Diabetes Flashcards by Peter Smith

Insulin apidra?

Rapid acting insulin
15 min onset
peaks in an hour
lasts for 4

take after start of meal

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Lispro?

Rapid
15 min onset
peaks 1-1.5hr
6-8 hour

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Insulin aspart

10-20 mins
1-3 hours peak effect
lasting 3-5 hour

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Insulin injection SQ

Short acting
30min - 1hour
2-4 hour peak
5-7 hour duration

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Insulin IV

Short acting
10-30 mins onset 
15-30 mins peak
30mins-1 hour duration
clear
30 minutes prior to a meal

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isophane insulin suspension

Intermediate acting
1-2 hour onset
4-12 hour peak

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Lantus/ Insulin glargine

3-4 hour
lasts for 24 hours
one daily at the same time every day

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Levemir/ insulin determir

3-4 hour
3-14 hour peak
lasts for 6-24 hours

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Describe the pharmacology of insulin

May be of short acting, intermediate acting and long acting character. Twice daily, multiple dosing and single daily regimens may be used. Requirements are increased by stress, infection, trauma, puberty and trimesters 2 and 3.

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Sulphonylurea

such as glibenclamide and tolbutamide, increase insulin secretion by inhibiting ATP sensitive K+ channels. Channel closure leads to depolarisation and insulin release. They cause weight gain and increased insulin resistance, and are associated with hypos in the elderly and meal skippers.

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Metformin?

Is a biguanide drug. They may activate AMP Kinase, and are the drug of choice in obese patients, but should not be used in renal impairment.

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Metflitinide analogues

such as nateglinide, also act at K+ channels. They are fast acting and may be used as prandial glucose control.

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Thiazolindiedione

such as pioglitazone act at nuclear PPAR-gamma to alter gene expression and produce insulin-like effects: reduced hepatic glucose output (monitor LFTs), increased GLUT receptor levels in skeletal muscle and increased fatty acid uptake into adipose cells.

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In the management of a patient with diabetes describe how blood pressure might be controlled and pharmacological strategies for the prevention of diabetic nephropathy.

ACEi protect against diabetic nephropathy. Control of blood glucose is of incredible importance in diabetes to avoid vascular consequences. Simvastatin is a sensible adjunct. BP should be controlled below 135/75 and HbA1c below 6.5-7.5%.

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What is Variable rate insulin infusion, and why is it used??

Diabetic patients who are going to b nil by mouth
blood glucose to check 1-2 hrly. The rate modified according to this
IV fluids containing glucose for basal glucose maintenance and hydration

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Guidance for VRII?

Always use the long-acting insulin even if they are NBM, rebound hyperglycaemia or DKA
Before you stop, confirm the patient is eating and drinking again
Long acting insulin has had time to take effect (at least 60 minutes before stopping)
Administer rapid acting insulin alongside meals an wait 30 mins before stopping the VROO
Monitor capillary glucose at least every 6 hours for a least 24 hours

What is the indication for Metformin?

Treating T2DM, particularly in overweight, when diet and exercise not enough
immediate or sustained release

Contraindications of Biguanide (metformin)

allergy, dehydration
in AKI or GFR<30 or hepatic impairment
severe infections or conditions which lead to tissue hypoxia, e.g. respiratory failure
IV iodinated contrast agents or metabolic acidosis

How does metformin work?

reducing hepatic glucose production by inhibiting gluconeogenesis and glycogenolysis
in muscle it increases insulin sensitivity, improving peripheral glucose uptake and utilisation
delay intestinal glucose absorption

It stimulates glycogen synthase
-It increases the transport capcity of all types of membrane glucose transporters known

Can metformin causes hypoglycaemia?

No because it does not stimulate insulin

Examples of sulphonylureas?

Gliclazide, glimepiride, glipizide, tolbutamide

Indications for tolbutamide and its other related drugs?

Non insulin dependent diabetes (type 2) in
adults when dietary measures, physical exercise
and weight loss alone are not sufficient to
control blood glucose.

Contraindications of sulphonylurea?

allergy
T1DM (because they require residual function) or DKA
severe renal or hepatic insufficiency

Can sulphonylureas cause hypoglycaemia?

Yes, due to overstimulation of residual insulin cells

How do sulphonyureas stimulate insulin release?

blocking ATP sensitive potassium channels, reducing potassium permeability. this causes depolarisation of the cell and increases calcium entry and insulin secretion

What are meglitinides indicated for? Name two

• For combination therapy with metformin in type 2 diabetic patients inadequately controlled despite a maximally tolerated dose of metformin alone. Nateglinide and Repaglinide

indications of sulphonylureas??

• For combination therapy with metformin in type 2 diabetic patients inadequately controlled despite a maximally tolerated dose of metformin alone.

contraindications of sulphonylureas??

Allergy • Diabetes type I or diabetic ketoacidosis (DKA) • Severe hepatic disorder • Pregnancy? Not enough data

What are thiazolidinedioines applied for? e.g.?

e.g. Pioglitazone Indicated as a second or third line treatment for T2DM Monotherapy: adult patients with poor control of weight or for whom metformin is contraindicated Dual oral- metformin, or a sulphonylurea Triple: with above

Who might pioglitazone be contraindicated for?

Hx of heart failure | Previous or active bladder cancer

How do pioglitazones act?

bind PPAR-y in adipocytes this promotes fat maturation and deposition into peripheral tissue reduce circulating fat to improve insulin sensitivity weight gain and peripheral fat mass increase

Treatment strategy for hyperglycaemia w/o DKA/HHS

``` rehydrate request blood glucose stat: rapid or short acting insulin investigate cause of hyperglycaemia and correct (i.e. insulin, infection) adjust insulin regimen to prevent recheck and assess blood glucose ```

Treatment strategy for hypoglycaemia

Unconscious IV stat glucose IM glucagon if no IV access Check after 10 mins Conscious but can't swallow 1-2 tubes of glucose gel around the gum line and wait 10 mins, check capillary glucose Can sallow: fast acting carbs and long acting carbs

What is your priority in managing a DKA?

IV hydration

What investigations should you include in a DKA?

urine dip glucose VBG (do they need potassium as well as saline IV fluid?)

After hydration, what should you do in managing a DKA?

Start a fixed rate insulin infusion normally 0.1unit/kg/hr from a 50unit rapid acting soluble insulin and 50mls of saline. • When glucose levels rise give a 10% IV glucose solution adjusted depending on capillary glucose level IN ADDITION to the saline being given. • Adjust the rate to account for extra fluid. • Why do we give a glucose infusion when they are already hyperglycaemic? • Do we continue the patients long acting insulin or not? • Investigations to determine the cause i.e. infection, medications • Consider intensive care if they are still not responding

How is HSS different to DKA? How is it managed

develops slowly usually from illness or dehydration glucose is very high but no acidosis risk comes from dehydration and increase in thrombotic state (so what other meds?) rehydrate your patient and start IV insulin if blood glucose doesn't go down withhold metformin for 48 hours