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CPD (Pre-Reg) > Diabetes CPD Boots Learning > Flashcards

Diabetes CPD Boots Learning Flashcards

1
Q

An HbA1c treatment target of 48mmol/mol (6.5 per cent) is recommended unless the individual is taking a medicine associated with hypoglycaemia (e.g. a sulfonylurea), in which case what is the target?

A

53mmol/mol (7.0 per cent) is recommended if the patient is taking a medicine associated with hypoglycaemia.

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2
Q

The NHS is currently spending around what per cent of its budget on treating diabetes?

A

10% (£10bn)

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3
Q

First-line treatment for T2 diabetes

A

Metformin

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4
Q

monotherapy options for T2 in those who cannot have metformin (4)

A

sulfonylureas
Pioglitazone
Dipeptidyl peptidase-4 inhibitors (DPP-4)
SGLT-2 inhibitors (only if a DPP-4 would otherwise be prescribed and a sulfonylurea or pioglitazone is not ok)

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5
Q

In May 2016, NICE recommended SGLT-2 inhibitors (canaglifozin, dapaglifozin and empaglifozin) as monotherapy for T2 diabetes only if:

A

A dipeptidyl peptidase-4 (DPP-4) inhibitor would otherwise be prescribed, and

• A sulfonylurea or pioglitazone is not appropriate.

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6
Q

If the first-line treatments are ineffective and blood glucose is not being controlled, a second antidiabetic drug should be added (dual therapy). For individuals who can tolerate metformin, the following combinations should be considered: (4)

A

Metformin and a DPP-4 (gliptin)
Metformin and pioglitazone
Metformin and a sulfonylurea
Metformin and a SGLT-2 inhibitor (only where a sulfonylurea is not suitable or the patient is at risk of hypoglycaemia).

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7
Q

If the first-line treatments are ineffective and blood glucose is not being controlled, a second antidiabetic drug should be added (dual therapy).

Metformin and a SGLT-2 inhibitor can be considered in what circumstances?

A

Where a sulfonylurea is not suitable or the patient is at risk of hypoglycaemia.

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8
Q

If the first-line treatments are ineffective and blood glucose is not being controlled, a second antidiabetic drug should be added (dual therapy).

For individuals who cannot take metformin, the following combination should be considered (3)

A

A DPP-4 and pioglitazone
A DPP-4 and a sulfonylurea
Pioglitazone and a sulfonylurea

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9
Q

If second-line treatments are ineffective and blood glucose is still not being controlled, a third antidiabetic drug should be added (triple therapy). For individuals who can tolerate metformin, the following combinations should be considered (3)

A

Metformin plus a DPP-4 and a sulfonylurea
Metformin plus pioglitazone and a sulfonylurea
Start insulin therapy

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10
Q

If second-line treatments are ineffective and blood glucose is still not being controlled, a third antidiabetic drug should be added (triple therapy). For individuals who can tolerate metformin, metformin + pioglitazone + DPP-4 is an option.

True or false.

A

False.

Options are:
Metformin plus a DPP-4 and a sulfonylurea
Metformin plus pioglitazone and a sulfonylurea
Start insulin therapy

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11
Q

Where triple therapy with metformin and the other two antidiabetic medicines is ineffective, not tolerated or contraindicated, the following treatment plans should be considered:

A

Metformin, a sulfonylurea and a glucagon-like peptide-1 (GLP-1) for people who:

Have a BMI or 35kg/m2 or over (adjusted accordingly for people from black, asian and other minority ethnic groups) and have specific psychological or other medical problems associated with obesity, or:

A BMI lower than 35kg/m2 where:

insulin therapy would have specific implication for their occupation, or weight loss would benefit other obesity related co-morbidities.

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12
Q

Where triple therapy with metformin and the other two antidiabetic medicines is ineffective, not tolerated or contraindicated, metformin, a sulfonylurea and a GLP-1 can be considered in what people?

A

people who:
• Have a BMI of 35kg/m2 or over (adjusted accordingly for people from black, Asian and other minority ethnic groups) and have specific psychological or other medical problems associated with obesity, or

• A BMI lower than 35kg/m2 where:

o Insulin therapy would have specific implications for their occupation, or

o Weight loss would benefit other obesity related co-morbidities.

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13
Q

GLP-1 therapy should only be continued if the individual has a beneficial response - i.e. a reduction in what value of HbA1c and a weight loss of what value in six months?

A

GLP-1 therapy should only be continued if the individual has a beneficial response – i.e. a reduction of at least 11mmol/mol (1.0 per cent) in HbA1c and a weight loss of 3 per cent of initial body weight in six months.

