diabetes Flashcards
What is pre-DM? Why is it impt to screen for pre-DM?
Asymptomatic, but can lead to T2DM and CVD
Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT)
Very impt to screen for pre-DM as many with impaired glucose tolerance and without lifestyle changes progress to T2DM
Who is recommended to go for screening for DM?
Recommended for aged >40 years old with or without risk factors for diabetes
18-39 years old can consider Diabetes Risk Assessment Tool (DRAT)
Screen what? What can the results tell you?
Screen for fasting plasma glucose (FPG) and HbA1c
If results are suggestive of DM —> Repeat test on subsequent day —> If results still above diagnosis thresholds, DM is diagnosed
How to prevent or delay progression to T2DM? (Lifestyle interventions)
- Healthy diet
- Increase physical activity
—– At least 150mins of moderate intensity exercise (brisk walking, leisure cycling) or 75mins of vigorous intensity exercise (jogging, fast-paced cycling, swimming) every week
How to prevent or delay progression to T2DM? (Pharmacology)
Metformin
—– When glycaemic status not improved despite lifestyle changes OR unable to adopt lifestyle interventions
—– Esp for those with BMI >23kg/m2, <60 years old , women with past gestational diabetes (aka diabetes during pregnancy which is normally temporary)
What is DM?
A metabolic disorder (not an illness) characterised by resistance to action of insulin or/and insufficient insulin secretion
What are the Clinical manifestations of DM?
Hyperglycemia which is when Blood sugar >10mmol
What are the Classifications of DM?
Type 1 and 2 can overlap, where the other type of DM can happen over time
What is Type 1 DM?
Insufficient secretion of insulin
Autoimmune disease where immune system mistakenly attacks and destroys beta cells, leading to an absolute deficiency of insulin
How to diagnose Type 1 DM?
Conduct blood test for positive antibodies to confirm diagnosis
- Islet cell autoantibodies (ICA)
- Autoantibodies to GAD (GAD65)
What are the stages of Type 1 DM?
All stages autoimmunity have Positive antibodies
Stage 1: Normoglycemia (Normal range) —- More commonly diagnosed in children
Stage 2: Dysglycemia (Abnormal range)
Stage 3: Hyperglycemia —- only stage that is symptomatic
What is Type 2 DM?
- Progressive loss of adequate insulin secretion by beta cells due to insulin resistance
——- Impaired glucose utilisation so muscle uptakes lesser glucose
——- Increased hepatic glucose output: Liver releases more than needed glucose from storage - Simultaneous elevations in both:
——- Glucose (no mechanism to remove glucose —> Hyperglycemia) and hence
——- Blood insulin levels (stimulated by high glucose levels —> Hyperinsulinemia) at early stage
What are the differences between Type 1 and 2 DM? (primary cause)
Type 1 (5-10%): Secretion problem
Autoimmune-mediated pancreatic beta cell destruction
Positive antibodies
Type 2 (90%): Resistance problem
Insulin resistance —> Impaired insulin secretion over time (similar to Type 1)
Negative antibodies
What are the differences between Type 1 and 2 DM? (insulin production as measured by C-peptide level)
Type 1 (5-10%): Secretion problem
Absent
Type 2 (90%): Resistance problem
Normal initially and abnormal at later stage
What are the differences between Type 1 and 2 DM? (age of onset)
Type 1 (5-10%): Secretion problem
<30 years old: Due to genetic disposition
Type 2 (90%): Resistance problem
>40 years old, but increasingly prevalent in obese children and younger adults
What are the differences between Type 1 and 2 DM? (onset of clinical presentation)
Type 1 (5-10%): Secretion problem
Abrupt (cause no insulin at all)
Type 2 (90%): Resistance problem
Gradual (still have some insulin)
What are the differences between Type 1 and 2 DM? (physical appearance)
Type 1 (5-10%): Secretion problem
Thin (cause pass a lot of sugar out in urine)
- without insulin, body cannot effectively use glucose for energy, leading to a state of chronic hyperglycemia. In an attempt to compensate for the lack of energy from glucose, the body breaks down fat and muscle for energy, resulting in weight loss
Type 2 (90%): Resistance problem
Overweight
- insulin resistance and the associated elevated insulin levels can contribute to weight gain.
