Diabetes Flashcards

Question

T o F Sulphonylureas should be reviewed in elderly patients?

Answer 1

The use of SU’s in the frail elderly should be reviewed. Episodes of hypoglycaemia can worsen dementia and confusion and increase the risk of falls and cardiac arrythmias.

Answer 2

* Hepatic - avoid in severe. Caution in mild to moderate (consider reducing inital dose/maintanince) - risk of hypo * Renal - Avoid in severe. Caution in mild-mod. Gliclazide can be used in severe impairment as primarily metabolised in liver but care should be taken.

Answer 3

Gliclazide IR and MR are not equipotent (I.e. 80mg IR = 30mg MR).

Answer 4

Examples include: alogliptin, sitagliptin, linagliptin

Answer 5

Dipeptidyl peptidase-4 is an enzyme released by the gut to rapidly breakdown the incretin hormone, glucagon like peptide-1 (GLP-1) and glucose dependant insulinotropic polypeptide (GIP). GLP-1 and GIP levels normally increase in response to food. By inhibiting DPP-4 the gliptins increase the time that GLP-1 and GIP are circulating and enhances their ability to increase insulin production and secretion. GLP-1 is also responsible for inhibiting glucagon secretion and glucose production in the liver.

Answer 6

DPP-4 inhibitors are prescribed as a single dose to be taken once daily. There is no dose titration but many of the gliptins needs to be prescribed at a reduced dose in renal impairment.

Answer 7

The gliptins are fairly well tolerated. The most commonly reported adverse effect with alogliptin therapy was headache. They may increase the risk of hypoglycaemia when taken in combination with insulin or SU’s which may necessitate a reduction in the insulin or SU’s but are in themselves considered to be a low hypoglycaemic risk option. Patients should be warned of the symptoms of acute pancreatitis (persistent, severe abdominal pain which may radiate to the back) although the incidence of this is low. Caution (not-reccomended) in mod-severe HF (little evidence)

Answer 8

F - weight neutral

Answer 9

They have a low to moderate efficacy, typically reducing HbA1c by 0.5%. Treatment with these should only be continued if HbA1c falls by more than 0.5% (5.5 mmol/mol) in 3-6 months.

Answer 10

Dapaglafozin, empaglaflozin, canagliflozin

Answer 11

**Summarised:** These increase urinary excretoin of glucose. They do not rely on endogenous insulin being present as they work entirely in the kidney to reduce the uptake of glucose from the glomerular filtrate. The amount of glucose lost depends on the blood glucose levels and the glomerular filtration rate. SGLT’s also reduce the reasorption of Na+, produce diuresis and a small reduction in blood pressure. Seen to have CV benefits. ** Detailed:** SGLT2 inhibitors aim to increase urinary glucose excretion to lower glucose levels in diabetic patients. In a healthy individual, the kidneys are able to filter through approximately 180 grams of glucose per day. All of that glucose is reabsorbed into the bloodstream through two sodium-glucose transporters, SGLT1 and SGLT2. In healthy subjects, the amount of glucose re-absorbed by SGLT1 and SGLT2 and equal to the amount of glucose filtered by the glomerulus. Hence there will be no glucose in the urine when you are not diabetic. In diabetic patients, the kidneys become saturated with more glucose than it can reabsorb. At a certain glucose concentration, the glucose flux becomes too high and the glucose transport system, SGLT 1 and SGLT 2, become saturated and cannot reabsorb the glucose back into the bloodstream. All of the filtered glucose in excess of this threshold is excreted in the urine. SGLT 2 inhibitors work by blocking the SGLT2 transporter and preventing the reabsorption of glucose, and allowing for more glucose excretion through the urine. SGLT2 inhibition lowers the maximum re-absorptive capacity of the proximal tubule and lowers the renal threshold for glucose. Therefore, treated subjects will start to renally excrete glucose. The amount of excreted glucose is dependent on the glucose filtration and therefore dependent on the blood glucose values. Empagliflozin does not inhibit other glucose transporters important for glucose transport into peripheral tissues and is 5,000 times more selective for SGLT2 compared with SGLT1, the major transporter responsible for glucose absorption in the digestive system. This is useful because unlike many current therapies, the mechanism of action of SGLT2 inhibition is independent of insulin secretion or insulin resistance. SGLT2 inhibition removes glucose directly. It has been shown that there is a significant added benefit to cardiovascular risk reduction when using the SGLT2 inhibitor, Empagliflozin.

