Pharmacological Management of Diabetes Flashcards
Why are glucose and insulin curves higher in the morning/before breakfast?
Following an overnight fast, the liver is actively producing more glucose from gluconeogenesis and glycogenolysis. The consumption of breakfast will reverse the situation and more insulin will be secreted to suppress gluconeogenesis
What is the difference between bolus insulin and basal insulin?
Bolus insulin is often fast acting and is used to regulate blood glucose after eating while basal insulin is used to mediate blood glucose levels between meals and during sleep
Basal insulin can be injected at the same time as bolus insulin
Premixed insulin is best recommended for which type of diabetic patients?
Older patients who do not wish to monitor their blood glucose levels or may not be well educated on CHO counting
Human premixed insulin tries to cover as many peaks as possible and typically cover two meals and a half throughout the day - may still be at risk of hyperglycemia
What is the difference between conventional and intensive insulin regimens?
Conventional regimen may be pre-mixed insulin or a fixed insulin plan
Typically insulin injections daily (1-3 times per day) and meals must be consistent from day to day
Strict meal plan: CHO content, meals should not be skipped
Physical activity may lead to hypoglycemia
Intensive regimen is recommended for better glycemic control
Multiple injections a day >3 or continuous subcutaneous insulin infusion
Describe the process of adopting an intensive insulin therapy and who would it be recommended for?
Intensive insulin therapy will use basal insulin and bolus insulin before meals to closely mimic physiology , this allows for more flexibility in timing and content of meals
Patients must learn to count carbs
SMBG is frequent
Intensive therapy can delay the onset and slows down the progression of complications, it is highly recommended for patients who are willing to learn
What are the four ways of insulin delivery?
Syringe, insulin pen (comes with disposable needles), insulin pump, continuous glucose sensor (can pump low levels of basal insulin throughout the day) patients must calculate CHO content and adjust the amount of insulin injected
Which type of DM is metformin used for and what is the mechanism of action?
It is the recommended initial drug treatment for T2DM
It works by decreasing gluconeogenesis which will decrease glucose production and increase insulin sensitivity to enhance glucose uptake
May affect GI and cause B12 deficiency but the risks are much lower than the benefits
List the two incretin mimetics and describe the function of mechanism
DPP-4 inhibitors and GLP-1 receptor agonists
Incretin mimetics stimulates insulin and reduces glucagon secretion, it also delays gastric emptying which will all help to lower blood glucose
GLP-1 can help increase satiety to help control weight
Describe the algorithm of T2DM diagnosis and interventions
Once T2DM is diagnosed, begin lifestyle intervention (diet, physical activity, smoking cessation) +/- metformin
If A1C <8.5%, if glycemic target is not reached after 2-3 months (<7%) then start or increase metformin
If A1C >8.5%, start metformin immediately and consider combination with another antihyperglycemic agent
If patient has symptomatic hyperglycemia with metabolic decompensation then insulin should be given with or without metformin
Glycemic targets still not met then add another agent best suited for the individual depending on the patients characteristics
What is the risk of using insulin secretagogue?
While it can lower A1C value, there is a risk of hypoglycemia in patients and it is likely to cause weight gain
Which antihyperglycemic drug will cause weight gain?
Insulin, Thiazolidinediones, Sulfonylureas, Meglitinides
What are some drug-nutrient interactions patients should be aware of?
Metformin may reduce folate and B12 absorption, should be taken with meals to reduce the potential risks
Alpha-glucosidase inhibitors should be taken with meals, it works by decreasing absorption of glucose
Insulin secretagogues should not be taken with alcohol, poses a risk for hypoglycemia
Incretin mimetics may have GI side effects including heartburn, belching, nausea, diarrhea and patients should be cautious with alcohol consumption
Thiazolidinediones do not have known drug-nutrient interaction
How does SGLT2 inhibitors work?
It blocks glucose transport in the proximal renal tubule leading to glycosuria which lowers blood glucose and body weight
When taken with metformin there is better efficacy on lowering A1C than other antihyperglycemic agents
It can lower blood pressure and raise HDL
Side effects may include UTI, hypotension, diabetic ketoacidosis and it may elevate LDL (CVD risk still needs to be evaluated)
What are the commercial names, onset, peak and duration of bolus insulin?
Name: Humalog or Hulimin-R
Onset: 10 - 15 mins (humalog), 30 mins (humulin)
Peak: 1 - 3 hrs
Duration: 3-5 hr (humalog), 6.4hr (humulin)
What are the commercial names, onset, peak and duration of basal insulin?
Name: Humulin-N, Lantus (glargine)
Onset: 1 - 3 hr (humulin), 90min (glargine)
Peak: 5 -8hr (humulin), no peak for glargine
Duration: 10 - 18hr (humulin), 20 - 24hr (glargine)