What are the differences between Type 1 and 2 DM? (Proneness to ketosis (diabetic ketoacidosis; compensate lack of glucose in cells so break down fats which produce ketones))
Type 1 (5-10%): Secretion problem
Frequent!!! SAD
Type 2 (90%): Resistance problem
Rare
What are the Signs and symptoms of Hyperglycemia DM?
- High blood glucose
- Causes: Too much food, too little insulin or diabetes medicine, illness, stress
- Onset: Gradual, may progress to diabetic coma
- S/s
- Polydipsia (Extreme thirst)
- Polyuria (Increase urination)
- Polyphagia (Increase appetite)
- Decrease healing (too much sugar in blood impairs immune system)
- Dry skin (cause dehydrated) <—> Itchy skin
- Blurred vision
- Drowsiness
What are the Signs and symptoms of Hypoglycemia DM?
(more life-threatening)
- Low blood glucose
- Causes: Too little food, too much insulin or diabetes medicine, extra activity
- Onset: Sudden, may progress to insulin shock
- S/s
- Shaking, tremor
- Fast heartbeat
- Sweating
- Dizziness
- Hungry
- Blurry vision
- Fatigue
- Moody
- Headache
- Confusion
- Nocturnal: Nightmares, restless sleep
What is defined as hypoglycemia? How to manage hypoglycemia?
Defined as Blood glucose <4mmol/L (70mg/dL)
15-15-15 rule
- Only applies to diabetic patients, for healthy patients is ok to have 3.7mmol/L BG
- 15g of fast acting carbs —> wait 15mins —> if still <4mmol/L then eat another 15g of fast acting carbs
- Fast-acting carbs or glucose tablets/gel
What are the 4 Measuring parameters to diagnose T2DM?
- Fasting plasma glucose (FPG)
- Random or casual plasma glucose
- Postprandial plasma glucose (PPG)
- Hemoglobin A1c (HbA1c or A1c)
What to take note of when using Fasting plasma glucose (FPG) to diagnose T2DM?
prior to measuring, ensure NO calorie intake for at least 8h
What to take note of when using Random or casual plasma glucose to diagnose T2DM?
can measure Any time of the day, regardless of meals
What to take note of when using Postprandial plasma glucose (PPG) to diagnose T2DM?
measure After meal (usually 2h): 2h postprandial glucose
- Because after 2h, level tends to be more stable
But since every meal consist of diff amounts of glucose —> can use a standardised 75g oral glucose tolerance test (OGTT) aka drink same amount of glucose to test each time
What to take note of when using Hemoglobin A1c (HbA1c or A1c) to diagnose T2DM?
Most common
HbA1c = 3 months average of (FPG + PPG)
- Basal (fasting; FPG) and postprandial (after meal; PPG) contribute to overall hyperglycemia
- Basal hyperglycemia is more important contributor at high HbA1c since constant high blood sugar are more concerning than spikes post eating
Measures average amount of glucose in blood over past 3 months
- Because glucose stays attached to hemoglobin for lifespan of RBC ~120days
What are the limitations of using Hemoglobin A1c (HbA1c or A1c) to diagnose T2DM?
Dependent on RBC
- Low RBC due to bleeding or menses —> Obv lower HbA1c
- High RBC where RBC dont turnover and last >120days —> Obv higher HbA1c
What is the Criteria to diagnose T2DM? Memorise cut off values!!!!
