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Management of GI and Endocrine Conditions > Lecture 19 - Pharmacy care in Diabetes & Thyroid Disorders > Flashcards

Lecture 19 - Pharmacy care in Diabetes & Thyroid Disorders Flashcards

1
Q

What is clinical management for?

A

To alleviate acute symptoms and prevent or limit the morbidity and mortality and its long term conditions

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2
Q

What drugs sensitise the body to insulin?

A

metformin and thiazolidinediones

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3
Q

What drugs stimulate the pancreas to produce more insulin?

A

sulphonylureas

meglitinides

GLP-1 agonists

DPP4 inhibitors

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4
Q

What drugs limit reabsorption of glucose from the kidneys?

A

SGLT2 inhibitors

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5
Q

In general, what do you start treatment of type 2 diabetes with?

A

one agent unless the patient is very symptomatic

if not well controlled then you might add in another agent

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6
Q

When do you stop an agent?

A

only when you reach triple therapy or are adding an injectable

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7
Q

In which case would you stop/change an agent?

A

if the patient is intolerant or there is no change in HbA1c in 6 months

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8
Q

How many diabetic medicines in a patient usually on?

A

Max is 3

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9
Q

Why do we gradually increase the dose of metformin?

A

to minimise the risk of GI side effects e.g. nausea, loss of appetite and diarrhoea

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10
Q

How is the dose of metformin increased?

A

weekly by 500mg

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11
Q

When should metformin be taken?

A

with food

e.g. a dose with breakfast and a dose with dinner

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12
Q

What is metformin cautioned in?

A

renal impairment

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13
Q

What is the creatinine clearance cut off point for someone being on metformin?

A

30ml/min

any lower and there is a risk of the drug accumulating and precipitating lactic acidosis

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14
Q

Common side effects of metformin?

A

diarrhoea (transient), anorexia and nausea and vomiting

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15
Q

How well does metformin reduce HbA1c?

A

by 1-2%

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16
Q

Advantages of metformin?

A

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

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17
Q

How does metformin affect lipid profile?

A

not classed as a cholesterol lowering agent but can rise HDL and lower LDLs

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18
Q

Effectiveness of sulphonylureas?

A

decreases HbA1c by 1-2%

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19
Q

When are sulphonylureas first line?

A

if the patient is metformin intolerant

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20
Q

Advantages of sulphonylureas?

A

good evidence base and are inexpensive

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21
Q

Disadvantages of sulphonylureas?

A

weight gain and increased risk of hypoglycaemia (1 in 100)

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22
Q

Most popular sulphonylureas?

A

gliclazide followed by glipizide

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23
Q

Duration of action of gliclazide and glipizide?

A

Shorter duration of action than glibenclamide

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24
Q

How often is glibenclamide taken?

A

once daily

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25
Q

How often is gliclazide taken?

A

twice daily

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26
Q

What is the issue with glibenclamide?

A

it has a long duration of action so is more likely to cause hypoglycaemia

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27
Q

Effectiveness of thiazolidinediones?

A

Decreases HbA1c by 1-2%

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28
Q

When are thiazolidinediones useful?

A

as a substitute for metformin in patients with renal failure

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29
Q

Advantages of thiazolidinediones?

A

low risk of hypoglycaemia

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30
Q

Disadvantages of thiazolidinediones?

A

causes weight gain and can cause fluid retention

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31
Q

When are thiazolidinediones contraindicated?

A

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)

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32
Q

When can DPP4 inhibitors be used?

A

in mono, dual or triple therapy

if weight gain is undesirable and we do not want to use sulphonylureas or glitizones

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33
Q

Advantages of DPP4 inhibitors?

A

not associated with weight gain, less incidence of hypoglycaemia than the sulphonylureas

34
Q

Effectiveness of DPP4 inhibitors?

A

reduces HbA1c by ~0.7%

35
Q

What is a disadvantage of DPP4 inhibitors?

A

take time to exert their effect whereas metformin etc tend to work a lot faster

no longterm outcome data

36
Q

When are DPP4 used as an alternative to glitazones?

A

when weight gain is a problem or glitazone contraindicated or poorly tolerated

37
Q

Linagliptin use?

A

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

38
Q

Effectiveness of SGLT2 inhibitors?

A

sodium glucose cotransporter 2 inhibitors

HbA1c decreases 5mmol/mol

39
Q

Advantages of SGLT2 inhibitors?

A

weight loss

BP reduction (promotes glucose excretion)

no hypos

40
Q

Disadvantages of SGLT2 inhibitors?

A

can take time to exert effect (4-6 weeks)

polyuria

genital infections

care with hypocolaemia/loop diuretics (dehydration)

41
Q

Why do SGLT2 inhibitors cause polyuria?

A

they pull glucose into the urine which also pulls water

42
Q

When can SGLT2 inhibitors not be given?

