treatment of diabetes

Question 1

What is the role of insulin?

Answer 1

To lower blood glucose to prevent hyperglycaemia and the complications associated with it

Question 2

What are the 3 insulins available in the UK?

Answer 2

• human insulins (produced in a lab by recombinant DNA technology)
• human insulin analogues (produced same way as human insulin but modified to produce specific characteristics)
• animal insulin (extracted and purified from animal sources - cows bovine insulin or pigs procine insulin

Question 3

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

Answer 3

onset 5-15 min
peak 30-60min
duration 2-5hr

Question 4

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

Answer 4

onset 30min
peak 1-3 hr
duration 4-8hr

Question 5

What is the onset, peak and duration time of immediate or long acting (isophane or zinc insulin)?

Answer 5

onset - 1-2hr (NPH Lente) 2-3hr (ultralente)
peak 4-8hr
duration 8-12hr (NPH) 8-24hr (ultralente)

Question 6

What is the onset, peak and duration time of long acting insulin analogue?

Answer 6

onset 30-60min
no peak
duration 16-24hr

Question 7

What are some problems with insulin?

Answer 7

Main problem is causing hypoglycaemia.
Lipohypertrophy (lump of skin by accumulation of extra fat) can occur due to repeatedly injecting insulin in same small area.

Question 8

How is insulin administered?

Answer 8

Inactivated by GI enzymes. Must be given by injection - into body area with plenty of subcutaneous fat.

Question 9

What is carbohydrate counting?

Answer 9

Some patients may administer a set amount of shorter acting insulin based on how much carbohydrates they have eaten

Question 10

What are the 4 insulin devices?

Answer 10

• insulin pens
• insulin vial and syringe
• innolet device
• insulin pump

Question 11

What are the two types of insulin pens?

Answer 11

1. A pen that already has insulin in
2. A pen that can be reused by replaceable cartridges

Question 12

What is the current advice about insulin storage from Diabetes UK?

Answer 12

• keep spare vials and cartridges in boxes in fridge. Current use can be storage at room temperature.
• check pack for expiry date. Do not use if expired
• Don’t expose insulin to sunlight or high temperatures
• cool bags should be used to keep insulin cool when on the move or when travelling abroad

Question 13

How are needles safely disposed of?

Answer 13

Sharps bins and needle clippers are safest way of disposing insulin needles.

Question 14

What are the 7 other diabetic medications?

Answer 14

1. metformin
2. pioglitazone
3. meglitinides
4. DDP4 inhibitors (gliptins)
5. sulphonylureas
6. GLP-1 mimetics
7. sodium glucose co-transporter 2 inhibitors (SGLT-2i)

Question 15

What are the key points about metformin?

Answer 15

Should be taken after food. Increase uptake and utilisation of glucose by cells, reduces glucose production. Must be some function islet cells remaining in pancreas to be effective. Symptoms such as nausea, diarrhoea and abdominal pain are common. Should not be used in patients with renal impairment.

Question 16

What are the key points about pioglitazone?

Answer 16

Advised to monitor for signs of liver toxicity (nausea, abdominal pain, vomiting, fatigue and dark urine), Increases insulin sensitivity in peripheral tissues and the liver. Side effects include bone fractures, risk of infection, numbness, visual impairment and weight gain. Can cause liver problems. Small increased risk of bladder cancer. Used in caution in patients with risk of bone fractures and heart failure. Contraindicated in patients with history of heart failure or bladder cancer. Use with insulin increases risk of heart failure.

Question 17

What are the key points about meglitinides?

Answer 17

Two drugs (repaglinide and nateglinide). Risk of hypoglycaemia to be discussed. Taken 30 minutes before meals. Increases insulin secretion. Not used very much. Can cause abdominal pain, diarrhoea, hypoglycaemia. Should be used with caution in patients with liver disease.

Question 18

What are the key points about DDP4 inhibitors (gliptins)

Answer 18

5 drugs in group - sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin. Gliptins inhibit DDP4-enzyme increases insulin secretion and reduced glucaogn secretion. GI disturbances are common. Acute pancreatitis uncommon but serious. Side effects include: hypoglycaemia, headache, tremor, rashes, muscle or joint pain. Gliptins used with caution in patients with renal impairment, and saxagliptin not used at all. Should be used with caution in patients with history of pancreatitis.

Question 19

What are the key points about sulphonylureas?

Answer 19

5 drugs in group - glibenclamide, gliclizide, glimepiride, glipizide and tolbutamide. Risk of hypoglycaemia should be discussed. Increase insulin secretion from pancreatic beta cells. Ineffective where there is absolute deficiency of insulin production. Can cause: hypohylcaemia, weight gain, abdominal upset, headache, hypersensitivity reactions and very rarely liver and blood disorders. Encourage weight gain. Glimepiride and glibenclamide are long acting and have increase risk of hypoglycaemia.

Question 20

What are the key points about GLP-1 mimetics?

Answer 20

drugs include: exenatide, liraglutide, semaglutide, dulaglutide, and lixisenatide. Told to recognise symptoms of pancreatitis. Drugs bind to and activate GLP-1 receptor to increase insulin secretion, suppress glucagon secretion and slow gastric emptying. Leads to weight loss. Drugs administered by injection. Acute pancreatitis is rare but serious. GI affects are common. Headache, dizziness, drowsiness, and injection-site reactions may occur. Should be used with caution with patients who have history of pancreatitis. Women of childbearing potential should be advised to use contraception.

Question 21

What are the key points about SGLT-2i?

Answer 21

3 drugs in group - canagliflozin, dapagliflozin and empagliflozin. Should be told signs and symptoms of DKA. Advised to drink plenty of water to avoid dehydration. Medications reversibly inhibit SGLT2 in part of kidney to reduce glucose reabsoprtion and increase urinary glucose excretion. Drugs associated with increased risk of DKA. Can cause infections of genital tract.

Question 22

What is first line treatment for type 2 diabetes?

Answer 22

monotherapy - metformin first line treatment.

Question 23

What is first line follow up treatment for type 2 diabetes?

Answer 23

alternative monotherapy or extra therapy in CVD - if not able to take metformin a gliptin, pioglitazone, sulphonylurea or SGLT-2i should be used instead

Question 24

What is second line treatment for type 2 diabetes?

Answer 24

dual therapy - skipped if patient on SGLT-2i and metformin.

Question 25

What is third line treatment for type 2 diabetes?

Answer 25

triple therapy - if dual therapy ineffective.
For people who can take metformin: metformin, a gliptin and sulphonylurea OR metformin, pioglitazone and sulphonylurea OR metformin, pioglitazone or a sulphonylurea and and SLGT-2i OR starting insulin based treatment.
For people who cannot take metformin: insulin based treatment

Question 26

What is failure of triple therapy treatment for type 2 diabetes?

Answer 26

metformin, a solphonylurea, and a GLP-1 mimetic or specialist review