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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
How does T2DM differ from T1?
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
What are the phases of T2DM?
Insulin resistance Pancreatic islet cell dysfunction Relative insulin def
27
What are some unmodifiable risk factors for T2DM?
Age Sex - males fam Hx genetic susceptibility
28
What are some modifiable risk factors for T2DM?
Overweight/obesity uncontrolled HTN Unhealthy diet Physical inactivity cigarette smoking alcohol intake
29
Why is central abdominal adiposity in metabolic syndrome a contributor to T2DM?
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
What is latent autoimmune diabetes in adults?
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
What are the sx of DM?
Excessive thirst, excessive urination excessive hunger, visual changes Weight loss Weakness/lethargy/fatigue freq skin and vaginal infections
32
Who are at high risk of developing DM?
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
How is true blood glucose/diabetes monitored?
HbA1C = every 2-3 months Aim is between 5.8-7.6% Between 7%-8% The lower the % the better
34
List the drug types/classes for diabetes tx
Biguanides Sulphonylureas Thiazolidinediones Dipeptidyl peptidase-4 inhibitors Glucagon-like peptide-1 agonist Sodium glucose transport-2 inhibitors acarbose Insulin
35
How is Metformin used in DM treatment?
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
What antihyperglycaemics are used in those with elevated CV risk?
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
How is SGLT2 inhibitors used in DM treatment?
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
How is dipeptidyl pepptidase-4 inhibitors used in DM?
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
How is glucagon-like peptide-1 receptor agonist used in DM?
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
How is sulfonylureas used in DM?
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
How is acarbose used in DM?
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
How is insulin used in DM?
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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