Diabetes Flashcards
1
Q
Quick recap glucose homeostasis
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2
Q
Aetiology of diabetes
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3
Q
Diagnosis
A
- Usually based on clinical symptoms in combination with measured blood glucose levels
- Symptoms: Polydipsia, polyuria, infections, blurred vision, lethargy
- HbA1c reflects average glucose over 8-12 weeks
- Can be used as a diagnostic test
- HbA1C more than 48 mmol/mol
- Some factors affect accuracy of HbA1C and in these patient HbA1C should not be used for diagnosis
4
Q
Monitoring
Blood glucose targets
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- Pre-meal- 4-7 mmol/L
- Post-meal- <9mmol/L
- Not always possible. Hypoglycaemia may occur if too tight
- Self monitoring essential in type 1
- Type 2 only in some patients (due to cost/those on insulins)
5
Q
HbA1C
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- Refers to glycated Hb, which identifies average plasma glucose concentration over 2-3 months
- Long term control
- Need to be realistic
6
Q
Blood ketones (type 1 only)
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- Only required when experiencing hyperglycaemia to try to avoid DKA
- Blood ketones (not urine dipstick)
7
Q
Treatments- INSULIN
Rapid and short-acting
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- 5 main types of insulin
- RAPID ACTING
- Rapid onset and shorter duration. Taken just before with a meal
- Begins to work 15 minutes after injection, peaks approx. 1 hour, and continues to work for 2-4 hours
- Aim to provide a physiological bolus of insulin when used at mealtimes
- Types: Insulin glulisine (Apidra), Insulin lispro (Humalog) and Insulin Aspart (Novorapid)
- SHORT ACTING
- Not as quick to act as rapid. Usually taken before meals
- Begins to work 30 minutes after injection, peaks from 2 to 3 hours, and is effective for approximately 3-6 hours
- Used as part of a basal-bolus, to provide bolus at mealtimes
- Soluble insulin (Actrapid, Humulin S)
8
Q
Intermediate (NPH) (Isophane)
A
- 24 hour duration
- Begins to work 2 to 4 hours after injection, peaks 4 to 12 hours later, and is effective for about 12-24 hours
- Used to cover blood sugar between meals, and to satisfy your overnight insulin requirement
- Can be OD or BD and can be used in combination with rapid or short-acting insulin
- Types: Insulatard
9
Q
Long acting
A
- Slower onset, prolonged duration
- Peakless insulin levels, over 24 hours period (Note tresiba acts for 40 hours)
- Aim to mimic basal physiological insulin
- Used in type 2 diabetes OD or as part of basal-bolus in type 1 + 2
- Types: Insulin detemir (Levemir), Glargine (Lantus, Toujeo), Degludec (Tresiba)
10
Q
Pre-mixed
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- Combination of intermediate and rapid-acting
- Rapid element starts to act immediately, peak at 1 hour and last 4 hours; long acting element begins onset 2 hours, no peak activity, lasts upto 24 hours
- BD injections (Breakfast and evening)
- Biphasic aspart (Novomix 30), Biphasic lispro (Humalog mix 25, 50)
11
Q
Insulins release profile
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12
Q
Insulin regimens- which profiles which?
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13
Q
The insulins regimens- How do you decide
What factors do you think affect the regimen we choose a patient?
