Endocrine: Oral Anti-diabetic drugs

Question 1

Name 2 key side effects of metformin

Answer 1

Lactic acidosis (if renal impairment or tissue hypoxia)

GI upset - take with or after meals

Question 2

What is a less common side effect of metfomin to do with vitamins?

Answer 2

Reduced vitamin B12 absorption

Question 3

How often is renal function monitored with metformin

Answer 3

baseline and annually (if risk factors then 2x yearly)

Question 4

What are key side effects of SGLT2 inhibitors?

Answer 4

1. DKA - reporting DKA symptoms e.g. nausea, vomiting, fast breathing, sweet smelling breath, different odours to sweat, confusion, fatigue (MHRA ALERT)
2. Hypovolaemia - postural hypotension and dizziness, polyuria, thirst, UTI

Question 5

What is an MHRA alert regarding canagliflozin?

Answer 5

Risk of lower limb amputations so counsel patients to report any skin ulcers/discoloration/pain - preventative foot care and hydration

Question 6

What is an MHRA alert regarding canagliflozin?

Answer 6

Risk of lower limb amputations so counsel patients to report any skin ulcers/discoloration/pain - preventative foot care and hydration

Question 7

What is an MHRA alert regarding SGLT2i/dapagliflozin?

Answer 7

Fourniers gangrene - necrotising fascitis of genitalia and perineum
Report any severe pain, tenderness and swelling in those areas

Question 8

What are key side effects of meglitinides and a counselling point

Answer 8

Hypersensitivity reactions
N&V Napglinide
Visual disturbance with rapaglinide

Counselling: take 30 min before main meal
Caution driving due to hypoglycaemia

Question 9

What are key side effects of meglitinides and a counselling point

Answer 9

Hypersensitivity reactions
N&V Napglinide
Visual disturbance with rapaglinide

Counselling: take 30 min before main meal
Caution driving due to hypoglycaemia

Question 10

What are the short acting sulfonylureas?

Answer 10

Gliclazide

Tolbutamide

Question 11

What situations are the short acting sulfonylureas preferred over long acting?

Answer 11

Elderly

renal impairment

Question 12

What are the long acting Ssulonylureas?

Answer 12

Glibenclamide

Glimepiride

Question 13

Which sulfonylureas cause the most risk of hypoglycaemia?

Answer 13

Long acting SU e.g. glmepiride, glibenclamide

Question 14

What is a contraindication of sulfonylureas

Answer 14

Acute porphyrias

Question 15

What are 5 key side effects of sulfonylureas

Answer 15

1. Hyponatraemia (glipizide, glimepiride)
2. Hypoglycamia (esp glibenclamide-long acting)
3. Weight gain
4. Skin rashes
5. Jaundice

Question 16

Which sulfonylureas are most commonly associated with causing hyponatraemia

Answer 16

Glipizide

Glimepiride

Question 17

Do NSAIDS interact with SUs? why?

Answer 17

Yes. - reduced renal excretion of drug- inhibition of pg in renal glomerulus

Question 18

Name 2 interactions of SUs

Answer 18

Warfarin
ACEi
- hypoglycaemia risk

Question 19

Which drug does NICE recommend to only continue of HbA1c is reduced by 0.5% in 6 months?

Answer 19

Pioglitazone

Question 20

Which drug does NICE recommend to only continue if after 6 months there is a weight loss of at least 3% and reduction in HbA1c of at least 1%?

Answer 20

GLP-1 agonists (e.g. semaglutide, exenatide etc)

Question 21

What are 3 key main side effects of pioglitazone

Answer 21

1. heart failure
2. bladder cancer
3. hepatotoxicity

Question 22

What are counselling points for pioglitazone

Answer 22

• cardiac effects-
• blood in urine, difficulty urination/pain and urgency = bladder Ca
• Dark urine, fatigue, jaundice, pruritis, abdo pain - stop if jaundice occurs

Question 23

What are contraindications of pioglitazone

Answer 23

Heart failure/history 
Hepatic impairment
DKA
bladder cancer
haematuria

Question 24

What oral anti-diabetics cause weight gain

Answer 24

pioglitazone

sulfonylureas

Question 25

Do gliptins (DPP4i) have less or more risk of hypoglycaemia

Answer 25

Less

Question 26

What is a side effect to counsel patients on in DPP4i?

Answer 26

Pancreatitis - severe persistent abdominal pain

Question 27

What does vildagliptin cause

Answer 27

Liver toxicity

Question 28

What is a key side effect of GLP1 agonists

Answer 28

Pancreatitis-severe persistent abdominal pain

Question 29

What is the MHRA warning regarding GLP-1 agonists?

Answer 29

Risk of diabetic ketoacidosis when concomitant insulin is rapidly reduced/stopped - need to dose reduce carefully and stepwise

Question 30

Which GLP1 agonists do you need contraception for?

Answer 30

MR exenatide lixisenatide albiglutide semaglutide

Question 31

How long after stopping semaglutide do you need to continue contraception?

Answer 31

2 months

Question 32

How long after stopping MR exenatide do you need to continue contraception?

Answer 32

12 weeks

Question 33

When are GLP1 agonists used in treatment pathway

Answer 33

- BMI >35kg/m2 OR | - insulin cannot be used and BMI<35

Question 34

Would you hold SGLT2i in surgery

Answer 34

Yes

Question 35

What is a counselling point for ascarbose

Answer 35

Tablet should be chewed with first mouthful of food or swallowed whole with little liquid immediately before bed

Question 36

if 2 or more antidiabetic drugs are initiated what is the target HbA1c?

Answer 36

53 mmol/l

Question 37

What is 1st line after diet and lifestyle interventions fail?

Answer 37

metformin - increase gradually - if GI issues - MR preparation

Question 38

What are alternative 1st line options if metformin c/i or not tolerated

Answer 38

DPP4inhibitor e.g. gliptins Sulfonylurea pioglitazone

Question 39

What is the HbA1c aim if a sulfonulyrea is used?

Answer 39

53 mmol /l due to hypoglycaemia risk

Question 40

Which sulfonylurea can be used in pregnancy

Answer 40

Glibenclamide in 2/3 trimester