Management of Diabetes Flashcards
How many amino acids are in insulin?
51
What 3 glucose homeostasis process occur in the body?
Glycogenesis: glucose –> glycogen
Glyconeogenesis: protein –> glucose
Glycogenolysis: glycogen –> glucose
What type of stress hormones can induce more glucose to be released/produced?
- Glucagon
- Adrenaline
- Glucocorticoids
- Growth hormone
What processes does insulin prevent from occuring?
- Gluconeogenesis
- Lipolysis
- Ketogenesis
- Glycogenolysis
What processes does insulin promote?
- Glucose uptake in muscles/adipose
- Glycolysis (respiration)
- Glycogenesis (glycogen formation)
- Uptake of ions (K+)
What should normal blood sugar levels be?
4-5.6mmol/L
What is the main difference between type 1 & type 2 diabetes?
Type 1: insulin dependent (genetics)
Type 2: non-insulin dependent (or insulin independent) (obesity/drug related)
What are the main features of someone diagnosed with type 1 diabetes?
- <50 years old
- Family history of it
- BMI <25kg/m^2
- Features like: hyperglycaemia, ketosis, rapid weight loss
At what age is type 2 diabetes most common in?
40-80 years old.
Why are diabetics more prone to candida infections?
Because they are excreting lots of sugar in their urine which is the appropriate environment for bacterial growth to occur.
What causes polyurea, thirst & weight loss in diabetes?
- Polyurea: osmotic diuresis, where too much glucose in the blood has to be excreted
- Thirst: loss of electrolytes/fluid
- Weight loss: fluid depletion/break down of muscle/fat due to insulin deficiency
What are the 3 investigations for diabetes?
- Fasting glucose test
- Random glucose test on 2 separate occasions
- OGTT - oral glucose tolerance test
How can the risk of CV events be lowered in diabetic patients?
Using an ACEi and a lipid regulating drug (Atorvastatin)
ACEi improves heart function + nephroprotective
How often should diabetics regularly get their bloods checked and what is specifically measured?
They should have a blood test every 3 months.
Their HbA1c is measured which is the % of haemoglobin that has sugar on it.
Since RBCs have a 3 month life span, this is why blood tests are done 3 months apart.
Why cant insulin be taken by mouth? Which route is it given it?
Because it includes amino acids which will be digested by the stomach.
Insulin is hence given by subcutaneous injection.
In which circumstances is insulin the 1st line treatment for?
- Type 1 diabetics
- Type 2 diabetics in which other methods have failed
- Temporarily during surgery
- In pregnant women, where everything else has failed
Which 2 type of insulin preparation are used for a basal-bolus regimen?
Basal: long-acting
Bolus: short acting
What are some examples of rapid acting human insulin analogues?
When are they taken?
- Insulin aspart - NovoRapid
- Insulin lispro - Humalog
- Insulin glulisine - Apidra
- They are taken shortly before/after a meal
What are some examples of intermediate insulins?
When are they taken?
Isophane insulin - Humulin I, or Insulatard
They are taken twice a day for stable basal levels.
What are some examples of longer acting insulins?
When are they taken?
- Insulin glargine - Lantus, or Toujeo
- Insulin detemir - Levemir
They are taken the same time once a day
What are some examples of biphasic insulins (mixed)?
- NovoMix 30
- Humalog Mix 25 or Mix 50
- Humulin M3
What are some examples of insulin regimens?
- Basal-bolus
- Short acting (or rapid) mixed with intermediate acting
- Intermediate OD or BD
- Continuous infusion - from a pump
- Long acting on its own - for type 2 diabetics
Which patients would benefit from a CSII (continuous subcutaneous insulin infusion) pump?
- Those with type 1 suffering from multiple hypos
- Those with multiple injecting regimens
- Those with a HbA1c >8.5%
- Those where their injecting regimens is considered impractical/inappropriate
Which drug is mainly given to patients with a BMI >27kg/m^2?
DPP4 inhibitors (linagliptin, sitagliptin)
What do diabetic patients monitor themselves at home?
- Blood glucose levels using a finger-prick blood sample
2. Urine testing for ketones
What ratio is measured nowadays which monitors for diabetic nephropathy?
