Revise Pharma Diabetes Flashcards
what are the different causes of all types diabetes?
- deficient insulin secretion (T1)
- resistance of the action of inuslin (T2)
- medication (steroids)
- gestational
- pancreatic impairment
do all diabetic patients need to alert the DVLA?
only those on insulin
what are drivers assessed on in terms of driving?
the awareness of hypoglycaemia
so the capability of the bringing their vehicle to a safe controlled stop
how many groups of drivers are there?
give examples
2
group 1 = normal car drivers
group 2 = lorrys etc
what are the group 1 driver requirements? (what do they need to be able to do and how many hypo episodes)
- adeqaute awareness of hypoglycaemia
- no more than 1 episode of severe hypoglycaemia whilse awakw in the preceeding 12 months
what are the group 2 driver requirements? (what do they need to be able to do and how many hypo episodes. glucose monitoring? visual compliactions?)
- full awareness of hypoglycaemia
- no episodes of hypoglycaemia
- must report all episodes of hypoglycaemia including those in sleep
- must use blood glucose monitor with suffiecient memory to store 3 months of readings
- any visual complications must notify DVLA and don’t drive
what is the advice from the DVLA to diabetics? (5 things)
- drivers treated with insulin should always carry a glucose meter and blood glucose strips
- check blood glucose conc no more than 2 hours before driving and every 2 hours while driving
- blood glucose should always be above 5mmol/l while driving
- if falls below 5 take a snack
- ensure supply of fast acting carbohydrate in vehicle
what level should glucose be whilst driving?
5mmol/l
what blood glucose level is considered hypo whilst driving?
<4mmol/l
what should drivers do if they have hypo?
- safety stop
- switch off engine, remove keys from ignition, move from drivers seat
- eat/drink sugar source
- wait 45mins after blood glucose has returned to normal
what should driver do if hypoglycaemia awareness has been lost?
inform DVLA and do not drive
what is T1DM characterised by?
insulin deficiency - destroyed beta cells in islets of langerhan - most common before adulthood
what are the typical features of T1DM?
- rapid weight loss
- fam hx of autoimmune disease
- hyperglycaemai >11mmol
- ketosis
- BMI <25kg/m2
how many times a day do t1DM need to monitor?
QDS - before each meal and before bed
whats the glucose target on waking?
5 - 7mmol/l
what is the glucose target level before eating?
4 - 7 mmol/l
whats the glucose target after eating?
5 - 9mmol/l
whats the 1st line insulin regimen for T1DM?
basal bolus = long/intermediate OD/BD
then short/rapid before meals
whats the first and second line choices of insulin in basal bolus?
1st line = detimer
2nd = glargine
in what 3 situations do insulin requirements increase?
infection
stress
trauma
when do you need to reduce insulin requirements?
physical activity
intercurrent illness
reduced food intake
impaired renal function
endocrine disorders
why does insulin need to be given SC?
would be inactivated by GI enzymes as is a protein
what areas of the body are best to inject insulin?
areas with plenty of SC fat
what areas of the body has the fastest insulin absorption? where is slower?
fastest = abdomen
slower = outer thigh, buttocks
why do you need to rotate injection site?
what are the risks of this?
risk of lipohypertrophy due to injecting in same area = leads to erratic absorpion of insulin
what are the 2 subtypes of short acting insulins?
soluble and rapid acting
what is soluble insulin?
- human + bovine/ porcine
how long before meals do you need to inject souble insulin?
whats the onset?
how long does soluble insulin work for?
15 - 30mins
onset = 30 - 60 mins
works for up to 9 hours
name 3 rapid acting insulins?
NO LAGing
lispro, aspart, glulisine
when do you inject rapid acting?
whats the onset?
whats the duration?
immediately before meal
onset - 15 mins
duration 2 - 5 hrs
what HbA1c is considered prediabetic?
42 - 47 mmol/l
what HbA1c is considered diabetic?
> 48mmol/l
what targets are T2DM now given?
an indivudually agreed threshold agreed by Dr
whats section 1 to the pathway for T2DM (low CVD risk)?
- assess HbA1c, kidney function and CV risk
treat with metformin
whats section 2 to the pathway for T2DM (low CVD risk)?
- if HbA1c still not controlled then add in DDP4i, sulfonylurea, SGLT2i or pioglitazone
whats section 3 to the pathway for T2DM (low CVD risk)?
- triple therapy if HbA1c still uncontrolled by adding/swaping class of antidiabetic
what factors mean someone with T2DM is high risk?
established atherosclerotic disease, heart failre, QRISK >10%
whats the treatment pathway for someone with T2DM and CV risk?
- treat with metformin
- once metformon tolerated add SGLT2i
what drug do you treat T2DM with if a patient with high CV risk doesn’t tolerate metformin/mr metformin?
SGLT2i alone
whats the 1st thing to do if a pt cant tolerate merformin SE?
switch to mr
what do you do if a pt os resisitant to all metformin preperations?
DDP4i, sulphonyurea, pioglitazome
SGLT2i if high CV risk
what are the 3 main SE with metformin?
lactic acidosis
GI effects
B12 deficiency
what eGFR should you avoid metformin in and why?
