Diabetes Flashcards
Name 3 suphonylureas
- gliclazide
- glimepride
- glipizide
moa - suphonylureas
Act directly on B-cells in pancreas to simulate insulin production
What are main disdvantages of suphonylureas? (4)
- higher risk of hypoglycaemia
- Weight gain
- Glucose-lowering effect wanes with time
- Many drug interactions
suphonylureas and hypos - what increases the risk? (2)
increased fraility and falling eGFR (reduce dose if eGFR <45)
Name 3 “Gliptins” (from list of 5)
- sitagliptin
- saxagliptan
- linagliptan
- alogliptan
- vildagliptan
MOA - Gliptans
Inhibit DPP4 enzyme that usually inactivates GLP1 - therefore physiological effect of GLP1 is prolonged.
What is GLP1?
A hormone (incretin) released from the intestine in response to eating.
What does GLP1 do? (4)
- Increases insulin production from Beta pancreas cells.
- Suppresses glucagon release from Alpha cells
- Slows gastric emptying.
- Reduces appetite
NOTE: GLP1 secretion is impaired with T2DM.
Which medications are good for fraility/ renal impairment?
- DPP4 Inhibitors (Gliptans)
- ?
What class to these belong to?
sitagliptin, saxagliptan, linagliptan, alogliptan, vildagliptan
DPP4 Inhibitors - gliptans
What is the full name of SGLT2 Inhibitors?
Sodium-Glucose Co-Transporter-2 Inhibitors
Give 2 examples of SGLT2-Inhibitors (4)
- dapaglifozin
- empaglifozin
- canagliflozin
- ertugliflozin
MOA - SGLT2-Inhibitors
increases renal secretion of glucose
Given the MOA of SGLT2 Inhibitors - what are the side effects? (2)
- Increase incidence of genitourinary infections - e.g. thrush (note this should reduce as glycaemic levels are controlled)
- mild risk of volume depletion
Given the MOA of SGLT2 Inhibitors - what can reduce it’s efficacy?
Decreased renal function
SGLT2 Inhibitors and the elderly - what do you need to be careful of?
Combined use of diuretics causing volume depletion, e.g. dapaglifozin
Which medication is associated with euglycaemic DKA?
SGLT2 Inhibitors, e.g. dapaglifozin
Which medication would you give for HF patients? (HFrEF)
SGLT2 Inhibitors, e.g. dapaglifozin or empaglifozin
What do ACEi and SGLT2 medications have in common?
Both are renal protective
SGLT2s are cardiac and renal protective, but if patient has CKD, what’s the problem?
Not much glycaemic control! (if eGFR <45)
Which SGLT2 would be preferred
Dapaglifozin
SADMAN includes which diabetic medication?
SGLT2, e.g. dapaglifozin or empaglifozin
When should you avoid using SGLT2s?
- If on ketogenic diet
- Acutely unwell patient
- Past history of DKA
- Alcohol abuse/ high consumption
What must you always do before starting SGLT2s? e.g. dapaglifozin or empaglifozin
Review other diabetic medications , and reduce dose by 25% if risk of hypoglycaemia.
What are the symptoms of DKA?
nausea, vomiting, abdominal pain, stupor, fatigue, difficulty breathing. Check ketones!
If metformin is not well-tolerated, what would be a good subsitute?
SGLT2,
e.g. dapaglifozin or empaglifozin
What does GLP1 (RA) stand for?
Glucagon-Like Peptide Receptor Agonists
Name 2 GLP1 receptor agnoist medications (5)
- Semaglutide
- dulaglutide
- lixisenatide
- liraglutide
- exenatide
What’s the advantages of GLP1 medications (5)(e.g. semaglutide)
- Potent
- Promotes weight loss
- low risk of hypoglycaemia
- can be use in moderate-severe renal function
- Some CVD protection
Disadvantages of GLP1 medications (3) e.g. semaglutide
- Injectable
- GI s/e common
3.expensive
Why stop a gliptan if starting a GLP1 medication?
Because they both affect the same pathway. GLP1 “trumps” the gliptin
MOA - pioglitazone
affects expression of genes which has the effect of potentiating the effect of insulin.
Advantages of pioglitazone? (7)
- Potent
- Reduces insulin resistance
- Low cost
- low risk of hypoglycaemia
- Improves lipid profile
- Can be used in CKD down to low eGFRs
Disadvantages of pioglitazone? (5)
- Significant weight gain (oedema and subcutaneous adipose tissue - not visceral!)
- CONTRAINDICATED in HF
- need to check for haematuria before starting - now discounted risk of bladder cancer
- Increased fracture risk (do FRAX score)
- Slow onset of action - benefits can take up to 3 months.
What’s the problem with recognising hypogycaemia in the elderly?
often loss of typical autonomic responses such as palpitations, and sweating.
How might a hypo present within the elderly?
confusion, drowsiness, unsteadiness, light-headedness - consider if >75 yrs with HbA1c <53
Why is a higher HbA1c associated with lower average blood glucose in older people? (2)
- Lower RBC turnover
- Their cell membranes are more friable and prone to glycosylation
With frailty there is a loss of adipose tissue - what implication does this have?
Less insulin needed as underlying insulin resistance declines.
Why is it important to monitor eGFR?
As eGFR falls, the risk of hypoglycaemia increases as excretion on medication takes longer - especially with the elderly.
What HbA1c levels are most favourable with frailty?
59-64 range
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099963/
When is HbA1c unrealiable and falsely elevated?
- IDA - RBC span is increased (less turnover), therefore more glucose exposure.
- Vit B12 deficiency (less RBC turnover)
- Chronic blood loss
- Pregnancy ( can be up or down)
