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RED - Clinical and Pharmacy Practice > Prescribing Issues in Diabetes > Flashcards

Prescribing Issues in Diabetes Flashcards

1
Q

How is DM classed?

A
  • Type 1; pancreas not producing enough insulin (often none) - autoimmune
  • Type 2; cells are not responding the the insulin that is produced often presenting later in life, and progressing to complete loss of β-cell function
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2
Q

How is DM characterised?

A

Hyperglycaemia (high blood glucose)

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3
Q

What are the aims for the therapetutic managment of diabetes?

A
  • Control symptoms of hyperglycaemia
  • Prevent diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS)
  • Prevent both long-term microvascular and macrovascular complications
  • Enable patients to maintain a close to normal lifestyle
  • Establish medication concordance with patient (importance of using/adhering to medication)
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4
Q

When is insulin therapy considered for T2DM?

A

When HbA1c levels remain above 59 mmol/mL (7.5%) despite other interventions (diet/lifestyle/metformin/SHs etc.)

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5
Q

What is the aim of insulin therapy?

A

To try and mimic normal physiological insulin release from the pancreas.

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6
Q

Why has human insulin replaced porcine/bovine?

A

Higher chance of hypersensitivity with animal-derived insulin.

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7
Q

What is the brand name for insulin aspart and what type of insulin does it belong to?

A
  • Novorapid

- Rapid-acting

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8
Q

What is the onset, peak and duration of action of rapid-acting insulin?

A

Onset: 10 - 20 minutes
Peak: 30 - 180 minutes
Duration: 2 - 5 hours

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9
Q

What are the generic names for Humalog and Apidra and what type of insulin are they?

A
  • Humalog; insulin lispro

- Apidra; insulin glulisine

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10
Q

What is the onset, peak and duration of action of short-acting insulin?

A

Onset: 30 - 90 minutes
Peak: 2 - 4 hours
Duration: 6 - 8 hours

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11
Q

Give two examples of short-acting insulin (brand names) and their one corresponding generic name.

A
  • Actrapid
  • Humulin S

Human sequence soluble insulin

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12
Q

What is the onset, peak and duration of action of intermediate-acting insulin?

A

Onset: 30 - 90 minutes
Peak: 6 - 8 hours
Duration: 11 - 24 hours (mostly 24)

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13
Q

Give two examples of intermediate-acting insulin (brand names) and their one corresponding generic name.

A
  • Insulatard
  • Humulin I

Human sequence isophane insulin

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14
Q

What is the onset, peak and duration of action of long-acting insulin?

A

Onset: 1 -2 hours
Peak: No peak
Duration: 20 - 26 hours

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15
Q

What are 3 examples of long-acting insulins and their brand names?

A 
Insulin glargine (Lantus)
Insulin detemir (Levemir)
Insulin degludec (Tresiba)
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16
Q

What is biphasic insulin and its advantage?

A
  • Insulin pen/vial with a mixture of rapid or short-acting insulin and an intermediate-acting insulin.
  • Reduces number of injections required
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17
Q

What is the onset, peak and duration of action of biphasic insulin?

A

Onset: 10 - 90 minutes
Peak: 2 - 4 hours
Duration: 11 - 24 hours

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18
Q

Name some biphasic insulins and their corresponding brand name.

A
  • Biphasic insulin aspart (Novomix 30)
  • Biphasic insulin lispro (Humalog Mix25, Humalog Mix50)
  • Biphasic isophane insulin (Humulin M3, Insuman Comb)
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19
Q

What does the basal-bolus insulin regimen entail?

A
  • Basal; OD injection of long-acting insulin (e.g. insulin detemir) for background level of insulin
  • Bolus; TDS injection of short-acting insulin (e.g. soluble insulin) giving big spike that lasts a few hours to tackle big blood glucose spikes at breakfast/lunch/dinner
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20
Q

What is a common regimen for young patients diagnosed with T1DM?

A
  • Basal-bolus

- Gives good control of blood glucose

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21
Q

What are the advantages and disadvantages of the basal-bolus regimen?

