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Diabetes and Endocrinology > Management of Diabetes - Type 2 > Flashcards

Management of Diabetes - Type 2 Flashcards

1
Q

Aware of the medications used in the treatment of T2 Diabetes.

A

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2
Q

Mechanism of action of these treatments.

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3
Q

Describe the important side effects and adverse drug interactions of medications used to treat Diabetes Mellitus.

A

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4
Q

Understanding of Home blood glucose monitoring and targets HbA1c and glycaemic control.

A

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5
Q

Appreciate SIGN guidance 116 and choice of therapies.

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6
Q

Demonstrate an awareness of new drug developments in Diabetes Mellitus.

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7
Q

Risk stratification for patients with T2 Diabetes.

A

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8
Q

Aware of patient education resources.

A

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9
Q

Discuss the natural progression of diabetes and the importance of patient centred care.

A

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10
Q

What type of support should a diabetic patient receive?

A
  • Blood glucose levels checked
  • Blood pressure checked
  • Blood lipids checked

Annual checks;

  • Eye screened
  • Feet checked
  • Kidney function monitored

Social;

  • Education course
  • Emotional and psychological support
  • Weight
  • Smoking cessation support
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11
Q

What are the aims of diabetes treatment?

A
  • Relief of primary symptoms
  • Prevention of complications
  • Preservation of QoL
  • Damage minimalisation
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12
Q

Why does increasing insulin release help treat T2DM?

A

Pancreas: beta cell dysfunction + diminished incretin effect –> decreased insulin production

Thus, increasing insulin release counteracts this.

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13
Q

What medications increase insulin release?

A
  • Sulphonylureas
  • Metiglinides
  • Incretin Mimetics
  • DPPIV inhibitors
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14
Q

What medications increase excretion of glucose?

A

SGLT2 inhibitors

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15
Q

Why does improving insulin action help treat T2DM?

A

Pancreas: excess glucagon –> decreased insulin action –> increase blood glucose levels

Periphery: insulin resistance –> decreased insulin action –> increase blood glucose levels

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16
Q

What medications improve insulin action?

A
  • Biguanides
  • Thiazolidiones

AND Weight reduction

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17
Q

Name the modifiable risk factors of T2DM.

A
  • Smoking
  • Dietary change
  • Physical activity
  • Blood pressure
  • Statins
  • Mood
18
Q

Describe the 5 step framework for choosing a glucose-lowering drug.

A
  1. Set a target HbA1c.
  2. Are there other risk factors that should be treated first?
    - Are the current treatments optimised?
    - Max dose?
    - Tolerated?
    - Taken?
  3. What are the glucose lowering options?
    - Remove any that are contraindicated.
    - List pros and cons.
    - Select the preferred choice.
  4. Agree a review date and the target HbA1c with the patient.
19
Q

In what cases should the target HbA1c levels be relaxed?

A
  • People who are older or frail

For adults with type2 diabetes:

  • With reduced life expectancy
  • High risk of the consequences of hypoglycaemia (increased risk of falling, impaired awareness of hypoglycaemia, people who drive or operate machinery as part of their job)
  • Intensive management not appropriate (multiple comorbidities)
20
Q

What is the first line medication for T2DM and why?

A

Metformin.

  • Improves outcomes
  • Well-tolerated
  • Cheap

(- Can be used in pregnancy
- Not associated with weight gain)

21
Q

Metformin;

  • What type of drug is it?
  • What is its mechanism of action?
  • What is its half-life?
A
  • Biguanide

Improves insulin sensitivity;

  • Affects glucose production
  • Decreases fatty acid synthesis
  • Improves receptor function
  • Inhibits gluconeogenic pathways
  • Half-life: 6 hours
22
Q

What are the side effects of metformin?

A
  • GI side effects (20-30%)

Risk of lactic acidosis (inhibits lactic acid uptake by liver);

  • Hypoxia
  • Renal failure
  • Hepatic failure
  • Alcohol abuse
  • Vitamin B12 malabsorption
23
Q

What are sulfonylureas? And how are they named?

A
  • Second line medication for T2DM

- The “Gli…ides” – Glimepiride, Gliclazide, Glipizide

24
Q

What is the mechanism of action of sulfonylureas?

A

Increase insulin release (by the pancreas).

  • Binds to sulfonylurea receptors (SUR-1) on functioning pancreatic beta-cells
  • Which closes the linked ATP-sensitive K+ channels
  • Decreased K+ influx –> depolarisation of the beta-cell membrane
  • Voltage-dependent Ca2+ channels open and result in an influx of Ca+
  • Translocation and exocytosis of secretory granules of insulin to the cell surface
25
Q

What are the advantages of sulfonylureas?

