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pre reg afsha endocrine > T2D > Flashcards

T2D Flashcards

1
Q

what is it

A

chronic metabolic condition characterised by insulin resistance and insufficient pancreatic insulin production resulting in hyperglycaemia

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2
Q

Commonly associated with

A

Obesity
Physical inactivity
Hypertension
Dyslipidaemia
Tendency to develop thrombosis - increased CV risk
Long term micro + macrovascular complications
Reduced QoL
Reduced life expectancy

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3
Q

Target HbA1c for T2D that is managed by diet and lifestyle alone, or when combined with a single antidiabetic drug that is not associated with hypoglycaemia (e.g. metformin)

A

48mmol/mol (6.5%)

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4
Q

Pt prescribed a single drug that IS associated with hypo (e.g. SU) should aim for HbA1c level of

A

53mmol/mol (7.0%)

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5
Q

what action to take if HbA1c levels poorly controlled despite treatment with a single drug & rise to 58mmol/mol (7.5%) or higher

A

intensify drug treatment alongside reinforcement of advice regarding diet, lifestyle and adherence

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6
Q

When 2 or more antidiabetics prescribed, target Hb1Ac level

A

53 mmol/mol (7.0%)

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7
Q

Consider relaxing target HbA1c level on a case-by-case basis - particular consideration for pt

A

Older or frail
Unlikely to achieve loner term risk reduction benefits
Tight blood glucose control not appropriate
High risk of consequences of hypoglycaemia

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8
Q

If pt reach a lower HbA1c level than their target, and are not experiencing hypo, encourage them to maintain it but be aware of other possible reasons for low level e.g.

A

deteriorating renal function or sudden weight loss

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9
Q

What is the HbA1c target generally recommended for T2D that is managed by diet and lifestyle alone, OR when combined with a single antidiabetic drug not associated with hypo?

A

48mmol/mol (6.5%)

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10
Q

What is the HbA1c target recommended for T2D that is being managed with a single drug that is associated with hypo (e.g. SU)?

A

53 mmol/mol (7.0%)

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11
Q

What is the target HbA1c level for patients taking 2 or more antidiabetic drugs?

A

53 mmol/mol (7.0%)

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12
Q

Consider rescue therapy with insulin or a SU for pt who become…

A

….somatically hyperglycaemic at any stage of treatment
Review treatment when BG control has been achieved

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13
Q

what treatment is recommended as 1st line for initial drug treatment for all pt and why

A

standard release metformin
Positive effect on weight loss (neutral to loss)
Reduced risk of hypo events
Long term CV benefits associated with use

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14
Q

dose of metformin

A

Increase dose gradually to minimise risk of GI SE
500mg OD for at least 1 week , take with breakfast, then 500mg BD for 1 week, take with breakfast and evening meal, then 500mg TDS (breakfast, lunch, evening), max 2g day

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15
Q

max dose of metformin

A

2g daily

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16
Q

metformin has to be taken with meals. as you titrate dose up, which meals do you take the tabs with

A

initially 500mg OD for a week - breakfast
then 500mg BD for a week - breakfast and dinner
then 500mg TDS - breakfast, lunch, dinner

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17
Q

MR metformin dose and titration - 2 options

A

initially 500mg OD, then increased up to 2g OD if needed, increase dose gradually, every 10-15 days, take dose with evening meal

alternatively increase to 1g BD, take with meals. only use this alternative dose if control is not achieved with OD dose regimen.

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18
Q

metformin dose for T2D reduction in risk or delay of onset.

A

use MR form. 500mg OD initially, then increase if necessary up to 2g OD, gradually increase every 10-15 days, take with evening meal

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19
Q

a patient has been commenced on metformin standard release tabs but experiences GI SE. what do. you do

A

offer MR metformin

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20
Q

1st line drug treatment for T2D in pt with chronic HF or established atherosclerotic CVD

A
  • metformin + SGLT2i with proven CV benefit
  • also consider SGTL2i in pt at high risk of developing CVD
  • not erugliflozin as there is uncertainty around CV benefits with this
  • start metformin first, then once tolerability to it is confirmed, start STGLT2i
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21
Q

If monotherapy with metformin (+ diet change) doesn’t control HbA1c level to below the agreed threshold, consider metformin +

A

DPP4 inhibitor (gliptins), or pioglitazone, or a SU
SGLT2 inhibitor may be considered in combination with metformin when SUs contraindicated or not tolerated, or if pt at significant risk of hypoglycaemia or its consequences

