Diabetes

Question 1

Name 3 suphonylureas

Answer 1

1. gliclazide
2. glimepride
3. glipizide

Question 2

moa - suphonylureas

Answer 2

Act directly on B-cells in pancreas to simulate insulin production

Question 3

What are main disdvantages of suphonylureas? (4)

Answer 3

1. higher risk of hypoglycaemia
2. Weight gain
3. Glucose-lowering effect wanes with time
4. Many drug interactions

Question 4

suphonylureas and hypos - what increases the risk? (2)

Answer 4

increased fraility and falling eGFR (reduce dose if eGFR <45)

Question 5

Name 3 “Gliptins” (from list of 5)

Answer 5

1. sitagliptin
2. saxagliptan
3. linagliptan
4. alogliptan
5. vildagliptan

Question 6

MOA - Gliptans

Answer 6

Inhibit DPP4 enzyme that usually inactivates GLP1 - therefore physiological effect of GLP1 is prolonged.

Question 7

What is GLP1?

Answer 7

A hormone (incretin) released from the intestine in response to eating.

Question 8

What does GLP1 do? (4)

Answer 8

1. Increases insulin production from Beta pancreas cells.
2. Suppresses glucagon release from Alpha cells
3. Slows gastric emptying.
4. Reduces appetite
   NOTE: GLP1 secretion is impaired with T2DM.

Question 9

Which medications are good for fraility/ renal impairment?

Answer 9

1. DPP4 Inhibitors (Gliptans)
2. ?

Question 10

What class to these belong to?
sitagliptin, saxagliptan, linagliptan, alogliptan, vildagliptan

Answer 10

DPP4 Inhibitors - gliptans

Question 11

What is the full name of SGLT2 Inhibitors?

Answer 11

Sodium-Glucose Co-Transporter-2 Inhibitors

Question 12

Give 2 examples of SGLT2-Inhibitors (4)

Answer 12

1. dapaglifozin
2. empaglifozin
3. canagliflozin
4. ertugliflozin

Question 13

MOA - SGLT2-Inhibitors

Answer 13

increases renal secretion of glucose

Question 14

Given the MOA of SGLT2 Inhibitors - what are the side effects? (2)

Answer 14

1. Increase incidence of genitourinary infections - e.g. thrush (note this should reduce as glycaemic levels are controlled)
2. mild risk of volume depletion

Question 15

Given the MOA of SGLT2 Inhibitors - what can reduce it’s efficacy?

Answer 15

Decreased renal function

Question 16

SGLT2 Inhibitors and the elderly - what do you need to be careful of?

Answer 16

Combined use of diuretics causing volume depletion, e.g. dapaglifozin

Question 17

Which medication is associated with euglycaemic DKA?

Answer 17

SGLT2 Inhibitors, e.g. dapaglifozin

Question 18

Which medication would you give for HF patients? (HFrEF)

Answer 18

SGLT2 Inhibitors, e.g. dapaglifozin or empaglifozin

Question 19

What do ACEi and SGLT2 medications have in common?

Answer 19

Both are renal protective

Question 20

SGLT2s are cardiac and renal protective, but if patient has CKD, what’s the problem?

Answer 20

Not much glycaemic control! (if eGFR <45)

Question 21

Which SGLT2 would be preferred

Answer 21

Dapaglifozin

Question 22

SADMAN includes which diabetic medication?

Answer 22

SGLT2, e.g. dapaglifozin or empaglifozin

Question 23

When should you avoid using SGLT2s?

Answer 23

1. If on ketogenic diet
2. Acutely unwell patient
3. Past history of DKA
4. Alcohol abuse/ high consumption

Question 24

What must you always do before starting SGLT2s? e.g. dapaglifozin or empaglifozin

Answer 24

Review other diabetic medications , and reduce dose by 25% if risk of hypoglycaemia.

Question 25

What are the symptoms of DKA?

Answer 25

nausea, vomiting, abdominal pain, stupor, fatigue, difficulty breathing. Check ketones!

Question 26

If metformin is not well-tolerated, what would be a good subsitute?

Answer 26

SGLT2, e.g. dapaglifozin or empaglifozin

Question 27

What does GLP1 (RA) stand for?

Answer 27

Glucagon-Like Peptide Receptor Agonists

Question 28

Name 2 GLP1 receptor agnoist medications (5)

Answer 28

1. Semaglutide 2. dulaglutide 3. lixisenatide 4. liraglutide 5. exenatide

Question 29

What's the advantages of GLP1 medications (5)(e.g. semaglutide)

Answer 29

1. Potent 2. Promotes weight loss 3. low risk of hypoglycaemia 4. can be use in moderate-severe renal function 5. Some CVD protection

Question 30

Disadvantages of GLP1 medications (3) e.g. semaglutide

Answer 30

1. Injectable 2. GI s/e common 3.expensive

Question 31

Why stop a gliptan if starting a GLP1 medication?

Answer 31

Because they both affect the same pathway. GLP1 "trumps" the gliptin

Question 32

MOA - pioglitazone

Answer 32

affects expression of genes which has the effect of potentiating the effect of insulin.

Question 33

Advantages of pioglitazone? (7)

Answer 33

1. Potent 2. Reduces insulin resistance 3. Low cost 4. low risk of hypoglycaemia 5. Improves lipid profile 6. Can be used in CKD down to low eGFRs

Question 34

Disadvantages of pioglitazone? (5)

Answer 34

1. Significant weight gain (oedema and subcutaneous adipose tissue - not visceral!) 2. CONTRAINDICATED in HF 3. need to check for haematuria before starting - now discounted risk of bladder cancer 4. Increased fracture risk (do FRAX score) 5. Slow onset of action - benefits can take up to 3 months.

Question 35

What's the problem with recognising hypogycaemia in the elderly?

Answer 35

often loss of typical autonomic responses such as palpitations, and sweating.

Question 36

How might a hypo present within the elderly?

Answer 36

confusion, drowsiness, unsteadiness, light-headedness - consider if >75 yrs with HbA1c <53

Question 37

Why is a higher HbA1c associated with lower average blood glucose in older people? (2)

Answer 37

1. Lower RBC turnover 2. Their cell membranes are more friable and prone to glycosylation

Question 38

With frailty there is a loss of adipose tissue - what implication does this have?

Answer 38

Less insulin needed as underlying insulin resistance declines.

Question 39

Why is it important to monitor eGFR?

Answer 39

As eGFR falls, the risk of hypoglycaemia increases as excretion on medication takes longer - especially with the elderly.

Question 40

What HbA1c levels are most favourable with frailty?

Answer 40

59-64 range https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099963/

Question 41

When is HbA1c unrealiable and falsely elevated?

Answer 41

1. IDA - RBC span is increased (less turnover), therefore more glucose exposure. 2. Vit B12 deficiency (less RBC turnover) 3. Chronic blood loss 4. Pregnancy ( can be up or down)