Diabetes Management Flashcards
What is first line for the management of type 2 diabetes?
Lifestyle modifications
What is the NICE guideline for target HbA1c?
6.5-7.5%
How should choice of diabetes medications be decided?
According to the needs of the pt as well as b mechanism of action of drug and NICE guidelines
What is firstline drug treatment offered for T2DM in adults?
Standard-release metformin
What do we do if a T2DM pt is symptomatically hyperglycaemic?
Rescue therapy - consider insulin or a sulfonylurea. Review meds once blood glucose back under control
How should metformin be started? Why?
Gradual dose increase over several weeks
Minimise risk of GI side effects
If an adult with T2DM experiences side-effects on standard release metformin, what can we do?
Condiser modified-release metformin
If initial treatment of T2DM isn’t sufficient to keep HbA1c below 7.5%, what do we do?
1st intensification - metformin dual therapy with DPP-4i, pioglitazone, an SU, or an SGLT-2
What do we work for with the pt after the 1st intensification?
HbA1c of 7.0% or 53mmol/mol
How do we decide which agent to use with metformin in the first intensification of diabetes management?
Depends on the pt, their co-morbidities, and their tolerance of the agents
For the Second intensification of drug treatment, what combinations can we use?
- Metformin, DPP-4 inhibitor, and a SU
- Metformin, piolglitazone, and a SU
- Insulin based treatment
What HbA1c indicates that second intensification is needed?
7.5% or 58mmol/mol
How does metformin work?
- Reduces hepatic glucose production
- Decreases insulin resistance
- Reduced GI absorption of carbohydrates
What are the side effects of metformin?
- GI upset in 20% of pts
- Lactic acidosis if pt has renal or liver failure
- Reduced vit b12 absorption - rarely clinically relevant
When is metformin contra-indicated?
CKD
Tissue hypoxia i.e. around the time of an MI
Significant co-morbidities like major organ failure
What dose range do we give metformin in?
500mg - 2.5g
How do sulphonylureas work?
Stimulate insulin secretion, very effectively
What are the benefits of sulphonylureas?
Decreased CV risk
Low cost
What are the side effects of sulphonylureas?
Weight gain
Hypoglycaemia
How do glitazones (TZDs) work?
- Increase insulin sensitiviy in muscle and adipose
- Decrease hepatic glucose output
- Bind to and activate PPARs
What are the side effects of pioglitazone?
Weight gain Fluid retention Heart failure Effects on bone metabolism ?Rsik of bladder cancer
How do GLP1 therapies work?
Hormone that affects glucose metabolism:
- Amplifies insulin release due to glucose
- Inhibits glucagon release
- Suppress appetite
- Slows gastric emptying
What is GLP-1 in the body?
Potent incretin hormone released by the gut
What are the side effetcs of GLP1 therapies?
N&V Changes in bowel habit Hypoglycaemia Injection-site reactions Weight loss
How else can we target GLP-1 for diabetes medication?
GLP-1 receptor agonists - mimic natural GLP-1
How do DPP-4 inhibitors work?
Inhibit DPP4 which normally breaks down GLP-1, so more native GLP-1 is available.
What is the suffix used to indicate a drug is a DPP-4 inhibitor?
Gliptin
Which diabetic drugs are weight neutral?
GLP-1 receptor agonists
Which diabetic drugs can cause weight gain?
Pioglitazone
Sulphonylureas
Which diabetic drugs are the best for weight loss?
SGLT-2 inhibitors
Where do SGLT2 inhibitors work?
In the kideny on the SGLT2 cotransporters in the PCT
How do SGLT2 inhibitors work essentially?
Block the channel so glucose cannot be reabsorbed. Basically you end up weeing out all the glucose.
What are the side effects of SGLT2 inhibitors?
Dehydration, UTI, candida infection.
Also weight loss, but thats a good one really.
What does insulin do within the body?
Stimulates glucose uptake into liver, muscle, and adipose tisue, inhibits hepatic gluconeogenesis, and promotes the uptake of fat.
What is the ideal insulin regime?
One that mimics normal physiological insulin secretion, with peaks after meals and snacks etc.
Why is it a good thing there are so many types of insulin therapy available?
Can tailor treatment to the pt and manage lots of different situations
Why is it a bad thing there are so many types of insulin therapy available?
There are many many types so prescribing errors are common.
What changes can we make to the structure of insulin, and what effect does it have?
We can change the sequence of amino acids in the B26-30 region of the insulin chain to make it faster or slower to absorb
What are the 6 broad categories of insulin?
Ultrafast Rapid Short Intermediate Long Very long
Also combined therapy is a cheeky seventh
How does an insulin pump work?
Sensor detects blood glucose level and injects the appropriate amount of insulin at a threshold. Varied amounts of insulin can be injected.
What are the adverse effects of insulin?
Hypoglycaemia Hyperglycaemia Lipidodystrophy Painful injections Allergy
Which type of insulin is often injected before meals? Tell me about these drugs.
Rapid acting e.g. Humalog, novorapid.
Acts within 15 minutes, peaks at 60. Lasts for 4-6 hours.
Which type of insulin is often several times throughout the day to cover meals? Tell me about these drugs.
Short acting e.g. Actrapid, Humulin S.
Acts within 30-60 mins, peaks at 2-3 hours. Lasts 8-10 hours.
If a pt injects with intermediate acting insulin, before bed what do they need to do and why?
Have a snack as it peaks at roughly 2/3 am so risk nocturnal hypoglycaemia. Peaks 4-8 hours after injection.
