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Pre Reg Pharmacy > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is diabetes?

A

Group of metabolic disorders in which persistent hyperglycaemia is caused by:
deficient insulin secretion or
resistance to the action of insulin.

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2
Q

What are the common types of diabetes?

A

Type 1
Type 2
Gestational
Secondary diabetes (may be caused by pancreatic damage, hepatic cirrhosis, endocrine disease, antiviral, antipsychotics, endocrine)

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3
Q

What is type 1 diabetes?

A

Absolute insulin deficiency: no or very little endogenous insulin secretory capacity due to destruction of the insulin producing beta cells in the Islet of Langerhans.

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4
Q

What are the typical features of type 1 diabetes?

A

Hyperglycaemia (random plasma glucose concs > 11mmol/L)
KETOSIS (increase in ketones)
Rapid weight loss
BMI< 25KG/m2
< 50 years old
Personal or family history of autoimmune disease

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5
Q

What is type 2 diabetes?

A

Chronic metabolic condition characterised by insulin resistance.
Insufficient pancreatic insulin production occurs progressively over time.
Commonly associated with obesity, physical inactivity etc.

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6
Q

What are the aims of treatment for type 1 diabetes?

A

Using insulin regimens to achieve an optimal level of blood glucose control while avoiding or reducing frequency of having hypo episodes.
Minimise risk of macro/microvascular complications.

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7
Q

What are the treatment aims of type 2 diabetes?

A

Minimising the long term macro/microvascular complications by effective blood glucose control.
Maintain HbA1C at or below the target value set for each patient.

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8
Q

What are the signs of symptoms of hypoglycaemia?

A 
Shaking and trembling 
Sweating
Pins and needles
Hunger 
Palpitations 
Occasional headache
Double vision 
Slurring of speech 
CNS/cognitive issues (confusion, convulsions, unconsciousness, change in behaviour)
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9
Q

What is the initial management of hypoglycaemia IN COMMUNITY ?

A 
1. Initially glucose 10-20g given by mouth in liquid form or sugar (2-4 teaspoons OR 3-6 sugar lumps)
Repeat after 10-15 mins is necessary. 
2. Non-diet version drinks:
Original lucozade energy 110ml 
Coca-cola 100ml 
Ribena blackcurrent 19ml (to be diluted)

Quick acting carbs products: Glucogel, Dextrogel, GSF-syrup, Rapilose gel.

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10
Q

What is the management of hypoglycaemia after the initial management IN COMMUNITY ?

A

Sustainable snacks: sandwiches, fruits, biscuits, milk or the next meal if due (to prevent the blood glucose from falling again)

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11
Q

Is chocolate, high fat and sugary snacks a good choice for hypoglycaemia management IN COMMUNITY?

A

No,

Has higher fat content so glucose takes longer to have an effect.

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12
Q

What is the management of hypoglycaemia if patient is nil by mouth/ or unconscious IN COMMUNITY?

A

Glucagon 1mg IM or SC injection

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13
Q

What are the requirements for drivers with diabetes?

A

Tell the DVLA

Depends on their treatment, the type of license they hold, any diabetic complications including hypoglycaemia.

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14
Q

What type of patients MUST notify the DVLA about their diabetes?

A

Patients treated with insulin (due the higher risk of causing hypoglycaemia).

SU, nateglinde and repaglinde: carry a greater risk of hypoglycaemia, more monitoring required.

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15
Q

What is the DVLA advice for patients on insulin?

A

Always carry blood glucose meter and testing strips when driving.

Check BG concs no more than 2 hours before driving and every 2 hours while driving.

More frequent self monitoring required for greater risk of hypoglycaemia (after physical activity, altered meal routine etc)

Ensure there is a supply of fast acting carbs in the car.

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16
Q

What should the BG always be while driving?

A

5 mmol/L or over

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17
Q

What should be done if the BG falls below or equal to 5mmol/L? (DVLA)

A

Take a snack

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18
Q

What should happen if BG < 4mmol/l or war ning signs of hypoglycaemia while driving?

A

Do not drive.
If already driving: stop car in a safe place.
Switch of engine and remove the keys from ignition.
Move over to the passengers seat.
Eat or drink a suitable source of sugar.

WAIT 45 mins once BG has returned to normal.

