T2DM theraputics Flashcards
What are the different oral-antihyperglycaemic agents available ?
Biguanides - Metaformin
Sulphonylureas: (think Gli…)
- Glicazide (most common one used)
- Glibenclamide
- Glimeparide
Thiazolidinediones - Pioglitazone
What is the first line treatment of T2DM ?
Metaformin
How does metaformin work ?
- It reduces HBA1c by reducing insulin resistance
- Doesn’t really affect weight
- Helps prevent micro and macrovascular complications
- Doesn’t cause hypo’s
Is metaformin safe to be used in pregnancy ?
yes
What are the potential side effects of metaformin ?
- GI problems - anorexia, nausea, vomiting, diarrhoea, abdo pain, taste disturbances
- Can cause anaemia (rare) due to interfering in B12 and folic acid absorption
- Lactic acidosis (rare)
- Liver failure
- Rash
- Renal toxicity
Due to Renal toxicity being a potential complication of metaformin use, what would indicate this is potentially happening and what would you do ?
- Avoid or stop if eGFR <30ml/min or serum creatinine >150μmol/l
- Half dose if eGFR 30-45 ml/min
What are the effects of sulphonylureas ?
- Reduces HBA1c by increasing insulin secretion
- Helps prevent microvascular complications but not macrovascular
What are the adverse effects of sulphonylureas ?
- Risk of hypo’s
- Can cause weight gain
- GI upset and headaches
When would you not give a SU (sulphonylurea)?
Avoid in severe renal or hepatic failure
What is the 2nd line agent used in the treatment of T2DM ?
Sulphonylureas - glicazide
What are the effects of Thiazolidinediones?
- Reduces HBA1c by increasing insulin sensitivity
- Doesn’t cause hypo’s unless used with a SU
- Weight gain is very common - due to increased S/C fat and fluid retention
- Helps prevent again micro and macrovascular complications except microalbuminuria
What is the main side effects to be worried about in patients on a Thiazolidinedione?
- Heart failure - Fluid retention results in near doubling of risk of admission with heart failure
- Also increased risk of hip fractures
In what patients are Thiazolidinediones (glitazones) not recommended in ?
Not recommended in those aged over 65 due to increased risk of hip fracture
What is the incretin effect ?
The incretin effect is when you give oral glucose and it produces a greater response than when given IV glucose
What are the other newet treatments available ?
- GLP-1 receptor agonists
- DPP-4 inhibitors
- SGLT2 inhibitors
Give examples of GLP-1 agnoists
- Exenatide
- Exendin
- Liraglutide
- Lixisenatide
What are the benefits of GLP-1 agnosits ?
- Promote insulin secretion from pancreas without hypoglycaemia
- Suppress glucagon (which is increased in T2DM)
- Decrease gastric emptying – early satiety
- Act on hypothalamus – reduce appetite – resulting weight loss (~3kg)
What are the potential side effects of GLP-1 agonists ?
- Nausea – usually resolves in most by 6-8 weeks
- Injectable
- Pancreatitis, Pancreatic Cancer????
Give examples of DPP-IV inhibitors
- Vildagliptin,
- Sitagliptin,
- Saxagliptin,
- Linagliptin
Think (liptin)
What are the benefits of DPP-IV inhibitors ?
- Promote insulin secretion from pancreas without hypoglycaemia
- Suppress glucagon (which is increased in T2DM)
- Weight neutral
- Limited side effects
What are the disadvantages of DPP-IV inhibitors ?
Generally well-tolerated but do have increased risk of pancreatitis
Give examples of the SGLT2 inhibtors
- DAPAGLIFLOZIN
- CANAGLIFLOZIN
- EMPAGLIFLOZIN
(Think flozin)
How do SGLT-2 inhibitors work ?
- Decrease sugar uptake and make you pee it out
- Possible CV benefit
What are the disadvantages of SGLT-2 inhibitors ?
- Increase in thrush
- Increase in urine infections
- Dad said theres meant to be controversy about it and has possible side effects
When is insulin given in T2DM?
When oral agents are no longer able to control the diabetes
What would be continued along with when the patient goes on insulin ?
Metformin plus or minus SU
Appreciate this overview of T2DM treatment
