Lecture 19 - Pharmacy care in Diabetes & Thyroid Disorders Flashcards
What is clinical management for?
To alleviate acute symptoms and prevent or limit the morbidity and mortality and its long term conditions
What drugs sensitise the body to insulin?
metformin and thiazolidinediones
What drugs stimulate the pancreas to produce more insulin?
sulphonylureas
meglitinides
GLP-1 agonists
DPP4 inhibitors
What drugs limit reabsorption of glucose from the kidneys?
SGLT2 inhibitors
In general, what do you start treatment of type 2 diabetes with?
one agent unless the patient is very symptomatic
if not well controlled then you might add in another agent
When do you stop an agent?
only when you reach triple therapy or are adding an injectable
In which case would you stop/change an agent?
if the patient is intolerant or there is no change in HbA1c in 6 months
How many diabetic medicines in a patient usually on?
Max is 3
Why do we gradually increase the dose of metformin?
to minimise the risk of GI side effects e.g. nausea, loss of appetite and diarrhoea
How is the dose of metformin increased?
weekly by 500mg
When should metformin be taken?
with food
e.g. a dose with breakfast and a dose with dinner
What is metformin cautioned in?
renal impairment
What is the creatinine clearance cut off point for someone being on metformin?
30ml/min
any lower and there is a risk of the drug accumulating and precipitating lactic acidosis
Common side effects of metformin?
diarrhoea (transient), anorexia and nausea and vomiting
How well does metformin reduce HbA1c?
by 1-2%
Advantages of metformin?
no weight gain or hypoglycaemia when given alone
beneficial effects on lipid profile
no blood glucose monitoring (maybe once or twice a week)
good evidence base, isn’t expensive
How does metformin affect lipid profile?
not classed as a cholesterol lowering agent but can rise HDL and lower LDLs
Effectiveness of sulphonylureas?
decreases HbA1c by 1-2%
When are sulphonylureas first line?
if the patient is metformin intolerant
Advantages of sulphonylureas?
good evidence base and are inexpensive
Disadvantages of sulphonylureas?
weight gain and increased risk of hypoglycaemia (1 in 100)
Most popular sulphonylureas?
gliclazide followed by glipizide
Duration of action of gliclazide and glipizide?
Shorter duration of action than glibenclamide
How often is glibenclamide taken?
once daily
How often is gliclazide taken?
twice daily
What is the issue with glibenclamide?
it has a long duration of action so is more likely to cause hypoglycaemia
Effectiveness of thiazolidinediones?
Decreases HbA1c by 1-2%
When are thiazolidinediones useful?
as a substitute for metformin in patients with renal failure
Advantages of thiazolidinediones?
low risk of hypoglycaemia
Disadvantages of thiazolidinediones?
causes weight gain and can cause fluid retention
When are thiazolidinediones contraindicated?
in patients with
heart failure (can exacerbate this)
fractures (could be due to parathyroid gland affecting calcium levels)
haematuria (due to increased amount of glucose going through and irritating the bladder)
When can DPP4 inhibitors be used?
in mono, dual or triple therapy
if weight gain is undesirable and we do not want to use sulphonylureas or glitizones
Advantages of DPP4 inhibitors?
not associated with weight gain, less incidence of hypoglycaemia than the sulphonylureas
Effectiveness of DPP4 inhibitors?
reduces HbA1c by ~0.7%
What is a disadvantage of DPP4 inhibitors?
take time to exert their effect whereas metformin etc tend to work a lot faster
no longterm outcome data
When are DPP4 used as an alternative to glitazones?
when weight gain is a problem or glitazone contraindicated or poorly tolerated
Linagliptin use?
in patient who has got diabetic kidney disease because this is extremely well tolerated in renal impairment because it is almost exclusively handled by the liver
Effectiveness of SGLT2 inhibitors?
sodium glucose cotransporter 2 inhibitors
HbA1c decreases 5mmol/mol
Advantages of SGLT2 inhibitors?
weight loss
BP reduction (promotes glucose excretion)
no hypos
Disadvantages of SGLT2 inhibitors?
can take time to exert effect (4-6 weeks)
polyuria
genital infections
care with hypocolaemia/loop diuretics (dehydration)
Why do SGLT2 inhibitors cause polyuria?
they pull glucose into the urine which also pulls water
When can SGLT2 inhibitors not be given?
if patient is >85 years
if eGFR <45
Why would SGLT2 inhibitors not be given to someone who is very symptomatic?
they take a long time to exert effects so will not deal with immediate symptoms
Advantages of meglitinides?
used in mono treatment or with metformin
When would meglitinides be used>?
in patients who have shown intolerance or have contraindications
Disadvantages of meglitinides?
weight gain
increased risk of hypoglycaemia (less than SU)
expensive
Weekly GLP1 receptor agonists?
albigutide (eperzan)
dulaglutide (trulicity)
exanatide MR (bydureon)
Daily or twice daily GLP1 receptor agonists?
exenatide (byetta)
liraglutide (saxenda and victoza)
lixisenatide (lyxumia)
What are GLP1 receptor agonists considered?
one of the last lines of treatment before insulin
How are GLP1 receptor agonists given?
subcutaneously
When are GLP1 receptor agonists used?
