New Diabetic Drugs

Question 1

How do you manage hyperglycaemia?

Answer 1

1. Diet and Exercise
2. Biguanides (metformin)
3. Sulphonylureas (gliclazide)
4. Insulin sensitisers (thiazolidinediones)
5. Insulin
6. Incretins (GLP-1 analogues)
7. Gliptins (DPP4 inhibitors)
   (8. SGLT-2 Ant.)

Question 2

How do we prescribe insulin?

Answer 2

1. Long acting insulin for background cover (Glargine/ Determir, not variable in plasma over 24 h) OD
2. Short acting insulin before meals (Lispro/ Aspart- analogues which dont hexamer under skin)

Question 3

What are Lispro, Aspart, Determir and Glargine?

Answer 3

Lispro- Proline/ Lysine switched
Aspart- Proline/ Aspart switched
Determir- 14 C fatty acid chain causing 7h delayed onset
Glargine- Asn to Gly

Question 4

What are the advantages of insulin?

Answer 4

• Can give best control of HbA1c when combined with diet and exercise.
• No side effects compared to:
  metformin (diarrhoea)
  SU (occasional reactions)
  thiazolidinediones (rare hepatic, ?osteoporosis)

Question 5

What are the disadvantages of insulin?

Answer 5

If you drive HGV, cannot work
(exenatide exempt)

Hypoglycaemia common with good control

Weight gain

Increased insulin as a consequence

Huge doses required

Question 6

Why does insulin cause weight gain?

Answer 6

• Stops loss of glucose in urine
• Increased appetite
• General well being
• Set point of body weight
• Poor control may cause weight loss

Question 7

What is GLP-1?

Answer 7

• Hormone secreted from the gut post prandially
• Decreases appetite and gastric emptying
• Increases hypothalamic satiety

Question 8

What drug is a GLP-1 agonist with a longer half life?

Answer 8

Exenatide - a synthetic version of the Gila monster venom exendin 4

Question 9

What are all the GLP-1 analogues?

Answer 9

Exanatide
Liraglutide
Semaglutide

Question 10

Which transporter reabsorbs glucose?

Answer 10

SGLT-2

Question 11

What are the common side effects of SGLT-2 inhibitors like canagliflozin?

Answer 11

• Hypoglycaemia
• Vulvovaginal candidiasis
• Constipation, thirst, nausea
• Polyuria
• UTI
• Balanitis
• Dyslipidaemia
• Increased Hct

Question 12

How long od SGLT-2 inhibitors take to prevent death?

Answer 12

6 months

Question 13

Why are SGLT-2 antagonists better?

Answer 13

• Improved cardiac risks

- Improved kidney risks

Question 14

How should we act if we cannot give metformin?

Answer 14

• non insulin monotherapy plus secon oral agent/ GLP1R agonist/ basal insulin
• Long standing poorly controlled T2DM and established CVS disease we should use and SGLT2 inhibitor or GLP1 antagonist