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7005PHM Pharmthera II > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is the role of insulin?

A

Stim glucose transport across cell

Stimulate glycogenesis

Inhibit glycogenolysis = prevent production of glucose from live/muscle glycogen

Stimulates lipogenesis

Inhibit lipolysis and ketogenesis

Promote incorporation of AA into protein

Inhibit gluconeogenesis

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2
Q

Compare and contrast Type I and Type II DM

A

T1 = earlier onset w/ acute onset polyuria, polydipsia, weight loss

T2 = incidence inc w/ age, may be asymptomatic or present w/ milder sx, associated with obesity and presents with other cardiometabolic risk factors

Ketosis = rare in T2 DM but common in T1DM

Fam Hx = T1DM usually has no Fam hx association, T2DM often associated with fam hx

Ethnic = higher risk of T2DM in Africans, Indigenous Australians, Asians (indian), southern europe

Tx = T1DM is treated w/ insulin whilst T2DM is lifestyle and progresses to insulin/oral therapies

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3
Q

What are the tx targets of diabetes?

A

HbAic = 53 mmol/mol (7%) or lower

BGC = fasting 4-7 mmol/L, postprandial 5-10 mmol/L

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4
Q

What types of insulins should be combined?

A

Long acting (esp at night) and short acting

e.g. A long acting insulin to maintain a baseline level combine with a rapid acting after/before meals

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5
Q

What are the ultrashort acting insulins?

A

Lispro

Aspart

Glulisine

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6
Q

What are the short acting insulins?

A

neutral (human insulin) = Humilin

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7
Q

What are the intermediate acting insulins?

A

isophane

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8
Q

What are the long acting insulins?

A

Detemir, glargine

glargine concentrate

degludec

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9
Q

How is insulin therapy changes in children?

A

They require higher insulin doses due to growth and pubertal development

Basal insulin = 40-50% of daily insulin req

Intensive or continuous infusion regimens preferred
- mixed regimen may be pre-prepared or free mixed

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10
Q

What does an intensive insulin regimen consist of?

A

Multiple daily injections = basal insulin 40% of daily insulin req + bolus insulin 60% of daily req

*may req correction doses

Continuous infusions = same regimen as above but with ultra-short acting insulin w/ bolus infusion at meals

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11
Q

What does an mixed insulin regimen consist of?

A

Combination of short and longer acting insulin, once or twice a day
- novomix 30% ultra short/70% intermediate
- mixtard 50% short with 50% intermediate

  • Splits daily requirements into two equal doses or 2/3 mane and 1/3 nocte

Has minimal T1DM role

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12
Q

When is blood glucose monitoring required for people w/ T1DM?

A

Before/after meals

Before exercise

when low BGC suspected

before critical activities (driving)

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13
Q

When is more freq monitoring of blood glucose required?

A

During periods of unwell

after treatment of hypoglycaemia

during times of inc activity

changes to usual insulin regimen are made

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14
Q

How does management of blood glucose change during illness?

A

Don’t stop insulin, increase monitoring 1-4 hrly

Send to hospital if = vomiting >4hrs, high fever, abdominal pain, severe headache, drowsiness, worsening hyperglycaemia, marked ketosis

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15
Q

What are the signs/sx of mild hypoglycaemia?

A

Adrenergic or cholinergic sx

Pallor, sweating, tachycardia, palpitations

Hunger, shakiness, paraesthesia

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16
Q

What are the signs/sx of moderate hypoglycaemia?

A

Neurological sx

Inability to concentrate, confusion, slurred speech, slowed reaction time

Blurred vision

somnolence, extreme fatigue

irrational or uncontrolled behaviour

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17
Q

What are the signs/sx of severe hypoglycaemia?

A

Extreme impairment of neurological function

Completely automatic/disoriented behaviour
Inability to arouse from sleep
loss of consciousness
seizures

18
Q

How is mild hypoglycaemia tx?