Do not drive if hypoglycaemia awareness has been lost
Medical report needed to confirm that its been regained.

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19
Q

What is the oral glucose tolerance test (OGTT) used for?

A
  • Used mainly for diagnosis of impaired glucose tolerance.
  • Used to establish presence of gestational diabetes
  • Can be used for those who have less severe symptoms and a BG that does not establish or exclude diabetes (e.g. impaired fasting glucose)
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20
Q

How is the OGTT performed?

A

Measure the BG concs after fasting, then 2 hours after drinking a standard anhydrous glucose drink (Polycal or Rapilose OGTT oral solution)

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21
Q

What does HbA1c test measure and are there any requirements?

A

It reflects the average plasma glucose over the previous 2-3 months and provides a good indicator of glycaemic control.

  • It can be performed at any time of the day
  • It does not require any special preparation like fasting
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22
Q

What is the units that Hba1c is expressed in?

A

mmol/mol

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23
Q

What is the Hba1c value for a non diabetic patient?

A

Less than 42mmol/mol (<6.0%)

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24
Q

What is the Hba1c value for a pre diabetic patient?

A

42-47mmol/mol (6.0-6.4%)

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25
Q

What is the Hba1c value for a diabetic patient?

A

More than or equal to 48mmol/mol (>=6.5%)

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26
Q

What is the target hba1c for a diabetic patient?

A

48 mmol/mol (6.5%) and less

For patients managed by diet and lifestyle alone or
For patients on a single anti diabetic drug not associated with hypoglycaemia e.g Metformin.

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27
Q

What group of patients cannot be tested with the hba1c?

A 
Children 
Pregnancy 
Women that are 2 months after birth
Patients that have had symptoms of diabetes for less than 2 months.
High diabetes risk and are acutely ill
Medication that causes hyperglycaemia 
Acute pancreatic damage 
End stage CKD
HIV infection
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28
Q

What is the hba1c test used for?

A

Monitoring glycaemic control in type 1 and 2.
Diagnoses type 2 diabetes only
Do not used to test type 1.
Also a reliable predictor of micro and microvascular complications and mortality.

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29
Q

In what patients should the hba1c test be interpreted with caution?

A

Patients with abnormal haemoglobin
Anaemia
Altered red cell life span
Recent blood transfusion.

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30
Q

How often do you measure hba1c?

A

Type 1: every 3-6 months (measure more frequently if BG changes rapidly)

Type 2: every 3- 6 months until hba1c and medication is stable, then reduce monitoring to every 6 months.

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31
Q

in what patients is hba1c monitoring invalid?

What other alternative testing can be done?

A

Patients with abnormal or lack of haemoglobin
Disturbed erythrocyte turnover.

Frutosamine estimation (less accurate than hba1c) measures all plasma proteins over the previous 2-3 weeks.

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32
Q

What are the BG ranges before meals for, non-diabetics, type 1 and 2 diabetics?

A

Non-diabetic: 4-5.9mmol/l

Type 2: 4-7mmol/l

Type 1: 4-7mmol/l
(When waking 5-7 mmol/l)

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33
Q

What are the BG ranges for 90 mins after meals with non-diabetics, type 1 and 2?

A

Non-diabetic: < 7.8mmol/l

Type 2: < 8.5mmol/l

Type 1: 5-9mmol/l

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34
Q

What type of patients should aim for a hba1c for 53mmol/mol (7.0%)?

A

Patients prescribed a single drug associated with hypoglycaemia (SU, NATEGLINIDE, REPAGLINDE)

Patients on 2 or more anti-diabetic drugs.

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35
Q

What initial advice would be given to a patient that has a hba1c higher than normal?

A

Lifestyle advice and adherence for 3 months

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36
Q

What is the initial treatment of type 2 diabetes and the dose?

A

Metformin
500mg OD, with breakfast for 7/7, then 500mg BD with breakfast and evening meals for 7/7, then 500mg TDS with breakfast, lunch and dinner. Max of 2g per day.

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37
Q

What is the first intensification of type 2 diabetes treatment if hba1c rises to 58mmol/mol?

A

Consider dual therapy with:

MET + DPP-4i (gliptins)
MET + PIOGLITAZONE
MET + SU
MET + SGLT-2i (flozins)

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38
Q

What is the second intensification for treatment of type 2 diabetes hba1c rises to 58mmol/mol?