A

if patient is >85 years

if eGFR <45

43
Q

Why would SGLT2 inhibitors not be given to someone who is very symptomatic?

A

they take a long time to exert effects so will not deal with immediate symptoms

44
Q

Advantages of meglitinides?

A

used in mono treatment or with metformin

45
Q

When would meglitinides be used>?

A

in patients who have shown intolerance or have contraindications

46
Q

Disadvantages of meglitinides?

A

weight gain

increased risk of hypoglycaemia (less than SU)

expensive

47
Q

Weekly GLP1 receptor agonists?

A

albigutide (eperzan)

dulaglutide (trulicity)

exanatide MR (bydureon)

48
Q

Daily or twice daily GLP1 receptor agonists?

A

exenatide (byetta)

liraglutide (saxenda and victoza)

lixisenatide (lyxumia)

49
Q

What are GLP1 receptor agonists considered?

A

one of the last lines of treatment before insulin

50
Q

How are GLP1 receptor agonists given?

A

subcutaneously

51
Q

When are GLP1 receptor agonists used?

A

3rd line with metformin and SU or TZD if

BMI>35
HbA1c >58mmol/mol
diagnosis <10 years

OR

BMI>35 and cannot tolerate insulin

52
Q

What type of patients get GLP1 receptor agonists?

A

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

53
Q

Symptoms of hypoglycaemia?

A

blood glucose <4mmol/l

54
Q

Autonomic symptoms of hypoglycaemia?

A

sweaty, hungry, cold, pounding heartbeat, tingling lips

55
Q

Neuroglycopenic symptoms of hypoglycaemia?

A

can lose consciousness, dizzy faint, tired, confused irritability

56
Q

Management of hypoglycaemia?

A

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

57
Q

What happens if a patient has a hypo and they drive?

A

they need to report this to the DVLA and test their glucose levels before they get in the car

58
Q

What factors exclude a patient from being at high CV risk?

A

not overweight, normotensive (no meds), no microalbuminuria, non smoker, no high risk lipid profile, no history or family history of CV disease

59
Q

What happens to diabetic patients that are at high risk of having a stroke or heart attack?

A

they are put on a low intensity statin - simvastatin, atorvastatin, rosuvastatin, pravastatin

60
Q

How often should a patient be monitored for diabetic nephropathy?

A

annually - foot care

61
Q

What is diabetic nephropathy confirmed by?

A

2 out of 3 abnormal ACR tests

ACR>2.5ng.mmol for men, >3.5ng/mmol for women

monitor ACR, serum creatinine and eGFR

62
Q

When should you suspect renal disease rather than nephropathy?

A

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

63
Q

What is given to patients with diabetic nephropathy?

A

ACE inhibitor or ARB

titrate to maximum tolerated dose

target BP <130/80mmHg

64
Q

What is the overall responsibility of the pharmacist when supplying medication?

A

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

65
Q

What should a pharmacist explain?

A

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

66
Q

What are most patients with hypothyroidism on?

A

99.9% of levothyroxine

67
Q

Causes of hypothyroidism?

A

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

68
Q

What strengths dose levothyroxine come in?

A

15mcg, 50mcg, 100mcg

69
Q

What is the other treatment for hypothyroidism?

A

liothyronine

70
Q

What can patients with high/low thyroid levels end up with?

A

impacts on heart including tachycardia

71
Q

When is the best time to take thyroxine tabs?

A

before food as they work better on an empty stomach

72
Q

Treatment for hyperthyroidism?

A

carbimazole and propylthiouracil

73
Q

Why is propranolol sometimes given to patients with hyperthyroidism?

A

to slow heart rate down and prevent thyroid induced palpitations

74
Q

What is the usual dose of carbimazole?

A

5-20mg daily, tend to keep an eye on thyroxine and TSH levels

75
Q

What is carbimazole?

A

a cytotoxic drug so has nasty adverse effects - particularly agranulocytosis

76
Q

What is agranulocytosis?

A

destroying of the white blood cells in the body

can increase patients chance of neutropenic sepsis

77
Q

Signs of agranulocytosis?

A

flu like symptoms e.g. cough, sore throat etc

78
Q

Side effects of hyperthyroid medication?

A

signs of hypothyroidism, rashes with carbimazole

79
Q

Rashes with carbimazole?

A

not a sign of an allergy

can be treated with antihistamines

80
Q

When to refer patients on hyperthyroid treatments?

A

mouth ulcers, bleeding, fever, feeling unwell

81
Q

Counselling for levothyroxine?

A

take 30 mins before breakfast and caffeine containing liquids and other medications

82
Q

Counselling for carbimazole?

A

warn to tell doctor immediately if signs of neutropenia or agranulocytosis appear - sore throat, mouth ulcer, bruising, fever, malaise, non specific illness

Management of GI and Endocrine Conditions (24 decks)

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