Answer 12

The efficacy of SGLT2s depends on renal function. SGLT2’s should not be initiated if CrCl <60mL/min. Dose needs to be reduced and may need to be avoided. See individual monographs. Renal function should be monitored before starting, if new meds which impact RF are started and at least annually.

Answer 13

Lower limb amputation (particularly toes) has been reported. Hypoglycaemia can occur with SGLT2 inhibitors, but occurs more frequently if co-prescribed with another hypoglycaemic agent. Vulvovaginitis and genital infections are a common side-effect, as are UTIs. Fournier's gangrene is a rare but serious and potentially life-threatening infection. Diabetic ketoacidosis is also a risk.

Answer 14

Risk factors for developing DKA while on this medicine include: alcohol abuse, little beta cell function, restricted food intake, severe dehydration, sudden reduction in insulin, increased insulin requirement in acute illness and surgery. Stop SLGT2 if risk of dehydration (sick day rules)

Answer 15

Pioglitazone is the only thiazolidinedione with a marketing authorisation in the UK.

Answer 16

Pioglitazone makes cells in the liver, fat and skeletal muscle more sensitive to insulin reducing the glucose in the blood.

Answer 17

Do not offer or continue to prescribe in patients with HF (or history of HF), hepatic impairment or ketoacidosis or active bladder cancer.

Answer 18

Causes dose-related weight gain (2-3kg in a year) and can cause fluid retention associated with an exacerbation or new onset HF. Oedema may be a higher risk when combined with insulin. Weight should be monitored. There is a small increase in risk of developing bladder cancer. Those with current or history of bladder cancer should not be used in. Risk factors such as previous radiotherapy to the pelvic area, age and smoking should be considered. Also, an increased fracture risk- initially higher in women – consider as risk in men and women.

Answer 19

* Avoid in impairment * Monitor liver function before treatment and periodically thereafter. * Liver toxicity - Patients should be advised to seek immediate medical attention if symptoms such as nausea, vomiting, abdominal pain, fatigue and dark urine develop.

Answer 20

Examples: Exenatide (Byetta) (twice daily) Semaglutide (Ozempic) (weekly) Liraglutide (Victoza, Saxenda) (daily) Lixisenatide (Adlyxin) (daily)

Answer 21

GLP-1s are third line option for patients who are not at their HbA1c target and have a BMI >30.

Answer 22

DPP-4 inhibitor

Answer 23

GLP-1 agonists bind to GLP-1 receptors resulting in an increase in insulin secretion, supressing glucagon secretion and slowing gastric emptying. These have high efficiacy.

Answer 24

GLP-1s are third line option for patients who are not at their HbA1c target and have a BMI >30.

Answer 25

These vary in dosing from twice daily to once weekly. All given by SC injection.

Answer 26

The most common is GI effects e.g. abdominal pain and distention, constipation or diarrhoea and reduced appetite. There is a small risk of pancreatitis – counsel if severe persistent abdominal pain, nausea and vomiting to seek medical care. If patients stop treatment for a period of time, they may need to be re-titrated to avoid GI side-effects.

Answer 27

Insulin acts to supress production of glucose in the liver, encourages glucose uptake by the muscles, promotes storage of glucose as glycogen, suppresses the breakdown of fat and regulate protein turn over.

Answer 28

As T2DM is a progressive condition, HbA1c will likely deteriorate with time despite treatment. It may therefore be necessary to move onto insulin. Patients with T2DM whose glycaemic control is not within target despite oral agents and whose BMI <30 are candidates.