A

Consider triple therapy:

MET + DPP-4i + SU
MET + PIO + SU
MET + PIO/SU + SGLT-2i

Insulin based treatment

Do not use piotigazone and dapaglifozin together

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39
Q

What is the 3rd option if triple therapy is not effective, CI, not tolerated? And for which patient groups?

A

MET + SU + GLP1-receptor agonist

For Adults with type 2 diabetes with a BMI of 35 or more AND specific psychological OR medical problems associated with obesity.

Or patients with a BMI of less than 35 AND insulin therapy have severe occupational implications OR if weight loss would benefit other obesity related co-morbidities.

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40
Q

What is the treatment of type 2 diabetes hba1c rises to 48mmol/mol when Metformin is CI or not tolerated?

A

Consider one of the following:
DDP-4i, PIO or SU
SGLT-2i (if others are not appropriate)

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41
Q

What is the first intensification for treatment of type 2 diabetes hba1c rises to 58mmol/mol when Metformin is CI?

A

DUAL THERAPY:
DPP-4i + PIO
DPP-4i + SU
PIO + SU

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42
Q

What is the second intensification for treatment of type 2 diabetes hba1c rises to 58mmol/mol WHEN Metformin is CI?

A

Consider insulin based treatment

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43
Q

what is recommended for insulin treatment for type 2 diabetes?
State alternatives?

A

NPH (ISOPHANE INSULIN)- OD or BD
NPH (Humulin I and Insuman) administered separated or as a biphasic mixture (Novomix and Humalog)

Appropriate for those with a hba1c of 75mmol/mol (9.0%)

Alternatives:Long acting insulin e.g insulin determir (Levemir) or glargine (Lantus) OD DOSING- patients may prefer this.

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44
Q

What is preferred? Biphasic prep that includes human analogue insulin OR Human soluble insulin? And for which patients?

A

Human analogue insulin is preferred.

For patients that prefer injecting insulin immediately before a meal, if hypoglycaemia is a problem or if BG concs rise a lot after meals.

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45
Q

What other anti diabetics drugs can be given with insulin

A

Metformin
SGLT-2i
GLP1-RECEPTOR AGONIST (under specialist care and careful MDT monitoring)

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46
Q

What is the mechanism of Metformin?

A

Decreases gluconeogenesis and increases peripheral utilisation of glucose.

Acts only in the presence of endogenous insulin.

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47
Q

What are the CI of Metformin?

A

Diabetic Ketoacidosis
Lactic acidosis

Dyspnea, SOB, asthenia (lack of energy), hypothermia

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48
Q

Side effects of Metformin

A

GI side effects (abdo pain , diarrhoea, N+V): reducing the dose, slow increase in dose or m/r preps can help.

Decreased appetite and anorexia.
Long term use: VIT B12 deficiency
Renal impairment (AKI)
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49
Q

What are the monitoring requirements for Metformin

A

Renal function before treatment and annually (avoid if eGFR <30mol/min in adults and children)

Reduce dose in moderate renal impairment

Measure vit b12

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50
Q

What is the mechanism of action for Dipeptidylpeptidase- 4 inhibitors?

A

Inhibits DPP-4 to increase insulin secretion and lower glucagon secretion, preventing incretin breakdown.

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51
Q

Main side effects of DPP-4i?

A

Pancreatitis, GI upsets and peripheral oedema.
Not associated with weight gain and has a lower incidence of hypoglycaemia than SU.

Increased risk of upper respiratory tract infections with sitagliptin
Increased risk of headache and liver impairment with vildagliptin (jaundice, pale stools, dark urine, N+V ETC)

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52
Q

What are the MONITORING requirements for DPP4i?

A

Vilagliptin: liver function before treatment, every 3 months for the 1st year and periodically thereafter.

Pancreatitis: STOP treatment if acute pancreatitis develops (severe abdo pain, N+V)

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53
Q

What is the mechanism of action of glucagon- like peptide -1 receptor agonist?

A

They bind to and activate the GLP1 receptor to increase insulin secretion, supress glucagon secretion and slows down gastric emptying.

54
Q

Side effects on GLP1-agonist?

A

GI side effects (N+V, diarrhoea)
Pancreatitis (stop treatment), weight loss, headaches.

