chocolate foot chunk of it? Brilliant. Whoever said that well done and so shocked. If it is, I think kind of a bit more, Um, like academic. You don't really tend to see it so much on the ward's. But could you could definitely picked it in your exams. So Charcot Foot, which is a combination off the patient, may fracture small bones and therefore not realized that they've done it. They might get bits of micro trauma on. They also get chronic inflammation. Um, on that just got this lack of awareness. That means that they they don't They don't treat the foot before it gets really bad. Um, and and all of that gives you this rocker bottoms foot where they have completely lost their natural curves of the foot. That's diabetic foot to see, uh, diabetic eye disease. Um, you would commonly see it as retinopathy. I don't know how confident everyone is looking at the back of an eye if you say you're very confident that I don't think hopefully be. But this is I'm reading off the side here because I'm not very comfortable. Resting is Preper lifted retinopathy, which is cotton wool spots, hard extra dates on dot and blocked and marriages s. So it should be nice and even the whole way across the retina. Just with the the disc on the right hand side that you can see that they've got all that rubbish eat dark brown stuff all over and vision other than the way I would describe it. Diabetics able to go double the risk of cataracts and glaucoma. So with all of those complications is really important that diabetics have known to their local services on that they have monitoring because it's better to prevent all of these rather than treat them afterwards. Eso diabetics should have the HBA one c HBA one C taken every three months and or every six months or so. Solid regime on every diabetic should check their own feet every day because they can change so quickly. But they should be checked by a podiatrist or a doctor or someone who's going to look at their feet at least every 12 months or more often if they're having problems with them. And that was again. Annual eye check BP check cholesterol levels on kidney function, and the reason for BP and cholesterol levels is eso. Diabetes can contribute to high BP because of the reduced elasticity of the vessels. But also, if you've got all three of those things, diabetes have been pressure and high cholesterol, then your chances of a cardiovascular event occurring are huge, so that's why we re check those. And then kidney function is because of the number No focal fee. Um, so looking back at these complications, you can see a little ones in red or your micro vascular complications and the ones in blue and microvascular addicting. I said the little. So with these micro vascular complications, it's important that you do primary cardiovascular prevention for any of your patients who are at risk. Um, so you would want to assess whether your patient needs to be taking a statin on. There's a score that you can use to calculate a patient's 10 year cardiovascular risk. Does anyone know what the score was? Scoring system is called Cues, I said. Curious school three US three. Brilliant. Um, so you can use the cure risk. Three school on. They will receive atorvastatin. If they've got high risk, many of them will, um, for BP. You aimed for the same levels as non diabetics. It used to be the your name for lower, but it's changed, I think, within the last year or two on. So if the BP is higher than 148 90 do something about it. This is where it gets really like, really, um, going because you have learned that you give Kelsey, um channel blockers to your patients who are over 55 years old or who are black cabin black, African. That's the rule that you have meant from really early on. But actually, in diabetic patients, um, you give a sin. Hibbitts is two pretty much everyone or your angiotensin receptor blockers like losartan. So those are the drugs that you normally avoid in people with kidney disease, because they can cause nephrography. But weirdly, those drugs can damage kidneys in normal patients, but they protect kidneys in diabetes. I don't know why I tried to look it up for the selective. It'll go bit confusing. You just Just remember, the ace inhibitor is on detention. Receptor blockers, like missile time, are renal protective in diabetic patients. Only eso this patient, who in our case, study who result of a lot of pain, should probably be switched around problem. Um, and you give anti platelets only if they have known cardiovascular disease. You don't start those, uh, prophylactically. Okay, Now, I got, uh, the, uh, bit but could get it heavy. So Type two diabetes management. I've got a very simplified, um, simplified flow chart here, and I'm trying getting a head around this before you get into the specifics of which anti diabetic drugs, which on but most of your patients will first in the lifestyle changes, so lose weight. Stop smoking, exercise more. Then most patients come move onto metformin, which is your main anti diabetic drug. Through the the exception that would be your renally impaired patients and where you, instead of you straight