Management of type 2 DM - part 2

Question 1

What is the incretin effect?

Answer 1

oral glucose causes a larger release of insulin in comparison to IV glucose
The gut hormones are stimulated after eating and this effect is diminished in type 2 DM

Question 2

When would DPPIV inhibitors be used as a second line agent?

Answer 2

when weight gain or hypos were a concern

Question 3

Brief mechanism of action of DPPIV inhibitors

Answer 3

increase insulin release

Question 4

What are the 2 incretin hormones called?

Answer 4

GLP-1 and GIP

Question 5

Effects of incretin hormones (2)

Answer 5

increase insulin production from beta cells to increase peripheral glucose uptake
decrease glucagon from alpha cells to reduce hepatic gluconeogenesis

Question 6

What enzyme rapidly degrades the incretin hormones?

Answer 6

DPP4

Question 7

How do DPPIV inhibitors work?

Answer 7

inhibit the DPP4 enzyme which breaks down the incretin hormones
Increases active incretin levels

Question 8

Advantages of DPPIV inhibitors

Answer 8

weight neutral 
no risk of hypos 
well tolerated 
2nd or 3rd line agent 
used in renal impairment

Question 9

Disadvantages of DPPIV inhibitors

Answer 9

Small effects on glycaemic control
increase risk of pancreatitis/pancreatic cancer
CI in pregnancy and breastfeeding
SE: nausea

Question 10

How are GLP-1 analogues administered?

Answer 10

third line agent - subcutaneous injection

Question 11

When are GLP-1 analogues used and why?

Answer 11

BMI>30 and less than 10 years since diagnosis

very expensive

Question 12

How do GLP-1 analogues work?

Answer 12

GLP-1 but resistant to enzymatic degredation

prolonged biological half life

Question 13

Why do GLP-1 analogues lead to weight gain?

Answer 13

feel full so lose weight and nauseas

Question 14

Advantages of GLP-1 analogues

Answer 14

lose weight
no risk of hypos
3rd line agent
used with basal insulin

Question 15

Disadvantages of GLP-1 analogues

Answer 15

injection 
very expensive 
increase risk of pancreatitis/pancreatic cancer 
CI pregnancy and breastfeeding 
SE: nauseas and vomiting

Question 16

When are SGLT-2 inhibitors used as 2nd line agent?

Answer 16

if weight gain or hypos are a concern

Question 17

What do SGLT-2 inhibitors do to glucose?

Answer 17

increase its excretion

Question 18

How do SGLT-2 inhibitors work?

Answer 18

selectively inhibit SGLT2 which usually absorbs the majority of glucose in the renal proximal tubule

Question 19

5 SGLT-2 inhibitor effects on :-

a) HbA1c
b) water
c) calories
d) systolic bp
e) UTI

Answer 19

a) excrete glucose and lower HbA1c
b) lose water - osmotic symptoms eg postural hypotension and dehydration
c) lose calories/glucose and lose weight
d) lose sodium - lower systolic bp
e) increased risk of cystitis/candidiasis

Question 20

Advantages of SGLT2 inhibitors

Answer 20

weight loss 
no risk of hypos 
beneficial on CVS 
2nd or 3rd line 
can add to insulin regimens

Question 21

Disadvantages of SGLT2 inhibitors

Answer 21

CI: pregnancy/breastfeeding and renal failure
expensive
SE: UTI, osmotic symptoms, fungal infection
risk of digital amputation
risk of DKA

Question 22

Why would insulin be added on to a type 2 DM medications?

Answer 22

rising HbA1c

osmotic symptoms

Question 23

Regimen of isophane insulin

Answer 23

1 injection daily before bed

prevent hyperglycaemia in the night

Question 24

Take 5

Answer 24

bp
lipids
diet 
smoking 
exercise