Asians tend to have higher HbA1c compared to caucasian, so dont follow American guidelines
Do screening for high risk of DM or age >40 years old
By MOH
1. HbA1c >7% —> No further test needed —> DM diagnosis
- HbA1c <6% —> No further tests if no symptoms —> No DM
- If have symptoms, do FPG or 2hOGTT - HbA1c between 6.1% - 6.9% —> FPG or OGTT
- FPG >7mmol/L or 2hOGTT >11.1mmol/L —> DM diagnosis
- FPG 6.1-6.9mmol/L or 2hOGTT 7.8-11mmol/L —> pre-DM diagnosis
- If not, no DM - If want to do via FPG or OGTT, need to have at least 2 abnormal results to confirm diagnosis of DM
- Normal FPG is 5-7mmol/L
What are the complications for T2DM? (Macrovascular)
Reduce life expectancy by 5-10 years
- Increase CVD by 2-4 times (heart attack, stroke, artery clot at peripheral arteries in extremities)
What are the complications for T2DM? (Microvascular)
Reduce life expectancy by 5-10 years
- Neuropathy (Nerve damage to cause pain, numbness, tingling in extremities)
- Severe cases: Amputation (majority toes, then foot, then lower and upper limb)
- Nephropathy —> Kidney failure
- Due to albumin in urine (albuminuria)
- Glucose are bigger molecules compared to urine, so cause kidney filter to create bigger holes which allow proteins like albumin to leak into urine
- Retinopathy (sugar enter eyeball and feed vessels and cause eye to swell —> burst blood vessels) —> Blindness
What to take note for this Screening tests for diabetic patients? (Microvascular- Retinopathy)
Retinopathy: Retinal fundal photography
- Test for diabetic retinopathy
- Initial dilated and comprehensive eye examination
- Adults with type 1 DM: Within 5 years after DM onset
- Indivs with type 2 DM: Upon DM diagnosis - Every 6 months, but annually if no evidence of any retinopathy
- Women with DM have eye exam before pregnancy or during first trimester of pregnancy AND closely monitored during pregnancy and up to one year after giving birth
- Because pregnancy can cause diabetic retinopathy to develop or worsen
What to take note for this Screening tests for diabetic patients? (Microvascular- Nephropathy)
Nephropathy: Urine microalbumin/ creatinine ratio
- Test for diabetic albuminuria/ nephropathy
- Every 6 months but annually if controlled
- Start screening after initial 5 years after T1DM diagnosis, and upon T2DM diagnosis
Methods of testing: 1 + 2 OR 3
1. Serum Cr and/or eGFR
——–If kidney not good, lower eGFR (filter blood slowly) and hence higher Serum Cr (lesser filtered out of blood)
- Urine Albumin/Creatinine ratio (uACR)
——–Check for presence of albumin
—If kidney not good, more albumin may pass through into urine
——–If albuminuria is heavy, do uPCR instead
—Abnormal albumin levels >30ug/mg - Protein-Creatinine Ratio (uPCR)
——–When proteinuria levels are significant
——–Measures ALL types of urinary protein, not just albumin
What to take note for this Screening tests for diabetic patients? (Microvascular- Neuropathy)
Diabetic foot screening
- Reduce risk of foot ulcers
- Monitor everyday by patient
- Annual foot assessment by podiatrist if controlled, more frequent if have higher risk of foot ulcers
- Inspect skin, assess foot deformities, neurological assessment, vascular assessment (include pulses in legs and feet) - Advise
- Maintain optimal glycaemic control
- Stop smoking as smoking elevates lower extremity amputations risk
- Good foot care and appropriate footwear
- Daily monitoring of feet
- Apply simple first aid for small wounds
- Seek medical help if wound not healing or worsens
- Moisturise regularly
- Maintain good foot care and hygiene
- Wear well-fitting and covered footwear
What to take note for this Screening tests for diabetic patients? (Macrovascular- HbA1c)
Every 3 months, but every 6 months if controlled
What to take note for this Screening tests for diabetic patients? (Macrovascular- Metabolic syndrome/ CVS: Lipid panel)
- Every 3-6 months, but annually if controlled
- If not controlled then start on statins
What to take note for this Screening tests for diabetic patients? (Macrovascular- Metabolic syndrome/ CVS: BP)
- Every visit
- If not controlled then start on anti-hypertensive drugs
What are the treatment goals for DM? (HbA1c (%))
Comparison with Non-DM: <5.7%
<7%
- Shows good stats on delaying microvascular outcomes (not sm on macrovascular)
What are the treatment goals for DM? (FPG (mmol/L or mg/dL))
Comparison with Non-DM: <5.6 or 100
4-7 or 72-126
- If less than 4, is hypoglycemia
What are the treatment goals for DM? (PPG (mmol/L or mg/dL))
Comparison with Non-DM: <7.8 or 140
<10 or 180
What is the general goal for diabetic patients?
