Diabetes Pharmcotherapy and the mechanism Flashcards
PA check list (4) TIMS
- Try to do 150min moderate to vigorous-intensity aerobic exercise/wk
- Include resistance exercise no less than 2 times/wk
- Minimise uninterrupted sedentary time
- Set a goal of PA and involve a multi-disciplinary team if available
Exercise (5)
aerobic, resistant, interval, other types, use pedometers/accelerometers
ABCDEs of diabetes care (Diabetes Canada) [ compared to the ABCDEs to protect vascular system]
all the same except s:
S= smoking cessation
S= screening for complication
S= self-management, stress and other barriers
2 types of new insulin Tx, besides conventional
- Basal-bolus injection therapy
2. continuous subcutaneous insulin infusion (intensive therapy)
the difference between basal insulin and bolus insulin
basal: constant during the day
bolus: fluctuate by the meal intake
why analogue basal is better than human basal
there is no peak but more constant during the day. Moreover, the action on set is earlier.
why analogue bolus is better than human bolus?
it follows the glucose level change in time and the peak is more closer to the glucose peak, which is better.
what is the conventional insulin therapy?
human and analogue premixed.
what is the problem of premixed insulin therapy?
need multiple injection every day before each meal. the insulin response cannot successively follow the glucose rise. It is easier to cause hypoglycemia.
in two types of premixed Therapy, which one is better? why?
analogue: the peak of response more follows the actual glucose peak,
Medication– Lispro: function, on set speed, peak lasting, duration, (others?)
Rapid-acting
- bolus insulin
- very fast: 10-15min
- very short: 1-2 hrs
- duration: 3-5hrs
- very expensive
Medication– Regular: function, on set speed, peak lasting, duration, (others?)
Short-acting
- bolus insulin
- fast: 30min
- short: 2-3hrs
- duration: 6.5hrs
- relatively cheap
Medication– NPH: function, on set speed, peak lasting, duration, (others?)
Intermediate-acting:(cloudy)
- basal insulin
- moderate: 1-3hrs
- have a peak: 5-8 hrs
- duration 10-18 hrs (2 injections/d)
Medication– Glargine: function, on set speed, peak lasting, duration, (others?)
Long-acting: (cloudy) - fast: 90 min - NO PEAK - very lasting: 20-24 hrs 1 injection/d
Medication– 30/70 : function, on set speed, peak lasting, duration, (others?)
premixed: 30% reg + 70% NPH
- fast: 30-60min
- dual peak
- duration: 10-16 hrs
what is the conventional insulin regimens?
- have to inject 1-3 times/d
- meal plan, times and CHO content are fixed
- PA may cause hypoglycemia
what is the intensive insulin regimens?
- inject more than 3 times/d or continuous subcutaneous insulin infusion
- require self-monitor
what is the benefits of intensive therapy (3)
- Basal + bolus injections of rapid type before meals: more close to the mimic physiology
- the time and CHO content is more adjustable: must know Carb counting
- insulin dose can adjust to exercise
What’s DCCT project told us?
- In long-term (21 yrs follow-up), intensive Tx always performed better than conventional Tx in terms of A1C level
- early intensive therapy reduced more risk of non-fatal MI, stroke or death from CVD in a long term (after 16 yrs)
3 ways of insulin intake
syringe, pen, pump
the advantage of continuous glucose sensor
can track if any
unexpected insulin burst.
4 classes of antihyperglycemic agent （DM2 medication)
- a-glucosidase inhibitor
- incretin mimetics
- insulin secretagogoues
- TZDs
mechanism of a-glucosidase inhibitor
delay intestinal glucose absorption
mechanism of incretin mimetics
stimulate insulin and reduce glucagon secretion; delay gastric emptying
mechanism of TZDs
increase insulin sensitivity in peripheral tissues and liver
mechanism of insulin secretagonous
stimulate insulin secretion in short (4-7 hrs) or long (once a day) term
which medication may cause hypoglycemia?
insulin secretagonous
what is the first initial drug for DM2?
- Metformin
- inhibit the gluconeogenesis in liver –> improve insulin sensitivity –> increase glucose uptake
what is the class of the initial drug?
biguanide
why it is the initial drug
- known safety, no hypoglycemia, help wt control
- just a few GI side effect (less than others)
Metformin contraindication
renal insufficiency, liver or heart failure
what is the difference and similarity between DPP-4 inhibitors and GLP-1 receptor agonists
- similarity:
1. antihyperglycemic agnets
2. the incretin mimetics: target on GLP-1 function - difference:
1. DPP-4: inhibited DPP-4 enzyme activate GLP-1.
2. GLP-1R Agonist: promotes the production of GLP-1
Mechanism of SGLT2 inhibitor
block the Na-glucose transporter in the proximal renal tubule— so decrease blood glucose and lower body weight, glycouria
advantage of SGLT2
- rare hypoglycemia, lower BP, elevate HDL
- when added to metform: the best agent to improve A1C profile
disadvantage of SGLT2
- side effects: risk of urinary track infection, hypotension, more risk of diabetic ketoacidosis
- no oral pill form, have to do injection
what are the three antihyperglycemic agents demonstrated CV benefit?
empagliflozin
liraglutide
canagliflozin
when we should start the antihyperglycemic agents demonstrated CV benefit?
- after applying the first line medication Tx: metformin or insulin for Pts with symtomatic hypolycemia, the glycemic target is not achieved.
- and the Pt have clinical CVD.
Diagnosis of DM2: A1C>or= __should go metformin immediately
1.5% above target
Diagnosis of DM2: if the glycemic target not meet after primary intervention but also no indication of clinical CVD, what’s the next step? give all conditions
add additional anti-hyperglycemia agents:
2 conditions
1. avoid hypoglycemia and/or weight gain with adequate glycemic efficacy
2. other concerns
what are the medications may cause hypoglycemia
insulin Tx and Insulin secretagogue
what are the medications may cause Wt gain
insulin, thiazolidinediones TZDs, Insulin secretagogue
what is the most expensive medication category?
incretin mimetics and possible insulin
what are the medications may help Wt loss
insulin
a-glucosidase inhibitor
incretin mimetics
dietary guidance: metformin
reduce Vb12, folate absorption,
take with meals
dietary guidance: TZDs
N/A
dietary guidance: incretin mimetics
Cation of EtOH, may have GI side effect
dietary guidance: insulin secretagogues
avoid EtOH
dietary guidance: alpha-glucosidase inhibitors
take with the first bite of meal, limit EtOH
What DM pts should take statin? (5)
what’s the warning to the women with child-bearing potential?
1. have CVD 2 age more than 40 3. have micro-vascular complication 4. with DM > 15 yrs, and age > 30 yr 5. follow warrants therapy - stop statin before conception; should ask for preconception counselling and reliable contraception
pharmacotherapy for HTN in Pts w/ DM: threshold? target?
- threshold: no less than 130/80 mmHg
- target: 130/80
pharmacotherapy for HTN in Pts w/ DM: what is the key factor to determine?
CVD and CKD if exist
pharmacotherapy for HTN in Pts w/ DM: what is the difference from pts w/ CVD or CKD and the one w/o?
the pts with CKD and CVD should not use HDP-CCB or thiazide/thiazide-like diuretics
they apply ACE inhibitor or ARB only
(w/o: can use both)
if a pt with insulin Tx have not met the glycemic target after 3 months, what should do? why?
add incretin mimetics and SGLT2 inhibitor may be considered before add more dose of insulin
- minimize wt gain and prevent hypoglycemia