3rd line with metformin and SU or TZD if
BMI>35
HbA1c >58mmol/mol
diagnosis <10 years
OR
BMI>35 and cannot tolerate insulin
What type of patients get GLP1 receptor agonists?
high risk patients who are very overweight and cannot use drugs that cause weight gain
patients with poor hyperglycaemic control over a long period of time
patients that might be considered for insulin at this time but cannot tolerate it
Symptoms of hypoglycaemia?
blood glucose <4mmol/l
Autonomic symptoms of hypoglycaemia?
sweaty, hungry, cold, pounding heartbeat, tingling lips
Neuroglycopenic symptoms of hypoglycaemia?
can lose consciousness, dizzy faint, tired, confused irritability
Management of hypoglycaemia?
eat or drink something immediately containing sugar, followed up by a longer acting carbohydrate (sandwich, fruit etc), eat normal meal as soon as possible
should feel better after 5-10mins
What happens if a patient has a hypo and they drive?
they need to report this to the DVLA and test their glucose levels before they get in the car
What factors exclude a patient from being at high CV risk?
not overweight, normotensive (no meds), no microalbuminuria, non smoker, no high risk lipid profile, no history or family history of CV disease
What happens to diabetic patients that are at high risk of having a stroke or heart attack?
they are put on a low intensity statin - simvastatin, atorvastatin, rosuvastatin, pravastatin
How often should a patient be monitored for diabetic nephropathy?
annually - foot care
What is diabetic nephropathy confirmed by?
2 out of 3 abnormal ACR tests
ACR>2.5ng.mmol for men, >3.5ng/mmol for women
monitor ACR, serum creatinine and eGFR
When should you suspect renal disease rather than nephropathy?
if there is no retinopathy
BP particularly high or resistant to treatment
heavy proteinuria when previously normal
sig haematuria
GFR worsened rapidly
person is systemically ill
What is given to patients with diabetic nephropathy?
ACE inhibitor or ARB
titrate to maximum tolerated dose
target BP <130/80mmHg
What is the overall responsibility of the pharmacist when supplying medication?
to ensure that the patient is able to take the prescribed medication in a safe and effective manner to ensure that the patient derives maximum treatment benefit
What should a pharmacist explain?
how to take medication (metformin with food etc)
additional cautions - see cautionary labels
what side effects to look out for (PIL)
heath checks - flu jab, eyes, feet
glucagon injections for hypoglycaemia
What are most patients with hypothyroidism on?
99.9% of levothyroxine
Causes of hypothyroidism?
autoimmune disease causing the thyroid to be destroyed, patient has hyperthyroidism and gets radiotherapy which means thyroid levels drop and we need to replace them manually
What strengths dose levothyroxine come in?
15mcg, 50mcg, 100mcg
What is the other treatment for hypothyroidism?
liothyronine
What can patients with high/low thyroid levels end up with?
impacts on heart including tachycardia
When is the best time to take thyroxine tabs?
before food as they work better on an empty stomach
Treatment for hyperthyroidism?
carbimazole and propylthiouracil
Why is propranolol sometimes given to patients with hyperthyroidism?
to slow heart rate down and prevent thyroid induced palpitations
What is the usual dose of carbimazole?
5-20mg daily, tend to keep an eye on thyroxine and TSH levels
What is carbimazole?
a cytotoxic drug so has nasty adverse effects - particularly agranulocytosis
What is agranulocytosis?
destroying of the white blood cells in the body
can increase patients chance of neutropenic sepsis
Signs of agranulocytosis?
flu like symptoms e.g. cough, sore throat etc
Side effects of hyperthyroid medication?
signs of hypothyroidism, rashes with carbimazole
Rashes with carbimazole?
not a sign of an allergy
can be treated with antihistamines
When to refer patients on hyperthyroid treatments?
mouth ulcers, bleeding, fever, feeling unwell
Counselling for levothyroxine?
take 30 mins before breakfast and caffeine containing liquids and other medications
Counselling for carbimazole?
warn to tell doctor immediately if signs of neutropenia or agranulocytosis appear - sore throat, mouth ulcer, bruising, fever, malaise, non specific illness
