Diabetes Mellitus Flashcards
Which drugs are diabetogenic (causing hyperglycaemia)?
Glucocorticoids
Thiazide diuretics
Atypical antipsychotics
Antiretroviral therapy (protease inhibitors)
Define the terms “prandial” and “basal” insulin.
Prandial insulin - immediately peaks after meals
Basal insulin - the base amount of insulin that is always available
What are the three types of insulin therapy?
Short acting: Actrapid
- regular human insulin
- usually given 30 minutes before meals
Intermediate acting: Protaphane
- neutral protamne hegodorn insulin
- usually given at night not later than 10pm
Biphasic: Actraphane
- mixtures of regular human insulin and 70%intermediate acting insulin
- usually given twice daily
Outline the insulin regimens available in Type 1 diabetes.
All patients are managed with insulin.
2 regimens to choose from:
- basal bolus (GOLD standard)
- biphasic/premixed insulin
Bolus: combined intermediate acting + short acting
- taken 30 minutes before every meal (short), and not later than 10pm (longer)
- initial total dose for daily insulin: 0.6 units/kg body weight
- 40 - 50% basal, the rest divided equally & taken before each meal
Premixed:
- 2 daily premixed (of intermediate or short acting insulin)
- 2/3 in the morning, 1/3 in the 2nd dose
What are the indication for insulin therapy in type 2 diabetes?
Inability to control blood glucose pharmacologically
Temporary use for major stress (e.g. surgery)
Severe kidney or liver disease
Pregnancy
Outline the 3 regimens to choose from in type 2 diabetes.
- Add on
- intermediate to long acting insulin
- 0,3 units/kg.day in the evening before bed time (before 22:00)
- if fasting glucose is within range but HBA1c not controlled, move to next 2 choices. - Biphasic/pre mixed
- total daily dose: 0.3 units/kg/day divided as 2/3 of total dose 30 minutes before breakfast and 1/3 of total daily dose 30 minutes before supper. - Basal bolus
- start with 0.4-0.6 units/kg.day and divide total daily dose into 50% bolus, using equal pre meal doses.
What are the two classes of non insulin therapy. Give examples of the drugs in each class.
Buguanides
- Metformin
Sulphonylureas
- glimepiride, gliclazide, glibenclamide
Describe the dosing for Metformin.
Initially 500mg once or twice daily, or 850mg once or twice daily with meals
Every 5-7 days, up titrate to max 2000mg/day
If GFR < 45, max dose is 500 mg twice daily (consider risk vs benefits)
What is the contraindications of Metformin?
If eGFR < 30
Drug to drug interaction with dolutegravir, max dose 500mg twice daily
What are some side effects of Metformin?
GIT disturbances
- loss of appetite, nausea, diarrhoea
- less severe for extended release formulation
Lactic acidosis
- due to inhibited conversion of lactate to glucose
Reduced Vit B12 absorption
Weight neutral and does not cause hypoglycaemia
Describe the mechanism of action of sulphonylureas.
Stimulates insulin secretion from pancreatic beta cells
Requires residual beta cell functioning
Outline the dosing of glimepiride.
Initiate 1mg daily
Titrate to response in 1mg increments at weekly intervals
Max dose of 6mg daily
Which sulphonylurea has the highest risk of hypoglycaemia?
Glibenclamide
Outline the dosing of glibenclamide.
Initiate 2.5mg daily
Titrate weekly to max of 15mg daily
When >= 10mg/day is needed (2 divided doses)
Outline the dosing of gliclazide.
40-80mg daily oral (divide dose into 2 if greater the 160mg)
Adjust according to response, max 320mg/day
MR formulation: 30mg once daily, increased monthly
