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Lecture Notes - Endocrinology > Treatment of Diabetes Mellitus > Flashcards

Treatment of Diabetes Mellitus Flashcards

1
Q

What are the 4 main components to the treatment of a patient with diabetes mellitus

A

patient education
glycaemic control
screening for and treatment of complications
screening for and treatment of cardiovascular risk factors

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2
Q

What should all newly diagnosed type 2 diabetic patients receive

A 
verbal and written information about their diagnosis 
possible complications 
need for regular follow-up 
treatment options 
lifestyle adjustments

Additionally, information on group classes, meetings with a diabetic specialist nurse, dietician, other educational resources such as books, charities and websites

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3
Q

What are important components of non-pharmacological therapy in patients with T1DM

A

diet and exercise

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4
Q

How is glutted haemoglobin (HbA1c) formed

A

in a non enzymatic pathway by irreversible attachment of glucose to haemoglobin

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5
Q

What does HbA1c correlate with

A

mean good glucose over the previous 8-12 weeks

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6
Q

When might HvA1c values be falsely high

A

when RBC turnover is low

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7
Q

What is the foal of glycemic control

A

TO achieve normal or near normal glycaemia with an HbA1c of 53mmol/mol

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8
Q

How often is HbA1c measured

A

every 6 months in those meeting glycemic goals and every 3 months in those who are not meeting glycemic goals and in those whose treatment has changed

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9
Q

Why are cow and pig insulin preparations no longer used

A

They may cause allergic reactions in some patients

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10
Q

What type of insulin is now used

A

Synthetic human insulin

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11
Q

What is a short acting form of insulin

A

soluble (regular) insulin

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12
Q

When is soluble insulin injected

A

30 minutes before meals

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13
Q

Hypoglycaemia occurs more often in rapid acting insulin or soluble acting insulin

A

Soluble acting insulin

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14
Q

What are the benefits of using rapid acting insulin analogues

A

They have faster absorption and more rapid onset and shorter duration of action

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15
Q

What does intensive therapy of insulin regimes involve

A

administration of a basal level of insulin and primal boluses of a rapid acting insulin preparation

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16
Q

What is an intermediate acting insulin

A

isophane insulin

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17
Q

What is a long acting insulin analogue

A

glargine or detemir

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18
Q

What is the difference between long acting and intermediate acting insulin

A

Long acting do not have a peak effect where as isophane has a 6-10 hour peak effect

They are the basal insulins

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19
Q

What are the rapid acting insulin preparations

A

lispro
aspart
glulisine

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20
Q

What does the administration of a basal on acting insulin and boluses of rapid acting insulin with meals intend to do

A

mimic the normal insulin secretion profile of the pancreas

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21
Q

What does the basal insulin suppress

A

lipolysis and hepatic glucose production

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22
Q

What do the boluses of insulin do

A

They minimise the postprandial rise in blood glucose

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23
Q

Why is the use of premixed insulins not recommended for patients with type 1 diabetes

A

intensive therapy in patients requires frequent adjustments of the primal boils of the rapid acting insulin

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24
Q

What is the main benefit of using glargine over isophane insulin

A

fewer hypoglycaemic episodes with isophane

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25
Q

Why must insulin deter be given twice daily

A

it has a shorter duration of action than glargine

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26
Q

How is insulin administered

A

Subcutaneously using single-use syringes with needles, insulin pens with needles or an insulin pump

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27
Q

What are the disadvantages of insulin pumps

A

they are costly and cumbersome for some patients

Ketoacidosis may occur if the pump malfunctions

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28
Q

How is the needle inserted for administration of insulin

A

perpendicular to the pinched skin

Held in place for several seconds after insulin injection to avoid insulin leakage after withdrawal of the needle

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29
Q

What determines the length of the needle used

A

The patient’s weight

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30
Q

Where are potential sites of insulin injection

A

upper arms
abdominal wall
upper legs
buttocks

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31
Q

Why are the long actin insulins best injected into the leg or buttock

A

the absorption is slowest here

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32
Q

Why is the rapid acting insulin preparations best injected into the abdominal wall

A

insulin is absorbed more rapidly here

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33
Q

Why must injection sites be rotated

A

to avoid the risk of lipohypertrophy

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34
Q

What does insulin requirement depend on

A

body weight
age
pubertal stage

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35
Q

How much insulin is required for newly diagnosed children

A

daily insulin dose of 0.5-1U/kg

36
Q

Patients in ketoacidosis require higher or lower doses of insulin

A

higher

37
Q

How much of the total daily dose of insulin does the basal insulin dose comprise of

A

50%

38
Q

What are the boluses adjusted according to

A

the carbohydrate content of the meals and the current blood glucose level

39
Q

What are the main side-effects of intensive insulin therapy

A

hypoglycaemia and weight gain

40
Q

How many times must patients monitor their blood glucose

A

4-7 times daily (before meals, mid morning, mid afternoon and before bedtime)

41
Q

What is the purpose of intensive therapy to achieve lower levels of glycaemia in patients with type 2 diabetes

A

Lowered the risk of microvascular complications

42
Q

Why should patients with proliferative retinopathy avoid weightlifting

A

due tot he increased risk of intraocular haemorrhage

43
Q

Why should patients with neuropathy avoid long distance running or prolonged downhill skiing

A

Activities may precipitate stress fractures and pressure ulcers in the feet

44
Q

What drug should be started at the time of diagnosis in patients with T2 DM

A

Metformin

45
Q

How does metformin work

A

it decreases hepatic glucose output, inhibits lipolysis and increases insulin mediated glucose utilisation in the peripheral tissues
It lowers serum lipid and blood glucose by working through LKB1 which phosphorylate sand activates the enzyme adenosine monophosphate activated protein kinase