Answer 29

Treatment for a patient with T2DM may begin with once daily basal insulin injected before bed. Isophane or longer acting insulin are recommended depending on the risk of hypoglycaemia. The dose of basal insulin should be titrated against morning fasting blood glucose levels. The insulin dose will also be titrated against trends in blood sugar. Insulin can be intensified by introducing short-acting meal-time insulin to a basal regime or changing to twice daily mixed biphasic insulin. Intensifying with a twice daily may mean using higher doses of insulin overall and is associated with a greater increase in weight than a basal insulin alone

Answer 30

Needles for insulin pens come in a variety of lengths and guages. 4mm are the most common and reduce the risk of injecting into muscle rather than SC tissue. A new needle should be used with each injection.

Answer 31

nsulin has a high efficacy but is associated with a significant risk of hypoglycaemia and causes weight gain. A 27mmol/mol reduction in HbA1c is associated with an average weight gain of 5kg. Metformin can be continued to counteract this.

Answer 32

Sulphonylureas should be stopped or dose reduced due to risk of hypoglycaemia.

Answer 33

Basal bolus insulin regimens are prescribed for all newly diagnosed patients with T1DM as this regimen most closely mimics endogenous insulin production. This consists of: Basal insulin – a long acting background insulin administered once or twice daily (always analogue insulin for type 1). Twice daily detemir is the basal insulin of choice. Bolus insulin- a rapid acting analogue insulin given with meals. This is usually administered 15 minutes before a carbohydrate meal. Twice daily mix insulins are no longer recommended for type 1 as they do not offer the same flexibility/responsiveness, however there are some patients who remain on this combination.

Answer 34

HbA1c – target 48mmol/mol or lower Daily BM monitoring Those on basal bolus regimens with carbohydrate counting can test up to 10x a day Blood ketone level monitoring – at times of sustained hyperglycaemia and/or intercurrent illness

Answer 35

Hypoglycaemia is low blood glucose (typically <4mmol/L)

Answer 36

* Sweating * Feeling hungry * * Feeling anxious * * Tingling lips * * Shakiness or trembling * * A fast pulse or palpitations * * A bad temper * Untreated it can also present as slurred speech, difficulty concentrating, confusion, disorderly or irrational behaviour or unconsciousness. Non-specific symptoms include nausea, falls, light-headedness, unsteadiness, confusion, more common in patients >65 years. Mild hypoglycaemia presents with a wide variety of symptoms, including hunger, anxiety or irritability, palpitations, sweating, or tingling lips. As the blood glucose levels fall lower, the person may experience weakness and lethargy, impaired vision, and confusion or irrational behaviour. Cognitive function deteriorates when blood glucose levels fall to less than 3.0 mmol/L. Severe hypoglycaemia may result in convulsions, loss of consciousness, and coma. People with severe hypoglycaemia are unable to self-manage a hypoglycaemic episode and require help from another person to achieve normoglycaemia. People receiving insulin therapy should be provided with education and information on awareness and management of hypoglycaemia including information on driving and should always have available a fast-acting source of glucose to manage hypoglycaemia. In cases of severe hypoglycaemia where a person has a reduced level of consciousness, intramuscular glucagon that is given by another person is recommended.

Answer 37

Hypoglycaemia should be treated quickly by eating fast-acting sugary snack e.g. 4-5 jelly babies, 200mL orange juice or 4-6 glucose tablets. If blood sugars are improving then a medium acting carbohydrate e.g. a piece of toast or the nect meal should be eaten [https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/2018-05/JBDS_HypoGuidelineRevised2.pdf%2008.05.18.pdf](http://)

Answer 38

* Tighter BP control * Statin (at risk)

Answer 39

* Human insulins are produced by recombinant DNA technology and have the same amino acid sequence as endogenous human insulin. * Human insulin analogues are produced in the same way as human insulin, but the insulin is modified to produce a specific desired kinetic characteristic e.g. extended duration of action or faster absorption * Animal insulins (rarely used now) are extracted and purified from either cows (bovine) or pigs (porcine).

Answer 40

1. Rapid 2. Short-acting 3. Intermediate acting 4. Long acting

Answer 41

Rapid and short-acting insulins have a quick onset of action and a short duration of action. They are used to replicate the insulin normally produced by the body in response to glucose absorbed from a meal or sugary drink.