General goal: <7%
More stringent of 6-6.5% if patient has:
- Short disease duration
- Younger; Long life expectancy
- No significant CVD
Less stringent of 7.5-8% if patient has:
- History of severe hypoglycemia
- Limited life expectancy
- Advanced complications
- Extensive comorbid conditions
- Target difficult to attain despite intensive self-monitoring blood glucose (SMBG), repeated counsellings, effective pharmacotherapy
what is the first line agent for dm type 2?
Metformin
when to do combi therapy for dm type 2?
if A1c still above goal (after first line agent)
- Glucose lowering efficacy: Insulin, certain GLP-1, Combi therapy
- Minimise hypoglycemia (eg. elderly): Avoid SU, Insulin
- Promote weight loss: GLP-1, SGLT-2
what meds to consider if have Hx of ASCVD, HF, CKD?
consider independently of A1c to add (but note costly)
- ASCVD: GLP-1 agonist, or SGLT-2
- HF: SGLT-2
- CKD: SGLT-2 > GLP-1 agonist
since GLP-1 agonist is preferred over insulin when possible (altho super costly), when to consider insulin then?
Consider insulin if have glucose toxicity
- Significant weight loss (since insulin can cause weight gain)
- Symptoms of hyperglycemia (3 Ps)
- A1c > 10% (means poorly controlled diabetes in which insulin can quickly and effectively bring down)
- BG > 16.7 mmol/L (likewise explanation as A1c)
GLP-1 agonist associated with weight loss or weight neutrality
GLP-1 agonist also have lower risk in causing hypoglycemia than insulin meaning insulin in a way is “more effective” in bringing down BG faster
how to counsel if dm type 2 patients rly dw injectables?
If die die dw injectables, counsel patients that even with multiple oral agents, may not be effective as pancreas working capabilities is very poor, might even aggravate pancreas and destroy pancreas further and faster —> Can eventually convert back to oral after using injectables if results improve
what happen if A1c still bad after adding basal insulin?
consider adding prandial insulin (eg. aspart 4units or 10% of basal insulin) for biggest meal —> Rmb to dose reduce basal insulin (eg. glargine) when adding on prandial insulin to make up the maximum of 0.5u/kg/day
what happen if A1c still bad after adding on oral agents, basal and prandial insulin?
consider full basal-bolus regimen (basal and prandial insulin with each meal) or BD pre-mixed insulin regimen
what are the meds that act on the gastro intestinal tract?
- Incretins
- Alpha-glucosidase inhibitors
what are the meds that act on the pancreas that INCREASE insulin secretion?
- Incretins
- Sulfonyureas
- Meglitinides
what are the meds that act on the pancreas that DECREASE insulin secretion?
- Incretins
what are the meds that act on the brain?
Appetite control: Feel full
- Incretins
how do drugs affect the kidney?
Drugs decrease Glucose reabsorption —> Increase urination of sugar
note: Different from how excess glucose (diabetes) overwhelms kidneys’ ability to reabsorb —> Glucose spill into urine
how do drugs affect the muscles and fats?
Drugs Increase insulin sensitivity
(i) Increase utilization of glucose by muscle cells
(ii) Storage of excess glucose by adipocytes via lipogenesis (carbs and proteins —> triglycerides)
what are the oral glucose lowering agents?
- biguanides: metformin
- thiazolidinediones (TZDs)
- Sulfonylureas (SUs)
- Meglitinides (fyi yay)
- DPP-4 Inhibitors
- SGLT-2 Inhibitors
- Alpha-Glucosidase Inhibitors
what is metformin used for?