on to the second line. Anti diabetic drugs, then the second line anti diabetic drugs. There were five of them or five classes on, but I'm going to talk you through all of those one by one. But they've all got silly names on. But all of the drugs found nothing like the name of their drug class s. So it's just a bit of time to get it into your head on, then finally, if the patients got difficult to control diabetes, then then you can move on to intravenous. Well, you start metformin. If the HBA one C is over 48 if it hasn't got better with lifestyle changes following on from that, the rule is that you can add a new drug. Um, when the HBA one C is over 58 this is a slightly more complex version off that flow charts. It would take me a long time to talk through all of it. So I'll just put it up there. And if anyone wants to take a photo that you can, um, you could just see the on the left is your patients with way out kidney disease, because Germany, they can take that form in. And then you just add, uh, drugs to make it double therapy, which is the second box down, or triple therapy, which is the third box? Uh, some tea, Um, sorry. Or on the right hand side, you can see patients who may have chronic kidney disease and you would start him on drugs that are not metformin starts off with. Okay, let's let's look at metformin. Um, so metformin is usually your first line treatment. The way that it works is it increases your sensitivity to insulin sensitivity body cells. Um, which means that they can take it more glucose, and it also decreases gluconate genesis, the things that you need to worry about if patient is really impaired. The reason for that is that metformin is really cleared so that it can accumulate in patients with renal impairment. It's know that metformin is nephrotoxic. Um and it can also cause GI upset. So diarrhea, nausea on Do you need to be wary of metformin during periods in which patients may experience tissue hypoxia. So by tissue hypoxia, I mean things like a heart attack, Because during that time, eso have sacral surgery. Actually s o at times when the body is under severe distress and some of your tissues might be poorly perfused, it's important to stop metformin because it can cause lactic acidosis, which is a serious complication. So you stop metformin for patients who are going into general anesthetic. Okay, sounds metformin. I see. In start patient on metformin, you give him lifestyle advice on you can switch him. It's amlodipine to ramipril. Um, cancel him on the likely side effects and he'll have all those check ups with his local diabetes team. So then two years later, he comes back into you and his HBA one c is poorly controlled. The first thing that the the diabetes thing would have done is is titrate is metformin dose up. So they've taken. It's a warm ground be D, which is your maximum dose. Um, but he's still struggling with his bunch of the levels. So what do you do now? Well, you've got all of these second line anti diabetic drugs that you're talking about. And I said there are five of these that will start now with number one, So finale areas a one of your options And these are things like little inside on the ultrasound, like, because I, um and it increases insulin production. Eso the body's own intrasellar, which would normally be making insulin make more insulin. Um, I think when trying to remember the side effects and how these drugs work, it's always just important to think where the glucose goes. So in this case, you get Morgan coz in cells, because the insulin is sending that goes into the cells and you get the last glucose in the blood. So from that kind of makes sense that you're likely to get things like hypoglycemia. Yes, because you're physically making more insulin. Some of the other drugs make you more sensitive to insulin, but you're not going to get hypoglycemia. Is I just be more sensitive to insulin because it's insulin that should have been, should have been working on getting it goes into those cells anyway. But if you're just having extra insulin, then you increase the risk of hypoglycemia. So, um, you get a thing. Morbid goes in your saddles, which means that you're going to get weight gain on then you've also got increased risk of cardiovascular disease, but I don't have a nice way of remembering that. So Sulfonylurea is, um, less commonly you can get pioplitazone. The class is called Fires Olinda Night. I can't say there's a little diet. Generally, people just a big letters own because it's the only one in that class that is currently licensed. So the mechanism is it increases sensitivity to incidence. As I was saying, you won't get high bows with this because it's insulin that should be working anyway. On it decreases hepatic gluconeogenesis. The reason that it is very ready you used is that it increases the risk of bladder cancer on. People aren't so keen on that as a side effect on. It's also got these side effects listed here. Weight gain, fluid retention, heart failure and so let's come leased. Then we got the ones that got silly names. So SGLT two inhibitors. SGLT two is a channel within the