46
Q

What are some side effects of metformin

A 
nausea
anorexia 
abdominal discomfort 
diarrhoea 
metallic taste in the mouth
47
Q

What is a rare but serious side effect of metformin

A

Lactic acidosis

48
Q

When should a sulphonylurea be started

A

If lifestyle modification and metformin do not achieve or sustain the glycemic goals within 2-3 months

49
Q

Who are sulphonylureas indicated in

A

patients who are not a candidate for metformin or who cannot tolerate it
patients in whom metformin therapy alone is not controlling the glycaemia

50
Q

How do sulphonylureas work

A

they bind to an inhibit the ATP dependent potassium channel in the pancreatic beta cells, resulting in a depolarisation of the beta cell membrane, calcium influx and a stimulation of insulin secretion

51
Q

What is the most common side effect of sulphonylureas

A

hypoglycaemia

52
Q

When is hypoglycaemia most likely to arise

A 
after exercise 
missed meal 
high drug dose 
malnourishment 
alcohol abuse 
impaired renal or cardiac function 
FI disease
concurrent treatment with salicylate etc.
53
Q

What are less common side effects of sulphonylureas

A

nausea
skin reactions (including photosensitivity)
abnormal LFTs

54
Q

Name some sulphonylureas

A

glipizide

gliclazide

55
Q

What is the main thiazolidinediones used for treatment of T2DM

A

Pioglitazone

56
Q

When is pioglitazone considered

A

when sulphonylureas are contraindicated or when hypoglycaemia is particularly undesirable

57
Q

How do thiazolidinediones work

A

Act mainly by increasing insulin sensitivity and the peripheral uptake and utilisation of glucose in muscle and fat
They bind to and activate peroxisome proliferator-activated receptors which regulate gene expression

58
Q

What are some side effects of thiazolidinediones

A

Weight gain

fluid retention and increased risk of heart failure

59
Q

What are meglitinedes

A

short acting drugs that act by regulating ATP dependent potassium channels in pancreatic beta cells thereby increasing insulin secretion

60
Q

When should a dose of meglitindes be missed

A

if a meal is missed

61
Q

What is the most common adverse effect of meglitinicdes

A

hypoglycaemia

62
Q

What does GLP-1 do

A

stimulates glucose-dependent insulin release, inhibits glucagon release
slows gastric emptying
reduces food intake

63
Q

What is an advantage of Eventide (GLP analogue)

A

weight loss

64
Q

What type of drug is sitagliptin

A

GLP-1 analogue

65
Q

How are GLP-1 analogues administered

A

Subcutaneous injection at least twice daily in T2 or with every meal in T1

66
Q

How does pramlintide work ?

A

it slows gastric emptying, reduces post-prandial rises in blood glucose and improves HbA1c in both type 1 and 2

67
Q

What patients may benefit from pramlintide

A

Type 1 or Type 2 who are inadequately controlled with insulin therapy alone, particularly in those who gain weight despite lifestyle intervention

68
Q

Why do HbA1c levels rise over time in T2DM

A

Worsening beta cell dysfunction, decreased insulin release and more severe insulin resistance

69
Q

What do premixed insulins contain

A

A mixture of short acting and intermediate acting insulin

70
Q

What does the effect of exercise on blood glucose depend on

A

whether the patients is hypoinsulinaemic or hyperinsulinaemic at the time of exercise

71
Q

Why might exercise cause hypoglycaemia in diabetic patients with adequate serum insulin

A

Exogenous insulin cannot be shut off and maintains muscle glucose uptake and inhibits hepatic glucose output

72
Q

What information should patients who exercise be told

A

May need to reduce the insulin dose that affects the time of day you exercise and the injection should be given 60-90 mins prior
Don’t inject near the muscles that are exercising to prevent increased insulin absorption

73
Q

How can late hypoglycaemia be avoided

A

Eating slowly absorbed carbohydrates immediately after exercise (dried fruit)

74
Q

What can slow the progression of retinopathy

A

laser photocoagulation therapy

75
Q

What can slow the progression of nephropathy

A

administration of an ACE inhibitor or ARB

76
Q

What is the earliest clinical finding in diabetic nephropathy

A

Microalbuminuria

Urinary albumin excretion rate of between 30 and 300 mg per day

77
Q

How is microalbuminuria diagnosed

A

by measuring the albumin-to-creatinine ratio in a spot urine sample

78
Q

How do Ace inhibitors work in nephropathy

A

they both lower iurinary protein excretion and slow the rate of disease progression

79
Q

What would a diabetic foot exam consist of

A

Inspection: integrity of skin between toes and under metatarsal heads, erythema, warmth and callus
Check for neuropathy with monofilament and vibration
Peripheral arterial disease: palpation of the pedal pulses and ask history of claudication

80
Q

What should be obtained if peripheral arterial disease is suspected

A

Ankle-brachial pressure index

81
Q

What are some risk factors of microvascular disease

A

hypertension
obesity
dyslipidaemia
smoking

82
Q

what would cardiovascular risk factor modification in patients with diabetes include

A

blood pressure control
screening for and treatment of dyslipidaemia
smoking cessation
aspirin

83
Q

Why might hypertension develop in diabetics

A

Reabsorption of the excess filtered glucose along with sodium i the proximal tubules
hyperinsulinaemia
increased arterial stiffness and diabetic nephropathy

84
Q

What is the recommended BP goal for most diabetic patients

A

less than 130/80mmHg

85
Q

What is the main indication for pancreatic islet cell transplantation

A

problematic hypoglycaemia unawareness

Lecture Notes - Endocrinology (40 decks)

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