First line, unless have contraindications (Not to be used if have kidney failure, use sulfonylureas instead)
Mono or in combi therapy
Indications
- Off-label use for polycystic ovarian syndrome (PCOS)
- High potency: Decreases HbA1C by 1.5% (up to 2%)
- Does not cause weight gain and hypoglycemia
- Possible reduction in CVD
- Prevent and delay T2DM
metformin CANNOT be used for…
- Not to be used if have kidney failure, use sulfonylureas instead
- Severe renal impairement (Stage 4 CKD: GFR <30ml/min)
- Hypoxic (low O2) states or at risk for hypoxemia —> Increase risk of lactic acidosis when cells search for alternative energy production through anaerobic metabolism
- Due to heart failure, sepsis, respiratory failure, liver impairement, alcoholism, >80 years old
metformin is safe for…
- Reco for preggos (insulin also)
- Prescribed for gestational diabetes
- Safe for children >10 years old (only for immediate release… prof fkn unclear in her teaching)
how does metformin work?
Primary: Decrease hepatic glucose production
Secondary: Increase insulin sensitivity by increasing peripheral/ muscle glucose uptake and utilisation
is metformin renally eliminated?
YES! so may need to dose adj for pts with renal impairment
is metformin taken orally? is the onset fast?
Oral tablet
Onset: V fast as within days, max effects take up to 2 weeks
what are the two dosage forms of metformin?
- Immediate release
- Extended release (over 24h): cannot crush tablet
what are the dosage amts available for 1. Immediate release and 2. Extended release?
- Immediate release: 250mg, 500mg, 850mg (more common), 1000mg
- Extended release: 500mg (more common), 750mg, 1000mg
how are 1. Immediate release and 2. Extended release administered?
- Immediate release: Max daily dose is 2550mg (wont be effective beyond this dose)
Max dose:
TDS: 850mg
BD: 850mg x2 during bigger meal, 850mg x1 during the other meal - Extended release: Max daily dose: 2000mg
>1000mg: Divide into two doses, 500mg x2 tablets in the morning, 500mg x2 tablets in the evening
whats the adr of metformin?
- GI disturbances (diarrhoea, n/v), loss of appetite, metallic taste
- So start at lowest possible dose —> 250mg BD, but in hospital normally 500mg BD (cos dh 250mg) —> Every week titrate up to the desired outcome
- Take after food to reduce GI side effects
- Usually transient (temporary)
- Long term use may decrease serum B12 conc
- So monitor B12 levels when there are numbness/ tingling in sensations in hands and legs —> B12 supplements
- Rare but fatal: Lactic acidosis
what are the ddi for metformin?
- Alcohol: Increase risk for lactic acidosis
- If really need, give lower dose to curb the blood sugar levels
- Iodinated contrast material (Iodine dye used in CT scans
- Iodine dye may cause worsening of renal function, and metformin is eliminated by kidney —> later metformin accumulate and cause toxicity
- Temporarily withhold metformin for >48h after iodine admin, restart when renal function is stable and acceptable post-procedure
- Inhibitors of organic cationic transporters (OCT)
- HIV meds (cimetidine, dolutegravir, ranolazine) —> Inhibit clearance of metformin
what is Thiazolidinediones used for?
- Alternative monotherapy if intolerant to metformin
- Combi therapy (more common)
- High potency: Decrease HbA1c by 0.5-1.4%
- Reduce fats in liver, so good for fatty liver disease (NAFLD, NASH)
- Reduce stroke (but increase risk of heart failure)
- No benefits to kidney
Not enough info if can give preggos
how does Thiazolidinediones work?
- Increases insulin sensitivity
- Acts on peroxisome proliferator-activated receptor-gamma (PPARgamma) agonist to promote glucose uptake into muscles and fats
- No effects on insulin secretion
does Thiazolidinediones work SLOW?
yes… :( Takes up to a month for maximal effect
how is Thiazolidinediones eliminated? isit the same as metformin?
nope, Eliminated via liver (so not used in liver failure patients)
what is the one type of dosing for Thiazolidinediones?