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14
Q

Alternative third line therapies with SGLT-2 inhibitors exist.

NICE recommends empagliflozin and canagliflozin be used in triple therapy as an option with what combinations of drugs?

A

Metformin and a sulfonylurea.

Metformin and a thiazolidinedione. Dapaglifozin is only recommended in triple therapy in combination with metformin and a sulfonylurea.

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15
Q

Dapaglifozin is only recommended in triple therapy in combination with what?

A

Dapagliflozin is only recommended in triple therapy in combination with metformin and a sulfonylurea.

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16
Q

How does metformin work?

A

Blocks the liver’s ability to produce glucose from fats and increases sensitivity to the insulin that the pancreas is producing.

It only acts in the presence of insulin, so is only effective if there is some residual functioning pancreatic islet cells.

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17
Q

Why does metformin standard release need to be given twice or three-times daily?

A

Relatively short half-life of 6.5 hours.

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18
Q

How do sulfonylureas, such as gliclazide, glimepiride, glipizide and tolbutamide, work?

A

They increase insulin production and improve its use by the body.

Insulin production is increased by the drug binding to proteins in the pancreas that stimulate insulin production.

Only work when some residual pancreatic beta-cell activity is present.

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19
Q

Who are sulfonylureas considered in?

A

Those who are not overweight as they encourage weight gain, or where metformin is contraindicated or not tolerated.

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20
Q

Which sulfonylureas have short half-lifes of two to four hours?

A

Most of them.
Gliclazide or tolbutamide for example.

Glibenclamide is a longer acting sulfonylurea, but should be avoided in the elderly due to the risks of falls from hypoglycaemia.

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21
Q

Why should glibenclamide be avoided in the elderly?

A

Due to the risk of falls from hypoglycaemia. It is a longer acting sulfonylurea.

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22
Q

When should sulfonylureas be taken?

A

Before, with or immediately after food.

23
Q

How does pioglitazone work in diabetes?

A

Pioglitazone reduces peripheral insulin resistance, which leads to a reduction in blood glucose.

24
Q

What is pioglitazone licensed for?

A
  1. Monotherapy (where metformin is not tolerated or contraindicated).
  2. Dual therapy
    or
  3. Triple therapy

at recommended doses of 15-30mg daily increased to 45mg once daily according to response.

25
Q

Why is pioglitazone contraindicated in heart failure?

A

It can cause fluid retention, which can exacerbate existing heart failure or even precipitate heart failure.

This adverse effect of fluid retention can cause weight gain in addition to the fat accumulation associated with the drug.

26
Q

How do DPP-4 agents work?

A

They block DPP-4, the enzmye that breaks down the gastrointestinal hormone incretin (which stimulates insulin production after eating) and prevents glucagon production during digestion (glucagon releases glucose into the blood from stores in the body).

By blocking the enzyme that breaks down incretin, more insulin is produced.

Gliptins will block the enzyme for over 24 hours after oral ingestion. Incretin activity is triggered by the action of eating, not by the amount of glucose in the blood.

27
Q

What is the normal function of incretin in the body?

A

Incretin is a gastrointestinal hormone which stimulates insulin production after eating and prevents glucagon production during digestion.

28
Q

Gliptins/DPP-4 inhibitors block the DPP-4 enzyme for how long?

A

24 hours after eating.

29
Q

What are some examples of DPP-4 inhibitors/gliptins?

A

Alogliptin (vipidia): 25mg once a day.

Linagliptin (trajenta): 5mg once a day.

Sitagliptin (januvia): 100mg once a day.

Vildagliptin (galvus): 50mg twice a day.

Saxagliptin (Onglyza): 5mg per day.

30
Q

GLP-1s work how?

A

Incretin mimetics which bind to and activate GLP-1 receptors, mimicking the action of incretin to increase insulin secretion, suppress glucagon secretion to prevent the liver from releasing its stored glucose into the blood stream, and slow gastric emptying.

31
Q

GLP-1 agonists only tend to be prescribed when:

A

Oral treatments have been exhausted but they are licensed from the dual therapy stage.

GLP-1 will often be considered rather than insulin, where progressing onto insulin is deemed not beneficial for the patient.

32
Q

Examples of GLP-1 agonists

A

Exenatide (Byetta), Bydureon MR - once weekly.

Liraglutide (Victoza)

Lixisenatide (Lyxumia)

Dulaglutide (Trulicity) once weekly.

33
Q

After six months of treatment with GLP-1 agonists, the individuals weight and HbA1c should be assessed to see what?