A

+ Best at mimicking normal physiological insulin release (best control)
- Most complex (4 injections required a day)

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22
Q

What does the twice-daily insulin regimen of short and intermediate acting insulins entail?

A
  • Short and intermediate-acting insulins (e.g. insulin aspart + isophane insulin)
  • One of each given at breakfast and dinner; intermediate giving background level
23
Q

What are the advantages and disadvantages of the twice-daily regime w/short + intermediate acting insulins?

A

+ BD not QDS

  • But still two injections each time
  • Poor insulin cover at lunchtime spike (only background intermediate insulin available)
24
Q

How does the twice daily regimen of bi-phasic insulin differ from the twice daily of short and intermediate-acting insulin and what are its advantages?

A
  • Same insulin cover

+ Only one injection each time at breakfast and dinner instead of two

25
When is the OD regime of insulin used and why?
- In T2DM ONLY - Basal level of long-acting insulin e.g. insulin determir - Patient probably supplementing breakfast/lunch/dinner peaks w/oral antidiabetic e.g. metformin
26
Why should patients rotate areas for SC injection insulin?
To prevent lipohypertrophy and lipoatrophy (hardening/soreness)
27
Where is suitable for SC injection of insulin?
- Lower abdomen - Upper outer thighs - Buttocks - Upper outer arm
28
What devices are available for insulin SC and why is it important to check as a pharmacist?
- Vials - Cartridges - Disposable pens - Innolet device (fancy pen) - Continuous subcutaneous insulin infusion (CSII); device giving continuous insulin maintaining blood glucose within tight range Show patient if unsure which device is used.
29
What is variable rate insulin infusion (VRII)?
- Consists of continuous intravenous (IV) insulin infusion (via cannula) and constant glucose infusion - Allows for very tight/close control
30
When is VRII used?
- In DM patients that are nil by mouth (NBM) for a sustained period e.g. going for surgery, or have uncontrolled hyperglycaemia - In critical care; tight glucose control beneficial for critically ill (better outcomes/recovery) - Fixed-rate infusion given for patients admitted with DKA or HHS - If patient is hyperglycaemic following an MI (studies shown better recovery w/tightly controlled glucose)
31
What must VRII treatment be given with/cautions are there?
- Blood glucose monitoring essential (every one or two hours); too much insulin = seizures/comas - Adjust insulin infusion according to blood glucose - Insulin closes ATP-dependent K+ channels; K+ retained in cells therefore hypokalemia risk = give K+ fluids as well as glucose (K+ monitored once or twice daily)
32
What does a variable rate insulin infusion scale entail?
- Blood glucose measured upon submission to ward - Refernce to a column/scale (e.g. Scale 2) describes how much insulin to infuse an hour for particular blood glucose measurement - Reducing insulin infusion to lower units - Want to be off IV insulin ASAP
33
Where are areas that errors can potentially occur with VRII?
- IV Glucose co-infusions; unless patient is very hyperglycaemic, glucose IV should always be prescribed - Monitoring; glucose levels to be monitored every 1-2 hours and hourly if unstable (avoid hypoglycaemia) - Labelling of insulin synringes; knowing the rate, mls and hour etc. - Discontinuation of insulin and recommencement of usual hypoglycaemic medicines; IV insulin to be stopped 30-60 minutes after restarting usual SC insulin and/or anti-diabetics - Long-acting insulin SC to be continued whilst patient is on VRII giving background level and to prevent rebound hyperglycaemia (blood glucose shooting back up) when infusion stopped (but stop biphasic/short acting SC insulin w/IV)
34
How is VRII given in DKA?
- Fixed rate insulin | - Vary fluid rate
35
What would a pharmacist check on a sliding scale insulin prescription (VRII)?
- Insulin appropriately made up and labelled - If suitable concomitant fluid is prescribed (glucose/K+) - Blood sugar levels; in range? If not is insulin rate being altered as per scale/protocol? - Can the sliding scale insulin be stopped? (switch back to SC?)
36
What factors should the doctor be considering when reviewing the patient's normal insulin regime?