Albumin/creatinine ratio (ACR)
What should HbA1c levels normally be?
<48mmol/mol (6.5%)
What is the HbA1C target for type 2 diabetics?
53 mmol/mol (7%)
What factors must be done/checked before a diabetic can drive?
- Must take regular breaks
- Bring treats if hypo occurs
- If reading is >5mmol/L, then it is ok to drive
- Regularly check blood sugar levels
- If reading is <4mmol/L, treat hypo & wait 45mins before you drive
What type of diet do you encourage for type 2 diabetics in order to lose weight?
High fibre, low glycaemic index sources of food e.g. fruit, vegetables, whole grains & pulses. Include low-fat dairy products & oily fish.
What type of diet reduces major CV events?
Mediterranean diet
When should oral anti-diabetic drugs be given?
When the patient fails to respond to diet/exercise for at least 3 months
What are the main oral anti-diabetic class of drugs?
- Biguanides - metformin
- Sulphonylureas - gliclazide, glipizide
- DPP4 inhibitors - linagliptin, sitagliptin (ending in -gliptin)
- Thiazolidinediones - pioglitazone
- SGLT-2 (sodium-glucose cotransporter 2) inhibitors - dapagliflozin (ending in -flozin)
- GLP-1 AGONIST (liraglutide, exenatide)
___________________________
DONT MEMORISE THESE, and never pick them in an MCQ question
- Alpha-glucosidase inhibitors - acarbose (not very used)
- Post prandial regulators - nateglinide, repaglinide
What is the mode of action of biguanides (e.g. metformin)?
They decrease gluconeogenesis & increase glucose uptake by muscles.
What is the dosing for metformin?
500mg OD for 7 days, then BD for 7 days, then TDS thereafter.
Dose is titrated to minimise side effects
What advantageous side effect can metformin cause in overweight patients?
It can aid in weight loss (careful not to let it cause anorexia)
What organ function should be good when using metformin?
Kidney function, since lactate can build up & cause lactic acidosis.
How do sulphonylureas (e.g. gliclazide, glipizide) work?
They stimulate insulin secretion by blocking K+ channels in B cells.
What 2 side effects can occur when using sulfonylureas?
- Further weight gain - so avoid using in overweight patients
- Hypoglycaemia
Can sulfonylureas be used in patients with renal or hepatic impairment?
No.
How do thiazolidinediones (e.g. pioglitazone) work?
They enhance receptor sensitivity, reducing insulin resistance & lowering blood sugar levels.
What conditions should you NEVER give pioglitazone with?
- Heart failure/history of HF - pioglitazone can increase this & cause oedema/weight gain
- Hepatic impairment - pioglitazone can cause liver toxicity
- Diabetic ketoacidosis
- History or current bladder cancer - risk can increase when using pioglitazone
How do DPP4 inhibitors (e.g. sitagliptin, linagliptin) work?
They delay GLP-1 deactivation (by inhibiting DPP4 enzyme), so insulin secretion increases after meals.
Glucagon secretion is also reduced.
How do GLP-1 agonists (e.g. liraglutide, exenatide) work?
They promote insulin release via incretins in the stomach, and decrease glucagon release.
What effects of GLP-1 agonists can patients benefit from?
- Delayed gastric emptying - most commonly used to help with weight loss
- CV protection - this is why it is used for high risk CV patients
- Available as modified release (and oral)
How do SGLT-2 inhibitors (e.g. dapagliflozin) work?
They inhibit renal reabsorption of glucose, so it is urinated out.
What condition is a patient taking dapagliflozin more at risk of?
Candida infections (e.g. thrush), because high levels of glucose are being passed in urine making it an ideal location for bacterial growth.
Can SGLT-2 inhibitors be used in patient with CVD?
Yes because it is a very potent drug which can reduce fluid build up.
It is the recommended option for CV patients.
What specific condition can a patient be at risk of when taking dapagliflozin?
Diabetic ketoacidosis.
This is because insulin secretion is not involved in dapagliflozin’s mode of action. Lipids are metabolised instead, which can cause ketone build up = DKA occurs
What should a patient do if they develop Fournier’s gangrene while taking an SGLT-2 inhibitor?
