Diabetes Mellitus Flashcards
At what age does DMT1 usually first present?
<40 years
What causes DMT1?
Destruction of beta-cells
Following viral infection/autoimmune process
What is the defining feature of DMT1
Inability of the beta-cells to produce insulin
How is DMT1 managed pharmacologically?
Insulin replaced to return BG to normal
What are the three insulin preparations used clinically?
Human insulin analogues
Short acting analogues
Intermediate/long acting analogues
Describe human insulin analogues
Modified insulin peptides (lispro/apart)
Rapid onset, short duration
Useful around meals
Describe short acting insulins
Effects of 6-8 hours (peak at 2-5)
Given 15-30 mins before meals
Describe intermediate/long acting insulins
Intermediate - Combination of insulin w/ protamine
Intermediate/LA - Combination of insulin w/ zinc
LA - Combination of insulin w/ protamine + zinc
Can have biphasic preparations
What are the three main type of insulin dosing regiments?
Twice daily
Multiple dosing
Single daily
Describe twice daily insulin dosing
2 daily injections
30 mins before breakfast/evening meals
Mix of SA/LA
Describe multiple dose insulin dosing
Single dose of intermediate acting insulin at bedtime
Doses of SA 30 mins before meals
BASAL-BOLUS
Describe single daily insulin dosing
Single injection of intermediate acting insulin before breakfast/bedtime
Generally DMT2 w/ poor control
What factors can increase insulin requirement?
Stress Infection Trauma Puberty Pregnancy (T2/3)
What factors can reduce insulin requirement?
Coeliac disease
Renal/hepatic impairment
Endocrine disorders
What are the three main routes of insulin administration?
Intravenous injection
Subcutaneous injection
Insulin pumps
Why should patients rotate the site of subcutaneous injection?
Repeated infections leads to lipohypertrophy - unpredictable insulin absorption
At what age does DMT2 usually present?
> 40 years
What causes DMT2?
Strong family association
Loss of beta-cells/reduced glucose sensitivity
What is the defining feature of DMT2?
Increased insulin resistance
What diseases are commonly associated with DMT2?
Obesity
Hypertension
Hyperlipidaemia
What is the management of mild DMT2?
Dietary modification
- replace simple with complex carbs (50-55%)
- limit intake of mono/disaccharides
- reduce intake of fat (30-55%)
- weight loss/exercise
At what point does management of DMT2 progress from dietary modification to antidiabetic drugs?
After 3 months of dietary changes alone
What are the four classes of drugs available to treat DMT2?
Sulphonylureas
Meglitinide analogues
Biguanides
Thiazoldinediones (glitazones)
How do Sulphonylureas work?
Increase insulin secretion
Inhibit ATP-sensitive K channels
What are the three clinically common Sulphonylureas?
Glibenclamide
Gliclazide
Tolbutamide
What are the main side effects of Sulphonylureas?
Weight gain + increased insulin resistance
w/ beta-blockers mask signs of hypo
Cause hypos
How do Meglitinde analogues work?
Act on beta-cells
Closure of KATP channels - insulin release
What are the two clinically common Meglitinide analogues?
Nateglinide
Repaglinide
What are the advantages of Meglitinide analogues?
Rapid rate of onset
Given at meal times, stimulate post-prandial insulin secretion
By what other name are Meglitinide analogues known?
Prandial glucose regulators
How do Biguanides work?
MoA unclear
-may activate AMP-kinase?
What is the main Biguanide used clinically?
Metformin
When is Biguanide use indicated?
Obese patient’s
Doesn’t cause weight gain/hypos
When is Biguanide use contrindicated?
Should not be used in renal impairment
How do Thiazolidinediones (glitazones) work?
Activate nuclear peroxisome proliferator-activated receptors gamma (PPAR-y)
Alters gene expression, results in insulin-like effects
What is the main Thiazoldinedione (glitazone) used clinically?
Pioglitazone
What are the cellular effects of treatment with Thiazoldinediones (glitazones)?
Reduced hepatic glucose output
Increased GLUTs in skm.
Increased peripheral glucose utilisation
Increased fatty acid uptake into adipose cells
What is the guidance regarding treatment with Thiazoldinediones (glitazones)?
Liver function monitored
Used alone
Not as 2nd line therapy (unless met+sulph not tolerated)
What is the first stage of treatment for DMT2?
3 months of diet control
What is the second stage of treatment for DMT2?
Normal renal function - Metformin
Renally impaired - Sulphonylurea
What is the third stage of treatment for DMT2?
2 from Met/Sulph/Glitazone
Add Insulin?
What is the main complication of DM?
Increased risk of IHD/stroke
What is the target BP for sufferers of DM?
<140/80mmHg
What is the first choice BP medication in DM sufferers?
ACEIs - reduce diabetic complications
What is diabetic nephropathy?
Damage to capillaries in the kidney glomeruli
Progressive
What should all patients with DMT1 and Microalbuminuria receive?
ACEI
In what patients is diabetic nephropathy likely?
Patients w/:
Albumin in urine
Increased plasma creatinine levels
What are the targets for patients w/ albumin in the urine or increased plasma creatinine levels?
HbA1c <47.5-53.0mmol/mol
BP <135/75mmHg
