Diabetes - Treatment Flashcards
What type of insulin (i.e. human or analogue) is most commonly used by type 1 diabetics and why?
Analogue, because it has a lower risk of hypoglycaemia
What is an example of a short-acting human insulin?
Actrapid
What is an example of a long-acting human insulin?
Insulatard
What are 2 examples of short-acting analogue insulins?
Novorapid (insulin aspart) and Humalog (insulin lispro)
What are 2 examples of long-acting analogue insulins?
Lantus (insulin glargine) and Levemir (insulin determir)
Which has a shorter duration of action- human or analogue insulin?
Analogue
Patients with type 1 diabetes should be given an insulin to carbohydrate ratio and should be educated to match their prandial insulin dose to what 3 things?
Carbohydrate intake, pre-meal glucose and anticipated exercise
Do fingerprick blood glucose levels taken before meals inform about the long or short acting insulin dose?
Long-acting
Do fingerprick blood glucose levels taken after meals inform about the long or short acting insulin dose?
Short-acting
Explain what is meant by the basal bolus regimen of giving insulin?
A long-acting insulin is given before bed, and short-acting insulin doses are given with each meal
In a bi-daily insulin regimen, what type of insulin is given at the two daily doses?
A mixture of short and intermediate acting insulin
How fast acting is isophane insulin?
Intermediate-acting
What type of insulin is given in a once daily insulin regimen? When should this dose be given?
An intermediate-long acting insulin is given before breakfast
When is a once daily insulin regimen used?
In type 2 diabetics, in conjunction with oral hypoglycaemic agents
Explain what is meant by continuous SC insulin infusion?
A rapid acting insulin is infused continuously, boluses are given with meals
When is IV insulin used?
In acute illness and fasting patients
If a patient is being given IV insulin and their blood glucose is > 12mmol/L, what should be checked?
Ketones
What effect does insulin therapy have on weight?
Weight gain
What is the name for a lump of fat which accumulates under the skin at the site of many SC injections of insulin? How can this complication be avoided?
Lipohypertrophy, this can be avoided by regularly changing the injection site and using new needles daily
What is the major potential risk of insulin treatment?
Hypoglycaemia
What gets replaced in a pancreas transplant for type 1 diabetes?
Pancreatic islet cells
Which oral hypoglycaemic agent has the following mechanism of action: helps to increase insulin sensitivity and decrease hepatic gluconeogenesis?
Metformin
Metformin is the first line pharmacological treatment for type 2 diabetes because it does not cause what two things?
Weight gain and hypoglycaemia
What is the most common side effect of metformin?
Gastrointestinal upset
Which oral hypoglycaemic agent can cause a metallic taste in the mouth as a side effect?
Metformin
Why should metformin be avoided in those with severe liver disease or renal failure?
Risk of lactic acidosis
What are the contraindications to the use of metformin?
CKD, and periods of time where there is tissue hypoxia (e.g. post-MI)
It is recommended that metformin should be stopped if the creatinine is greater than what, or the eGFR is less than what?
Creatinine > 150 / eGFR < 30
Is metformin safe to use during pregnancy and breastfeeding?
Yes
When should metformin be taken in relation to food?
After food
Gliclazide and glibenclamide are examples of which class of oral hypoglycaemic agents?
Sulfonylureas
When may sulfonylureas be used as a first line treatment for type 2 diabetes?
In patients who are intolerant of metformin, or those who are significantly underweight
Which oral hypoglycaemic agent has the following mechanism of action: increases pancreatic insulin secretion by binding to an ATP-dependent potassium channel on the cell membrane of pancreatic beta cells?
Sulfonylureas
What are the two major adverse effects of sulfonylureas?
Hypoglycaemia and weight gain
Due to the risk of hypoglycaemia, sulfonylureas should be avoided/given with caution in who?
The elderly/frail
Sulfonylureas may cause which electrolyte abnormality?
Hyponatraemia (secondary to SIADH)
Bone marrow suppression, hepatotoxicity and peripheral neuropathy are all relatively rare side effects of which oral hypoglycaemic agent?
Sulfonylureas
Are sulfonylureas safe to use in pregnancy and breastfeeding?
No
Exenatide and liraglutide are examples of which class of drug?
GLP-1 analogues
What effect do GLP-1 analogue drugs have on weight?
Weight loss
Which oral hypoglycaemic agents cause weight gain?
Sulfonylureas and thiazolidinediones
Which oral hypoglycaemic agents risk hypoglycaemia?
Sulfonylureas and thiazolidinediones
Which oral hypoglycaemic agent has the following mechanism of action: agonist to the PPAR-gamma receptor, working by reducing peripheral insulin resistance?
Thiazolidinediones
Pioglitazone is an example of what class of oral hypoglycaemic agent?
Thiazolidinediones
What blood test should be monitored regularly in those taking thiazolidinediones?
LFTs
What is the major contraindication to the use of thiazolidinediones and why?
Heart failure - due to the adverse effect of fluid retention
How and when should exenatide (a GLP-1 analogue) be given?
