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Clinical Pharmacology and Therapeutics > Diabetes Management > Flashcards

Diabetes Management Flashcards

1
Q

What is first line for the management of type 2 diabetes?

A

Lifestyle modifications

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2
Q

What is the NICE guideline for target HbA1c?

A

6.5-7.5%

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3
Q

How should choice of diabetes medications be decided?

A

According to the needs of the pt as well as b mechanism of action of drug and NICE guidelines

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4
Q

What is firstline drug treatment offered for T2DM in adults?

A

Standard-release metformin

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5
Q

What do we do if a T2DM pt is symptomatically hyperglycaemic?

A

Rescue therapy - consider insulin or a sulfonylurea. Review meds once blood glucose back under control

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6
Q

How should metformin be started? Why?

A

Gradual dose increase over several weeks

Minimise risk of GI side effects

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7
Q

If an adult with T2DM experiences side-effects on standard release metformin, what can we do?

A

Condiser modified-release metformin

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8
Q

If initial treatment of T2DM isn’t sufficient to keep HbA1c below 7.5%, what do we do?

A

1st intensification - metformin dual therapy with DPP-4i, pioglitazone, an SU, or an SGLT-2

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9
Q

What do we work for with the pt after the 1st intensification?

A

HbA1c of 7.0% or 53mmol/mol

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10
Q

How do we decide which agent to use with metformin in the first intensification of diabetes management?

A

Depends on the pt, their co-morbidities, and their tolerance of the agents

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11
Q

For the Second intensification of drug treatment, what combinations can we use?

A
  • Metformin, DPP-4 inhibitor, and a SU
  • Metformin, piolglitazone, and a SU
  • Insulin based treatment
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12
Q

What HbA1c indicates that second intensification is needed?

A

7.5% or 58mmol/mol

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13
Q

How does metformin work?

A
  • Reduces hepatic glucose production
  • Decreases insulin resistance
  • Reduced GI absorption of carbohydrates
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14
Q

What are the side effects of metformin?

A
  • GI upset in 20% of pts
  • Lactic acidosis if pt has renal or liver failure
  • Reduced vit b12 absorption - rarely clinically relevant
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15
Q

When is metformin contra-indicated?

A

CKD
Tissue hypoxia i.e. around the time of an MI
Significant co-morbidities like major organ failure

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16
Q

What dose range do we give metformin in?

A

500mg - 2.5g

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17
Q

How do sulphonylureas work?

A

Stimulate insulin secretion, very effectively

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18
Q

What are the benefits of sulphonylureas?

A

Decreased CV risk

Low cost

19
Q

What are the side effects of sulphonylureas?

A

Weight gain

Hypoglycaemia

20
Q

How do glitazones (TZDs) work?

A
  • Increase insulin sensitiviy in muscle and adipose
  • Decrease hepatic glucose output
  • Bind to and activate PPARs
21
Q

What are the side effects of pioglitazone?

A 
Weight gain
Fluid retention
Heart failure
Effects on bone metabolism
?Rsik of bladder cancer
22
Q

How do GLP1 therapies work?

A

Hormone that affects glucose metabolism:

  • Amplifies insulin release due to glucose
  • Inhibits glucagon release
  • Suppress appetite
  • Slows gastric emptying
23
Q

What is GLP-1 in the body?

A

Potent incretin hormone released by the gut

24
Q

What are the side effetcs of GLP1 therapies?

A 
N&V
Changes in bowel habit
Hypoglycaemia
Injection-site reactions
Weight loss
25
Q

How else can we target GLP-1 for diabetes medication?

A

GLP-1 receptor agonists - mimic natural GLP-1

26
Q

How do DPP-4 inhibitors work?

A

Inhibit DPP4 which normally breaks down GLP-1, so more native GLP-1 is available.

27
Q

What is the suffix used to indicate a drug is a DPP-4 inhibitor?

A

Gliptin

28
Q

Which diabetic drugs are weight neutral?

A

GLP-1 receptor agonists

29
Q

Which diabetic drugs can cause weight gain?

A

Pioglitazone

Sulphonylureas

30
Q

Which diabetic drugs are the best for weight loss?

A

SGLT-2 inhibitors

31
Q

Where do SGLT2 inhibitors work?

A

In the kideny on the SGLT2 cotransporters in the PCT

32
Q

How do SGLT2 inhibitors work essentially?

A

Block the channel so glucose cannot be reabsorbed. Basically you end up weeing out all the glucose.

33
Q

What are the side effects of SGLT2 inhibitors?

A

Dehydration, UTI, candida infection.

Also weight loss, but thats a good one really.

34
Q

What does insulin do within the body?

A

Stimulates glucose uptake into liver, muscle, and adipose tisue, inhibits hepatic gluconeogenesis, and promotes the uptake of fat.

35
Q

What is the ideal insulin regime?

A

One that mimics normal physiological insulin secretion, with peaks after meals and snacks etc.

36
Q

Why is it a good thing there are so many types of insulin therapy available?

A

Can tailor treatment to the pt and manage lots of different situations

37
Q

Why is it a bad thing there are so many types of insulin therapy available?

A

There are many many types so prescribing errors are common.

38
Q

What changes can we make to the structure of insulin, and what effect does it have?

A

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

39
Q

What are the 6 broad categories of insulin?

A 
Ultrafast
Rapid
Short
Intermediate
Long
Very long

Also combined therapy is a cheeky seventh

40
Q

How does an insulin pump work?

A

Sensor detects blood glucose level and injects the appropriate amount of insulin at a threshold. Varied amounts of insulin can be injected.

41
Q

What are the adverse effects of insulin?

A 
Hypoglycaemia
Hyperglycaemia
Lipidodystrophy
Painful injections
Allergy
42
Q

Which type of insulin is often injected before meals? Tell me about these drugs.

A

Rapid acting e.g. Humalog, novorapid.

Acts within 15 minutes, peaks at 60. Lasts for 4-6 hours.

43
Q

Which type of insulin is often several times throughout the day to cover meals? Tell me about these drugs.

A

Short acting e.g. Actrapid, Humulin S.

Acts within 30-60 mins, peaks at 2-3 hours. Lasts 8-10 hours.

44
Q

If a pt injects with intermediate acting insulin, before bed what do they need to do and why?

A

Have a snack as it peaks at roughly 2/3 am so risk nocturnal hypoglycaemia. Peaks 4-8 hours after injection.

Clinical Pharmacology and Therapeutics (26 decks)

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