General Medicine

Question 1

Biguanide MoA

Answer 1

Decerase insulin resistance and hepatic glcose production.

Limit weight gain.

Question 2

Biguanide Efficacy

Answer 2

• 1-2%
• Can be used with others
• Little side effects
• Low cost
• No hypoglycaemia

Question 3

Biguanide side effect

Answer 3

• Little or no weight gain
• GI
• Lactic acidosis (with resp, CVD, Renal) HRH
• Vit B12 (absorption)

Question 4

Sulphonylureas drugs used`

Answer 4

Gliclazide
Glibenclamide
Glimepiride
Tolbutamide

Question 5

Sulphonylureas MoA

Answer 5

Stimulate B cells to release insulin. Antagonise B cell K/ATP channel activity, increase in K (as it accumulates) so depolarisation. Increased Ca, increased release

Question 6

Sulphonylureas efficacy

Answer 6

• 1-2%
• Low cost
• Tolbutamide has good post prandial control as it has a short half life so taken 30mins before.
• Others have higher half life and more potent

Question 7

Sulphonylureas side effect

Answer 7

• Weight gain

* Hypoglycaemia (especially CKD)

Question 8

Glitazone (TZDs) example

Answer 8

Pioglitazone

Question 9

Glitazone (TZDs) MoA

Answer 9

Increase sensitivity in muscle and adipose tissue. (via upregulation of signals/ genes)

Question 10

Glitazone ADRs

Answer 10

•	Wegith
•	Fluid (HF)
•	Bone metab (osteoporosis)
•	Bladder cancer
•	Hoever don’t get hypos
•	Increase in LDL and HDL
Rarely used now

Question 11

Describe Gliptins and e.gs

Answer 11

Sitagliptin
Vildagliptin
Saxagliptin
Linagliptin
•	0.5-0.8
•	Weight loss

Question 12

Gliptins ADRs

Answer 12

•	GI symptoms
•	High cost so 2nd line
•	Infection
Pancreatitis
Hypos rare

Question 13

GLP-1 agonists e.g.s MoA, efficacy

Answer 13

Exenatide Liraglutide
GLP from intestine increases insulin secretion and biosynthesis, decreases glucagon secretion, decreases liver glucose production (indirectly).
Decreases satiety, decreases gastric emptying.
Increases glucose uptake into muscles (indirect)
1-=1.5%

Question 14

GLP-1 ADRS

Answer 14

• GI, nausea, loose stools, diarrhoea
• GORD
• Painful to inject

Question 15

SGLT2 e.g.s

Answer 15

Dapagliflozin
Canagliflozin
Empagliflozin

Question 16

SGLT2 MoA and efficacy

Answer 16

Prevents glucose absorption in the the PCT by SGLT2 (90%)

0.5-1%

Question 17

SGLT2 ADRS

Answer 17

•	Only one extra void a day
•	UTI, thrush
•	Polyuria
•	Hypo (low risk)
Urosepsis
One one episode of above

Question 18

Rapid acting insulin onset and name

Answer 18

Insulin Aspart (Novorapid)
Insulin Lispro (Humalog)
Insulin Glulisine (Apidra)
o 5-15
P: 30-60min
D: 3-4hr

Question 19

Short acting

Answer 19

Humulin S
Actrapid
Insuman Rapid

O: 30-60
P: 2-3
D: 6-8

Question 20

Intermediate acting

Answer 20

Humulin I
Insuman Basal
Insulatard
Isophane (NPH)

O: 1-2
P: 4-6
D: 14-16h

Question 21

Long acting

Answer 21

Insulin glargine (Lantus); Abasaglar
O: 2-4h
No peak
D@ 20-24h

Insulin Detemir (levimer) Analogue
O:2-4
P: 6-14
D: 16-20

Question 22

Importance of insulin Toujeo(R)

Answer 22

High strength insulin
Basal once daily
exlusive units
Glargine but flatter peak than other glargine products e.g. Lantus
Always prescribe by brand name and include the concentration of insulin

Question 23

What is Degludec

Answer 23

Long acting

U100 and U200

Question 24

What is Humulin R (resistant)

Answer 24

Very potent
U500 - 5x stronger than normal insulin
For insulin resistant patients
Normally TDS before meals
Prescribed in marks not U
Marks based on 0.3 or 0.5ml insulin syringe. 1 mark = 0.01ml = 5 units

Question 25

Who needs insulin infusion?

Answer 25

``` DKA HHS - Hypersmolar hyperglycaemic state Surgical patients - NBM and missing more tna one meal Vomiting Major vasc event - ACS and Post CVA TPN/ entral fed patients Steroid use Metabolically unwell not eating and drinking -most cortisol related ```

Question 26

Difficulties of IV insulin

Answer 26

x

Question 27

Limitations to IV insulin

Answer 27

x

Question 28

Practical aspects of IV insulin. What would you do?

Answer 28

To make 50 units of Human Actrapid 50 units of actrapid and 49.5ml of NaCl aline ina 50ml luer lock syringe so conc of 1unit/1ml Non returnable valve No more than 24 hrs as crystalises Volumetric pump used Rate used that gives 6-10mmols/L of glucose Discard after 24hrs In most cases needs substrate (glucose) Different degrees of insulin sensitivity accounted for Patients have different sensitivities to insulin to adjust accordingly related to weight, concurrent illness and medication (steroids) Tables for rate guides CBGs done hourly for first 24h

Question 29

Ketone monitoring in IV insulin

Answer 29

Monitor ketones in T1 if glucose >12 on 2 readings 1 hr apart T2 - Monitor if unwell, get a baseline

Question 30

Treatmeny of hypos from IV insulin

Answer 30

CBG <4mmols/L Stop insulin Give 75mls of 20% glucose IV over 15 minutes or equivalent Repeat CBG and if needed treatment Once above 4mmol/L restart IV insulin with a review of dose

Question 31

Which patients should be kept over 6mmols/L during IV insulin

Answer 31

In patients with ACS or stroke do not let CBGs drop below 6

Question 32

Explain concurrent fluids with IV insulin

Answer 32

0.9% saline if vomiting, pyrexial, dehydrated with glucose If HF or renal, no saline due to overload. Elderly too Replace electrolytes with NaCl and KCl if on insulin for prolonged period

Question 33

Explain discontinuation proceedure for IV insulin

Answer 33

Stop 30 mins after usual diabetes treatment begins and patient can eat and drink Check CBGs after 1 hr and 4x in next 24 hrs - rebound hyperglycaemia