Management of type 2 diabetes

Question 1

what is the first line treatment for diabetes? (drug class and name)

Answer 1

biguanides -= Mteformin

Question 2

when is sulphonylureas used for the treatment of type 2?

Answer 2

second line treatment if asymptomatic

first line treatment if symptomatic

Question 3

name an example of a sulphonylurea drug.

Answer 3

glimerpride
gluclazide
glipizide

Question 4

what are the side effects of metformin?

Answer 4

risk of lactic acidosis by inhibiting lactic acid uptake by the liver; hypoxia, renal failure, hepatic failure, alcohol abuse
GI side effects
risk of vitamin B12 deficiency

Question 5

how does metformin improve insulin sensitivity?

Answer 5

improves insulin receptor function
improved glucose transport
reduce fatty acid synthesis

Question 6

how does sulphonylureas work to decrease blood glucose?

Answer 6

bind to sulphonylure receptors in the pancreatic beta cells
they close K channels therefore causing depolarisation of the cell
this causes Ca influx = exocytosis of insulin

Question 7

what are the side effects of sulphonylureas?

Answer 7

hypersensitivity
photosensitivity
blood disorders

Question 8

what are the disadvantages of sulphonylureas?

Answer 8

risk of hypoglycaemia
weight gain
can cause renal and hepatic disease
Cl in pregnancy and breast feeding

Question 9

name a thiazolidinedione drug.

Answer 9

giltazone

Question 10

what are the disadvantages of thiazolidinediones?

Answer 10

risk of bladder cancer
fluid retension
weight gain
fractures in females

Question 11

what drugs used in the treatment of type 2 diabetes cause weight gain?

Answer 11

sulphonylureas i.e. Glimepride

thiazolidineodiones i.e. Giltazone

Question 12

what is a condraindication for metformin?

Answer 12

eGFR < 30

Question 13

why would you choose giltazone instead of sulphonylueas as a second line treatment ?

Answer 13

if hypo’s are a concern

Question 14

what are the defects in type 2 diabetes?

Answer 14

beta cell dysfunction
diminished incretin effect (stimulates insulin production & glucose uptake)
excess glucagon
insulin resistance

Question 15

what medication improves insulin action and which increases insulin release?

Answer 15

sulphonylureas increase insulin release

metformin & giltazone improve insulin action

Question 16

what are the aims of treatment in diabetes?

Answer 16

relief of primary symptoms
prevention of complications
preservation of quality of life
damage minimisation

Question 17

what effects do giltazone’s have?

Answer 17

modulates the transcription of insulin sensitive genes which play a role in regulating BG -
decreases glucose removal from the liver
reduces insulin resistance in liver and other tissues
decreases HbA1c, BG and insulin in the blood

Question 18

What drugs used for the treatment of type 2 diabetes cause weight loss?

Answer 18

SGLT-2 inhibitors

GLP-1 analogues

Question 19

What drugs used for the treatment of type 2 diabetes have nausea as a side effect?

Answer 19

DPP-4 inhibitors

GLP-1 analogues

Question 20

What insulin is used for the treatment of type 2 diabetes?

Answer 20

Humalin I or H insulatard

Question 21

How do DPPIV- inhibitors work?

Answer 21

They blocks the DPP-4 enzyme which causes the degradation of incretin hormones
Therefore DPP4 prolongs incretin effects =
Increased release of insulin from B cells, decreased release of glucagon from A cells (thus decreased releases of glucose form the liver)

Question 22

What are the disadvantages of DPPIV-inhibitors?

Answer 22

Increased risk of pancreatitis and pancreatic cancer
Relatively small effect on glycaemic control
Contraindicated in pregnancy and breast feeding

Question 23

Name examples of DPPIV-inhibitors.

Answer 23

Gliptins i.e. saxagliptin, sitagliptin, vildagliptin

Question 24

Name examples of GLP-1 analogues.

Answer 24

Lixisenatide
Liraglutide
Exenatide

Question 25

How does GLP-1 analogues work?

Answer 25

GLP-1 is an incretin hormone which is resistant to degradation
Therefore synthetic injection of GLP-1 analogues will prolong incretin effect

Question 26

What are the disadvantages of GLP-1 analogues?

Answer 26

Expensive
Injections
Risk of pancreatitis and pancreatic cancer
Contraindicated in pregnancy and breast feeding

Question 27

What are the side effects of GLP-1 analogues?

Answer 27

Nausea and vomiting

Question 28

What a re the incretin mimetic drugs?

Answer 28

GLP-1 analogues

DPPIV-inhibitors

Question 29

Name examples of SGLT2-inhibitors.

Answer 29

Gliflozins i.e. canagliflozins, explagliflozin

Question 30

How does SGLT2 inhibitors work?

Answer 30

They inhibit the SGLT2 which is involved in the reabsorption of glucose from the renal proximal tubule
This increases the excretion of glucose in the urine

Question 31

What are the disadvantages of SGLT2 inhibitors?

Answer 31

Postural hypotension 
Increased risk of digital amputation
Risk of DKA
Cannot be used in renal impairment
Contraindicated in pregnancy and breast feeding

Question 32

What are the side effects of SGLT2 inhibitors?

Answer 32

UTI’s
Fungal infections
Osmotic symptoms

Question 33

What are the advantages of SGLT-2 inhibitors?

Answer 33

Weight loss
No risk of hypoglycaemia
Beneficial effect on CV morbidity and mortality
Good effect on glycaemic control

Question 34

What drugs used to treat type 2 diabetes cannot be used in renal impairement and what are the cut offs for treatment in such cases?

Answer 34

Metformin - stop if eGFR <30
GLP-1 analogues - avoid if eGFR <30
SGLT2 inhibitors - only start if eGFR > 60 but stop if falls below 45

Question 35

When would you reduce a patients target HbA1c?

Answer 35

Frail or older patients
Intensive management isn’t possible 
Type 2 with:
- reduced life expectancy
- high risk of complications with hypo i.e no warning signs, operate machinery’s, risk of falling

Question 36

how does SGLT 2 inhibitors help reduce CV morbidity and mortality?

Answer 36

reduces systolic blood pressure due to excretion of Na due less re-uptake