Insulin and Hypoglycaemics and Endocrine Flashcards
as a rule, all insulin is given via what route?
s/c
except for sliding scales using short-acting insulin - Actrapid® or NovoRapid® - given by IV infusion
what kind of insulin is Novomix 30®
a combination of short and medium acting insulin
what is first line Tx for T1DM?
standard-release metformin
(gradually ↑ dose over several weeks to minimize the risk of adverse effects - GI)
if intolerable, consider modified-release metformin
monitor renal function before and during treatment with metformin
CIs and cautions for metformin?
At risk of LACTIC ACIDOSIS:
- DKA
- eGFR <30 (standard) , <45 (modified)
- acute dehydration, fasting, infection, shock (renal function)
- HF, resp failure, recent MI, shock (tissue hypoxia)
- hepatic insufficiency, alcohol intoxication/addiction
ELECTIVE SURGERY:
- discontinue 48 hrs before if GA, spinal, or peridural anaesthesia
- Tx restarted >48 hrs following surgery/ resumption oral nutrition + if normal renal function
CAUTION:
- CKD
- elderly people (↑ risk of lactic acidosis)
max daily dose of metformin?
2g
if metformin not tolerated/CI?
sulfonylurea (GLICLAZIDE)
OR
- gliptin (dipeptidyl peptidase-4 inhibitor)
- pioglitazone
- Na+-glucose cotransporter 2 inhibitors (SGLT-2i)
2nd line Tx for T2DM?
metformin/gliclazide + gliptin/pioglitazone
3rd line Tx for T2DM?
met + glicla + gliptin/pioglitazone
consider insulin therapy
if 3rd line unaffective, consider adding in glucagon-like peptide-1 (GLP-1) mimetic
if creatinine is >150, what drug to use as 2st line in T2DM?
gliclazide
beware metformin if renal impairment, or overweight
sulfonylurea S/Es?
↑ weight
hypos
avoid in renal or liver impairment
(BNF says also common: abdo pain, D, N)
RARE: SIADH BM suppression (↓↓↓all bc) liver damage (cholestatic) peripheral neuropathy
what time of day to take gliclazide?
mornings (to avoid overnight hypos)
define a hypo?
< 4 mmol/litre
how to Tx a hypo if patient is conscious?
oral glucose 10-20g
how to Tx a hypo if patient is unconscious?
- 75ml glucose 20% IV (15 g) for an unconscious patient in hospital
- or 50ml (10g)
- or 100ml (20g bc 20%)
(also IM glucagon, but not ideal for patients who are anticoagulated + IV is more readily available)
- if glucagon ineffective after 10 mins give 20% glucose IV
diagnosing a DKA? (3)
VBG pH < 7.3
glucose > 11
serum ketones >3, urine 2+
Tx DKA?
- BP<90 500ml NaCl STAT
- BP>90 1 litre in 1 hr, then in 2/4/8
- K+ ↓ with Tx, therefore add 40mmol per litre if <5.5: measure at 60 minutes, 2 hours, and 2 hourly
- IV insulin mixed with NaCl to 1 unit/mL, given at fixed rate of 0.1 units/kg/hour (eg 50 units in 50ml)
- established S/C long-acting insulin (detemir or glargine) should be continued during Tx*
monitor:
- BM - aim ↓ 3mmol/L/h, when <14 start 10% glucose
- ketones - aim ↓ 0.5 mmol/L/h
- pH - aim >7.3
Continue insulin infusion until ketones< 0.3, pH >7.3, able to eat and drink, S/C fast-acting insulin and a meal, and stop infusion 1hr later.