Pioglitazone: 15, 30mg (tablet), max dose is 45mg
whats the ddi for Thiazolidinediones?
DDI with CYP enzymes inhibitors/ inducers
what are the adr for Thiazolidinediones?
- Hepatotoxicity
- So check liver function test prior to initiation and periodically thereafter if start
- Dont start if ALT>3x UNL
- Weekly monitor if ALT>x1.5UNL until normal
- Fluid retention
- Legs and hands become puffy
- Also a symptom of heart failure, so monitor for s/sx of heart failure
- Fracture
- Higher risk in women
- Non-spinal!!
- Weight gain
- Likely due to fluid retention
- Dose related
- Blackbox warning: Increased risk of bladder cancer
- Increased risk of hypoglycaemia with insulin therapy
when should you not take Thiazolidinediones? (active or past)
- Liver disease
- Heart failure
- Bladder cancer
what is Sulfonylureas used for?
Mono or in combi therapy
Can be used in renally impaired patients because not renally cleared
note: Require WORKING beta cells
- Very potent: Decrease HbA1c by 1.5%
- No other good outcomes apart from lowering blood glucose levels
- Exercise to minimise weight gain
- Cost effective cos subsidised by government
what are the 3 gens of Sulfonylureas?
1st gen: Shortest duration of action, need take most frequently
2nd gen
- Glipizide
- Gliclazide MR: Taken OD
3rd gen: Can take once daily (but higher cost)
- Glimepride
how does Sulfonylureas work?
Primary: Cause pancreas to release more insulin by blocking K+ channel (so need working beta cell, if not just give insulin directly)
Secondary: Decrease hepatic glucose output (to low extent) and increase insulin sensitivity
what is Sulfonylureas not safe for?
Not recommended for preggos, use metformin and insulin instead
Hypersensitivity to SUs
what are the adr for Sulfonylureas?
- Hypoglycemia (esp in elderly)
- If nv eat sufficiently and drug too effective
- Weight gain
- Not good for obese patients —> Exercise!!
when should you not take Sulfonylureas?
Beta blockers slow down HR —> Mask s/sx hypoglycemia (Palpitations, anxiety)
Disulfiram-like reactions (flushing, tremors) with alcohol esp with 1st gen
- But can still drink but wayyy lesser
- 2nd and 3rd gen preferred
CYP2C9 inhibitors which may increase potency
how to take Sulfonylureas?
Must be taken immediately before meals, do not miss or delay any meal
- Want to coincide with the spike —> Helps reduce risk of hypoglycaemia
- Use with caution if have irregularities in meal schedules
is DPP-4 Inhibitors popular like the rest?
Not very popular compared to the rest
what normally happens upon eating in relation to GLP-1 hormones? what happens to such hormones after eating?
Upon eating, stomach linings will release GLP-1 hormones to make you feel full to reduce food intake AND release insulin to work on glucose AND reduce glucagon AND helps intestine to slow mobility to feel full
- Life span of GLP-1 is v short, only a few mins
- DPP-4 enzyme rapidly degrades GLP-1 to inactive form
how does DPP-4 Inhibitors work?
DPP-4 inhibitors help to prevent the breakdown of GLP-1 to lengthen the effects of GLP-1
what are the 3 diff types of DPP-4 Inhibitors?
- Sitagliptin (Subsidised)
- Vildagliptin
- Linagliptin
what are the doses for the following DPP-4 inhibitors?
- Sitagliptin (Subsidised): 100mg OD
- Vildagliptin:
50mg BD (with Met or TZD) or OD (with SU) - Linagliptin; 5mg OD
what are the dose adjustments for the following DPP-4 inhibitors?
- Sitagliptin (Subsidised):
eGFR <30 give 25mg
eGFR <45 give 50mg - Vildagliptin:
CrCl not 50 give 50mg - Linagliptin: nil
what are the ddis for the following DPP-4 inhibitors?