proximal tribunal of the kidney. Uh, proximal trouble of the nephron so you can see the diagram of where it sits in there from the, um, on board SGLT two and as reabsorption of glucose. So if you block that, then it means that you get, um, increased glucose in the urine because you haven't really solved it. Um, and it means that you decreased the amount of glucose in the blood. So I remember these because, um, they all end with good flows in and purple flows in chemical flows, and, um and you could remember glue flows into the urine. If I helps you, you're welcome. Um, so I think it is kind of intuitive, this one, Um, because if you are losing the total amount of glucose in the body on D, then what you're going to get because you're going to get weight loss, which is one of the real advantages of these, because a lot of patients who take it will be overweight Already. Those previous drugs were just getting glucose into the body cells. The total amount of glucose in the body was staying the same. Where is unless you're losing glucose out of the body in the urine? Um, sounds intuitive that you would get weight loss. Um, on then, the side effects kind of intuitive as well. Can anyone tell me what you think? Side effects you might get if you're getting gum. Well, you guys in your urine Beauty eyes. Yeah, you guys, the bacteria love growing in that sugary environment. Um, the UTI is a risk, and then you can also get it if anyone would have said this, but you go, I see Mick DKA and and if you think through it, that makes sense is well, we told about DKA last time. Diabetic ketoacidosis. That's the cause of DKA is when the body cells don't have enough glucoses to do that metabolic process is So instead of using glucose, they break down fats on. A byproduct of that is key tones on the raise level of ketose in the blood cause you to become acutely a well, and that's it dot It um so if you look at where the glucose is going, it's all going out in the year and none of us going into the cells. Still, your cells are still going coast poor and then consistent. Turn teo other sources or, um, for their energy like fat. So that means that you can have patients who go into DKA. But you have controlled the glucose level in that blood, which means that you could have a patient in DKA with a normal cm, which could be really scary when you're trying to assess a patient that you might miss. A. You buy scenic DKA because you take their budget sugar and it's normal. So you think fine, I can rule out that differential. But if you see a patient on epical flows and he's coming in with some pain and vomiting and you can't exclude DKA until you've taken a keto level, Okay, if that was, uh, three of those drugs the final two, um, kind of what? My the same mechanism. And it involves these hormones called incretins. So incretins are hormones which he naturally secrete in the G. I tracked in response to a large may go, and the function of incretins is that they they help you to absorb all of the glucose from your large meal. So you have you ever get a release for your injections. Your insulin secretion goes up, your glucagon production goes down on its lawyers down absorption from the GI tract. Um, so you can see that anything which, uh, boost your level of incretins or works like an incretin is probably going to be quite good management for type two diabetes. Um, however, can anyone tell me a side effect that you think that mimicking incretin might have based on the fact the incretins slow down absorption from the GI I tracked, they slowed absorption from the GI tract. If you massively accelerate that, anyone guess what kind of side effects you have The gastric distention, gastric distention door in your diarrhea. Yeah, Great. Everybody said that so, you know, absorbing it so it stays really watery. So both of these next drugs give you diarrhea? Okay. On They work by mimicking included in on inhibiting DPP. Full DPP four breaks down incretins. So if you stop DPP four, then you'll have more incretin. So these are the drugs GLP one mimetic. My GLP one is the main incretin. So essentially just does the work of the incretins. They're not so common because then, on tablets that given subcutaneously, um, they're not actually just given in diabetes, Some people take them for weight loss. Um, and they can cause GI. I upsets the diarrhea because they stop. You're absorbing everything from UTI tract. Um, weight loss. Dizziness on is a low risk of hypoglycemia, but nothing compared to the sulfonylurea is that we talked about earlier. And then the two sides of the same coin. So there's the ones that act as incretins on the left and then on the right. You got your DPP four inhibitors, which stop your incretins for being broken down. Um, and sit a gliptin, which is a DPP four inhibitor, is more commonly used than the ones which are given subcutaneously. So it's given orally, and in the cautions, it can cause gi I upset. So diarrhea on it can cause respiratory symptoms on grease itis as well. Okay, so you give the patient on big flows in, uh, which has the advantage of helping with his weight loss. Um, and