Exenatide: severe pancreatitis which can be fatal STOP TREATMENT
M/R PREP (Bydureon) the effect can last for up to 10 weeks after discontinuation.

55
Q

What is done when a dose of GLP1 agonist is missed?

A

Advice patient not to administer after a meal (can cause severe pancreatitis)
Continue with next scheduled dose.

56
Q

What do you do when you a dose when on lixisenatide?

A

Inject within 1 hour before next meal.

57
Q

When do you take oral medication when you’re on exentaide and lixentaide?

A

Take 1 hour before or 4 hours after the injections.

58
Q

What is the mechanism of action of (prandial glucose regulators) metlitnides?

A

Stimulates insulin secretion when BG levels are at their highest and not a fasting levels.

They have a rapid onset on action and short duration of activity.

59
Q

Which megtitinde should only be given with Metformin

A

Nateglitide

60
Q

What are the side effects of metiglitides

A 
Hypoglycaemia, GI side effects (N+V, abdo pain, diarrhoea and constipation)
Hypersensitivity reactions (Pruritis, rashes)
Repaglinide also may cause visual disturbances
61
Q

When should meglitinides be taken?

A

30 mins before main meals

62
Q

What is the mechanism of action for sodium-glucose co-transporter 2 (SGLT2)?

A

Inhibit SGLT2 in the renal PCT to reduce glucose absorption and increase urinary glucose excretion

63
Q

What are the SEs of SGLT2 inhibitors?

A 
Volume depletion
Constipation
Thirst, polyuria
UTIs
Genital infections
64
Q

What are the MHRA/CHM advice for SGLT2 inhibitors?

A
  • Diabetic ketoacidosis (DKA) - SEEK MEDICAL ATTENTION and STOP flozin if DKA suspected
    Signs: rapid weight loss, N&V, abdo pain, fast and deep breathing, fatigue, pear/sweet breath, urine and bodily fluids or metallic taste in mouth
    Test for raised ketones, even if plasma glucose levels are near normal
65
Q

What is the additional MHRA/CHM advice for canagliflozin?

A
  • Lower limb amputation, mainly toes
  • Preventative foot care essential in all patients (watch out for skin ulceration, discolouration, new pain or tenderness and seek immediate treatment)
  • STOP if skin ulcer, gangrene or osteomyelitis occurs
  • Monitor patients at higher risk of amputation e.g. previous amputation, existing peripheral vascular disease or neuropathy
  • Monitor all patients for signs and symptoms of water or salt loss (volume depletion)
  • Advice patients to stay well hydrated
66
Q

What is the mechanism of action for pioglitazone?

What is the name of the drug class?

A

Reduces peripheral insulin resistance, leading to reduction in BG conc.

Drug class: thiazolidinedione

67
Q

What are the CIs for pioglitazone?

A

History of heart failure
Previous or active bladder cancer
Uninvestigated macroscopic haematuria

68
Q

What are the SEs of pioglitazone?

A

Bone fracture, liver toxicity (report signs and STOP if liver dysfunction occurs: N+V, abdo pain, dark urine, fatigue), haematuria, GI upset
Weight gain
Anaemia
Visual disturbances

69
Q

What is the MHRA/CSM advice for pioglitazone?

A

-Increased incidence of HF (when combined with insulin, esp in patients with previous MI)
STOP if cardiac status worsens

  • Small increased risk in bladder cancer
    Use with caution in elderly
    Assess smoking status, age, exposure to certain occupational or chemotherapy agents or previous radiation therapy to pelvic region BEFORE starting treatment
    -Safety and efficacy reviewed after 3-6 months. Stop if patients do not respond adequately
    Report haematuria, dysuria or urinary urgency during treatment
70
Q

That is the mechanism of action for sulfonylureas?

A

Augment insulin secretion.
Only effective when there is some residual pancreatic beta cell activity present.
During long term admin, they also have an extrapancreatic action.

71
Q

What are the CI and cautions for sulphonylureas?

A

CI: presences of ketoacidosis

Cautions: can encourage weight gain, elderly, G6PD deficiency.

72
Q

What are the common side effects of sulphonylureas?

A

GI discomfort, diarrhoea, hypoglycaemia (INFORM PATIENT!especially with other antidiabetic drugs, also be careful with driving and skilled tasks).
Nausea, weight gain (due to increased insulin concs)

73
Q

What side effect could happen in the 1st 6-8 weeks of therapy?