A
  • Can be used with metformin
  • Rapid improvement in control/if symptomatic
  • Cheap
  • Generally well-tolerated
26
Q

What are the side effects of sulfonylureas?

A
  • HYPOGLYCAEMIA
  • Weight gain
  • Caution in renal and hepatic disease
  • NOT in pregnancy and breastfeeding
  • Hypersensitivity and photosensitivity reactions
  • Blood disorders
27
Q

What are thiazolinediones? And how are they named?

A
  • Second line medication for T2DM

- The “…..glitazones” - Pioglitazone

28
Q

What is the mechanism of action of thiazolinediones?

A

Improve insulin sensitivity (in the liver and muscles).

  • Selectively stimulates the PPAR-gamma
  • Modulates the transcription ofinsulin-sensitive genes involved in the control of glucose andlipid metabolism(inmuscle,adipose tissue, liver)
    THUS
  • Reduces insulin resistancein the liver and peripheral tissues
  • Increases the expense of insulin-dependent glucose
  • Decreases withdrawal of glucose from the liver
  • Reduces quantity of glucose, insulin andglycated haemoglobinin the bloodstream
29
Q

What are the side effects of thiazolinediones?

A
  • Increase risk of bladder cancer
  • Fluid retention (HF)
  • Weight gain

Fractures in females;

  • Small increased risk
  • Affects bone turnover
  • Reduced bone mineral density (BMD)
30
Q

What are DPPIV-inhibitors? And how are they named?

A
  • Second/third line medication for T2DM

- The …Gliptins - Saxagliptin, Sitagliptin, Vildagliptin

31
Q

What is the mechanism of action of DPPIV-inhibitors?

A
  • Mimic incretins (gut hormones that increase insulin and decrease glucagon)
  • Delay the breakdown of incretin and thereby increase incretin levels
32
Q

What are the side effects of DPPIV-inhibitors?

A
  • Relatively small effects on glycemic control
  • NOT in pregnancy and breastfeeding
  • Possible increased risk of pancreatitis and pancreatic cancer
  • Nausea
33
Q

What are GLP-1 analogues? And how are they named?

A
  • Third/fourth line medication for T2DM
  • Mimic incretins like DPPIV-inhibitors
  • The …Tides - Exenatide, Liraglutide, Lixisenatide
34
Q

What are the advantages of GLP-1 analogues?

A
  • Resistant to enzymatic degradation

- Greatly prolonged biological half-life

35
Q

What are the NICEE and SIGN guidelines on GLP-1 analogues?

A

NICE;

  • BMI >35
  • Stop after 6/12 unless HbA1C down 1% AND Weight down 3%

SIGN;

  • Third line agent
  • BMI >30
  • Use in combo with oral agents and/or basal insulin (usually as third or fourth line)
  • Stop after 3-6/12 unless HbA1C >5mmol/mol fall or individual target reached
36
Q

What are the side effects of GLP-1 analogues?

A
  • Injection
  • Very expensive
  • Possible increased risk of pancreatitis and pancreatic cancer
  • NOT in pregnancy and breastfeeding
  • Nausea, vomiting

(Similar to DDPIV-inhibitors.)

37
Q

What are SGLT-1 inhibitors? And how are they named?

A
  • Second/third line medication for T2DM
  • The …Gliflozins -
    Canagliflozin, Dapagliflozin, Empagliflozin
38
Q

What is the mechanism of action of SGLT-1 inhibitors?

A
  • Selectively inhibits SGLT-2 in proximal renal tubule
  • Stops reabsorption of glucose
  • Thus, increases glucose excretion
39
Q

What are the effects of SGLT-1 inhibitors on the body?

A
  • Excretion of glucose –> lowers HbA1c
  • Wastes glucose –> lose weight
  • Less reuptake of Na –> lowers systolic BP
  • Osmotic diuresis (excretion of water) –> postural hypotension, dehydration
  • Greater risk of urogenital infection e.g. cystitis, candiasis
40
Q

What are the disadvantages of SGLT-1 inhibitors?

A
  • Expensive
  • UTI, fungal infections, osmotic symptoms
  • Risk of digital amputation
  • Risk of DKA
  • NOT in pregnancy and breastfeeding
  • NOT in renal impairment

Diabetes and Endocrinology (26 decks)

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