30ml/min due to lactic acidosis risk
when do you need to hold metformin?
when acutely unwell due to AKI risk
name the 2 short acting sulphonylureas
gliclazide
tolbutamide
name 2 long acting sulphonylureas
glibeclamide
glimpride
why should you avoid long acting sulphonylureas in the elderly?
associated with prolonged and sometimes fatal hypoglycaemia
what are 3 side effects of sulphonylureas?
- high risk of hypoglycaemia
- need to avoid prescribing in acute porphyria
- avoid in hepatic and renal impairment
in patients with heart failure, what antidiabetic should you avoid?
piogliazone
what antidiabetic should you avoid in patients with bladder cancer/hx of bladder cancer?
pioglitazone
what antidiabetic should you avoid in pts with high risk of bone fractures?
pioglitazone - increases risk of bone fractures
as piogliazone increases risk of bladder cancer, what monitoirng should be in place?
- review safety and efficacy after 3 - 6 months
- stop treatment if pt doesn’t have much benefit
- report signs of haematuria, urinary urgency
does pioglitazone cause renal or liver toxicity?
liver toxicity
what do DDP4i end in? name some
gliptin
alogoliptin
linagliptin
saxagliptin
sitagliptin
vildagliptin
what is the main risk with DDP4i?
what are the symptoms?
what should you do to the medicine?
pancreatitis
signs - persistnet abdo pain
discontinue
what DDP4i can cause heptaotoxicity?
new one - vildagliptin
what are the 4 MHRA warnings with SGLT2i?
- severe DKA risk
- need to monitor ketones if treatment interrupted for surgical prodcedure or illness
- fourniers gangrene
- risk of lower limb amputation (canglifozin only)
what 3 SGLT2i require renal funciton monitoirng?
canaglifozin, dapaglifozin, empaglifozin
what should you do if a patient is volume depleted and needs to start SGLT2i?
correct hypovolaemia before starting
NB makes pt wee a lot
whats the MHRA warning with GLP-1 agonists?
DKA risk - especially when sed with insulin and insulin dose reduced rapidly
along with DDP4i, what other class of antidiabetic drug can cause acute pancreatitis?
GLP1 agonists
why is there a risk of dehydration with GLP1 agonists?
due to GI side effects - need to avoid fluid depletion
if someone if being treated with meglitides (nateglinide, repaglinide) what should you do in stress expousre?
treat interruption and replacement with insulin to maintain glycaemic control
what antibiabetics cause weight gain?
pioglitazone, sulphonylureas
what antidiabetics are weight neutural?
DDP4i
what antidiabetics cause weight loss?
metformin, glp 1 agonists, sglt2i
what patients need a low dose statin?
all type 1
offerred to age 40+, diabetic for 10+ years, nephropathy or other CVD risk factors
what antihypertensive is given to diabetics?
ACEi
when do you add an ACEi/ARB for nephropathy?
what are the risks associated with it?
when its causing proteinuria
can potentiate the signs of hypoglycaemia
what cuases diabetic foot?
diabetic neuropathy
what are the 5 parts to diabetic neuropathy?
- painfu peripheral neuropathy
- autonomic neuropathy (diarohea)
- neuropathy postural hypotension
- gustatory sweating
- erectile dysfunction
how often to diabetics need eye checks ?
annually
what is DKA characetrised by?
severe hypoerglycaemia
what are the symptoms of DKA?
pear drop breath
polyuria
thirsty
confusion
lethargy
deep/fast breathing
confusion
what ketone level means pt at increased risk of DKA? what should you do?
1.6 - 2.0
refer to gp
what ketone level means medical emergency?
3.0
what drugs are used to treat DKA?
NaCl
insulin
glucose
at what time point do you stop DKA treatment?
1 hour after food
how long do you continue insulin to treat DKA? (what does the ketone level and pH need to be?)
<0.3
pH 7.3
what do you need to do to insulin for elective surgery, minor procedure and good glycaemic control?
day before: reduce OD long acting by 20%
rest as usual
what do you do to insulin for major surgery or poor glycaemic control?
day before = reduce OD long acting by 20%, rest as normal
on day: reduce OD long acting by 20%, stop other insulin until pt eating
- IV infusion of glucose
- variabe rat einsulin
- hourly blood glucose for 12 hrs
what should you do in major surgery in glucose dips under 6mmol/l?
give IV glucose 20%
what are the SICK day rules?
sugar levels - blood glucose should be checked regularly
Insulin - carry on taking it
Carbohydrates - keep eating and hydrated
Ketones - measre regularly
what HbA1c level should pateints with diabetes who want to get pregnant aim for?
<48mmol/l
what dose folic acid is given to pregnant diabetics?
5mg
whats the insulin of choice in pregnancy?
isophane
can antidiabetic drugs be continued during pregnancy?
only metformin
pts should be switched to insulin unless taking metformin
do you continue antidiabetic treatment after birth in gestational diabetes?
no
how do you manage gestational diabetes when fasting BG <7mmol/l?
diet ans exercise for 2/52, if requirements not met then start metformin
how should you manage gestatinal diabetes in fasting BG >7mmol/l ?
diet and exercise + insulin and/or metformin
