Diabetes Flashcards
Example of sulfonylurEA
Gliclazide - avoid in acute porphyrias
Glimepiride
Glipizide
Tolbutamide- avoid in acute porphyrias
Sulfonylurea side effects
Hypos
Weight gain
Rare:
Hyponatraemia secondary to SIADH
Bone marrow suppression
Hepatotoxicity (typically cholestatic)
Peripheral neuropathy
Sulfonylurea contraindications
Pregnancy and breastfeeding
Thiazolidinediones example
Pioglitazone
pioglitazone mechanism
agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance.
Pioglitazone side effects
Think alien LOL
- Weight gain
- Liver impairment: monitor LFTs
- Fluid retention - Risk of this is increased if the patient also takes insulin. C/I in CCF
-Increased risk of fractures
- Increased risk of bladder ca
Pioglitazone contraindications
Heart failure
Bladder ca
Sulfonylurea mechanism of action
Increase pancreatic insulin secretion so only work if B-cells are working
DPP4 inhibitor examples
Think DPD man delivering your hairclip HAHAH
GLIP(i)Tin(s)
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Vildagliptin
SGLT2 inhibitor
1. Examples?
2. Mechanism
Mechamism: inhibit sodium-glucose co-transporter 2 - so pee out more glucose.
Examples: Think of that sugar FLO in out
Canagliflozin
Dapagliflozin
Empagliflozin
Ertugliflozin
SGLT2 inhibitor side effects
-UTIs
-Fournier’s gangrene
-Normoglycaemic ketoacidosis
-Increased risk of lower-limb amputation: feet should be closely monitored
**can’t give in mod- severe renal impairment or to people with foot disease
What do you need for diagnosis of T2DM?
Symptomatic:
- Random ≥ 11.1 or fasting ≥ 7
- Hba1c of 48 (6.5%) or above
Asymptomatic need above on 2 sep occasions
**HbA1c value of less than 48 does not exclude diabetes, so if you think they have it do fasting/random.
Pre-diabetes diagnostic criteria
Hba1c 42-47
or
Fasting 6.1-6.9
What is impaired fasting glucose?
What do you do if they have this?
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)
If they have IFG then do OGTT.
if ≥ 7.8 but < 11.1 then they don’t have diabetes but do have impaired glucose tolerance
What is impaired glucose tolerance and when do you do this?
First do fasting glucose. If fasting 6.1-6.9 then do OGTT.
Impaired glucose tolerance (IGT) is defined as:
Fasting plasma glucose less than 7.0
AND
OGTT 2-hour value ≥ 7.8 but < 11.1
Type 2 diabetes hba1c targets and when to step up treatment?
Lifestyle = 48
Lifestyle and metformin = 48
Any drug that might cause hypos = 53
Intensify treatment if hba1c over 58
When to use SGLT2 inhibitors
Need to assess cardio risk. If any of:
1. Heart failure
2. Q risk> 10%
3. Atherosclerotic disease e.g. ACS, prev MI, angina, prev. ischaemic stroke or TIA, PVD
then add SGLT2 inhibitor (flozins)
T2DM 1st line management
Metformin - titrate dose upwards, if GI side effects arise then offer MR
If any CVS risk then add SGLT2 inhibitors once established on metformin.
T2DM 2nd line management
Add any of
Sulphonylurea (gliclazide)
DPP4 inhibitor (gliptins)
Pioglitazone
What to do first line if metformin C/I or not tolerated
If CCF/Q-risk >10%/ atherosclerotic disease - SGLT2 monotherapy
If not any of sulfonylurea/ DPP4/ Pioglitazone
3rd line therapy for T2DM
Add another drug from 2nd line options OR start insulin
When to use GLP-1 mimetic?
If triple therapy not effective or tolerated consider swapping one out for this.
Must have:
-BMI ≥ 35 AND and specific psychological or other medical problems associated with obesity
OR
- BMI < 35 kg/m² and insulin would have occupational implications, or - weight loss would benefit other significant obesity-related comorbidities
Don’t add them to insulin - must be specialist led
GLP-1 mimetic examples
Think of people walking along the beach in America… -TIDES
Cause wt loss
Adverse effects:
Nausea and vomiting.
Exenatide, has been linked to severe pancreatitis in some patients.
How would you start insulin?
NICE recommend starting with human NPH insulin (isophane, intermediate-acting) taken at bed-time or twice daily according to need
Gestational diabetes blood glucose targets
CBG should be below following
fasting: 5.3mmol/L
AND
1 hour postprandial: 7.8 mmol/L or
2 hours postprandial: 6.4 mmol/L
Gestational Diabetes diagnostic criteria
Fasting glucose over 5.6
2h glucose over 7.8
How to manage gestational DM
If fasting glucose below 7:
Trial diet and exercise
R/v in 2 week. If no better then add metformin.
If still no better add insulin.
If fasting glucose above 7:
Start insulin
If 6.1-6.9 but complications eg macrosomia, insulin
Which diabetes drug can you use if metformin no good or pt refuses insulin
glibenclamide
Is C-peptide high or low in T2DM
High in T2, Low in T1
T1DM hba1c target
48
When would you give T1 metformin?
considering adding metformin if the BMI >= 25 kg/m²
