Diabetes medications Flashcards
The BGL is lowered/raised by:
The blood glucose is lowered by
insulin
The blood glucose is raised by
Glucagon
Adrenaline (so that glucose is available for an emergency)
Growth hormone (by stimulating lipolysis so that lipids are available for growth leaving glucose to be available for the brain)
Cortisol (which makes additional glucose available to deal with stress situations)
Principles of Insulin Therapy
Aim is maintain stable BGL that avoids hypoglycaemia and hyperglycaemia
HbA1c, gold standard of care: 50-55 molar (7%)
Blood glucose levels:
4-8 mmol/l
ideally 4-6 mmol/l on waking
ideally 4-8 mmol/l rest of day
Elderly maybe 5-10/12mmol/l
Indications for use of Insulin . Which diabetes need insulin? When may you require short term insulin therapy?
All persons with type 1 diabetes require regular insulin
Persons with type 2 diabetes may eventually require regular insulin due to disease progression
Acute conditions that result in hyperglycaemia that require short term insulin therapy
Surgery, stress, infection, pregnancy
Insulin formulations differ in
Time of onset
Peak effect
Duration of action
Why are there different formulations
To enable more individualized optimization of BGL and reduce incidence of fluctuations in BGL
Type 1 diabetes will use a combination of formulations to maintain BGL over a 24 hr period
What do you need to know about the different formulations
e.g. Rapid acting
Short acting
Intermediate acting
Long acting
Rapid acting = rapid onset & short duration of action
Short acting = quick onset a& moderate duration of action
Intermediate acting = longer onset of action & longer duration
Long acting = longest onset of action & longest duration
What would you educate a pt on insulin therapy
Need to educate on: Rotating the site to avoid lipohypertophy (usually abdomen & thighs) Needle inserted at 90º angle Ensure appropriate needle size Safe disposal of sharps
What would you educate on the Safe storage & handling of Insulin
Avoid extreme temperatures (both high and freezing) and exposure to sunlight – this denatures the proteins
Keep unopened insulin in fridge (2-4ºC)
Keep insulin currently in use at room temperature
Use within 1 month of opening and before expiry date
Never shake insulin (destroys the proteins) gently roll and invert
Insulin ADR’s
Hypoglycaemia
Education must focus on avoiding a “hypo” and treating a “hypo”
Give quick acting carbohydrate (e.g. 6 jelly beans)
Recheck BGL in 10 minutes if still low repeat above
When BGL above 4mmol/L have a complex carbohydrate snack
If BGL not responding seek medical help
Avoid driving or operating machinery if having a “hypo”
Let GP or diabetes nurse know if having regular “”hypo’s”
If person is unconscious, ABCD and give glucagon injection
Weight gain
Education on healthy eating plan
Care with low carbohydrate diets
Teenage support groups
Lipohypertrophy
From not rotating sites of injection – not specifically a drug ADR
What are the tx’s of T2DM
Identification of appropriate glycaemic target
Lifestyle changes & metformin (unless contraindicated)
Add an additional oral hypoglycaemic (non-insulin glucose-lowering medicine) Combination oral therapy
Oral hypoglycaemic plus insulin
Insulin only
What is the only biguanide used in NZ and MOA?
Metformin. Increase glucose uptake and utilisation in skeletal muscle. Reduces glucose production in liver. Increases insulin sensitivity. Reduces low and very low density lipoproteins
Metformin contraindications and cautions
Conditions prediposing to increased lactate production causing lactic acidosis with is fatal - pt’s with renal or hepatic impairment, cardiac disease, dehydration, severe burns and infections, recent major surgery or trauma.
Not recommended for us in pregnancy or lactation
Cautions: acute gastric illness - stop metformin while unwell
Stop prior to surgery to reduce ris of lactic acidosis
Pt education for metformin? AR’s etc.
Adverse reactions:
GI upset - nausea, abdo discomfort, diarrhea
Lactic acidosis - rare but life threatening
Take with food or at the end of the meal Start on low dose to minimise GI effects Avoid alcohol Healthy diet and exercise Regular checks of Hba1c
What factors determine which oral hypoglycaemic agent is selected?
Selection of oral antihyperglycaemic agents as first-line drug or combined therapy should be based on both the pharmacological properties of the compounds (efficacy and safety, profile) and the clinical characteristics of the patient (stage of disease, bodyweight, etc.).
Why would metformin be selected for treatment of diabetic patients who are overweight?