A

Conscious/able to swallow

Oral administration of glucose or sucrose = Jelly beans, juice or soft drink, 3 teasp of honey, glucose tabs

Followed by slow digestion of carbohydrate snack if next meal >20 mins away

19
Q

How is moderate hypoglycaemia tx?

A

Patient disoriented/argumentative/uncooperative/need help

Give rapidly absorbed carb followed by slowly absorbed carb

30 mins rest before normal activity, monitor BGL

20
Q

How is severe hypoglycaemia tx?

A

Unconscious and unable to take oral foods or fluids

NOTHING by mouth = if done, put in recovery position until airway clear

Seek medical help

Tx w/ glucagon –> responds in 5-10 mins, no response –> IV glucose

21
Q

What is the mechanism behind diabetic ketoacidosis?

A

Hyperglycaemia –> insufficient glucose uptake –> cells use proteins and fat as energy –> FFA broken down in liver to ketone bodies (kidney - ketonuria) –> acetoacetate converted to acetone in liver (exhaled - fruity breath)

Cont lipolysis –> inc ketogenesis –> exceeds elimination –> ketonaemia –> inc FFA lvls –> worsening acidosis

Initial compensation through Kussmaul breathing and buffering in blood –> blood and breathing no longer able to compensate –> ketoacidosis

22
Q

How is diabetic ketoacidosis (DKA) treated?

A

progressive normalisation of blood pH whilst clearing body of excessive ketones

Tx:

- aggressive fluid replacement and insulin (improve BG) - hyperglycaemia corrects before acidosis 
- IV glucose --> allows insulin to suppress ketone production

- correct electrolyte disturbances - K+ loss
23
Q

What are the signs and sx of DKA?

A

Consistent positive urine/blood test for sugar/ketones

Excessive urination and thirst, flushed skin, dehydration

Weakness, fatigue, abdominal pain, nausea, vomiting

Blurred vision

Kussmaul breathing (rapid, deep breaths)

Fruity odour to breath, drowsiness, unconsciousness

24
Q

What are the difference in pulse, BP, and reflexes for hyper and hypoglycaemia?

A

Hyper:
- pulse = weak and rapid
- BP = lowered
- reflexes = diminished

Hypo:
- full, rapid
- normal, raised
- Brisk

25
Q

How does T2DM differ from T1?

A

Endogenous insulin lvls may be normal, inc, or dec = requirement of exogenous insulin is variable

Despite insulin levels, B-cell function is manifested by insulin insufficiency to maintain euglycaemia

Diagnosed in older patients (.30 y/o) and is associated w/ obesity and comorbid conditions

Not usually prone to ketosis

26
Q

What are the phases of T2DM?

A

Insulin resistance

Pancreatic islet cell dysfunction

Relative insulin def

27
Q

What are some unmodifiable risk factors for T2DM?

A

Age

Sex - males

fam Hx

genetic susceptibility

28
Q

What are some modifiable risk factors for T2DM?

A

Overweight/obesity

uncontrolled HTN

Unhealthy diet

Physical inactivity

cigarette smoking

alcohol intake

29
Q

Why is central abdominal adiposity in metabolic syndrome a contributor to T2DM?

A

It is a pre-disposing factor due to it being a source of FA which travel to liver and in circulation

Adipokines, released by adipose tissue, release adiponectin (enhance insulin action) as well as resistin (inhibits insulin action)

30
Q

What is latent autoimmune diabetes in adults?

A

Slow onset T1 or T1.5 diabetes = T2DM may be undiagnosed T1DM

Occurs due to islet autoimmunity (GAD Ab positivity) -> causes a little insulin resistance

Patient often not overweight

31
Q

What are the sx of DM?

A

Excessive thirst, excessive urination

excessive hunger, visual changes

Weight loss

Weakness/lethargy/fatigue

freq skin and vaginal infections

32
Q

Who are at high risk of developing DM?