A

Allergic dermatitis

74
Q

Which sulphonylurea are more likely to cause hypoglycaemia?

A

Long acting sulphonylureas

Glibenclamide: associated with severe prolonged and sometimes fatal cases of hypoglycaemia.

75
Q

List examples of sulphonylureas

Which ones are short and long acting?

A 
Gliclazide (short acting)
Glibenclamide (long acting)
Glimpepiride 
Tolbutamide (short acting)
Glipizide
76
Q

Can sulphonylureas be taken during pregnancy?

A

Generally, it should be avoided due to the risk of Neonatal hypoglycaemia.

But Glibenclamide can be used during the 2nd and 3rd trimester in women with gestational diabetes.

77
Q

What additional side effects is gliclazide likely to cause?

A

Anaemia , angioedema, GI disorder, dyspepsia, skin reactions,

78
Q

What strength of standard release of gliclazide is equivalent to gliclazide M/R 30mg equivalent to?

A

80mg of standard release gliclazide

79
Q

Which sulphonylurea is preferred to be taken during significant renal impairment and why?

A

Gliclazide

Mostly metabolised by the liver

80
Q

Which sulphonylrea is preferred in elderly patients?

A

Gliclazide

Avoid long acting such as glienclamide as they can cause severe hypoglycaemia

81
Q

What Advice and counselling would be offered when taking sulphonylureas?

A

Discuss risk of hypoglycaemia and possible symptoms of weakness, confusion, sweating, slurred speech, aggression, fits, loss of consciousness, palpitation.

Never miss a meal
Always carry around sugary drinks or sweets to treat hypoglycaemia when it occurs.

82
Q

What is the mechanism of alpha glucosidase inhibitor?

A

Acarbose

Inhibits alpha glucosidases and delays the digestion and absorption of starch and sucrose;

83
Q

What are the common SEs of acarbose?

A

flatulence! Leads to non-adherence.
Diarrhoea can occur: dose may be reduced or withdrawn.

Other GI side effect: soft stools, abdo distension and pain.

84
Q

What advice and counselling are given when taking acarbose?

A

Flatulence can decrease with time. Antacids will not help with these side effects.

Chew tablets with first mouthful of food or swallow whole with little liquid immediately before food.

When taking acarbose+ insulin/SU: to o=counteract possible hypoglycaemia, patients should carry glucose NOT sucrose.

Acarbose delays absorption of sucrose.

85
Q

What is the target total cholesterol for type 2 diabetes?

A

Less than 5 mmol/L

86
Q

What are the three different insulin regimens for type 1 diabetes?

A

Multiple daily injection (basal bolus): OD dosing or more long acting/intermediate as background + short acting before meals

Mixed (biphasic) regimen: 1-3 dosing with intermediate + short acting.
Can be combined in one pen or pre mixed by the patient.

Continuous SC insulin infusion (insulin pump): rapid acting or soluble insulin.

87
Q

What is first line recommendation for insulin therapy in type 1 diabetes?

A 
Multiple basal-bolus insulin regimen.
Long acting (basal): Levemir BD (or OD), alternative: Lantus (OD)

Rapid acting insulin analogue is preferred rather than soluble Human insulin and animal (rarely used)

88
Q

What is second line recommendation for insulin therapy in type 1 diabetes?

A

BD mixed (biphasic) regime.

Patients on human insulin that have hypoglycaemia that affects quality of life should be offered trail of insulin analogue.

89
Q

When do you offer the insulin pump regimen?

A

When patients that have disabling hypoglycaemia
Or with high hba1c concs (69mmol/mol, 8.5% and above)
And have been doing the multiple daily basal bolus with high level of care with no benefits.

Initiated by specialist only

90
Q

List examples of rapid acting insulin (human insulin analogues)

A 
Insulin aspart (Novorapid)
Insulin Glulisine (Apidra)
Insulin Lispro (Humalog)
91
Q

Which insulin has a faster onset of action? Rapid acting insulins, or short acting insulins (neutral/soluble)?

A

Rapid acting insulin

92
Q

List animal and human examples of short acting insulin (neutral or soluble)

A

Animal:
Hypurin Porcine/bovine neutral

Human:

  • Actrapid
  • Humulin S
  • Insuman Rapid
93
Q

Which insulin is common used for DKA (diabetic ketoacidosis) and before surgery?