Because theres no side effect of weight gain
Which groups of patients should not take metformin and why?
type 1 diabetes because they cannot produce insulin from their pancreas gland. Their blood glucose is best controlled by insulin injections.
Why does Metformin NOT cause hypoglycaemia?
Because insulin secretion is unaltered, hypoglycemia is not a side effect of metformin
What group of oral hypoglycaemics have been the second line tx or used when metformin is contraindicated? And examples
Sulfonylurea drugs Gliclazideglipizide glibenclamide
Sulfonylurea drugs Gliclazideglipizide glibenclamide MOA
Increase insulin release from pancreas
Increases cellular sensitivity to insulin by increasing # of insulin receptors
Reduces heaptic glycogenolysis
Contraindications and warnings for Sulfonylurea drugs
Caution in older persons due to decreased renal and hepatic function and higher risk of hypoglycaemia Avoid in persons with: Hypersensitivity, Severe renal or hepatic impairment, Ketoacidosis or diabetic coma, Undergoing surgery Pregnancy & lactation
Sulfonylurea drugs - patient education
AR's hypoglycaemia weight gain GI upset rash hypersensitivity
Other Take 15-20 minutes before breakfast to minimise risk of hypo Need to check BGL's How too recognise and treat hypo Caution with driving if at risk o fhypo health diet and exercise avoid alcohol
The risks for persons with diabetes who are also taking beta blockers
In insulin-dependent diabetics, beta-blockers can prolong, enhance, or alter the symptoms of hypoglycemia, beta-blockers can potentially increase blood glucose concentrations and antagonize the action of oral hypoglycemic drugs.
Glucagon increases the release of all of the following hormones
Glucagon increases the release of GH, ACTH as well as insulin but does not directly affect adrenaline release
Hyperglycaemia + hypoglycaemia increases the release of
Hyperglycaemia increases insulin release, however hypoglycaemia promotes the release of glucagon, growth hormone and adrenaline.
The class of oral hypoglycaemic agents (OHA) that should be avoided in those with severe infections is:
Correct The OHA metformin, a biguanide, is contraindicated in severe infections because of the risk of severe lactic acidosis.
The secretion of glucagon is inhibited by:
High blood glucose inhibits the secretion of glucagon; conversely, low blood glucose stimulates glucagon secretion.
In Australasia, the indigenous people (e.g. Aboriginal Australians and Maori New Zealanders) are more susceptible to developing type 2 diabetes mellitus compared to people of European descent:
Diabetes is more prevalent in the Aboriginal and Torres Strait Islander communities of Australia , as well as among Maori and Pacific Island people of New Zealand . Diabetes occurs at a younger age and lower BMI in these population groups.
Insulins of various action length (eg short acting and long acting) may be combined. - T/F
T
The secretion of endogenous insulin by beta cells is either absent or low in both type 1 and type 2 diabetes mellitus: T/F
Type 1 diabetes is characterised by a critical lack of endogenous insulin production; however, in type 2 diabetes, insulin secretion may be low, normal or high. Type 2 diabetes is associated with insulin resistance, due to receptor or postreceptor defects.
Type 1 diabetes cannot be treated with oral hypoglycaemic agents: T/F
T - This is because the actions of oral hypoglycaemic agents all depend on some remaining islet tissue to secrete some insulin.
Acarbose, an alpha-glucosidase inhibitor, works as an antidiabetic agent by:
.
delaying digestion and absorption of carbohydrates in the small intestine
Insulin release by the beta cells is stimulated by an increase of:
GLUCOSE
One of the following cardiovascular drugs is known to cause hyperglycaemia:
thiazide diuretics, on the other hand, have been reported to induce hyperglycaemia.
One of the following cardiovascular drugs is known to cause hypoglycaemia:
Aspirin, disopyramide and ACE inhibitors have been reported to induce hypoglycaemia
One of the following signs and symptoms could be an indication of hypoglycaemia:
Confusion - Manifestations of hypoglycaemia include increased anxiety, blurred vision, diaphoresis, pallor and confusion.
Which of the following antidiabetic agents does not induce hypoglycaemia
Metformin does not cause hypoglycaemia.
Diabetics need to be warned about the potential for hypoglycaemia and to be aware of this risk when taking alcoholic beverages: T/F and what does alcohol do
Alcohol promotes hypoglycaemia by blocking the formation, storage and release of glycogen.
hypoglycaemic agents vs hyperglycaemic agents - you will need to know about this in exam
hypoglycaemic agents (drugs that decrease BGL) but you do also need to know the hyperglycaemic agents (drugs to increase BGL).