we have already talked about the likely side effects, and people said that, uh, last time. So, um yeah, period here. The likely side effects. UT eyes aren't equal. I scenic DKA. Okay, that was quite heavy. Very happy. When we go through the questions to go through any of those bits again because they've all got silly names, and I'm happy to go for it. So this is a list off the six diabetic drugs that you should know bit about. Metformin is main one, and then the remaining five, Um, on as we saw with the flow chart earlier, you can, after metformin, usually moved to any of the other five based on your patients own risk factors and preference. It's not like you have to move from one to the other, and then you can in triple therapy combined. Three of these drugs. Um, so if you have a little back at that more complicated flow chart from earlier, that will give you an idea which ones you can you can combine. I'm following on from all of that. If your patients but because that'll still on controls, then you can put them on insulin and really difficult to control type team. You don't give insulin with other blood glucose lowering drugs because the chances of hypos are raised by too much and you can carry on with metformin. So I was management Type two diabetes I'm just gonna do is slide on gestational diabetes because it doesn't really sort in anywhere else. Um, so the risk factors are fairly similar to the risk factors With Type two diabetes East in the Asian ethnicity Family History of diabetes. Gestational diabetes is, um, reduced insulin sensitivity that you exclusively have during pregnancy, and it goes away pretty much immediately after birth. Um, you can treat it with lifestyle, lifestyle measures any country that with metformin or if it's really resistant, you can add insulin as well. But you don't tend to use those second line anti diabetic drugs. Um, there are complications. So with this huge supply of glucose on, baby can get really big. And that's macrosomia Big Baby on That can cause problems that your shoulder dystocia so huge baby trying to squeeze out of a narrow space on can get their shoulder stuck, which is an obstetric emergency on the neonatal. Hyperglycemia is where the babies have become accustomed to a really large the politically goes on. Then, after the struggles remained in that supply, just using milk, Um, and then there's also a higher chance for any of your ladies with gestational diabetes. We'll wait. I want to develop Type two diabetes was that one a lot quicker than I was expecting, actually, and I've listed three complications of diabetes that you should be aware of in the left. On the second half of the lecture, we went through the treatment of Type two diabetes, which is done in the order as displayed, and I'll go through the quiz now and then. We'll have time for bit of questions afterwards. So which of these does not need to be done yearly for diabetic patients for Check your knees, I examine me. See, J. Yep. Great. Easy, G. Um, they should all be having for checks and I exams and then you and eases to check for any kidney disease Well done. To which of these is not a relevant factor to consider when deciding to start metformin. Renal impairment, Elective surgery tomorrow. History of bladder cancer and irritable bowel syndrome. For the person asking what insulin sensitivity means, it means how likely your cells are. Teo, um, react to insulin in the proper way, so the proper ways that they take glucose from the bloodstream into the south. So if you've got reduced insulin sensitivity and the glucose stays in the blood stream and you get hypoglycemic. And so reduced insurance sensitivity is kind of the definition of type two diabetes. Everybody's put history of bladder cancer. Very good. So that be relevant if you're starting them on a collect his own, Um, but to go through the others are real impairment. You just you would prescribe metformin it a much lower dose for that. CGF are, and you wouldn't prescribe it a tall if the Jeff I was less than 30. Um, you would need to hold metformin for their elective surgery tomorrow, anyway, that you could start afterwards. You can start in two days, and on an irritable bowel syndrome, it doesn't necessarily mean it's It's definitely not contraindications. But if this person has got crippling lifelong diarrhea, then they may prefer not to go on metformin, which can cause a G. I upset final question, which is a side effect off. Little aside, I bet I see me a bladder cancer. Weight loss or pancreatitis is great, but it's like the lectures gone in. Or have you already knew? It s o. B. Correct answer is Blick was I'd at which is a sulfonylurea. Um, so bladder cancer is a side effect of pioplitazone weight loss could be caused by SGLT two inhibitors and GLP. One minute six. Um, pancreatitis is side effect off. DPP four inhibits is so that was the end of my grace. Um, well done. Everyone keep, uh, sending announces, Um, that was the fourth and a crime lecture. And this one, I've done overall. Eso just for people who wanted to know where this fits into, Like the long list of Endicott, the endocrinology