Diabetes Management

Question 1

What is the mainstay of Type 1 treatment?

Answer 1

Lifestyle changes and Insulin!

Question 2

How is insulin delivered?

Answer 2

By SC or IV injection (because its a polypeptide inactivated by the GI tract so it doesnt work orally)

Question 3

What are the types of insulin?

Answer 3

• Rapid acting
• Short Acting
• Intermediate Acting
• Long acting
• Continuous SC insulin infusion (CSII)

Question 4

What changes the time insulin takes to take effect?

Answer 4

Soluble insulin associates into hexamers in SC fat.
It needs to dissociate into monomers in order to diffuse into capillaries.

Altering the structure/solubility of insulin affects how long it takes to dissociate

Question 5

Describe a twice daily insulin regime

Answer 5

Mix of rapid and intermediate acting insulin Before breakfest (BB) & before tea (BT)

Question 6

Describe a thrice daily insulin regime?

Answer 6

Mix or rapid and intermediate BB

Rapid BT

Intermediate Bbed

Question 7

Describe a 4x daily insulin regime?

Answer 7

Short acting insulin BB, BL & BT

Then Intermediate Bbed or long acting insulin at a fixed time once per day

Question 8

How is Type 2 Diabetes treated?

Answer 8

Lifestyle modifications
1st line - Metformin (OHG)
2nd line - A Sulphonyurea (E.g. glimepiride)
3rd line - A thiazolidinedione (e.g. pioglitazone) (aka Glitazones)

Further 3rd line meds include:
DPP-IV inhibitors - SGLT-2 inhibitors - GLP-1 agonist - Insulin

Question 9

What does metformin do?

Answer 9

It increases insulin sensitivity

Question 10

What do Sulphonyureas do?

Answer 10

Increase insulin production by blocking ATP sensitive K+ channels in Beta cells

Question 11

What do Thiazolidinediones do?

Answer 11

E.g. Pioglitazone

They improve insulin sensitivity by acting on PPARgamma receptors in muscle, fat & liver

Question 12

Pros & Cons of Metformin?

Answer 12

Cheap, Well tolerated, Efficacious, can be used in pregnancy and doesn’t promote weight gain.

Risk lactic acidosis, GI side effects and Vit B12 malabsorption

Question 13

Pros and cons of Sulphonyureas?

Answer 13

Cheap, well tolerated, rapid action (So good for the acutely ill), can be combined with metformin and rapid titration (scaling up the dose)

Risks hypoglycaemia, associated with weight gain and containdicated in pregnant or breastfeeding women, renal disease and hepatic disease

Question 14

Pros and cons of Thiazolidinediones?

Answer 14

Cheap, safe for CV system & good effect on significant insulin resistance

Associated with weight gain & bladder cancer, fluid retention and fractures due to increased bone turnover

Question 15

What is the most important complication to educate patients about?

Answer 15

Hypos! When blood sugar drops below 4mmol/l

Question 16

How would you educate patients about Hypos?

Answer 16

• How to test their blood sugar
• How to recognise the signs of a hypo
• How to treat it
• How to avoid it

Question 17

How is a hypo treated?

Answer 17

Rapid acting carb e.g. 200ml of fruit juice
OR 1mg IM glucagon
OR if in hospital then 80ml 20% glucose

Follow up with a long acting carbohydrate

Question 18

How do patients avoid hypos?

Answer 18

• Blood glucose monitoring
• Rotate & check injection sites
• Review diet (carb counting)
• Maybe change the insulin regime

Question 19

What are the rules for driving and Hypos?

Answer 19

Diabetics have to check their glucose within 2 hours of driving and repeat on long journeys
They should carry short acting carbs in the car
If they can’t recognise a hypo or have >1 severe hypo a year they cant drive

Question 20

How would we advise a patient to deal with DKA at home?

Answer 20

1) They think they’re getting symptoms
2) Test their ketones
3) +ve? Test Blood Glc
4) Elevated? Take an extra insulin dose
5) still high after 4 hours? Take another dose
6) Call diabetes team, notify them of possible DKA

Question 21

What tests would we do on a DKA diabetic in hospital?

Answer 21

• Glucose
• Venous blood gasses
• Urinalysis & blood ketones
• U+E /FBC
• Blood/urine culture (infections triggering DKA)
• ECG
• ~CXR

Question 22

How do we treat DKA?

Answer 22

IV saline, IV insulin & IV potassium in saline.
Abx if infected
Heparin to prevent thromboembolism
NG tube if potential for coma

Question 23

What drugs can replace sulphonyurea’s as 2nd line Type 2 treatment if neccessary?

Answer 23

• Thiazolidinediones e.g. pioglitazone
• DPP-IV inhibitors e.g. Sitagliptin
• SGLT-2 inhibitors e.g. Empagliflozin

Question 24

How do DPP-IV inhibitors work?

Answer 24

They inhibit DPP-IV, an enzyme that breaks down incretin hormones.

This prolongs the life of incretins allowing them to cause Glc Dependant Decrease in Glucagon release and Increase in Insulin Release

Question 25

Pros and cons of DPP-4 inhibitors?

Answer 25

Pros

• Well tolerated
• Weight Neutral
• Works in renal impairment
• No hypoglycaemic risk

Cons:

• small effect
• CI in pregnant/breastfeeding
• risk of pancreatitis/pancreatic cancer
• Nausea

Question 26

How do GLP-1 analogues work?

Answer 26

Similar to DDP-IV inhibitors.
GLP-1 is an incretin, the analogues are resistant to DPP-4 degradation so have a long half life causing:
- Glc dependant insulin release and glucagon inhibition

Question 27

Pros & Cons of GLP-1 Analogues?

Answer 27

Pros - Do cause some weight loss

Cons - Nausea (by delaying gastric emptying)

Question 28

Example of each Type 2 drug?

Answer 28

Biguanides - Metformin

Sulphonyureas - Glimepiride

Thiazolidinediones - Pioglitazone

DPP-IV inhibitors - Saxagliptin

GLP-1 Analogue - Liraglutide

Question 29

How do SGLT-2 Inhibitors work?

Answer 29

Inhibit Sodium Glucose Transporter 2 in the proximal tubule of kidney

Causes increased Glucose & sodium excretion

Question 30

Pros & Cons of SGLT-2 Inibitors?

Answer 30

• Diuretic effect can cause dehydration & postural hypotension
• Excrete more calories so Weight Loss
• Excreting Na so lowers BP
• Risks urogenital infections

Question 31

Example of an SGLT-2 inhibitor?

Answer 31

Empagliflozin (Gliflozins)