Session 5 Flashcards
- Have properly revised the hormonal control of blood glucose and diabetic pathology
- Understand the scale of diabetic clinical burden and appreciate the role of diet and weight control in therapy
- Understand the general pharmacology of the major groups of oral hypoglycaemics and differentiate their main side effects with regards therapeutic use
- Understand the use of the main categories of Insulin analogues and how they are used in Type I and II diabetes
- Describe the main treatment steps used in Type II combination therapy
- The crucial role by patient and clinical monitoring in acute and chronic treatment
• Harve properly revised the hormonal control of blood glucose and diabetic pathology
Session 10 MEH
• Understand the use of the main categories of Insulin analogues and how they are used in Type I and II diabetes LO
- 6 Main Insulin Categories
- How are they taken?
- ? of insulin influences rate of absorption
- • Ultrafast acting
- Rapid acting
- Short acting
- Intermediate acting
- Long acting
- Very long acting
- Absorption into blood stream via subcutaneous injection
- Formulation
Give an example of an ultra fast insulin
Aspart (FiAsp)
- Give examples of Rapid Acting insulins
- How to use?
- Onset of action, peak and duration?
- Humalog, Novorapid, Apidra
- Inject just before eating
- • Rapid onset of action 5 to 15 minutes
- Peaks ~ 60 minutes
- Duration 4 to 6 hours
- Give examples of Short acting insulins
- How to use?
- Onset of action, peak and duration?
- Actrapid, Humulin S, Hypurin Bovine and Porcine Neutral
- Need to inject at least 15 to 30 minutes before eating several times daily to cover meals
- Starts to work 30 to 60 minutes
- Peaks at 2 to 3 hours
- Duration 8 to 10hours
- Starts to work 30 to 60 minutes
- Give examples of Intermediate acting insulins
- How to use?
- Onset of action, peak and duration?
- Insulatard, Humulin I and Insuman Basal, Hypurin Bovine and Porcine Isophane
- • Slower onset 2 to 4 hours
- Peaks 4 to 8 hours
- Duration up to 12 to 20 hours
- Give examples of Long and very acting insulin
- How to use?
- Onset of action, peak and duration?
- Glargine, Detemir, Degludec
- Slow onset 2 to 6 hours
- Duration up to 24 hours
- Very long up to 50+ hours (DEGLUDEC insulin)
- Slow onset 2 to 6 hours
• Describe the main treatment steps used in Type II combination therapy LO
Many fixed combinations too: (6)
- Novomix 30
- Humulin M3
- Humalog Mix 25 and 50
- Hypurin Porcine 30/70
- Insuman Comb 15 and 25 and 50
- And modes of delivery using syringes, insulin Pens, insulin pumps
• Understand the use of the main categories of Insulin analogues and how they are used in Type I and II diabetes LO
Insulin pump therapy
• Sensor augmented pump therapy with threshold suspend
Adverse effects of insulin
- Hypoglycaemia
- Hyperglycaemia
- Lipodystrophy – lipohypertrophy or lipoatrophy
- Painful injections
- Insulin allergies
• Understand the general pharmacology of the major groups of oral hypoglycaemics and differentiate their main side effects with regards therapeutic use LO
- Why does blood glucose rise?
- Inability to produce insulin due to beta cell failure and / or
- Insulin production adequate but insulin resistance prevents insulin working effectively
How do we treat Type 2 diabetes?
Lifestyle plus non-insulin therapies
Pharmacological: Biguanides, sulphonylureas, thiazolidinediones, DPP4 inhibitors, α-Glucosidase inhibitors, SGLT2s, GLP1 analogues and Insulin
Non pharmacologic: bariatric surgery & very low calorie diets
• Above require patient education and ability to monitor results of therapy
• Understand the scale of diabetic clinical burden and appreciate the role of diet and weight control in therapy LO
Key challenges for patients with Type 2 diabetes
Weight gain and hypoglycaemia are important factors in patient adherence and quality of life
NICE Targets in Type 2 Diabetes
- In general target for all is HbA1c 6.5 to 7.5%
- HbA1c 6.5%:Diet and first 2 treatment steps
- HbA1c 7.5%:Beyond this or if at risk of severe hypoglycaemia
- Common sense: Limited life expectancy and Co morbid conditions
• Understand the general pharmacology of the major groups of oral hypoglycaemics and differentiate their main side effects with regards therapeutic use LO
- *Metformin**
1. Benefits/mechanism
- ADRs
- Dose range? And cost?
