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
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
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
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)
