Diabetic medication management and pharmaceutical care

Question 1

What is the first line treatment for a newly diagnosed patient with Type 2 diabetes?

Answer 1

Can be dependent on how high glucose levels are at the point of diagnosis but normally the first line treatment is lifestyle interventions before introducing oral hypoglycemics.

Question 2

What sort of lifestyle advice should be provided to a patient with newly diagnosed Type 2 diabetes?

Answer 2

Sufficient exercise each week as according to NHS guidelines (150 mins of moderate exercise a week split over 4-5 days)
Moderate alcohol intake (14 units a week)
Stop smoking
Healthy, balanced diet- 5 portions of fruit/ veg a day, switching saturated fat to dietary fibre
If obese they need to try to reduce their portions and be in a calorie deficit of about 600kcal a day
Low sodium diet if they also have hypertension

Question 3

What are the most common side effects of Metformin?

Answer 3

Gastrointestinal disturbances- (nausea, vomiting, diarrhea etc)
Vitamin B12 deficiency

Question 4

How would you advise the patient to minimize the side effects of Metformin and how should it be prescribed to minimise these effects?

Answer 4

To take the medication during or after a meal however if the symptoms persist they should contact their GP to consider possible switch over to Metformin MR.
Metformin dose should be increased gradually to reduce the risk of side effects occurring.

Question 5

When should an SGLT-2 inhibitor be introduced management of Type 2 diabetes?

Answer 5

If the patient has a QRISK2 of greater than 10% and they have tolerated the Metformin.

Question 6

What are some of the therapeutic monitoring parameters of Metformin and how often should they be assessed?

Answer 6

Fasting blood glucose
Postprandial blood glucose
HbA1c

For all three parameters you would measure them regularly every 3 months and then once the results are stabilised, every 6 months.

Question 7

How often should the toxic monitoring parameters of Metformin be monitored?

Answer 7

Renal function- less than 45mL/min/1.73 every three months; eGFR between 45-60mL/min/1.73 every three to six months
Vitamin B12 deficiency- regularly especially in those with anaemia and peripheral neuropathy
Gastrointestinal side effects- as the patient reports (New medicines service)

Question 8

What are some examples of sulfonylureas?

Answer 8

Glimepride
Gliclazide
Gliprizide

Question 9

What is the starting dose for Metformin?

Answer 9

500mg once daily and then titrated upwards accordingly

Question 10

What is the starting dose for SGLT-2 inhibitors?

Answer 10

10mg once daily

Question 11

What are some examples of SGLT-2 inhibitors?

Answer 11

Empagliflozin
Dapagliflozin
Canagliflozin

Question 12

Why might a patient not be on the maximum dose of Metformin before adding in another medication?

Answer 12

Normally, as seen with hypertension you would expect to max out the dose of the medication before adding in another drug, however Metformin is known to cause gastrointestinal side effects therefore they may remain at the maximum dose they can tolerate.

Question 13

What are the most common side effects associated with sulfonylureas?

Answer 13

Weight gain
Hypoglycaemia
Increased risk of cardiovascular disease when used as monotherapy

Question 14

Is the risk of hypos greater with Glimepride or Gliclazide?

Answer 14

Whilst both can induce hypos, the risk is slightly reduced with Gliclazide as it has a shorter half life in comparison to Glimepride.

Question 15

Explain the side effects caused by SGLT-2 inhibitors?

Answer 15

As in their name SGLT-2 inhibitors block the SGLT-2 transporters inhibiting the re absorption of mainly glucose (but also sodium) into the proximal tubules of the nephron and therefore causing an overall decrease to plasma glucose levels.
However increased excretion of glucose (glucoseuria) can have clinical complications:
Increased urinary infections, UTIs and thrush (Gram-negative bacteria and yeast thrive off glucose)
Polyuria (more sodium excreted, more water excreted also due to osmotic pressure)
Weight loss
Diabetic ketoacidosis

Question 16

Describe the cardiac benefit of SGLT-2 inhibitors.

