diabetes treatment Flashcards
Treatment of diabetes 1
5
- at dx start insulin immediately
- structured education programme
- DAFNE- dose adjustment for normal eating
- diet modify: restrict refined sugars+ saturated fats but calorific intake not reduced
- exercise
diabetes 2 general treatment escalation
5
- diet +exercise
- oral monotherapy
- oral combination
- oral + insulin
- Insulin
contraindication for oral monotherapy
ketoacidosis
severe intercurrent illness
indications for insulin therapy with type 2 diabetes
3
- persistently elevated blood glucose and HBA1C on maximum doses of anti-diabetic drugs (secondary failure to anti-diabetic drugs)
- symptoms of hyperglycemia and/or infections (eg candidiasis) (severe intercurrent illness)
- metabolic complications (non-fasting ketonuria and hyperosmolar state)
3 classes of anti-diabetic drugs
mechanism
- augment supply of insulin on pancreatic beta cells
- enhance insulin action and reduce resistance-liver, fat & muscle
- delay carbohydrate absorption- gut
4 drugs that augment insulin supply
- sulfonylureas eg -zide
- prandial glucose receptors (end in glinides)
- incretin mimics (-tide, exenatide)
- gliptins: DPP4 inhibitors so incretin increased
2 drugs that enhance insulin action and reduce resistance at liver, fat and muscle
- biguanide eg metformin
2. thiazolidineoides (eg pioglitazone)
3 drugs that delay carb absorption
- alpha glucosidase inhibitors (eg acarbose, miglitol)
- incretin mimics
- glicretics, SGLT2 inhibitors
what is gliplizide
sulphonylurea
how does gliplizide work
stimulates secretion of endogenous insulin by closing the K-ATP channel
pros of gliplizide
reduces blood glucose level
well tolerated generally
cons of gliplizide
- promotes weight gain
- need reduced dose in renal impairment
- risk of hypoglycaemia
- increased appetite
action of metformin
biguanide
decreases hepatic glucose production and increases sensitivity of insulin in muscle
pros of metformin
encourage weight loss
old and cheap
good at controlling blood glucose
what anti-diabetic drug is first line
metformin
cons of metformin
nausea
diarrhoea
when is metformin contraindicated
in renal impairment (risk of lactic acidosis <30 egfr)
when is gliplizide contraindicated
hepatic failure
but also reduce dose in renal impairment
what are the 2 glucose prandial regulators
repaglinide (meglitinide)
notglinide (amino acid derivative)
what is the action of repaglinide
insulin secreatogogues-direct effect on beta cells they stimulate rapid endogenous insulin release when given with meals
side effects of repaglinide
weight gain
hypoglycaemia but lower risk than sulfonylurea
how does acarbose work
alpha-glucosidase inhibitors, delay digestion of carbohydrates and slow down postprandial absorption of glucose
cons of acarbose and miglitol
limited weight efficacy but can be used in combination
- Bloating
- flactulence
how does miglitol
inhibitors, delay digestion of carbohydrates and slow down postprandial absorption of glucose
how does pioglitazone work
thiazolidenoides
- activates PPAR gamma nuclear receptors on adipose tissue
- reduces insulin resistance in liver and muscle by lowering plasma FFA and increases adiponectin
- enhances actions of endogenous insulin
what does PPAR
peroxisome proliferated activated receptors= family of nuclear transcription factors regulating expression of genes involved in lipid and carbohydrate metabolism
pros of pioglitazone
- effective
- rare hypo
- sustained improvements in HbA1C
- potential benefits in fatty liver
cons of pioglitazone
- slow onset of action 2-3 months
- promotes weight gain
- redistributes body fat to reduce visceral deposits
- fluid retention- oedema
- bladder cancer increase risk
contraindication of pioglitazone
ci in cardiac failure and hepatic failure as may cause fractures
what is the action of exenatide and liraglutide
mimics Glucagon like peptide 1
incretin mimic
potent insulinotrophic hormone is released in response to meals, but lower in IGT
stimulate glucose-dependent insulin secretion, suppresses glucagon secretion, slow gastric emptying, reduces food intake and improves insulin sensitivity
how is exenatide given
injected
pros of exenatide
- promotes weight loss
- reduces appetite as feel fuller for longer
- reduces risk of cardiac disease
cons of exenatide
- nausea
- hypo risk but rare unless given with SU
- risk of pancreatitis
- only available as injection
how do gliptins work
DPP4 inhibitors
dipeptidyl pepitdase enzyme
so get more GLP-1 so enhance action on insulin
what are gliptins given with
metformin
what is exenatide often given with
metformin and SU
Pros of gliptins
weight neutral
safe in renal impairment
modest reduction in HBa1C
oral taken
cons of gliptins
minimal hypo
what action empaglifozin, canglifozin have
act at kidney to prevent glucose resorption
SGLT2 inhibitors
pros of empaglifozin
weight loss BP reduction not assoc. to hypos CV mortality improved moderately effective
cons of canglifozin
- can’t be used if eGFR <45 or >60
- polyuria
- care with hypoloaemia/ loop diuretics
- glycosuria: leads to UTI and genital infections
contraindication of canglifozin
> 85
what are the ultra short acting drugs insulin
novorapid
humalog
apidra
how long are ultra short acting drugs
4 hours
what are the short acting drugs
actrapid, humulin s, hypurin neutral
what length are short acting drugs
6 hours
what are the intermediate acting insulin drugs
insulatard
humulin I
hypurin
isophane
how long are intermediate acting insulin drugs
12 hours
what are the fixed mixed insulin drugs
humulin M3
novomix 30
humalog mix 25
humalog mix 50
what are the long acting insulin drugs
glargine (lantus)
levemir (detemir)
degludec
long acting insulin drugs how long
18-36 hours
what is an insulin analogue
substitution of single amino acid in insulin chain
alters absorption characteristics of insulin
time-action profile is modified by amino acid
sick day rule
take 10% of insulin every 2 hours when ill
what regimens of insulin are there
- basal-bolus (multiple injections) : short or fast acting insulin before meals then intermediate or long acting once daily
- Twice daily: soluble or fast acting and isophane (NPH) insulins combined; free or fixed mix
- once daily: intermediate or long acting insulin with diabetic drug
when is intraperitoneal insulin used
in dialysate or renal failure
complications of insulin
lipohypertrophy at insulin site
side effects on insulin
hypoglycaemia weight gain lipohypertrophy peripheral oedeam insulin antibody form local allergy
when is islet transplantation used
-impaired awareness of hypo in 1dm
how is islet transplantation done
double donor transplants
benefits of islet transplantation
insulin independence
establish awareness of hypos and glycaemic stability
what add’s have the highest efficacy
insulin 1st
SU, tzd, glp1
highest hypo risk
insulin then su
highest weight gain
insulin, SU, TZDs
