Diabetes 6 Flashcards
What is the mechanism of action of thiazolidinediones (-glitazones) and what is an example of them?
Enhance the effects of insulin in adipose tissue and skeletal muscle, and inhibits hepatic gluconeogenesis.
Pioglitazone.
What are the advantages of glitazones?
- Effective in insulin resistant patients
- Reduced risk of hypoglycaemia
- Positive effect on lipids
What are the disadvantages of glitazones?
- Inc. risk of heart failure, bladder cancer, renal impairment and weight gain (fluid retention)
What monitoring requirements are required for pioglitazone and what serious symptoms need to be looked out for?
Baseline LFTs, every 2 months for a year then periodically.
Symptoms suggesting liver disease: seek medical attention
Jaundice: discontinue treatment
What are incretins?
Gastrointestinal hormones released in response to meals to increase insulin secretion.
What are the two types of incretins?
GLP-1 (Glucagon like peptide 1), GIP (Glucose dependent insulinotropic peptide)
What enzyme rapidly degrades Incretins?
Dipeptidyl peptidase-4 (DPP4)
What effect does type 2 diabetes have on incretin levels?
Reduced GLP-1 levels, GIP action is defective/absent
What are two examples of DPP4 inhibitors and what are their advantages?
Apogliptin (OD), Vildagliptin (BD)
Weight neutral, well tolerated.
How are GLP-1 agonists administered and what are two examples?
Subcutaneous injection.
Liraglutide (once/twice daily), semaglutide (once weekly)
What are the side effects of GLP-1 receptor agonists?
Slight weight loss.
Nausea.
Hypoglycaemia with sulfonylureas.
What is the first line treatment for type 2 diabetes in patients not at high CVD risk?
Metformin (Initial dose 500mg OD to 500mg after three weeks, inc dose gradually)
- GI disturbance - Metformin MR
- If Metformin contraindicated:
- DPP4 inhibitor or
- Pioglitazone or
- Sulfonylurea or
- SGLT2 inhibitor
What is the first line treatment for type 2 diabetes in patients at with ASCVD, heart failure or high risk of CVD?
Metformin/Metformin MR + SGLT2 inhibitor (started as soon as tolerability to Metformin confirmed)
- If metformin contraindicated: SGLT2 inhibitor alone
What additional treatment is offered for type 2 diabetes patients whose CVD risk/status changes while on metformin?
Offer an SGLT2 inhibitor (if not already prescribed)
What dual therapy treatment is available for type 2 diabetes patients when metformin monotherapy not controlling HbA1c?
Metformin + DPP4 inhibitor/Pioglitazone/sulfonylurea/SGLT2 inhibitor
What is an example of triple therapy treatment that is available for type 2 diabetes patients?
Metformin + sulfonylurea + DPP4 inhibitor/SGLT2 inhibitor/Pioglitazone
According to NICE guidelines, when are GLP-1 agonists considered to replace a drug for triple therapy?
If previous triple therapy with metformin and two other oral drug not effective/contraindicated/not tolerated
AND BMI ≥ 35 OR BMI <35 and insulin therapy would have significant occupational implications e.g. operating heavy machinery
When would you start insulin therapy in type 2 diabetes?
Dual therapy not controlled HbA1c to below agreed threshold
- Metformin continued, other oral medication reviewed and stopped if necessary
What three insulin regimens are available for type 2 diabetes?
- Basal insulin at night/BD (human isophane insulin/prolonged action analogues)
- Biphasic insulin injected OD/BD
- Intensive basal Bolus
When is blood glucose monitoring required for type 2 diabetes (not on insulin)
Illness, medication changes, patients troubled by hypoglycaemia, to monitor lifestyle changes.
Test twice in one day per week.