- • DECREASE Insulin resistance leading to increased glucose by tissues
- DECREASE hepatic glucose production (reduces hepatic gluconeogenesis)
- Limits weight gain
- DECREASE CVS events (UKPDS)
- Can be combined with all other diabetes medications
- • GI symptoms
- Lactic acidosis rare
- Vitamin B12 deficiency uncommon
- Stop if CKD < 30ml/min or significant comorbidities
- Dose range typically 500mg to 2.5g (also Modified Release available) and Cost low
Sulphonylureas
- Mechanism
- ADRs
- Cost?
- Give e.g. of commonly used
- • Stimulate beta cell to release insulin
• Extensive experience
DESCREASE Microvascular risk (UKPDS)
- • Weight gain
• Hypoglycaemia
- Cost low
- Commonly used:
Gliclazide (Modified Release too) (hepatic metabolism so can be used in renal impairment)
Glimepiride
Acarbose: α glucosidase inhibitor
- Only ? available in the class
- Mechanism?
- Side effects?
- Common or no?
- 1
- Inhibits breakdown of carbohydrates to glucose by blocking action of the enzyme
α Glucosidase
- Inhibits breakdown of carbohydrates to glucose by blocking action of the enzyme
- Modest reduction in HbA1c ~ 0.5%
3. Flatulence, loose stools and diarrhoea
4. Rarely if ever used nowadays
- Glitazones [e.g.]
- Mechanism
- Benefits
- ADRs
- Common or no?
- Pioglitazone
- INCREASE insulin sensitivity in muscle and adipose tissue & DECREASE hepatic glucose output
• They bind to and activate one or more peroxisome proliferator-activated receptors (PPARs)
- Can be used in combination with other oral agents
- • Cardiovascular concerns with Rosiglitazone
• Pioglitazone still available but concerns regarding weight gain, fluid retention and heart failure, effects on bone metabolism and bladder cancer
- Rarely used nowadays
Glucagon Like Peptide 1 Therapies
- Used for?
- Give e.g. of GLP 1 therapy
- Mechanism
- Alternative hormone system influencing glucose metabolism
- High glucose in Type 2 diabetes due to insufficient release of insulin and over production of glucagon
- Alternative hormone system influencing glucose metabolism
- Exenatide, Liraglutide, Lixisenatide
- • Increase insulin secretion from the beta cells
• Decreases production of Glucagon from alpha cells
Physiological effects of GLP-1
Benefits of Exenatide
Benefits of Exenatide
Gliptins or DPP- 4 inhibitors
- Give e.g.
- Mechanism
- ADRs
- Benefits
- Disadvantage except ADRS
- Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin
- Inhibits DPP-4 activity increasing postprandial active GLP-1 concentrations
- GI symptoms, ?pancreatitis
- Low risk of hypoglycaemia
- Weight neutral
- Modest HbA1c reduction
- Low risk of hypoglycaemia
- Cost high
GLP-1 agonists: adverse side effects (5)
Is it still used?
- Gastrointestinal symptoms, nausea, loose stools or diarrhoea
- Gastro oesophageal reflux
- Low risk of hypoglycaemia
- Occasional painful to inject
- ? Pancreatitis and pancreatic carcinoma
- NICE and FDA found no evidence of pancreatitis in the reported studies
- Generally perceived to be safe and well tolerated agents
- Widely used
- Avoid if eGFR < 30ml/min
How does Dapagliflozin work?
Dapagliflozin selectively inhibits SGLT2 in the renal proximal tubule
*Increases urinary volume by only ~1 additional void/day (~375 mL/day) in a 12-week study of healthy subjects and patients with Type 2 diabetes.
