Diabetes Flashcards

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1
Q

What causes production and inhibition of insulin? What is it’s role?

A
Secreted in response to:
Glucose
Incretins(GLP-1, GIP) 
Glucagon 
Parasympathetic activity

Inhibited:
Low glucose
Cortisol
Sympathetic activity

Role:
Decreased hepatic glucose output via inhibition of gluconeogenesis, inhibits glycogenolysis, promotes uptake of fats

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2
Q

Which drugs increase your risk of developing type 2 diabetes?

A

Thiazides/ thiazide- like, glucocorticoids, beta blockers

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3
Q

How far back does HbA1c predict the percentage of red blood cells with sugar coating?

A

Reflects average blood sugar over last 10-12 weeks mmol/ mol or %

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4
Q

Types of therapeutic insulins

A

Bovine - human (3aa)
Porcine - human (1aa)
Immunogenicity

Human insulin - recombinant DNA or enzymatic modification of porcine

Protein - must given parenterally to avoid gut digestion

Usually 100 U/ mL

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5
Q

Pharmacokinetics of insulin

A

Routine delivery by injection (upper arms, thighs, buttocks, abdomen)

I.v. For emergency treatment

t1/2 5 mins (plasma, renal, hepatic metabolism and elimination)

Plasma conc greatest after 2-3hrs - dose 15-30mins prior to meals

Protamine &/ or zinc used to modify absorption

Site of administration route - lipodystophy

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6
Q

Why do diabetics need to rotate the injection site of insulin?

A

Can get lipodystrophy - hypertrophy of lipids around injection site can affect vasculature

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7
Q

List some different insulin profiles, the onset of action, peak, duration and class

A

Insulin aspart - 10- mins onset, 40-50mins peak, 3-5hrs duration, rapid class

Soluble insulin (Humulin S, Actrapid) - 30-60mins onset, 2-12hrs peak, 5-8hrs duration, short class

Isophane insulin (NPH) - 60-120mins onset, 4-12hrs peak, 18-24hrs duration, intermediate class

Insulin glargine- 60-90mins, plateau between 2-20hrs, 20-24hrs duration, long class

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8
Q

What are potential risks of insulin therapy and what other drugs should you be cautious of prescribing simultaneously?

A

❌hypoglycaemia, lipohypertrophy, lipoatrophy, renal impairment -> hypoglycaemic risk

Increased dose if taking steroids, caution with other hypoglycaemic agents

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9
Q

What is meant by basal-bolus dosing?

A

Can take a bolus dose which is rapid acting after meals e.g. aspart

Basal dose is long acting and taken first thing in the morning e.g. glargine

Normal ppl have basal level of insulin which increases after meals

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10
Q

When would you suspect a diabetic ketoacidosis, how would you treat?

A

Blood glucose _>11mmol/ L (not always) and:

Infection 
Stress/ trauma
Poor insulin adherence 
ADRs 
Ketosis 
Can have low blood ketones 

✅fluids priority then insulin, then glucose and K+ if needed
(Total K+ levels in body quite low but measurements of blood may suggest higher as acidosis)

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11
Q

How does type 2 diabetes occur?

A

Slow progression of disease

Cellular resistance to insulin associated with obesity
- resistance initially overcome by increased pancreatic secretions
Decreased insulin receptors, decreased GLP-1 secretion in response to oral glucose and reduced beta cell response

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12
Q

What is the NIcE guidance for type 2 diabetes glucose lowering therapy if they can take metformin?

A

If HbA1c rises to 48mmol/mol on lifestyle interventions ->
standard release metformin, aim for HbA1c 48. If rises to 58->

Consider dual therapy metformin and DPP-4i/ pioglitazone/ SU/ SGLT-2i. Aim for 53. If rises to 58 ->

Consider triple therapy metformin and: DPP-4i + SU OR pioglitazone + SU OR pioglitazone/ SU + SGLT-2i. Consider insulin based. Aim for 53.

(Is standard release metformin not tolerated e.g. GI upset consider trial of modified release)

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13
Q

What is the NIcE guidance for type 2 diabetes glucose lowering therapy if metformin contraindicated or not tolerated?