Answer 42

Intermediate- and long-acting insulins have a slow onset of action and a long duration of action. They mimic the effect of endogenous basal insulin (insulin that is secreted continuously throughout the day).

Answer 43

Short-acting (regular or neutral) insulins have an onset of action of 30–60 minutes and a duration of action of up to 8 hours. Examples include Actrapid® and Humulin S®.

Answer 44

Rapid-acting insulins have an onset of action of about 15 minutes and a duration of action is 2–5 hours. Examples include Humalog® (insulin lispro) and Novorapid® (insulin aspart).

Answer 45

Intermediate- and long-acting insulins have a slow onset of action and a long duration of action. They mimic the effect of endogenous basal insulin (insulin that is secreted continuously throughout the day).

Answer 46

Long-acting insulins have a duration of action of up to 24 hours; steady-state level achieved after 2–4 days to produce a constant level of insulin. Examples include Lantus® (insulin glargine), Levemir® (insulin detemir), and Tresiba® (insulin degludec).

Answer 47

**High strength insulins** have concentrations greater than 100 units/mL and have been developed for people with large daily insulin requirements, to reduce the number and volume of injections. Examples are Tresiba® (200 units/mL), Humalog® (200 units/mL), and Toujeo® (300 units/mL). Toujeo is not bioequivalent to Lantus.

Answer 48

Insulin in fixed combination with liraglutide is a combination of a long-acting basal insulin and liraglutide (a glucagon-like peptide-1 [GLP-1] receptor agonist licensed for the treatment of type 2 diabetes). **Xultophy®** is a combination of insulin degludec 100 units/mL with liraglutide 3.6 mg/mL in a prefilled pen.

Answer 49

Biosimilar insulin is a biological copy of an original insulin. Abasaglar® is a biosimilar insulin product based on insulin glargine 100 units/mL (Lantus®) and is licensed for the treatment of diabetes in adults, adolescents, and childrenmaged 2 years and older.

Answer 50

1st line: Multiple daily injection basal-bolus insulin regimens 2nd line: Mixed (biphasic) regimen 3rd line: Continuous subcutaneous insulin infusion (insulin pump) therapy

Answer 51

the person has injections of short-acting insulin or rapidacting insulin analogue before meals, together with one or more separate daily injections of intermediate-acting insulin or longacting insulin analogue to cover the basal requirement. This offers greater flexibility for blood glucose control.

Answer 52

the person has one, two, or three insulin injections per day of short-acting insulin or rapid acting insulin analogue mixed with intermediate-acting insulin. The insulin preparations may be mixed by the person at the time of injection, or a premixed product can be used.

Answer 53

this is a programmable pump and insulin storage reservoir that gives a regular or continuous amount of insulin (usually in the form of a rapid-acting insulin analogue or short-acting insulin) by a subcutaneous needle or cannula. Insulin pump therapy dispenses with the need for an intermediate-acting or long-acting insulin to provide basal cover.

Answer 54

to local tissue reactions, changes in insulin sensitivity, blood flow, depth of injection, and/or the amount of insulin injected. Other factors that affect insulin absorption include but are not limited to: * * Larger dose — absorption is slower if a large insulin dose is injected. * * Accidental intramuscular injection (due to poor injection technique or the use of an inappropriate needle length) * * Exercise — absorption is faster owing to increased blood flow at the injection site of the exercised region (for example thighs of runners). * * Injection site — the rate of insulin absorption varies depending on which part of the body is used. This might have some effect on blood glucose control. * * Age — absorption is faster in young children as they have less subcutaneous fat. ✓ Fat mass — absorption is slower if there is a large amount of subcutaneous fat. Other factors that may increase or decrease insulin requirements: * * Decreased Requirements: Physical activity, Intercurrent illness, decreased food intake, decreased renal function, endocrine disorders * * Increased Requirements: Infection, stress, trauma – accidental or surgical.