that you need to know. We've covered everything in the grade. I'm going to be doing well, actually a few of the end of may and I think you've got some people come to go into crying as well, so hopefully they'll cover some of the things on the left hand side of the screen as well on d I. Yet if you wanted to know what's going learn independently than try some other things on the left hand side and oh, I don't know why it's lasting. And I have made a quest on the five lectures that we've done so far. That's 40 marks, endocrinology and 10 marks on Parkinson's. If you want to fill that and then you can do entirely and your own time. It's completely anonymous. So I'm not gonna be looking at what anyone has answered. And yep. So fill that in at any time that you want to. It doesn't create some feedback on me as a teacher at the end because of the blinds and teaching job. So anything back is useful for my CV on, But I think some of you got my email address. If if there is anything that you really wanted to ask about the quest, then you can email me Holly Doctor Richardson to at FT. Doctor in a chest dot UK a. Complete that in the trash. Few once. Please don't know. You know me all of your answers, because I will not be marking. Thank you, Doctor Richardson. There were a few questions up for, uh to school that quite early to dig. Take these out what we've got and you explain the mechanism of Charcot Foot Charcot. Yeah. Ah, shock. A fits. So a pitches shocking. Um, so with diabetic patients anyway, they have always like if they've got little bits of microtrauma like imagine you stub your toe you're you're acutely or wherever and it's really painful. And you then don't continue putting pressure on that toe or you've got a or some of your shoe is rubbing you. So you put plaster on at the end of the day. Diabetic patients just don't realize that that is happening with Sounds crazy, but you imagine that some of the like a lot of these patients are quite old and came or bit anyway. And, you know, it might be overweight and might not be looking down at the feet so much, um, on. But they said they have this micro chewable that they can get kind of chronic inflammation around the's sites of trauma as well. Um, and then that means that the tissues deformed. So it's literally just like the bits of tissue that already complained to push the other bits out of the way on a conveyor, a little fractures as well. I'm not realized that there there on, then you end up with. So you think you initially start with ulcers on. It's just if a patient with with ulcers continues to know, get them treated or continues to get um to get foot trauma in other ways, I mean This is my own Nicely. This is quite a nice set of skin on this foot. I think if you had a Charcot foot, you would normally see a lot. Moles is over anyway, but yes, So all of these little injuries can default the tissue and they end up with this, uh, for this Got the wrong angulations to it. Second, that include, um, fractures as well. Just get Yeah. Okay. Uh, no sensational docking. You see, next question was can you explain the poor wound healing? The diabetics have the core we're dealing. Okay. Okay. Um, so they like a large part of it is based on where the wound is. So if you've got wounds on your feet or or far away from your heart, then the blood supply to get to there is very poor because of all this damage to the arterial walls, eh? So you end up, it is very poorly refused. Um, so you can you remember those those were dealing. Get the sequence of how it happens on you don't have the energy to allow that entire process to happen. Um, yeah, You've got quite a bit. It's a before, and so Yeah. Poor blood supply on down in, you know, suppression as well. Um, yeah. And then that leads to a pool waiting to you know, I can't really answer much more than that. Thank you. So if you've got, um, poor blood supply and you've got neuropathy by the ulcers, um, purely neuropathic, or are they a combination of arterial on neuropathic ulcers? They are there anything you can your combination so, like, kind of, by definition, that diabetics would usually have arterial disease as well. So you can say it's a mixed arterial on diabetic also, So you can have exclusively arterial and you can have exclusively venous on. Then with diabetic ALS is, you would usually say, is a bit of like arterial elements to it as well. It was That did. That's the question. Yeah. Thank you. I'm sorry. Asks We did not make sense to start off with cell phone out your ears as they increase production of beater cells rather than metformin. Well, the issue with type two diabetes is that you are failing, Teo, that you have got reduced sensitivity. Teo. Insulin. So you're talking about so some of your drugs make you produce more insulin, and some of your drugs make you more sensitive to it on. But with Type two diabetics, the pathology is that I'm not sensitive to insulin anymore, so it makes more sense to reverse that and make them sensitive to insulin. So that's for things like metformin and also with a peel. It's own, but that's not very popular. It doesn't like