A

Soluble insulin

94
Q

Which insulin should be injected within 30 mins before meals and why?

A

Short acting (soluble) insulin’s

To avoid hypoglycaemia occurring

95
Q

List examples of intermediate acting insulin

A

Isophane insulin (NPH)

Animal:
-Hypurin procine isophane

Human:
-Insultard, Humulin I, Insuman Basal

96
Q

Can intermediate acting insulins be administered via IV?

A

NEVER!

Particulate matter in the suspension may lodge in the capillary beds of lungs and brain, leading to thrombus formation.

97
Q

What advice and counselling should be given with intermediate insulins?

A

Ensure that insulin is being injected SC to prevent accidental IV injection.
Protamine can cause allergic reactions.

98
Q

List examples of long acting insulins?

A 
Insulin Detemir (Levemir)
Insulin Glargine (Lantus, Abasaglar)

Insulin Degludec (Tresiba)

99
Q

At what point during the day should you inject long-acting insulin?

A

Inject at the same time each day, in order to provide cover for the whole 24-hour period

100
Q

List examples of biphasic insulins

A
  • NovoMix 30 (30% insulin aspart, 70% insulin aspart protamine)
  • Humalog Mix 25 (25% insulin lispro, 75% insulin lispro protamine)
  • Humulin M3 (30% soluble human, 70% isophane human)
  • Insuman Comb 50 (50% soluble human, 50% isophane human)
101
Q

What are the benefits of patients using biphasic insulins?

A

Prevents patients from having to inject short and long acting insulins separately, esp for those with poor dexterity and difficulty in measuring insulins

102
Q

What are the disadvantages of using biphasic insulins?

A
  • These mixtures may offer less control of treatment regimens as proportions are fixed
  • Acutely ill patients cannot use biphasic mixtures to boost their insulin levels but should ideally have short/rapid-acting insulins to manage insulin requirement while being ill
103
Q

Do you give biphasic preparations immediately?

A

No! Needs to be resuspended before use

104
Q

When should insulin dosing be increased?

A

When the patient has:
Infection
Stress
Accidental or surgical trauma

105
Q

What can reduce insulin requirements (therefore increasing risk of hypoglycaemia)?

A
  • Physical activity
  • Intercurrent illness (disease which intervenes during course of another disease)
  • Reduced food intake
  • Impaired renal function
  • In certain endocrine disorders
106
Q

What scores are used to assess patients awareness of hypoglycaemia?

A
  • Gold score

- Clarke score

107
Q

What is meant by SICK DAY RULES?

A

S.I.C.K (Sugar, Insulin, Carbohydrates, Ketones)

Sugar - BG levels can increase even if patient is not eating well
Monitor BG levels more frequently (3-4 times/day)
Insulin - NEVER stop taking normal insulin or oral antidiabetics doses
Insulin doses may need to be increases
Carbs - Maintain adequate hydration, continue eating despite appetite.
Seek immediate advice if violently sick/can’t keep fluids down
Ketones - In type 1, check for ketones every 2-4 hrs

108
Q

What are the symptoms of DKA?

A 
Pear dropped breath
N+V
Blurred vision
Dehydration 
Abdominal pain
Polyuria
109
Q

What are the common management for DKA?

A

-Start IV insulin infusion of soluble insulin (mixed with NaCl 0.9% to a conc of 1 unit/ml) at fixed rate of 0.1 units/kg/hr
-To restore volume depletion give NaCl. (Add KCl but don’t give if anuria suspected)
-Established insulin regimen with long-acting insulin should continue
-Monitor blood ketones and glucose hourly
(If BG falls <14mmol/l give glucose 10%)

110
Q

What are the long-term complications of uncontrolled diabetes?

A

Macrovascular (Damage to large vessels):

  • CVD
  • Peripheral arterial disease
  • Cerebral disease (stroke)

Microvascular (Damage to small vessels):
Neuropathy, Nephropathy, retinopathy

Metabolic complications: DKA

111
Q

What are the regulars test carried out for diabetic nephropathy?