A

If there has been a beneficial metabolic response:

Reduction of HbA1c of at least 11mmol/mol (1.0 per cent) and weight loss of at least 3 per cent of initial body weight.

34
Q

Acute pancreatitis, although rare, is a serious adverse effect of what drug class?

What are the symptoms?

A

GLP-1 agonists, -tides.

Persistent, severe abdominal pain, nausea and/or vomiting present, medical advice must be sought promptly.

35
Q

What is the newest oral antidiabetic treatment to be introduced?

How is it unique?

A

SGLT-2 inhibitors.
They are unique in that they do not work on insulin, but by reverisibly inhibiting sodium-glucose transport proteins in the kidney, reducing glucose re-absorption and increasing excess glucose excretion via urine.

36
Q

Examples of SGLT-2 inhibitors:

A

Dapaglifozin, not for patients over 75.

Canaglifozin.

Empaglifozin: not for over 85.

37
Q

SGLT-2 inhibitors are recommended as monotherapy by NICE when metformin is contraindicated or not tolerated, only if: (2)

A
  1. A dipeptidyl peptidase-4 (DPP-4) inhibitor would otherwise be prescribed, and
  2. A sulfonylurea or pioglitazone is not appropriate.
38
Q

What are the complications of insulin therapy in type 2 diabetes?

A
  1. Weight gain.

2. Hypoglycaemia

39
Q

Most people with type 2 diabetes will be started on what type of therapy?

A

An intermediate acting isophane insulin once or twice a day in combination with their antidiabetic drugs.

Insulin determir or glargine can be used once a day, which can be useful for those patients who require assistance from a carer to inject the insulin.

40
Q

What laboratory tests and investigations should take place in an annual diabetes review?

A

HbA1c
Renal function
Blood lipids

41
Q

What phyiscal examinations should take place in an annual diabetes review?

A
  1. BMI.
  2. Legs and feet should be examined to check skin, circulation and nerve supply.
  3. Blood pressure.
  4. Eyes should be examined at least annually using a digital camera, where the pupils are dilated and a photograph is taken to check for retinopathy.
  5. If using insulin, sites should be examined.
42
Q

True or False

Metformin works only in the presence of endogenous insulin by blocking the liver’s ability to produce fats from glucose

A

False.

43
Q

True or False
SGLT-2 inhibitors work by reversibly inhibiting sodium-glucose co-transporter 2 in the kidney to increase glucose re-absorption and also increase urinary glucose excretion

A

False.

Increase glucose excretion.

44
Q

True or False
Glucagon-like peptide 1 (GLP-1) agonists bind to and activate GLP-1 receptors, mimicking the action of incretin to increase insulin and glucagon secretion and slow gastric emptying

A

False

Suppress glucagon secretion.

45
Q

True or False
DPP-4s block the DPP-4 enzyme that breaks down the GI hormone incretin, which stimulates insulin production after eating. Incretin activity is triggered by the action of eating

A

True.

46
Q

Which antidiabetic drug can cause fluid retention and can exacerbate or precipitate heart failure?

A

Pioglitazone

47
Q

What antidiabetic agents can cause the serious but rare side-effect of acute pancreatitis?

A

GLP-1s

48
Q

Which sulfonylurea has a long half-life and hence can cause hypos more commonly?

A

Glibenclamide.

49
Q

What effect does sitagliptin have on the rate of stomach emptying and glucose absorption?

A

Sitagliptin inhibits DPP-4, allowing incretins to stimulate the pancreas to produce insulin for longer. It also slows down digestion and decreases appetite for longer. This results in a more gradual absorption of glucose from the food and lowering blood sugar levels.

50
Q

Which statement is appropriate for triple therapy or alternative third-line therapy?

1) A GLP-1 mimetic and insulin can be prescribed together routinely
2) Metformin, a sulfonylurea and a GLP-1 can be used in people with a BMI under 35kg/m2 as an alternative to insulin therapy
3) Insulin is only an option for patients who cannot tolerate metformin
4) Triple therapy with metformin, pioglitazone and a sulfonylurea is an option where metformin is not contraindicated and is tolerated

A

Triple therapy with metformin, pioglitazone and a sulfonylurea is an option where metformin is not contraindicated and is tolerated.

51
Q

How often is dulaglutide given?

A

Once weekly

52
Q

Patients taking SGLT-2 inhibitors may see what other improvements?

A

Reduction in blood pressure

Body weight

53
Q

Exenatide should only be continued if the individual has a beneficial response, what is this classified as?

A

Reduction of at least 11mmol/mol (1.0 per cent) in HbA1c and a weight loss of 3 per cent of initial body weight in six months.

CPD (Pre-Reg) (21 decks)

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