Diabetes Mx in Primary care (2) Flashcards
What are (4) aims in the management of diabetic patient?
- glycaemic control
- identification and modification of risk factors
- identification and management of microvascular complications
- identification and management of macrovascular complications
Micro vs Macro vascular complications of diabetes
What risk factors should be assessed and addressed in diabetes?
- HTN -> target 130/80
- high BMI
- assessment of complications -> micro and macro vascular
- increased cholesterol -> assess and manage (statins)
- smoking cessation
- alcohol
- drugs that pt is on -> e.g. steroids increase glucose
How do we measure glycaemic control? (what is the target)
* is there any exception to it?
- Target HbA1c is 48 mmol/mol (6.5%) if lifestyle and +/- drugs (not associated with hypos)
* may accept higher values if we worry about ‘hypos’ -> then target for HbA1c is 53 mmol/mol (7%)
Class: Biguanide
- example of the drug (name)
- MoA
- side effects
Biguanide
- Metformin
it is 1st line Rx for T2DM (if tolerated)
- MoA: increase peripheral insulin sensitivity; decreases gluconeogenesis
- side effects: GI upset (introduce drug slowly), lactic acidosis, weight loss
*Metformin may contribute to renal disease -> reduce dose/ stop if eGFR <30
Class: Sulphonylurea
- example of the drug (name)
- MoA
- side effects
Sulphonylurea (oral)
- Gliclazide
- MoA: increase insulin release
- side effects: hypoglycaemia, weight gain
*no issues with renal function
Class: DPP-4 inhibitors
- example of the drug (name)
- MoA
- side effects
DPP-4 inhibitors
‘gliptins’
- Sitagliptin, Linagliptin
- MoA: Inhibit DDP-4 -> less degeneration of incretin hormones (GLP-1 and GIP) -> more insulin release stimulation; decrease in glucagon; slowing down gastric emptying
- side effects: GI upset, pancreatitis
*neutral to weight
- Name two incretin hormones
- What do they do?
GIP (gastric inhibitory polypeptide) and GLP-1 (glucagon-like peptide-1)
MoA:
- secreted from intestine upon ingestion of glucose or nutrient
- stimulate insulin secretion from the pancreatic B cells
What would inhibit incretins?
DPP 4 (dipeptidyl peptidase 4) - it degrades incretins
*Drugs known as DPP 4 -inhibitors‘gliptins’ will inhibit the action of DPP 4 -> therefore more incretin will be present
What’s SGLT2 and where is it located?
SGLT2 = Sodium/glucose cotransporter 2
- reuptake of glucose in proximal convoluted tubule
Class: SGLT2 inhibitors
- example of the drug (name)
- MoA
- side effects
SGLT-2 inhibitors
- ‘Gliflozins’*
- Dapagliflozin, Canagliflozin
- MoA: reduce glucose reabsorption in proximal convoluted tubule
- side effects: UTI -> as more glucose is excreted in the urine, dehydration -> due to polyuria, weight loss
*dose needs to be adjusted if reduced eGFR
Class: Thiazolidinedione
- example of the drug (name)
- MoA
- side effects
- contraindication (!)
Thiazolidinedione
* ‘glitazones’
*oral (PO)
- Pioglitazone
- MoA: increases peripheral insulin sensitivity
- side effects: oedema, weight gain, HF
- contraindication: do not use in HF
* no issues with renal function
Class: GLP-1 receptor agonist
- example of the drug (name)
- route
- MoA
- side effects
- when is it only indicated
GLP-1 receptor agonist
- Exenatide, Liraglutide
- route: S/C
- MoA: as it will induce incretin (GLP-1) -> increase insulin secretion, decrease glucagon, slows gastric emptying
- side effects: GI upset, pancreatitis, weight loss
* it is expensive -> only indicated if pt has a BMI of 35 or more
Insulin
- example of the drug (name)
- route
- MoA
- side effects
Insulin
- Lantus
- route: S/C
- MoA: it is synthetic insulin -> increase uptake of glucose into the cells, glycogenolysis, conversion of glucose to fat
- side effects: hypoglycaemia, weight gain, lifestyle factors / ‘fuff’ factors
What patient factors do we need to consider when deciding what diabetic Rx would we put the patient on
- other drugs
- weight
- age/frailty
- risk of hypos
- occupation
- patient’s attitude towards injectable insulin
Shortly, what is 1st and what is 2nd line med Rx for diabetis type 2?
1st Metformin
2nd Gliclazide (sulphonylurea)
What 1st line Rx do we start if HbA1c raises to 48 mmol/mol in T2DM patient?
Monotherapy if HbA1c raises to 48 mmol/mol
Metformin
- first offer standard release
- if not tolerated -> modified release
When is Rx with Metformin contraindicated? (2)
- bad renal function
- pt cannot tolerate side effects
Monotherapy Rx of T2DM if metformin is contraindicated
Monotherapy - if HbA1C raises to 48 mmol/mol
DPP -4 inhibitororPioglitazone
1st line Rx of T2DM if HbA1c raises to 53 mmol/mol
Ig HbA1c raises to 53 mmol/mol = time doe dual therapy
*target would be to maintain 53 mmol/mol
Dual therapy 1st line: combination of Metformin + any other drug
What if we HbA1c raises to 53 mmol/mol and Metformin is contraindicated?
Dual therapy - combination of any other drugs but not metformin
Example: DPP -4 inhibitor + Sulfonylurea
What meds to go on if HbA1c raises to 58 mmol/mol in T2DM?
Triple therapy
1st line - metformin and any other drug
*If metformin contraindicated -> consider insulin
What pt factor do we take into account if considering the induction of short-acting insulin analogues?
- person prefers injecting before meals
- blood glucose raises before meals
- hypoglycaemia is a problem
When do we consider therapy with GLP-1 agonist (Exenatide)?
Exenatide considered if:
- BMI over 35 and
- BMI undr 35 and either:
- psychological issues associated with obesity
- insulin therapy would have significant occupational implications
*or weight loss would benefit other obesity-related co-morbidities
If triple therapy fails, consider these (3) drugs
Metformin + Sulponylurea + Glucacgon like peptide -1 (GLP-1) mimentic (Exenatide)