Glifozins: adverse side effects
- Can be used for patients with ?
- Give e.g.
- Side effects
- Type1 and Type 2 diabetes as add on therapy
- Dapagliflozin, Canagliflozin and Empagliflozin available
- Can be predicted:
• Increase risk of lower urinary tract symptoms including genital & urinary infections
especially in women (5%)
- Polyuria
- Hypoglycaemia risk low
• Understand the regulation of sex steroid hormones in the menstrual cycle and
pregnancy
- Outline the mechanism of action of the sex steroid hormones
- Understand the different mechanisms of COCP and POP contraceptives
• Understand the impact of potential side effects and adverse drug interactions
of COCPs and POPs
• Understand why sex steroid hormone derivatives should be given for the
menopause
- Understand some of the major side effects and adverse drug reactions of hormone replacement therapy (HRT)
- Be able to outline the role of SERMs/anti-estrogens and anti-progestogens
• Outline the general biochemistry of the sex steroid hormones and of their
therapeutic derivatives
• Revise hormonal regulation of the female reproductive cycle
• Review and differentiate between the mechanisms of actions of the two
classes of oral contraceptives (COCPs and POPs)
- Describe the major side effects of contraceptives
- Describe the use of sex steroid hormones and their analogues in post-reproductive health and their major adverse side effects
- Provide clinical context through guidance
• Understand the regulation of sex steroid hormones in the menstrual cycle and
pregnancy LO
• Outline the mechanism of action of the sex steroid hormones LO
Drug groups for sex steroid hormones in contraception and post-reproductive health
- *Sex steroid hormones**
- Oestrogens, progestagens, androgens
- *Inhibitors & antagonists**
- Clomiphene, RU486, finasteride
- *Mixed agonists/antagonists**
- Selective estrogen receptor modulators (SERMs) and selective progesterone receptor modulators (SPRMs)
- [there are SARMs, but they are only (and rarely) used in the treatment of women with PCOS]
Sex steroid hormones
Effects of:
- Oestradiol
- Progesterone
- Testosterone
- Stimulates growth of the endometrium and breast; stimulates production of PR.
- Stimulates growth of the endometrium and breast; maintains pregnancy; inhibits production of ER.
- Stimulates male characteristics; hairy body; deep voice; anabolism; aggression.
Draw a diagram showing the derivatives of the sex hormones
• Outline the mechanism of action of the sex steroid hormones LO
Oestrogen action and side effects
Action
Mild anabolic Sodium and water retention Raises HDL, lowers LDL Decrease bone resorption Impair glucose tolerance Increase blood coagulability
Oestrogen action and side effects
Side effects
Breast tenderness
Nausea,
vomiting
Water retention
Increased blood coagulability
Thromboembolism
Impaired glucose tolerance
Endometrial hyperplasia & cancer
Ovarian metaplasia & cancer
Breast hyperplasia & cancer
• Outline the mechanism of action of the sex steroid hormones LO
Progesterone / progestin action and side effects
Actions
Secretory endometrium
Anabolic
Increases bone mineral density
Fluid retention
Mood changes
Maintains pregnancy
Progesterone / progestin action and side effects
Side effects
Weight gain
Fluid retention
Anabolic
Acne
Nausea/vomiting
Irritability
Depression,
PMS Lack of concentration
Testosterone
Actions/Side effects
Male secondary sex characteristics
Anabolic
Acne
Voice changes
Increases aggression
Metabolic - adverse effects on lipid profiles particularly the HDL- C/LDL-C ratio hence increased risk of atherosclerotic disease in males
Routes of Administration*
Oral:
+ Oestrogens - Synthetic derivatives: ethinyloestradiol, methoxy derivative (mestranol), valerate
+ Progestins - Synthetic derivatives:
1- Progesterone derivatives: Medroxyprogesterone, Dydrogesterone
2- Testosterone derivatives: Norethisterone, norgestrel, ethynodiol
Transdermal patch (Evra®) norelgestromin
Implants
Nasal
Vaginal