Answer 16

Causes osmotic diuresis by blocking the sodium-glucose transporter 2, therefore as more sodium is excreted, more water is excreted, this decreases the ECF volume and blood pressure. This reduces the pre-load and afterload and hence improves cardiovascular structure and function.
Also increased urinary volume reduces the uric acid concentration, reducing oxidative stress on the heart.
Also causes weight loss, decreasing the physical stress on the heart

Question 17

How does SGLT-2 inhibitors cause Diabetic ketoacidosis?

Answer 17

SGLT-2 increases the ketone body production and circulation and therefore when high concentrations of ketones are absorbed by the tubules this can result in ketoacidosis, and may not present clinically with a high rise in blood glucose levels.

Question 18

Are SGLT-2 inhibitors safe to be taken leading up to surgery?

Answer 18

No, they are normally stopped in the pre-operative period as this is the time diabetic ketoacidosis is greatest. Ketone levels should be monitored closely throughout the surgical process.

Question 19

What is the recommended treatment of hypertension in patients who also have diabetes?

Answer 19

First line treatment is ACE inhibitors, regardless of age, this is because they have reno-protective activity and is beneficial as one of the complications of diabetes is peripheral nephropathy.

Question 20

What is the first line recommendation for patients with diabetes who also have hyperlipidaemia?

Answer 20

20mg Atorvastatin once daily at night
Atorvastatin is the preferred statin of choice as it has been shown to prevent/delay development of complications of diabetes such as retinopathy and has reno-protective activity.

Question 21

When is Atorvastatin contra-indicated?

Answer 21

In those with active liver disease, so if they were an alcoholic you most likely would avoid/ use with caution.
You would conduct liver function tests before starting the drug therapy.

Question 22

When is Atorvastatin prescribed in treatment for diabetes?

Answer 22

When the QRISK2 is greater than 10% in patients with diabetes but now it is recommended for all adults over the age of 40 with Type 2 diabetes regardless of whether they have hyperlipidemia.

Question 23

Is aspirin prescribed as a pre-caution in patients with diabetes at an increased risk of CVD?

Answer 23

It is no longer recommended to be used as a pre-caution and is only given if they have diagnosed CVD.

Question 24

Which type of beta blockers should be avoided when a patient has diabetes?

Answer 24

Non-selective beta blockers such as Propranolol. This is because non-selective beta blockers can mask the adrenergically mediated hypoglycaemia symptoms such as heart palpitations and tremor and therefore make you unaware that your blood glucose levels have dropped. If beta blockers are required selective beta blockers such as Bisoprolol or Atenolol should be prescribed.

Question 25

What is the risk associated with metformin in renal impairment?

Answer 25

Increases the risk of lactic acidosis (build up of lactic acid in the bloodstream) and should therefore be used with caution.

Question 26

Aside from diabetes where might you also see prescribed metformin?

Answer 26

Symptom relief in polycystic ovary syndrome

Question 27

What are some of the side effects of Pioglitazones?

Answer 27

Weight gain
Fluid retention
Anaemia
Heart failure
Extended use may increase the risk of bladder cancer

Does not cause hypos

Question 28

What are some side effects of GLP-1 agonists?

Answer 28

GI disturbances
Weight loss
Dizziness

Low risk of hypos- only when used with other oral hypoglycaemics

Question 29

What are some examples of GLP-1 mimetics?

Answer 29

Liraglutide - s/c injection
Exenatide - given by s/c injection twice daily or once weekly in modified release form

Question 30

What are some examples of DPP-4 inhibitors?

Answer 30

Sitagliptin
Saxagliptin
Alogliptin
Linagliptin

Question 31

What are some of the side effects of DPP-4 inhibitors?

Answer 31

GI side effects
Pancreatitis
Symptoms of upper respiratory infection