- Patient preference - Lifestyle - Eating patterns (e.g. extra injection at lunch if on BD?) - Insulin device used - Ability to self-monitor (issue w/eldery who have dementia etc.) - Risk or previous history of hypoglycaemia (seizure/coma risk) - Knowledge of conditions and awareness of complications
37
How is sliding scale insulin stopped in a patient normally on rapid-acting + intermediate-acting SC?
- Give the SC insulin (Humalog) w/meal e.g. breakfast or lunch (can't monitor patient at night as closely) and stop IV insulin 30-60 minutes after meal (gives time for SC insulin absorption) - Humulin I (intermediate) to give that night as doesn't need to be given with food; doesn't really have peak/24 hrs - Don't stop IV insulin at night; patient can be monitored for hypoglycaemia during the day when stopping with breakfast/lunch
38
What does metformin do?
- Biguanide - Decreases gluconeogenesis - Increases peripheral utilisation of glucose
39
What are the advantages of using metformin?
- Gold-standard - Lower incidence of weight gain - Unlikely to cause hypoglycaemia (elderly patients at risk; not as aware of symptoms of dizziness etc, can lead to falls from loss of consciousness)
40
What are the main side effects of metformin and how can they be avoided?
- GI disturbances (bloating/abdominal pain/diarrhoea); avoid by stepping up gradually/consider trial of MR preparation if GI tolerability an issue - Lactic acidosis (rare); caution in renal impairment, or if tissue hypoxia likely (e.g recent MI) - Taken w/meals to tackle peaks in glucose
41
What do sulphonylureas do and when can they considered 1st line?
- Stimulates insulin secretion - Consider for first line if patient: > not overweight (causes weight gain) > metformin not tolerated/contraindicated (poor renal function etc) > rapid therapeutic response required because of hyperglycaemic symptoms (can bring down blood glucose quickly)
42
What are the risks/side effects of sulphonylureas?
- Risk of hypoglycaemia; use short-acting preparations e.g. gliclazide (main one) especially in renal impairment/elderly - short acting less likely to build-up and cause hypo - Weight gain - Choose lowest cost/shortest acting
43
What are the notable adverse effects of acarbose and the main counselling point?
- Flatulence (but decreases over time) | - Tablets should be chewed with 1st mouthful of food or swallowed whole with a little liquid immediately before food
44
What are the notable adverse effects of pioglitazone and the main counselling point?
- Increased risk of bladder cancer, heart faiure and bone fractures - May cause weight gain - Monitor liver function
45
What are the notable adverse effects of DPP-4 inhibitors/gliptins and the main counselling point?
- GI upset - Peripheral oedema - May enhance risk of hypoglycaemia when given with sulphonylureas
46
What are the notable adverse effects of SGLT-2 inhibitors e.g. dapagliflozin and the main counselling point?
- Polyuria - Dysuria - Contra-indicated in renal impairment, CrCl
47
How do target blood glucose levels compare between T1DM adults/children and T2DM?
- Most lax for T1DM children - Then T1DM adults - But T2DM v. tightly controlled
48
How often are HbA1c levels measured in DM?
- Monitor 2-6 monthly until stable on unchanging therapy | - Then monitor 6-monthly once blood glucose level and therapy stable.
49
What are HbA1c target for DM patients?
48 - 59 mmol/mol (6.5 - 7.5%)
50
Why is the sulphonylurea gliclazide appropriate for an elderly lady already on metformin?
- 80mg OD; lower dose for elderly - Lowest cost - Short-acthing sulphonylurea appropriate due to increased risk of hypoglycaemia
51
How can metformin MR relieve abdominal pain from metformin 1g BD?
Released more gradually into GI tract = more tolerable?
52
Should short-acting insulin be given at night without food?
No; only long-acting to provide basal level, short-acting should always be given with food.
53
What interventions should be made if a DM patient was hypertensive?
- Start on hypertensives to reduce CVD risk; 130/90 mmHg target for DM - Start on statin to reduce CVD risk (even on normal cholesterol level); can have anti-inflammatory effect - Antiplatelet therapy e.g. low-dose aspirin

RED - Clinical and Pharmacy Practice (3 decks)

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