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22
Q

At any stage after starting initial treatment, offer an SGLT2 inhibitor with proven CF benefit to pt who

A

develop chronic heart failure or established atherosclerotic CV disease

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23
Q

If dual therapy (metformin + DPP4 inhibitor gliptins/ pioglitazone/SU) unsuccessful, consider triple therapy by adding in

A

either a DPP4 inhibitor, or pioglitazone, or a SU
SGLT2 inhibitor may be considered in the some certain triple therapy regimens (separate flashcard on this)

24
Q

give examples of regimens of triple therapy that include SGTL2i

A

Metformin + SU and either canag/dapag/empagliflozin
Metformin + pioglitazone and either canag/empgaliflozin
Metformin and a DPP4 inhibitor and ertugliflozin (only if SU or pioglitazone not appropriate)

25
Q

alternative to triple therapy if dual therapy with metformin + DPP4 inhibtor/SU/pioglitazone is unsuccessful

A

start insulin based treatment

26
Q

name 3 short acting SUs

A

gliclazide or tolbutamide or glipizide

27
Q

Elderly & renal impairment - these pt are at particular risk of hypo. So, if a SU is indicated, which ones?

A

a short acting one e.g. gliclazide or glipizide or tolbutamide should be prescribed to reduce risk of hypo

28
Q

If triple therapy with metformin and 2 other oral drugs is tried and not effective, or not tolerated, or contraindicated, consider….

A

GLP1 receptor agonist OR tirzetapide as part of triple therapy regimen by switching one of the other drugs for this

29
Q

GLP1 receptor agonists (-tide) should only be considered for pt with:

A
  • BI 35 or above (adjust for ethnicity) and how also have a specific psychological or medical problem associated with obesity
  • B<I <35 and insulin therapy would have significant occupational implications, or if weight loss associated with GLP1RA would benefit other significant obesity related comorbidities
30
Q

Can consider GLP1RA as part of triple therapy regimen if other regimens have failed/unsuitable etc
GLP1 receptor agonist therapies with proven CV beenfit should be considered in pt with established CVD e.g.

A

liraglutide

31
Q

when to review GLP1 RA and what to look out for to see if it should be continued

A
  • review after 6 months
  • only continue if beneficial metabolic response (reduction of at least 11mmol (1%) HbA1C and weight loss of at least 3% of initial body weight)
32
Q

can you give insulin in combo with GLP1RA

A

yes under specialist care advice with ongoing support from consultant led MDT

33
Q

what drug is 1st line if metformin is contraindicated or not tolerated and the pt has chronic HF or established atherosclerotic CVD

A

SGTL2 inhibitor with proven CV benefit
(also consider for pt at high risk of developing CVD)

34
Q

what is 1st line if metformin is contraindicated or not tolerated and the patient DOES NOT have chronic HF or established atherosclerotic CVD

A

DDP4i (liptin) or pioglitazone or SU
alternative option to a DPP4 if SU or pioglitazone are not appropriate: SGLT2

35
Q

repaglinide is an effective alternative option for single therapy but has limited role in treatment because

A

if intensification in treatment is required, it is not licensed to be used in any combination other than with metformin
therefore it would require a complete change of treatment in pt who have started it due to intolerance or contraindication to metformin

36
Q

further treatment options - If initial monotherapy does not control HbA1c to below the patient’s agreed threshold, consider adding either

A

(DPP-4) inhibitor, pioglitazone, or a sulfonylurea.

37
Q

when insulin is started for intensification of treatment, metformin should be continued unless it is contraindicated or not tolerated, but other anti diabetic drugs

A

should be reviewed and stopped if necessary

38
Q

When starting insulin therapy, bedtime basal insulin should be initiated and the dose titrated against

A

morning (fasting) glucose

39
Q

recommended insulin regimens for T2D

A

Human isophane insulin injected OD or BD, according to requirements
Human isophase insulin in combination with a SA insulin, administered either separately or as a pre mixed (biphasic) human insulin preparation (this may be particularly appropriate if HbA1c is 75mmol/mol (9.0%) or higher
Insulin detemir or insulin glargine as an alternative to human isophase insulin

40
Q

when might Human isophase insulin in combination with a SA insulin, administered either separately or as a pre mixed (biphasic) human insulin preparation regimen be particularly appropriate compared to other insulin regimens?