Seek emergency medical assistance & stop taking the drug.
How are GLP-1 agonists (e.g. siraglutide, liraglutide) administered?
Subcutaneous injection once a week.
What condition can arise if patients are on a GLP-1 agonist & insulin?
Diabetic ketoacidosis.
What is the step-wise management of type 2 diabetic treatment?
- Diet + exercise for 3 months
- If above not worked, metformin given as 1st line
- If above intolerated/additional therapy needed, then give a DPP4 inhibitor (gliptins), or pioglitazone, or sulfonylurea (gliclazide, glipizide)
- If above intolerated, then give SGLT-2 inhibitor (dapagliflozin) only if they cannot have a sulphonylurea, or they are at risk of hypos.
- If triple therapy does not work, start insulin treatment
- Remember do not give pioglitazone in CV patients, or sulfonylureas in overweight patients.
What is the most common dual therapy for type 2 diabetes?
Metformin + a DPP4 inhibitor (gliptins)
When would a GLP-1 agonist be initiated in a type 2 diabetic’s treatment?
If the person is intolerant to their triple therapy, and they have a BMI >35 kg/m^2
They would receive metformin + sulfonylurea + GLP-1 agonist
What is the target blood pressure for a type 1 diabetic?
135/85 mmHg
Why is an ACEi always given as treatment for hypertension in diabetes, regardless of ethnicity?
Because they have more benefits than just controlling blood pressure.
ACEi: Ramipril, others ending in -pril
What is is the step 2 management for a patient with diabetes + hypertension?
ACEi PLUS: either a CCB, or a diuretic
CCB: Amlodipine, diltiazem, others ending in -pine
Diuretic: Indapamide
What physiological response does hypoglycaemia cause?
Suppression of insulin secretion, & an increase in catecholamine secretion.
What are the symptoms of hypoglycaemia?
- Sweating
- Shaking
- Anxiety
- Palpitations
- Weak
- Sudden hunger
- Further cognitive impairment - confusion, poor concentration, coma
Which class of drugs can mask the symptoms of hypoglycaemia?
B-blockers
What is the treatment of hypoglycaemia?
Instant glucose, e.g. a sugary drink or granulated sugar
A carbohydrate/snack is then given
If patient is unconscious, give glucagon gel or injection.
IV glucose given if patient does not respond to glucagon.
How does diabetic ketoacidosis occur?
- Absence of insulin leads to lipolysis (fat broken down into energy)
- Fats get broken down into fatty acids & then ketones
- This causes metabolic acidosis
- This process is accelerated by cortisol, glucagon & catecholamine release
What are the symptoms of DKA?
- Dehydration, dry tongue
- Deep rapid breathing (Kussmaul breathing)
- Ketone breath smell
- Low body temp.
- Abdominal pain
- Sunken eyes, low BP
What blood/urine results do you expect of a person suffering from DKA?
- Blood glucose >20mmol/L
- Urine test for ketones/glucose
- Acidic blood
- Low K+ levels - due to absence of insulin
- Low bicarbonate levels
How is DKA treated?
IV insulin infusion, fluids & K+ infusion
What are the 3 microvascular complications in diabetes?
- Retinopathy
- Neuropathy
- Nephropathy
How is diabetic nephropathy treated?
An ACEi is given, or an angiotensin-II receptor antagonist (even if BP is normal)
- They all end in -sartan
How is diabetic neuropathy managed?
No treatment, only pain relief with: 1, Paracetamol 2. NSAIDs 3. Pregabalin 4. Gabapentin 5. Oxycodone, tramadol
How do diabetic foot infections arise?
Neuropathy in the small vessels in the foot means wound healing is very slow. Small injuries to the foot can result in ulcers/infections in a diabetic.
What is the 1st line antibiotic given for a diabetic foot infection?
Flucloxacillin 500mg-1g QDS 7/7
What alternative antibiotics are given for a diabetic foot infeciton?
- Clarithromycin 500mg BD
- Erythromycin 500mg QDS (in pregnancy)
- Doxycycline 200mg on day 1, then 100mg OD
How is a patients diabetes controlled during surgery (what is given instead of their oral medication)?
IV insulin infusion, K+ infusion, and glucose with KCl