- Sitagliptin (Subsidised): Digoxin
- Vildagliptin: nil
- Linagliptin: CYP3A4 inducer
what are the adrs of DPP-4 Inhibitors?
- Severe joint pain (may persist while on meds, not transient)
- Headache: Most common
- Rare: Acute pancreatitis
- Hypersensitivity reaction
- Rare: Bullous pemphigoid (skin rash with blisters) —> Need prednisolone
what is DPP-4 Inhibitors for?
Mild potency: Decrease HbA1c by 0.5-0.8% —> Good for SLIGHTLY elevated levels, or if have renal impairment
what are the adv of DPP-4 Inhibitors over GLP-1 agonists?
- not SC injectables so cheaper!!, lower incidence of GI ADR
- Mild ADR except joint pain
what are the disadv of DPP-4 Inhibitors over GLP-1 agonists?
No other good outcomes like ASCVD, HF, CKD (instead increase risk of Heart failure): So 2nd or third-line agent
- Does not increase weight unlike SUs
what is SGLT-2 Inhibitors?
Sodium–glucose cotransporter 2 that Works in the kidneys
why is SGLT-2 Inhibitors becoming more used?
due to good cardiovascular outcomes
Good for: (but costly!)
1. ASCVD (eg. MI): But only canagliflozin and empagliflozin
2. Heart failure: For dapagliflozin, empagliflozin
3. CKD: For dapagliflozin
how does SGLT-2 Inhibitors work?
Normal: As glucose passes through proximal tubules, SGLT-2 and 1 receptors reabsorb glucose
- If too much sugar aka DM, cannot reabsorb much —> Urine in sugar
Inhibit receptors so cannot reabsorb sugar —> increase renal glucose excretion —> Decrease blood glucose
what are the 3 types of SGLT-2 Inhibitors?
- Canagliflozin 100mg OD
- Empagliflozin 10mg OD
- Dapagliflozin 5mg OD
what are the dosing considerations for the following SGLT-2 Inhibitors?
- Canagliflozin:
Do not initiate if eGFR <30ml/min and no other issues apart from high sugar - Empagliflozin:
Do not initiate if eGFR <45ml/min and no other issues apart from high sugar - Dapagliflozin:
Do not initiate if eGFR <45ml/min and no other issues apart from high sugar
when to initiate SGLT-2 Inhibitors?
if for Glycemic control ONLY (no other problems): eGFR > 45ml/min
if for Glycemic benefit and cardiorenal benefit: eGFR > 25 for dapagliflozin and > 20 for empagliflozin 10mg
when to discontinue SGLT-2 Inhibitors?
if for Glycemic control ONLY (no other problems): eGFR becomes persistently < 45 (from healthy to kidney failure) —> but for cardiorenal can continue
if for Glycemic benefit and cardiorenal benefit: Upon starting dialysis
whats the adr for SGLT-2 Inhibitors?
- Hypotension as push out sugar —> Decrease in water content
- So check bp
- Hypoglycaemia (not to a great extent as is based on how much one eats, unlike SUs)
- So check bp
- Renal impairment
- Female: Genital mycotic infection cause pee out sugar —> Higher risk of fungal infection —> increase risk of UTI
- Euglyemia (normal sugar levels) diabetic ketoacidosis (DKA)
- Need insulin infusions as very serious, no longer can use SGLT-2 Inhibitors
- Causes: Severe stress (sick, surgery, work), not eating well, severely dehydrated, alcohol abuse —> Once recover then give back
- Quite prominent so in FDA warning
- Male: Fournier’s gangrene (infections on perineum)
- Quite prominent so in FDA warning
- Only for Canagliflozin: Lower limb amputation, hyperkalemia, fractures
what is an impt adr to note for SGLT-2 Inhibitors?
Euglyemia (normal sugar levels) diabetic ketoacidosis (DKA)
- Need insulin infusions as very serious, no longer can use SGLT-2 Inhibitors - Causes: Severe stress (sick, surgery, work), not eating well, severely dehydrated, alcohol abuse —> Once recover then give back - Quite prominent so in FDA warning