A

if HbA1c is 75mmol/mol (9.0%) or higher

41
Q

Insulin detemir or insulin glargine as an alternative to human isophase insulin - 3 points about this regimen. when would it be beneficial, when would you consider swapping to D/G from human isophane insulin, and when might biphasic preps be preferable

A

Can be preferable if OD injection would be beneficial (e.g.. if assistance needed to inject) or if recurrent symptomatic hypoglycaemic episodes are problematic, or if the pt would otherwise need BD human isophane injections in combination with oral glucose lowering drugs
Consider switching to insulin detemir or insulin glargine from human isophase insulin if significant hypo is problematic, or in pt who cannot use the device needed to inject human isophane insulin
Biphasic preps that include a SA human analogue insulin (rather than SA human soluble insulin) may be preferable for pt who prefer injecting insulin immediately before a meal, or if hypo is a problem , or if BG conc rise markedly after meals

42
Q

Pt who are prescribed a basal insulin regimen (human isophase insulin, insulin detemir, insulin glargine) should be monitored for

A

the need for SA insulin before meals (or a biphasic insulin preparation)

43
Q

Pt who are prescribed a biphasic insulin should be monitored for the need for

A

further injection of SA insulin before meals or a change to basal-bolus regimen with human isophane insulin or insulin detemir or insulin glargine if BF control remains inadequate

44
Q

name the only dual glucose depend insulinotropic polypeptide (GIP) and GLP-1 receptor agonist + brand name

A

tirzepatide - mounjaro

45
Q

what is tirzepatide and when can it be used?

A

it is a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP1 receptor agonist which promotes weight loss
can be used as alternative to GLP1-R agonists in combination with other drugs when other treatments have failed

46
Q

how often is tirzetapide administered and via which route

A

SC iniection
once weekly, with dose increments in steps of 2.5mg in intervals of at least 4 weeks

47
Q

if tirzetapide is being used, the dose of the following drugs may need to be reduced

A

Dose of concomitant insulin or sulfonylurea may need to be reduced.

48
Q

important safety info: GLP1 receptor agonists - reports of DKA when concomitant insulin was rapidly reduced or discontinued

A

Serious and life-threatening cases of diabetic ketoacidosis have been reported in patients with type 2 diabetes mellitus on a combination of insulin and the glucagon-like peptide-1 (GLP-1) receptor agonist exenatide, liraglutide, or dulaglutide, particularly after discontinuation or rapid dose reduction of concomitant insulin. Healthcare professionals are advised that any dose reduction of insulin should be done in a stepwise manner with careful blood glucose self-monitoring, particularly when GLP-1 receptor agonist therapy is initiated. Patients should be informed of the risk factors for and signs and symptoms of diabetic ketoacidosis, and advised to seek immediate medical attention if these develop.

49
Q

tirzetapide is a long acting GIP receptor and GLP1 receptor agonist but how does it work

A

increases insulin sensitivity and secretion, suppresses glucagon secretion, and slows gastric emptying.

50
Q

what potential effect may tirzetapide have on oral medicines

A

Tirzepatide delays gastric emptying, particularly following the first dose. This has the potential to slow the rate of absorption of concomitant oral medicines. The risk of a delayed effect should be considered for oral medicines where a rapid onset of action is important. Monitor patients on oral medicines with a narrow therapeutic index, especially at the start of tirzepatide treatment and after dose increases

51
Q

the main interactions of tirzetapide are drugs that increase risk of hypo e.g. oral antidiabetics and insulin. however there is one severe interaction - what is it

A

Tirzepatide might affect the absorption of Warfarin. Manufacturer advises monitor.

52
Q

tirzetapide - any effect on contraception and conception?

A

Tirzepatide delays gastric emptying which may affect absorption of concomitant oral medicines. Since reduced efficacy of oral contraceptives cannot be excluded, it is advised that female patients who are overweight or obese and using an oral contraceptive should add a barrier method of contraception or switch to a non-oral contraceptive method for the first 4 weeks of treatment, and for 4 weeks after each dose increase.

Discontinue treatment at least one month before planned pregnancy.

53
Q

patient and carer advice with tirzepatide

A
  • acute pancreatitis: recognise signs and seek immediate medical attention if symptoms develop
  • dehydration: inform of potential risk in relation to GI SE and advise to take precautions to avoid fluid depletion
54
Q

patient and carer advice with tirzetapide - missed doses

A

If a dose is more than 4 days late, the missed dose should be omitted and the next dose administered at the normal time.

55
Q

mounjaro kwikpen storage

A

Mounjaro Kwikpen® should be stored in a refrigerator (2–8℃); may be stored at 30℃ or below for up to 30 days.

pre reg afsha endocrine (29 decks)

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