Answer 55

To self-monitor, the person would need a blood glucose monitor, lancets (which fit into a finger-pricking device), and testing strips. Advise routine self-monitoring of blood glucose levels **at least 4 times a day** (including before meals and before bed). More frequent monitoring (up to 10 times a day or more) may be required in certain patients. Continuous glucose monitoring is not routinely recommended for adults with type 1 diabetes.

Answer 56

The optimal targets for glucose self- monitoring in adults with type 1 diabetes are: Fasting plasma glucose level of 5–7 mmol/ * L on waking. * Plasma glucose level of 4–7 mmol/L before meals at other times of the day. * For adults who choose to test after meals, plasma glucose level of 5–9 mmol/L at least 90 minutes after eating. Bedtime target plasma glucose levels with the person which should be agreed and take into account timing of last meal and insulin dose and be consistent with the recommended fasting level on waking.

Answer 57

Remind drivers wit diabetes of the need to be particularly careful to avoid hypoglyacemia and that they need to notify the DVLA that they are receiving insulin. Drivers should also: Have a supply of a fast-acting carbohydrate in the vehicle and avoid driving if their meal is delayed. Check their blood glucose level just before they start the journey and then every 2 hours during the journey. If the blood glucose level is low, they should stop the car in a safe place, switch off the engine and move from the driver's seat, eat or drink something sugary, then wait until 45 minutes after the blood glucose has returned to normal before continuing the journey. Take regular meals, snacks, and rest periods on long journeys, and always avoid alcohol. Take particular care during changes of insulin regimens, changes of lifestyle, exercise, and travel. Remind young people of driving age that the optimal target blood glucose self- monitoring level when driving is at least 5 mmol/L. Advise drivers with diabetes to always carry diabetes identification to show that they have diabetes in case of injury in a road traffic collision.

Answer 58

Diabetic ketoacidosis (DKA) is a serious condition that affects people with type 1 diabetes, and occasionally those with type 2 diabetes. DKA happens when there is severe lack of insulin in the body. This means the body can’t use sugar for energy and starts to use fat instead. When this happens, chemicals called ketones are released and if left untreated can build up and make your blood become acidic – hence the name acidosis. The early signs of DKA can often be treated with extra insulin and fluids if it is picked up quickly. But if it isn’t, DKA needs hospital treatment and can be life-threatening.

Answer 59

During a period of illness, remind the person to adhere to the 'sick-day rules' that should have been provided by their diabetes team: * Never stop or omit insulin. The dose of insulin may need to be altered during periods of illness; they should seek advice from their diabetes team if they are unsure of how to adjust insulin doses. * Check blood glucose more frequently, for example every 1–2 hours including through the night. The insulin dose should be titrated according to the blood glucose results and the written 'sick-day rules'. * Consider checking blood or urine ketone levels regularly, for example every 3–4 hours including through the night, and sometimes every 1–2 hours depending on results. * If the urine ketone level is greater than 2+ or blood ketone levels are greater than 3 mmol/L, the person should contact the GP or diabetes care team immediately. * Maintain their normal meal pattern (where possible) if appetite is reduced. * Their normal meals could be replaced with carbohydrate-containing drinks (such as milk, milk shakes, fruit juices, and sugary drinks). * Aim to drink at least 3 L of fluid (5 pints) a day to prevent dehydration. Carbonated drinks should be avoided if possible. * If blood glucose levels are normal or high, water or sugar-free fluids are probably most appropriate in the majority of cases. * If blood glucose levels are low, drinks containing glucose are required (or the person should take carbohydrates if possible). * Seek urgent medical advice if they are violently sick, drowsy, or unable to keep fluids down. * Intravenous fluids may be required. * When feeling better, continue to monitor their blood glucose carefully until it returns to normal which may take some time. * The person should seek medical advice if their blood glucose remains uncontrolled

Answer 60

Drugs that can enhance the hypoglycaemic effects of insulin (reduce insulin requirement) include: * Anabolic steroids. * Angiotensin-converting enzyme (ACE) inhibitors. * Beta-blockers — beta-blockers may also mask the warning signs of hypoglycaemia (such as tremor). * Fibrates. * Lanreotide and octreotide — octreotide may also increase insulin requirements. * Monoamine oxidase inhibitors. * Salicylates. * Sulphonamides.