A

HbA1c rises to 48 mmol/mol on lifestyle interventions ->

Consider one: DPP-4i/ pioglitazone/ SU/ SGLT-2i. Aim for 48 or 53 if on SU. If rises to 58->

Consider dual therapy: DPP-4i + pioglitazone, DPP-4i + SU, pioglitazone + SU. Aim for 53. If reaches 58 ->

Consider insulin based treatment. Aim for 53.

Slide 14

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14
Q

What type of drug is metformin and how does it work? Side effects and drug cautions

A

Biguanide

  • Decrease hepatic glucose output (gluconeogenesis, glycogenolysis)
  • Increase glucose utilisation in skeletal muscle
  • suppress appetite

Typically first drug offered can be taken concomitantly with other options

❌GI upset - nausea, vomiting, diarrhoea, lactic acidosis STOP if eGFR <30mL/ min

Drug cautions: ACEi, diuretics, NSAIDS (any drugs that may impair renal function) thiazide- like diuretics increase glucose so can reduce action

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15
Q

Give an example of a sulfonylurea, how do they work, side effects, drug cautions?

A

Gliclazide, stimulate beta cell pancreatic insulin secretion blocking ATP dependent K+ channels, need residual pancreatic function

Typically in combo with other agents or a first line option if metformin contraindicated

❌ mild GI upset, hypoglycaemia, rare hypersensitivity reactions, weight gain through anabolic insulin effects

Drug cautions: other hypoglycaemic agents, hepatic impairment, renal impairment thiazide like diuretics increase glucose so can reduce action

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16
Q

Give examples of thiazolidinediones (glitazone), how do they work, side effects, drug cautions?

A

Pioglitazone, rosiglitazone

  • Increase insulin insensitivity in muscle and adipose, decreased hepatic glucose output
  • activation of PPAR-gamma -> gene transcription t1/2 not related to duration of action - 6-8weeks

❌weight gain (fat cell differentiation, GI upset, fluid retention, CVD concerns, bladder cancer

Drug cautions: other hypoglycaemic agents

17
Q

Give examples of sodium-glucose co-transporter (SGLT-2) inhibitors (gliflozins), how do they work, side effects, drug cautions?

A

Dapagliflozin, canagliflozin

Decrease glucose absorption from tubular filtrate, increase urinary glucose, competitive reversible inhibition of SGLT-2 in PCT

Used in type 1 and type 2 diabetes as ado on therapy

❌ modest weight loss, hypoglycaemic risk low, UTI, genital infection, thirst, polyuria

Cautions: antihypertensive sand other hypoglycaemic agents

18
Q

Physiological effects of glucopeptide -1

A

Pancreas: increased insulin secretion, decreased glucagon secretions, increased insulin biosynthesis

Brain: decreased food intake through increased satiety

Liver (indirect): decreased glucose production

Muscle (indirect): increased glucose uptake

Stomach: decreased gastric emptying

19
Q

Give examples of Dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins), how do they work, side effects, drug cautions?

A

Sitagliptin, saxagliotin

Prevent incretin degradation -> increase plasma incretin levels
Incretins glucose dependant so postprandial action, don’t stimulate insulin secretion at normal blood glucose - lower hypoglycaemic risk

Suppress appetite - weight neutral

Combination with other agents or first line if metformin contraindicated

❌GI upset, small pancreatitis risk, avoid in pregnancy

Cautions: other hypoglycaemic agents, drugs increased glucose can oppose gliptin action - thiazide like, loop diuretics

20
Q

Give examples of glucagon- like peptide-1 (GLP-1) receptor agonists (incretin mimetics), how do they work, side effects, drug cautions?

A

Exenatide/ liraglutide

Increase glucose dependent synthesis of insulin secretion from beta cells, activate GLP-1 receptor - not degraded by DPP-4

Subcutaneous injection

Promote satiety - weight loss

Add on if triple therapy ineffective

❌GI upset, GORD, stop of eGFR <30mL/ min

Cautions: other hypoglycaemic agents

21
Q

Positives and negatives to modified release drugs

A

Positives: less drugs to take - improves adherence, slower realease may mean less side effects e.g. GI symptoms

Negatives: harder to change dose of individual drugs, must take tablet whole as coating is what is modified