Managing Diabetes/Diabetic Drugs

Question 1

What is the first line drug in T2 diabetes?

Answer 1

Metoformin

Question 2

What is the MoA of metoformin?

Answer 2

Decreases hepatic glucose production

Increases insulin sensitivity

Question 3

What diabetic drugs are weight neutral/loss?

What diabetic drugs cause weight gain?

Answer 3

Weight loss/neutral

• metformin
• SGLT2 inhibitors
• Incretin drugs (in part. GLP-1 receptor agonist)

Weight gain

• TZDs (pioglitazone)
• SUs

Question 4

What drug class is associated with hypoglycaemia?

Answer 4

SUs

Question 5

Both incretin drugs and SUs are insulin secretagogues, why do incretin drugs not carry the same risk of hypoglycaemia?

Answer 5

Incretin drugs use the amplifying pathway so are glucose dependant

SUs bind to the SUR1 of the ATP dependant K+ channels - glucose independent

Question 6

What side effect is associated with DPP4 inhibitors?

Answer 6

Pancreatitis

Question 7

How do DPP4 inhibitors work?

Answer 7

They inhibit DPP4 which breakdown GIP and GLP-1 (incretins) so with more of them in blood - amplified insulin secretion

Question 8

Describe the incretin effect.
Where are the incretins released?
How is this affected in T2 diabetes?

Answer 8

Oral consumption of glucose leads to a greater increase of insulin due to incretins produced in the gut that amplify insulin secretion as they bind to their receptors on the pancreatic beta cell

GLP-1 - ileum
GIP - duodenum
(I before L, I released first in intestine)

In T2 diabetes this effect is greatly reduced

Question 9

Match the following drug suffixes/prefixes/ drug names to their drug class

• flozin
• gliptin
• tide
• gliptin
• gli-…-ide

Empagliflozin
semaglutide 
Alogliptin
 gliclazide
Pioglitazone

Answer 9

• flozin (Empagliflozin) - SGLT2 inhibitors (think floz = flow = increase sugar in urine)
• gliptin (Alogliptin) = DPP4 inhibitors (P = dPP4)
• tide (semaglutide) = GLP-1 receptor agonist
• gli-…-ide (gliclazide) = SUs (glide into coma into coma = hypoglycaemia = worrying side effect)

Pioglitazone = TZD (zone = movement of fat from visceral to subcutaneous = move zone)

Question 10

What drug is contradicted in older patients but allowed in young obese female in particular?

Answer 10

Pioglitazone

Question 11

How many times a day should metformin be taken?

Answer 11

BD

Question 12

What is the very common side effect of metformin?

Why is it contradicted in kidney disease?

Answer 12

GI upset

Can cause MALA (metformin assoc. lactic acidosis)
- important to test for eGFR and U&Es as a result

Question 13

How do thiazolidinediones (TZDs) work?
(link to increase weight side effect)

Name the TZD used in the UK?

Answer 13

Bind and activate PRAR-gamma
->
increase subcutaneous fat mass
-> 
decreases visceral fat
->
increase adiponectin
-> 
increase insulin sensitivity

pioglitazone

Question 14

What are the two classes of incretin drugs?

Answer 14

DPP4 inhibitors

GLP-1 receptor agonists

Question 15

What drug is given via 1x weekly injection as opposed to tablets?

Answer 15

Semaglutide

Question 16

How do SGLT2 inhibitors work?

Answer 16

Partially block SGLT2 in kidneys -> increase in blood sugar urine secretion -> decrease in blood glucose and kcals

Question 17

Side effects of SGLT2 inhibitors?

Answer 17

Thrush
Polyuria and thirst
Fournier Gangrene - v rare but buzzword I feel

Question 18

What drugs are protective for the heart post coronary syndrome?

Answer 18

• GLP-1Ra

- SLGT2i

Question 19

What oral drug requires blood glucose monitoring?

Answer 19

SUs due to risk of hypo

Question 20

What should all >50 T2 diabetic patients be started on for CV protection?

Answer 20

Statin

Question 21

If there is proteinuria present on dipstick what does this mean?

Answer 21

Impaired renal function -> changes what drug might decide to use

Question 22

What is the most important factor in diet when encouraging a patient to lose weight?

What specific components of the diet should be reduced/increased?

Answer 22

Maintenance to the diet

Increase fibre
Decrease fat

Question 23

What categories of people should be assessed for their diabetic risk when in clinic using computer scoring methods?

Answer 23

• individuals >40
• ethnic minority groups 25-39
• individuals with conditions that raise risk of T2

Question 24

T1 diabetics can undergo carbohydrate counting to adapt their insulin treatment to best suit them.
What are the 3 steps involved?
What is the name of the education programme which teaches how to do this?

Answer 24

1. Identify carbohydrates (CHO)
2. How much CHO is in each meal?
3. What is my insulin:CHO ratio and apply this

DAFNE = dose adjustment for normal eating

Question 25

Why are low GI diets no longer recommend for T1 diabetics?

Answer 25

There positive effect is so easily impacted by many variables e.g. how the food is cooked, what it is served alongside etc.

Question 26

How are the following monogenic diabetic conditions managed?

• Neonatal
• MODY caused by defect in glucokinase
• MODY caused by defect in HNF-1alpha (transcription factor)

Answer 26

Neonatal - high dose SUs
MODY caused by glucokinase - no treatment at all
MODY caused by HNF-1alpha - low dose SUs

Question 27

How do T1DM use insulin on a daily basis?

Answer 27

Long acting insulin - to maintain basal levels

Short acting insulin - taken 15 mins prior to each meal

Question 28

How often should glucose levels be checked on IV insulin?

Once trasnferred from IV insulin back to SC, how many times should blood glucose be checked in the first 24hrs?

Answer 28

Hourly

4x

Question 29

How is a patient transferred from IV insulin back to SC?

Answer 29

SC must be given at a suitable mealtime and IV is stopped an hour after this

Question 30

When should SUs be taken?

Answer 30

20 mins before meal due to risk of hypo

Question 31

What is the MoA of SUs?

Answer 31

Close K+/ATP channels on beta cells -> continual depolarisation