A

Annual tests for urinary protein (using albustix) and serum creatinine measurement.
If urinary protein test is -ve, test for microalbuminuria

112
Q

What drug treatment is given to patients with diabetic nephropathy causing proteinuria or established microalbuminuria?

A

Provided there are no CIs TREAT WITH ACEI or ARB

To minimise risk of renal deterioration, BP should careful be controlled

113
Q

What drugs are given to manage painful diabetic neuropathy?

A
  • Duloxetine (amitriptyline or nortriptyline alternative)
  • Monotherapy pregabalin, gabapentin or carbamazepine
  • Tramadol (opioid) can be tried if patient is waiting for assessment if other treatments are unsuccessful
  • Capsaicin 0.075% cream may also have an effect
114
Q

What is the common SE of Capsaicin 0.075% cream?

A

It produces an intense burning sensation during the initial treatment period

115
Q

What drugs are given to relieve mild to moderate diabetic neuropathy?

A

Paracetamol

NSAID e.g. ibuprofen

116
Q

Diabetics patients who are planning to conceive should be prescribed what drug? For how long?

A

Folic acid 5mg as they are at high risk of conceiving a child with a neural tube defect

Before conception and for up to 12 weeks

117
Q

That is the mechanism of action for sulfonylureas?

A

Augment insulin secretion.
Only effective when there is some residual pancreatic beta cell activity present.
During long term admin, they also have an extrapancreatic action.

118
Q

What are the CI and cautions for sulphonylureas?

A

CI: presences of ketoacidosis

Cautions: can encourage weight gain, elderly, G6PD deficiency.

119
Q

What are the common side effects of sulphonylureas?

A

GI discomfort, diarrhoea, hypoglycaemia (INFORM PATIENT!especially with other antidiabetic drugs, also be careful with driving and skilled tasks).
Nausea, weight gain (due to increased insulin concs)

120
Q

What side effect could happen in the 1st 6-8 weeks of therapy?

A

Allergic dermatitis

121
Q

Which sulphonylurea are more likely to cause hypoglycaemia?

A

Long acting sulphonylureas

Glibenclamide: associated with severe prolonged and sometimes fatal cases of hypoglycaemia.

122
Q

List examples of sulphonylureas

Which ones are short and long acting?

A 
Gliclazide (short acting)
Glibenclamide (long acting)
Glimpepiride 
Tolbutamide (short acting)
Glipizide
123
Q

Can sulphonylureas be taken during pregnancy?

A

Generally, it should be avoided due to the risk of Neonatal hypoglycaemia.

But Glibenclamide can be used during the 2nd and 3rd trimester in women with gestational diabetes.

124
Q

What additional side effects is gliclazide likely to cause?

A

Anaemia , angioedema, GI disorder, dyspepsia, skin reactions,

125
Q

What strength of standard release of gliclazide is equivalent to gliclazide M/R 30mg equivalent to?

A

80mg of standard release gliclazide

126
Q

Which sulphonylurea is preferred to be taken during significant renal impairment and why?

A

Gliclazide

Mostly metabolised by the liver

127
Q

Which sulphonylrea is preferred in elderly patients?

A

Gliclazide

Avoid long acting such as glienclamide as they can cause severe hypoglycaemia

128
Q

What Advice and counselling would be offered when taking sulphonylureas?

A

Discuss risk of hypoglycaemia and possible symptoms of weakness, confusion, sweating, slurred speech, aggression, fits, loss of consciousness, palpitation.

Never miss a meal
Always carry around sugary drinks or sweets to treat hypoglycaemia when it occurs.

129
Q

What is the mechanism of alpha glucosidase inhibitor?

A

Acarbose

Inhibits alpha glucosidases and delays the digestion and absorption of starch and sucrose;

130
Q

What are the common SEs of acarbose?

A

flatulence! Leads to non-adherence.
Diarrhoea can occur: dose may be reduced or withdrawn.

Other GI side effect: soft stools, abdo distension and pain.

131
Q

What advice and counselling are given when taking acarbose?

A

Flatulence can decrease with time. Antacids will not help with these side effects.

Chew tablets with first mouthful of food or swallow whole with little liquid immediately before food.

When taking acarbose+ insulin/SU: to o=counteract possible hypoglycaemia, patients should carry glucose NOT sucrose.

Acarbose delays absorption of sucrose.

Pre Reg Pharmacy (36 decks)

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