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- Type 1 or 2
- Who will administer the insulin
- Dexterity of patient
- Patient compliance
- Diet
- What is their blood glucose control
- Do they have post-prandial high blood glucose
14
Q
How do you decide
Once-daily regimens
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- Suitable for type 2
- Long-acting or intermediate insulin
- People with hyperglycemia through the day and night
- Require assistance injecting
- NG feeds/insulin infusions
- Intermediate insulin for people who high blood glucose overnight and in the morning but better during the day. Give at night
15
Q
How do you decide
Twice daily mix
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- Type 1 or 2
- Keep a consistent daily routine that includes 3 meals a day
- Some flexibility for adjusting doses, not as much as a basal-bolus regimen
- Type 2 diabetes, useful for high blood glucose levels after meals
- Easy for patients to understand
- Fewer injections than basal-bolus
- More effective at reducing HbA1C than basal alone
16
Q
How do you decide
Basal-Bolus
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- Type 1 and 2
- At least 4 injections per day
- A long-acting or intermediate-acting dose and separate injections of short or rapid-acting insulin at each meal
- Advantage flexibility over when meals are taken and allows doses to be varied in response to different carbohydrate quantities in meals
- Better potential for metabolic control if used optimally
- Potential for better lifestyle choices in terms of adjustment for diet and activity
17
Q
How do you decide
Continuous subcutaneous insulin infusion
A
- Type 1 diabetes
- Rapid-acting insulin
- Insulin pump connected to your body
- Delivers a constant feed of insulin into the body via an s/c cannula
- At meals times, an increased burst (bolus) of insulin can be delivered to keep blood glucose levels under control
- Predictable insulin release
- Reduced episodes of severe hypo’s
18
Q
Summary of insulins- Mnemonic
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19
Q
General principles of insulin dose adjustment
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- Do not adjust based on a one-off reading
- After an adjustment of long-acting insulin wait 3-4 days before the further adjustment (5 days with degludec)
- Once-daily insulin regimen
- Hyperglycaemia, increase by 10% in increments of 2,4,6 units
- If Hypoglycaemia, reduce by 2-4 units or 20% whichever is greater
- Mix insulin regimen
- Morning dose titrated against pre-launch and pre-evening meal BG
- Evening dose titrated against pre-bed and pre-breakfast BG
- Hyperglycaemia increase by 10%
- Hypoglycaemia reduce by 20% or 2-4 units whichever is greater
20
Q
General principles of insulin dose adjustment
Basal-bolus regimens
A
- Adjust long-acting to control pre-breakfast blood glucose
- Reduce if BG low overnight or pre-breakfast
- Adjust rapid-acting to control BG pre-lunch and tea
- Increase or decrease quick-acting insulin by 0.5 units to 10g carbohydrate (or 2-5g carbohydrate per unit of insulin)
- Hyperglycaemia and trend increases overnight increase basal by 10-20%
- If type 2 and on larger doses than 10%
- If hypo overnight or pre-breakfast reduce basal by 20%
21
Q
Dose adjusting insulin
Once-daily regimen
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22
Q
Dose adjusting insulin
Mixed or intermediate insulin-twice daily
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- As a general rule if a 2-3 mmol/L improvement needed increase dose by 5% initially and for greater than a 5mmol/L improvement increase by 10%
23
Q
Basal-Bolus regimen
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- If type 2 diabetic and on larger doses of insulin only increase by 10%
26
Q
NICE type 2 diabetes
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32
Q
DPP4- Inhibitors
(Dipeptidyl Peptidase 4 inhibitor)
A
- Inhibits the degradation of GLP-1
- MOA: reduce incretin turnover => increase 1st phase insulin response, suppress glucagon
- Glycaemic impact: HbA1c decreased 0.5-0.8%.
- Side-effects: GI dysmotility; Pancreatitis; bowel cancer
36
Q
GLP-1 modes of action
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40
Q
Do they cause hypoglycaemia
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44
Q
DKA
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- Life threatening complication of type 1
- Insufficient insulin intake
- 10-30% cases first presentation of diabetes
- 50% precipitated by infection
- Clinical features: Polyuria, polydipsia, muscle crampls, ab pain, SOB, ketone smelling breath
- Definitions
- Acidaemia: Bicarbonate <15mmol/L And/Or Venous blood gas pH <7.3
- Hypreglycaemia: BG> 11.1 mmol/L or known diabetic
- Ketones: Ketonaemia >3mmol/L; Ketonuria (2++)
48
Q
DKA role of the pharmacist- sick day rules
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