Diabetes Management Flashcards
What is the mainstay of Type 1 treatment?
Lifestyle changes and Insulin!
How is insulin delivered?
By SC or IV injection (because its a polypeptide inactivated by the GI tract so it doesnt work orally)
What are the types of insulin?
- Rapid acting
- Short Acting
- Intermediate Acting
- Long acting
- Continuous SC insulin infusion (CSII)
What changes the time insulin takes to take effect?
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
Describe a twice daily insulin regime
Mix of rapid and intermediate acting insulin Before breakfest (BB) & before tea (BT)
Describe a thrice daily insulin regime?
Mix or rapid and intermediate BB
Rapid BT
Intermediate Bbed
Describe a 4x daily insulin regime?
Short acting insulin BB, BL & BT
Then Intermediate Bbed or long acting insulin at a fixed time once per day
How is Type 2 Diabetes treated?
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
What does metformin do?
It increases insulin sensitivity
What do Sulphonyureas do?
Increase insulin production by blocking ATP sensitive K+ channels in Beta cells
What do Thiazolidinediones do?
E.g. Pioglitazone
They improve insulin sensitivity by acting on PPARgamma receptors in muscle, fat & liver
Pros & Cons of Metformin?
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
Pros and cons of Sulphonyureas?
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
Pros and cons of Thiazolidinediones?
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
What is the most important complication to educate patients about?
Hypos! When blood sugar drops below 4mmol/l
How would you educate patients about Hypos?
- How to test their blood sugar
- How to recognise the signs of a hypo
- How to treat it
- How to avoid it
How is a hypo treated?
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
How do patients avoid hypos?
- Blood glucose monitoring
- Rotate & check injection sites
- Review diet (carb counting)
- Maybe change the insulin regime
What are the rules for driving and Hypos?
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
How would we advise a patient to deal with DKA at home?
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
What tests would we do on a DKA diabetic in hospital?
- Glucose
- Venous blood gasses
- Urinalysis & blood ketones
- U+E /FBC
- Blood/urine culture (infections triggering DKA)
- ECG
- ~CXR
How do we treat DKA?
IV saline, IV insulin & IV potassium in saline.
Abx if infected
Heparin to prevent thromboembolism
NG tube if potential for coma
What drugs can replace sulphonyurea’s as 2nd line Type 2 treatment if neccessary?
- Thiazolidinediones e.g. pioglitazone
- DPP-IV inhibitors e.g. Sitagliptin
- SGLT-2 inhibitors e.g. Empagliflozin
How do DPP-IV inhibitors work?
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
Pros and cons of DPP-4 inhibitors?
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
How do GLP-1 analogues work?
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
Pros & Cons of GLP-1 Analogues?
Pros - Do cause some weight loss
Cons - Nausea (by delaying gastric emptying)
Example of each Type 2 drug?
Biguanides - Metformin
Sulphonyureas - Glimepiride
Thiazolidinediones - Pioglitazone
DPP-IV inhibitors - Saxagliptin
GLP-1 Analogue - Liraglutide
How do SGLT-2 Inhibitors work?
Inhibit Sodium Glucose Transporter 2 in the proximal tubule of kidney
Causes increased Glucose & sodium excretion
Pros & Cons of SGLT-2 Inibitors?
- Diuretic effect can cause dehydration & postural hypotension
- Excrete more calories so Weight Loss
- Excreting Na so lowers BP
- Risks urogenital infections
Example of an SGLT-2 inhibitor?
Empagliflozin (Gliflozins)
