Diabetes medications

Question 1

The BGL is lowered/raised by:

Answer 1

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)

Question 2

Principles of Insulin Therapy

Answer 2

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

Question 3

Indications for use of Insulin . Which diabetes need insulin? When may you require short term insulin therapy?

Answer 3

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

Question 4

Insulin formulations differ in

Answer 4

Time of onset
Peak effect
Duration of action

Question 5

Why are there different formulations

Answer 5

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

Question 6

What do you need to know about the different formulations

e.g. Rapid acting
Short acting
Intermediate acting
Long acting

Answer 6

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

Question 7

What would you educate a pt on insulin therapy

Answer 7

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

Question 8

What would you educate on the Safe storage & handling of Insulin

Answer 8

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

Question 9

Insulin ADR’s

Answer 9

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

Question 10

What are the tx’s of T2DM

Answer 10

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

Question 11

What is the only biguanide used in NZ and MOA?

Answer 11

Metformin. Increase glucose uptake and utilisation in skeletal muscle. Reduces glucose production in liver. Increases insulin sensitivity. Reduces low and very low density lipoproteins

Question 12

Metformin contraindications and cautions

Answer 12

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

Question 13

Pt education for metformin? AR’s etc.

Answer 13

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

Question 14

What factors determine which oral hypoglycaemic agent is selected?

Answer 14

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.).

Question 15

Why would metformin be selected for treatment of diabetic patients who are overweight?

Answer 15

Because theres no side effect of weight gain

Question 16

Which groups of patients should not take metformin and why?

Answer 16

type 1 diabetes because they cannot produce insulin from their pancreas gland. Their blood glucose is best controlled by insulin injections.

Question 17

Why does Metformin NOT cause hypoglycaemia?

Answer 17

Because insulin secretion is unaltered, hypoglycemia is not a side effect of metformin

Question 18

What group of oral hypoglycaemics have been the second line tx or used when metformin is contraindicated? And examples

Answer 18

Sulfonylurea drugs Gliclazideglipizide glibenclamide

Question 19

Sulfonylurea drugs Gliclazideglipizide glibenclamide MOA

Answer 19

Increase insulin release from pancreas
Increases cellular sensitivity to insulin by increasing # of insulin receptors
Reduces heaptic glycogenolysis

Question 20

Contraindications and warnings for Sulfonylurea drugs

Answer 20

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

Question 21

Sulfonylurea drugs - patient education

Answer 21

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

Question 22

The risks for persons with diabetes who are also taking beta blockers

Answer 22

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.

Question 23

Glucagon increases the release of all of the following hormones

Answer 23

Glucagon increases the release of GH, ACTH as well as insulin but does not directly affect adrenaline release

Question 24

Hyperglycaemia + hypoglycaemia increases the release of

Answer 24

Hyperglycaemia increases insulin release, however hypoglycaemia promotes the release of glucagon, growth hormone and adrenaline.

Question 25

The class of oral hypoglycaemic agents (OHA) that should be avoided in those with severe infections is:

Answer 25

Correct The OHA metformin, a biguanide, is contraindicated in severe infections because of the risk of severe lactic acidosis.

Question 26

The secretion of glucagon is inhibited by:

Answer 26

High blood glucose inhibits the secretion of glucagon; conversely, low blood glucose stimulates glucagon secretion.

Question 27

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:

Answer 27

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.

Question 28

Insulins of various action length (eg short acting and long acting) may be combined. - T/F

Answer 28

T

Question 29

The secretion of endogenous insulin by beta cells is either absent or low in both type 1 and type 2 diabetes mellitus: T/F

Answer 29

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.

Question 30

Type 1 diabetes cannot be treated with oral hypoglycaemic agents: T/F

Answer 30

T - This is because the actions of oral hypoglycaemic agents all depend on some remaining islet tissue to secrete some insulin.

Question 31

Acarbose, an alpha-glucosidase inhibitor, works as an antidiabetic agent by:

Answer 31

.

delaying digestion and absorption of carbohydrates in the small intestine

Question 32

Insulin release by the beta cells is stimulated by an increase of:

Answer 32

GLUCOSE

Question 33

One of the following cardiovascular drugs is known to cause hyperglycaemia:

Answer 33

thiazide diuretics, on the other hand, have been reported to induce hyperglycaemia.

Question 34

One of the following cardiovascular drugs is known to cause hypoglycaemia:

Answer 34

Aspirin, disopyramide and ACE inhibitors have been reported to induce hypoglycaemia

Question 35

One of the following signs and symptoms could be an indication of hypoglycaemia:

Answer 35

Confusion - Manifestations of hypoglycaemia include increased anxiety, blurred vision, diaphoresis, pallor and confusion.

Question 36

Which of the following antidiabetic agents does not induce hypoglycaemia

Answer 36

Metformin does not cause hypoglycaemia.

Question 37

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

Answer 37

Alcohol promotes hypoglycaemia by blocking the formation, storage and release of glycogen.

Question 38

hypoglycaemic agents vs hyperglycaemic agents - you will need to know about this in exam

Answer 38

hypoglycaemic agents (drugs that decrease BGL) but you do also need to know the hyperglycaemic agents (drugs to increase BGL).