Answer 61

Drugs that can antagonize the hypoglycaemic effects of insulin (increase insulin requirements) include: * Corticosteroids. * Danazol. * Diuretics (loop and thiazides). * Glucagon. * Growth hormone. * Levothyroxine. * Oral contraceptives. * Sympathomimetic drugs (such as * adrenaline, salbutamol, and terbutaline).

Answer 62

Alcohol:- signs of hypoglycaemia may also become less clear following alcohol intake, and delayed hypoglycaemia may occur (which can be hours after alcohol consumption). Advise people on insulin treatment to: * Drink alcohol in moderation (max 14 units a week with 2 or more drink-free days in the week). * Not drink alcohol on an empty stomach (as the alcohol will be absorbed faster). * Eat a snack that contains carbohydrate (such as a sandwich or crisps) before and * after drinking alcohol — extra insulin is not required. * Measure their blood glucose regularly, and maintain their blood glucose with appropriate carbohydrate intake. * Always wear some form of diabetes identification as the reduced awareness of hypoglycaemia may be confused with alcohol intoxication.

Answer 63

Acute metabolic acidosis

Answer 64

Risk factors for lactic acidosis (i.e. Manufacturer advises caution in chronic stable heart failure (monitor cardiac function), and concomitant use of drugs that can acutely impair renal function; interrupt treatment if dehydration occurs, and avoid in conditions that can acutely worsen renal function, or cause tissue hypoxia)

Answer 65

* Alcohol – increased risk of lactic acidosis. Hypoglycaemic effect may also be enhanced. Concurrent use is not recommended * Beta-blockers – warning signs of hypoglycaemia (e.g. tremor) masked * Diabetic agents – risk of hypoglycaemia And those as seen for insulin

Answer 66

* Sick Day Rules * Advice on signs of lactic acidosis i.e., dyspnoea, muscle cramps, abdominal pain, hypothermia or asthenia. See medical attention immediately.

Answer 67

These are an alternative first-line choice, particularly if there are osmotic symptoms or if the patient is intolerant of, or has CI to metformin. Elderly patients or those with renal impairment are at particular risk of hypoglycaemia; if a sulfonylurea is indicated, a shorter-acting sulfonylurea, such as gliclazide or tolbutamide should be prescribed.

Answer 68

ketoacidosis

Answer 69

ketoacidosis

Answer 70

Obesity (weight-gain), Elderly, G6PD defiency

Answer 71

* Nil monitoring required * Driving and hypoglycaemia

Answer 72

Contraindications * Ketoacidosis. * Hepatic impairment — avoid vildagliptin; avoid saxagliptin and alogliptin if severe hepatic impairment. Cautions * History of pancreatitis * Heart failure — avoid vildagliptin if severe heart failure; avoid alogliptin if moderate-to-severe heart failure (limited data)

Answer 73

* Alogliptin: 12.5 mg once daily if estimated glomerular filtration rate (eGFR) is 30–50 mL/minute/1.73 m2. Reduce to 6.25 mg once daily if eGFR is less than 30 mL/minute/1.73 m2. * Linagliptin: no dose adjustment is required. * Saxagliptin: 2.5 mg once daily in moderate to severe renal impairment. * Sitagliptin: 50 mg once daily if eGFR is 30–45 mL/minute/1.73 m2. Reduce to 25 mg once daily if eGFR is less than 30 mL/minute/1.73 m2. * Vildagliptin: 50 mg once daily if eGFR is less than 50 mL/minute/1.73 m2.

Answer 74

Prior to starting saxagliptin, vildagliptin or alogliptin check liver and kidney function. During treatment with: * Vildagliptin: monitor liver function at 3-monthly intervals during the first year, and periodically thereafter. If the person develops increased transaminase levels, repeat liver function tests (LFTs) and monitor until results normalize. * Saxagliptin: monitor renal function periodically. * Alogliptin: monitor renal function periodically.

