Management of type 2 DM - part 2 Flashcards
What is the incretin effect?
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
When would DPPIV inhibitors be used as a second line agent?
when weight gain or hypos were a concern
Brief mechanism of action of DPPIV inhibitors
increase insulin release
What are the 2 incretin hormones called?
GLP-1 and GIP
Effects of incretin hormones (2)
increase insulin production from beta cells to increase peripheral glucose uptake
decrease glucagon from alpha cells to reduce hepatic gluconeogenesis
What enzyme rapidly degrades the incretin hormones?
DPP4
How do DPPIV inhibitors work?
inhibit the DPP4 enzyme which breaks down the incretin hormones
Increases active incretin levels
Advantages of DPPIV inhibitors
weight neutral no risk of hypos well tolerated 2nd or 3rd line agent used in renal impairment
Disadvantages of DPPIV inhibitors
Small effects on glycaemic control
increase risk of pancreatitis/pancreatic cancer
CI in pregnancy and breastfeeding
SE: nausea
How are GLP-1 analogues administered?
third line agent - subcutaneous injection
When are GLP-1 analogues used and why?
BMI>30 and less than 10 years since diagnosis
very expensive
How do GLP-1 analogues work?
GLP-1 but resistant to enzymatic degredation
prolonged biological half life
Why do GLP-1 analogues lead to weight gain?
feel full so lose weight and nauseas
Advantages of GLP-1 analogues
lose weight
no risk of hypos
3rd line agent
used with basal insulin
Disadvantages of GLP-1 analogues
injection very expensive increase risk of pancreatitis/pancreatic cancer CI pregnancy and breastfeeding SE: nauseas and vomiting
When are SGLT-2 inhibitors used as 2nd line agent?
if weight gain or hypos are a concern
What do SGLT-2 inhibitors do to glucose?
increase its excretion
How do SGLT-2 inhibitors work?
selectively inhibit SGLT2 which usually absorbs the majority of glucose in the renal proximal tubule
5 SGLT-2 inhibitor effects on :-
a) HbA1c
b) water
c) calories
d) systolic bp
e) UTI
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
Advantages of SGLT2 inhibitors
weight loss no risk of hypos beneficial on CVS 2nd or 3rd line can add to insulin regimens
Disadvantages of SGLT2 inhibitors
CI: pregnancy/breastfeeding and renal failure
expensive
SE: UTI, osmotic symptoms, fungal infection
risk of digital amputation
risk of DKA
Why would insulin be added on to a type 2 DM medications?
rising HbA1c
osmotic symptoms
Regimen of isophane insulin
1 injection daily before bed
prevent hyperglycaemia in the night
Take 5
bp lipids diet smoking exercise