A

Hx of CV event

People >35 yrs originating from Pacific Islands, Indian subcontinent, China

People >40 yrs w/ BMI >30kg/m2, or HTN

Hx of gestational diabetes

Polycystic ovary syndrome if obese

People on antipsychotic meds

People with IGT or IFG

33
Q

How is true blood glucose/diabetes monitored?

A

HbA1C = every 2-3 months

Aim is between 5.8-7.6%
Between 7%-8%

The lower the % the better

34
Q

List the drug types/classes for diabetes tx

A

Biguanides

Sulphonylureas

Thiazolidinediones

Dipeptidyl peptidase-4 inhibitors

Glucagon-like peptide-1 agonist

Sodium glucose transport-2 inhibitors

acarbose

Insulin

35
Q

How is Metformin used in DM treatment?

A

Action - reduced hepatic gluconeogenesis and hence insulin req

Does not cause weight gain

Commenced at lowest dose and titrated up, GI effects reduced when taken with food

Immediate release = max dose 3, limited benefit in inc above 2g
- reduced dose when creatinine clearance impaired (no more than 1g for severe impair, no more than 2g for moderate)

Metformin no appropriate in those w/ CrCl <30 mL/min

36
Q

What antihyperglycaemics are used in those with elevated CV risk?

A

Atherosclerotic CVD = GLP-1 receptor agonist (dulaglutide, liraglutide, semaglutide) OR SGLT2 inhibitor (dapagliflozin or empagliflozin)

HF = SGLT2 inhibitor (dapagliflozin or empagliflozin)

CKD = SGLT2 inhibitor (dapagliflozin or empagliflozin) (preferred) OR GLP-1 receptor agonist (dulaglutide, liraglutide, semaglutide)

37
Q

How is SGLT2 inhibitors used in DM treatment?

A

Action = reduce glucose reabsorption in kidney

Unlikely to cause hypo, rarely DKA

Weak diuresis effect, cause genitourinary infections

Dose = dapagliflozin and empagliflozin - 10mg orally once a day
=erugliflozin 5mg once daily, inc according to response up to 15mg

38
Q

How is dipeptidyl pepptidase-4 inhibitors used in DM?

A

Action = inc incretin (GLP-1 and GIP) hormones after food –> GLP-1 stim insulin release, reduce glucagon sec

Well tolerated = no weight gain or hypoglycaemia, rare pancreatitis

Linagliptin/Saxagliptin 5mg once daily

Sitagliptin 100mg

Vildagliptin 50mg once or twice daily

39
Q

How is glucagon-like peptide-1 receptor agonist used in DM?

A

Action =synth analogue of GLP-1, inc insulin sec and red glucagon sec, small appetite red

Sub cut injection, more potent than DPP-4 inhibitors

Associated w/ weight loss and improve satiety but sig GI ADRs, rare pancreatitis

Dulaglutide 1.5mg
Liraglutide 0.6 mg once a week, max 1.8g

Semaglutide 0.25mg once weekly, max 1g

40
Q

How is sulfonylureas used in DM?

A

Action = inc insulin sec

Glibenclamide, gliclazide, glimerpiride = risk of sleep hypo
Glipizide

Long actin sulfonyls (glibenclamide, glimepiride) = avoid in older people w/ T2DM

Gliclazide and glipizide = short acting, converted by liver –> sulfons of choice in older people w/ T2DM

Can cause weight gain = consider incretins or insulin if this occurs

41
Q

How is acarbose used in DM?

A

Action = delays carbohydrate digestion and glucose absorption –> dec in postprandial glucose peak

Used in px whose glycaemic targets cannot be met w/ non-insulin antihyperglycemic drugs

Begin low dose to prevent GI ADRs = flatulence, bloating, diarrhoea

If causes hypoglycaemia, will not respond to sucrose

42
Q

How is insulin used in DM?

A

All kinds are effective

Started w/ single basal dose (nocte usually) or mixed insulin before biggest meal

start low and go slow = e.g. 10 basal units/a day

7005PHM Pharmthera II (18 decks)

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