An Introduction To Diabetes Flashcards
What are the four T’s to look out for in T1 diabetes?
The four T’s – toilet, thirsty, tired and thinner
What is DKA?
Diabetic Ketoacidosis:
where body completely switches to lipid metabolism – ketones = product
Presentation of T1 diabetes?
- Nearly a quarter of patients will present with Diabetic Ketoacidosis (DKA).
- The four T’s – toilet, thirsty, tired and thinner
- Community pharmacy = look out for signs, oral thrush, vitamins if child feeling run down
Presentation of T2 diabetes?
- Often not symptomatic
- Like type 1 but slower onset and less extreme
- Increased episodes of genital thrush
- Slow wound healing
- Routine checks are when it is usually picked up (blood sugar high)
- Complications e.g. stroke, infection not healing, heart problems etc
- Tends to be older patients
- Larger bmi
Compare T1 diabetes to T2 diabetes:
T1 =
- no insulin produced
- Quickly life threatening
- Usually diagnosed in childhood - they have no real risk factors (slightly genetic)
- Treatment = replace insulin
- No diet restrictions – just careful monitoring of carbs
- More likely to have complications
- No risk factors (slight genetic link)
T2= ▫ Insulin is usually produced but body doesn’t respond to it adequately ▫ Rarely life threatening unless left for a long time ▫ Much of treatments is via diet and exercise ▫ If you lose 20% of your body weight after being diagnosed, you can pretty much put that diabetes into recession. ▫ Insulin is last option ▫ Still have complications ▫ Often diagnosed in adulthood ▫ Lots of risk factors o Ethnicity o Age o Obesity o Genetics o Smoking/alcohol o Raised BP o PCOS o Poor sleep▫
Oral therapies for type 2 diabetes:
Reduce hepatic glucose out put (injectables)
- Metformin, Pioglitazone, DPP-4 inhibitors, GLP 1 agonists
- most drugs have a secondary effect on reducing how much glucose your liver produces – DDP-4 alagliptin
Oral therapies for type 2 diabetes:
Delay carbohydrate absorption
- acarbose popular in east (because of cheap) stops you digesting carbohydrates – unpleasant side effects
- Acarbose, GLP 1-agonists
Oral therapies for type 2 diabetes:
Enhance action of incretin
GLP 1 agonists require a high BMI (injectables) they slow gastric emptying so you feel fuller for longer, incretin is the hormone from the stomach that sends a signal to the pancreas to make insulin. DDP-4 is the enzyme and works on the same pathway,
Oral therapies for type 2 diabetes:
Enhance insulin secretions
Sulfonylureas, Meglitanides
Oral therapies for type 2 diabetes:
Reduce peripheral insulin resistance
- Pioglitazone, Metformin
- improbing muscles uptake of glucose (type 2)
Oral therapies for type 2 diabetes:
Reduce glucose re-uptake from glomerular filtrate
- SGLT-1 inhibitors
Advantages and disadvantages of metformin?
Advantages
• Cheap
• Weight neutral
• Low risk of hypo
Disadvantages
• Commonly causes GI side-effects – often started with meals.
• Rare but serious side-effect of lactic acidosis – cannot use in patients who have a high risk of lactic acidosis e.g. patients who have had a heart attack, sepsis, respiratory problems etc.
• Short t1/2 so TDS frequency. However, MR available but more expensive.
• Caution in egfr<45
• Contraindicated in egfr <30
Advantages and disadvantages of Sulfonylureas e.g. Glicalzide :
Advantages
• Can be OD or BD
• Quickly lowers cBG so improves symptoms
• Fewer GI side effects than metformin
Disadvantages
• Can cause hypos. Issue if you drive or live alone.
• Can cause weight gain
• Need residual pancreas function
• Can be un-predicatable in renal impairment and in the elderly (problem in elderly due to risk of falls caused by hypos)
Advantages and disadvantages of Pioglitazone:
Advantages
• OD dosing
• Low risk of hypo
• Suitable in renal impairment
Disadvantages
• Associated with heart failure. Because it causes fluid retention.
• Increased risk of bladder cancer and fractures. Not advisable for people with osteoporosis.
• Causes weight gain
• Rarely causes liver toxicity
• Can take 3-6 months to show benefit. Not a good choice for someone who is symptomatic.
Advantages and disadvantages of DPP-4 Inhibitors:
Advantages • Once a day • No weight gain • Low risk of hypo • Some can be used in renal impairment
Disadvantages
• Commonly causes GI side-effects, rash and UTI
• Rarely causes pancreatic inflammation
Advantages and disadvantages of SGLT-2 Inhibitors?
Advantages
• Can cause weight loss
• Can reduce BP
• Low risk of hypo
Disadvantages
• Can cause thrush and UTIs especially on starting treatment
• Only effective if reasonable renal function
• Lower BP can increase fall risk
• Risk of DKA
• ?risk of kidney injury and foot ulcers?
Advantages and disadvantages of GLP-1?
Advantages
• Weight loss
• Once a day (or weekly with some preparations!)
• Rarely cause hypos
Disadvantages • Injections as they are a big molecule • Need BMI greater than 30 • Severe GI side-effects are very common • Suitable in moderate renal impairment • Rarely causes pancreatitis
What is the aim of insulin?
Keep as close to a non-diabetic as possible
Type 1 diabetes insulin regimen?
Basal bolus
▫ One (or two) long acting in evening (and morning)
▫ 3 doses of short/ rapid acting during day before meals
Biphasic (insulin and salt)
▫ Two biphasic insulin doses, one in the morning and one at teatime
▫ Dose split (breakfast/teatime) dependent on when biggest meals is eaten
▫ Some insulin sticks to the salt whereas some of it is free in solution and acts immediately on the cells. The insulin stuck to the salt starts to break off and has its effect.
hat does a ‘normal’ insulin profile look like?
Insulin is released as soon as blood sugar increases
First line therapy for T1 DM in adults and children?
- Long-acting insulin analogue ONCE daily (night-time)
- Long-acting insulin analogue TWICE daily (breakfast and night-time)
- Rapid acting insulin analogue THREE times daily
- With meals
- Dose based on carb intake
What is short acting insulin (onset, peak and duration) and give examples.
Soluble
- onset 1/2-1 hour
- peak 2-3 hours
- duration 8-10 hours
Examples: • Human Actrapid® • Humulin S • Insuman Rapid® • Human insulin – recombinant DNA
Give onset, peak and duration and give examples of rapid acting insulin analogues:
▫ onset 5-15mins
▫ peak 30-90 mins
▫ duration 4-6 hrs
- Humalog® = Insulin Lispro
- Novorapid® = Insulin Aspart
- Apidra® = Insulin Glulisine
Give onset, peak and duration and give examples of Intermediate acting insulin:
Shake before use as protamine sinks to the bottom.
• Isophane (Neutral Protamine Hagedorn=NPH)
- onset 2 – 4 hours
- peak 4 -10 hours
- duration 12-18 hours
- Human insulatard
- Humulin I
- Insuman Basal