As SC injection, 60 minutes before the morning and evening meals
What is the main advantage of liraglutide over exenatide?
It is only given once daily
What is the main adverse effect of GLP-1 analogue drugs?
Nausea/vomiting (usually resolves by 6-8 weeks)
Which class of type 2 diabetes drug comes with an increased risk of developing pancreatitis and pancreatic cancer?
GLP-1 analogues
Vildagliptin and sitagliptin are examples of which class of oral hypoglycaemic agent?
DDP-4 inhibitors (Gliptins)
What effect do DDP-4 inhibitors (gliptins) have on weight?
Weight neutral
Canagliflozin and dapagliflozin are examples of which class of oral hypoglycaemic agent?
SGLT-2 inhibitors
Which oral hypoglycaemic agent has the following mechanism of action: works in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion?
SGLT-2 inhibitors
What effect do SGLT-2 inhibitors have on weight?
Weight loss
What is the major adverse effect of SGLT-2 inhibitors?
Urinary and genital infections
SGLT-2 inhibitors will be of no use in individuals with an eGFR of less than what?
60ml/min
How often should HbA1c be monitored in type 1 diabetics?
Every 3-6 months
How often, and when, should self-monitored testing of blood glucose be done in type 1 diabetics?
At least 4 times a day, including before each meal and before bed
On average, for type 1 diabetics, what should their blood glucose target be when monitoring it throughout the day?
4 - 8mmol/L
What is the insulin regimen of choice for all adult type 1 diabetics?
Multiple daily injection basal bolus regimen
What is the basal insulin regimen of choice for all adult type 1 diabetics?
Twice daily Levemir (insulin determir)
NICE recommends the addition of what drug in type 1 diabetics with a BMI of 25 or more?
Metformin
How often should HbA1c be checked in type 2 diabetics?
Every 3-6 months until stable, 6 monthly after that
Complete the blanks: in type 2 diabetics, you can titrate up metformin and encourage lifestyle changes to aim for an HbA1c of (X), but should only add a second drug if the HbA1c rises to (Y)
X = 48mmol/mol, Y = 58mmol/mol
What is the HbA1c target for type 2 diabetics on lifestyle, or lifestyle + metformin management?
48mmol/mol
What is the target HbA1c for type 2 diabetics who are taking any drug that comes with a risk of hypoglycaemia?
53mmol/mol
What is the first line pharmacological treatment for type 2 diabetes and when should it be offered?
Metformin: offer when HbA1c 48mmol/mol+ on lifestyle intervention only
A second drug should be added to metformin in type 2 diabetic patients if their HbA1c has risen above what?
58mmol/mol
What are the 4 options of second line drug class that can be offered to patients as second line therapy in addition to metformin, if HbA1c is 58mmol/mol or more?
Sulfonylureas, thiazolidinediones, DDP-4 inhibitors, SGLT-2 inhibitors
What are the two treatment options that can be considered for type 2 diabetic patients who are on metformin plus one other oral hypoglycaemic agent yet still have an HbA1c of 58mmol/mol or more?
Add one more drug (triple therapy) or start insulin
In those type 2 diabetic patients who can tolerate metformin, if triple therapy is not effective, not tolerated or contraindicated for any reason AND the patient has a BMI of > 35, a combination of what three drugs can be tried?
Metformin, sulfonylurea and GLP-1 analogue
What targets must be met for treatment with a GLP-1 analogue to be continued in type 2 diabetic patients?
Reduction in HbA1c of 11mmol/mol and weight loss of at least 3%, both in 6 months
In those type 2 diabetic patients who cannot tolerate metformin, if the HbA1c rises to 48mmol/mol on lifestyle interventions alone, one of what 3 drug classes can be considered as first line treatment?
Sulfonylurea, thiazolidinedione, DDP-4 inhibitor
In those type 2 diabetic patients who cannot tolerate metformin, if one drug is started but the HbA1c remains at 58mmol/mol or more, what should be done?
Combine two drugs (sulfonylurea, thiazolidinedione, DDP-4 inhibitor)
In those type 2 diabetic patients who cannot tolerate metformin, if two drugs are started in combination but the HbA1c remains at 58mmol/mol or more, what should be done?
Start insulin therapy
What drug should always be continued alongside insulin therapy for type 2 diabetes (if the patient is already on the drug)?
Metformin
What is the recommended insulin regime for type 2 diabetics starting insulin treatment?
Intermediate acting human insulin (isophane insulin) given once or twice daily
If treatment for hypertension is required in a diabetic patient, what is the drug of choice?
ACE inhibitor or ARB
Should anti-platelets be offered routinely to diabetic patients?
No
What drug is typically used as primary prevention against hyperlipidaemia in diabetic patients?
Atorvastatin 20mg
When should atorvastatin 20mg be given to type 1 diabetic patients?
This is started in most adult type 1 diabetics
When should atorvastatin 20mg be given to type 2 diabetic patients?
If they have a 10 year CV risk > 10%
How many units of insulin are usually found within 1ml?
100 units