making the fetal cells work really hard and produce lots of insulin is really a best first thing to fix the problem, because it's time one diabetics that I've got problems with the V cells, not type two. Thank you, Doctor asks, Um, is insulin given after other oral treatments fail? Or I guess, how do you decide when it's time for some insulin? I'm so you look, I'm just gonna leave that outside because I think, let it be, summarizes things nicely in a picture of that as well. If you want, um, so you follow back slow charts. So lifestyle metformin. Usually then all of your five drugs that extra that we discussed on day insulins really like debilitating for people's lives because they've always got to be checking the blood sugar levels and they can go into hypos and they've got to be doing injections. And it's different doses a long time S O. That is kind of last line, and it's on metformin plus one or two of these other anti diabetic drugs. If your HBA one C is still above 58 because 58 is the cut off of which he usually reads on to the next stage of treatment, then you would consider adding insulin. But look at the ones which cause hypoglycemia so so often I'll, um, you rate is primarily on, and sometimes things like GLP. One minute, six on. You don't want those drugs that can cause high hypoglycemia with insulin, because that's two drugs that can cause hypoglycemia, and you run the risk of a really dangerous hypo so you would usually stop those drugs. But you do carry with metformin, so sometimes you've got patients who are just on metformin and insulin because they've tried all of the with his eyes and flows in and they just lab slip. I'm just another question on timing of the the flow chart. Let's say Start with metformin and then you decide. I'm going to give yourself another your ear. Now you would have a situation where the glucose control with so called that you're going to actually jump in at more than one drug at a time. Or do you add on drug give a period of time to see the effect, then re evaluate? You don't really you? Because you can. You can monitor it like you can monitor it within a week. So, uh, within a couple of months, so like actually, people were absolutely atrocious. HB a one C's are. So someone 120 a few weeks Go on. No, you don't tend to add in multiple drugs because then, if they get, you know, some signing more vague side effects and you won't know which one is the problem. It's yet and also having high blood sugar. It's not kind of like a parchment. Very rare circumstances, Um, like DKA or hyper as motor hypoglycemic state, which is another diabetic emergency apart from in those situations, is never going to kill you that month like it's no animal Cincy. You've got time to try out different treatments and see which ones are helping. The patient's given a few weeks and see if it helps. Um, number asks, how is the immune suppression? Cause I feel like I'd be guessing. I know there are immuno suppressed. I don't know the mechanism behind. I'm sorry, baby. Look it up and put it in the fat few. Uh, if you're inclined. Sorry. Someone needs to go back. Yes. So So, um, right after the six, um, can can diabetes drugs caused be to sell depletion? Can, I guess kind of. Number of your beater cells go down because of the drugs you're being given. Um, I have I have not had that. I'm surprised. I would be surprised if they did, but it sounds like from the question someone thinks they might do it on the only ones that really affect your beater cells are sulfonylurea is. So consider the ones that affect the kidneys. Like SGLT two inhibitors. I can't see why that would change other things to the beach cells on, but the ones that affect incretin. I can't see that. Well, that would affect b cells either because, well, type two diabetics, B cells and usually working very hard anyway to try and find out the insulin to meets the the high levels of glucose that they have. Um, if they do cause Beach South placed in, then it's nothing that has ever affected me clinically again. Feel free to look that up for yourself. Brilliant. Um, when asked, Can't write one. Turning to type two. Yeah, So it can be the because time ones I take lots of insulin that they can get type two elements involved in their disease. On do there are sometimes overlaps with the medications aside from insulin. So, for example, type one diabetics who have a bm i over 25 off and put on metformin because they are more likely Teo their their body cells in type one, diabetics who are overweight more likely to become insensitive to insulin. Um, so metformin is usually a good treatment to decrease the likelihood of that. Um, yep. So it so you can get time to elements in type one A swell, but then the treatment stables, a mixture of the treatments for the two of them. She's down here in soon, and you can add a little the extra type T drugs. Brilliant. Thank you. So I think that's all the questions I can find in the chat. But if I have missed your drop it below, I get the other thing is can can you share the link to that quiz you've made? Yeah, it stops. Help. Um, I am I looking while, um, seconds.