Answer 75

Before starting treatment with pioglitazone: Monitor liver function tests (LFTs). If alanine aminotransferase (ALT) is more than 2.5 times the upper limit of normal, or there is any other evidence of liver disease, do not start treatment. Assess the risk of heart failure and bone fracture. See the CKS topics on Heart failure and Osteoporosis - prevention of fragility fractures for more information. Assess the risk of bladder cancer. See the CKS topic on Urological cancers - recognition and referral for more information. Risk factors include: Increasing age. Current or past history of smoking. Exposure to some occupational or chemotherapy drugs, such as cyclophosphamide. Previous radiation therapy to the pelvic region. Following initiation of treatment with pioglitazone: Monitor LFTs periodically, based on clinical judgement. Monitor for signs and symptoms of heart failure, such as weight gain or oedema. Stop pioglitazone if any deterioration in cardiac function is seen. Assess the safety and efficacy of pioglitazone 3–6 months after treatment is initiated, and regularly thereafter. Stop pioglitazone in people who do not respond adequately to treatment. Advise the person to seek urgent medical assessment if any symptoms or signs of bladder cancer develop. See the CKS topic on Urological cancers - recognition and referral for more information.

Answer 76

should be reserved for combination therapy when other treatment options have failed. Liraglutide has proven cardiovascular benefit and should be considered in patients with type 2 diabetes and established cardiovascular disease. should only be prescribed for patients who have a BMI of 35 kg/m2 or above and who also have specific psychological or medical problems associated with obesity; or for those who have a BMI lower than 35 kg/m2 but for whom insulin therapy would have significant occupational implications or if the weight loss associated with glucagon-like peptide-1 receptor agonists would benefit other significant obesity-related comorbidities. After 6 months, the drug should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight).

Answer 77

should be reserved for combination therapy when other treatment options have failed. Liraglutide has proven cardiovascular benefit and should be considered in patients with type 2 diabetes and established cardiovascular disease. should only be prescribed for patients who have a BMI of 35 kg/m2 or above and who also have specific psychological or medical problems associated with obesity; or for those who have a BMI lower than 35 kg/m2 but for whom insulin therapy would have significant occupational implications or if the weight loss associated with glucagon-like peptide-1 receptor agonists would benefit other significant obesity-related comorbidities. After 6 months, the drug should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight). Should not be used in patients with a history of pancreatitis or gastroparesis Usually in triple therapy (SU + MT + GLP-1) Licensed in T2 diabetes in those over the age of 18 always check kidney function

Answer 78

3-8 degree. Once out of frdige can keep for 4 weeks at room temp (below 30). Protect from heat/light

Answer 79

Abdomen, thigh, buttocks

Answer 80

Insufficent tissue for injection - risk of injecting into muscle

Answer 81

* Lipohypertrophy is a lump under the skin caused by accumulation of extra fat at injection sites of insulin * It can be unsightly, painful and affect insulin action * Complication of insulin therapy * Leave area of skin for 1 month to let settle * Rotate insulin injection sites

Answer 82

Injecting into muscle, absorption rate/onset of insulin action is faster - can potentially lead to hypo

Answer 83

Abdomen fastest, then thigh & then buttocks

Answer 84

With correct needle length there should be no need to pinch. If you are particularly lean then it may be advisable to use a shorter needled and/or pinch up t he skin prior to injection

Answer 85

No pinch up: Inject 'straight in' at 90 degree angle, flush with skin for easy injection at all sites. Hold needle in skin while slowly counting up to 10 seconds pich up: Pinch your skin taking care to fold the top layers and not to pull muscle into the fold. Inject straight into the skn fold or at an angle to aviod injecting into te muscle

Answer 86

after every injection pen needles should be changed

Answer 87

Accelerates insulin absorption - risk of hypo. Beaware of hot baths, saunas etc

Answer 88

injecting into lipos makes insulin action very iunpredicatable (e.g. may be slowed down so BG levels rise, or may suddenly all absrob at once causing a sevre hypo. IF changing from lunpy sites - require to reduce insulin doses - due to risk of hypo

Answer 89

Long acting insulin detemir

Answer 90

long acting insulin glargine

Answer 91

rapid insulin aspart