anti diabetic drugs incl insulin Flashcards
(64 cards)
1
Q
does metformin cause weight loss
A
neutral to weight loss
does not cause weight gain
2
Q
does metformin cause hypoglycaemia and why
A
no because it does not stimulate insulin secretion, it just lowers basal and postprandial BG levels
3
Q
which SU’s are more likely to cause hypoglycaemia
A
long acting e.g. glimepiride can cause severe, prolonged and sometimes fatal cases
4
Q
do SU’s cause weight loss and why
A
no are associated with modest weight gain probably due to increased plasma insulin concentrations
5
Q
what drug class is pioglitazone
A
thiazolidinedione
6
Q
how does pioglitazone work
A
reduces peripheral insulin resistance leading to reduced BG conc
7
Q
if a pioglitazone is given, which concomitant anti diabetic drugs dose may need to be reduced?
A
Su’s and insulin dose may need to be reduced
8
Q
why is concomitant use of insulin with pioglitazone cautioned?
A
risk of HF
9
Q
MHRA safety advice for pioglitazone - CV safety
A
- increased risk of HF when pioglitazone + insulin, esp in pt with predisposing factors e.g. previous MI
- closely monitor pt who take pioglitazone for signs of HF
- discontinue if any deterioration in cardiac status
- do not use in pt with with HF or Hx HF
10
Q
which anti diabetic drug must not be used in heart failure?
A
pioglitazone
11
Q
which anti diabetic drug has MHRA safety risk of bladder cancer
A
pioglitazone
12
Q
MHRA: pioglitazone risk of bladder cancer advice
A
- small increased risk of bladder cancer but in pt who respond well to treatment, benefits of pioglitazone outweighs the risk
- do not use in active bladder cancer or Hx bladder cancer, or in pt with univestigsted microscopy haematuria
- use with caution in elderly as risk increases with age
- pt must report haematuria, dysuria, urinary urgency
13
Q
pioglitazone holds a small increased risk of bladder cancer. therefore, before initiating treatment, what should you do
A
- assess pt with RF e.g. age, smoking status, exposure to certain occupational and chemotherapy agents, or previous radiation therapy to pelvic region
- investigate any microscopic haemturia
- do not give to pt with active bladder cancer or previous Hx
- caution in elderly as increased risk
- review safety and efface cy after 3-6 months and stop if pt do not respond adequately
14
Q
pioglitazone is contraindicated in…
A
DKA
Hx HF
previous or active bladder cancer
uninvestigated microscopic haematuria
15
Q
what are some common side effects of pioglitazone
A
bone fracture, increased risk of infection, numbness, visual impairment, weight gain
16
Q
cautions for pioglitazone
A
- elderly (increased risk HF, fractures, bladder cancer)
- increased risk bone fractures, esp in women
- RF for bladder cancer
- RF HF
- concomitant use with insulin (risk of HF)
17
Q
does pioglitazone cause weight gain
A
yes
18
Q
what to do if jaundice occurs while on pioglitazone
A
discontinue, rare reports of liver dysfunction
19
Q
pioglitazone in P & BF
A
avoid
20
Q
monitoring pioglitazone
A
monitor liver function before and periodically thereafter
21
Q
a pt comes into the pharmacy and says they have been feeling nauseous lately, with abdominal pain, very tired and have dark urine. you look at their pmr and see they are on pioglitazone. what do you do
A
seek immediate medical attention
discontinue if jaundice
22
Q
pioglitazone in liver impairment
A
avoid
23
Q
when does pioglitazone need to be reviewed
A
after 3-6 months and regularly thereafter
24
Q
what are the DDP4 inhibitors?
A
-gliptins
25
do DDP4 inhibitors cause weight gain
glipitins do not
26
what are the SGLT2 inhibitors
-flozins
27
do -flozins cause weight gain
no, they may promote weight loss
28
which class of drugs may promote weight loss and improve CV outcomes in certain pt?
SGLT2 inhibitors (flozins)
29
are SGLT2 inhibitors associated with risk of DKA
yes
30
how do SGLT2 inhibitors work
reversibly inhibit sodium glucose cotransporter 2 in the renal proximal convoluted tubule to reduce glucose reabspriton and increase urinary glucose excretion
31
which drug class holds MHRA safety advice about reports of Fournier's gangrene
SGLT2 inhibitors
32
MHRA safety info: SGLT2 inhibitors and DKA
- rarely there have been reports of serious, life threatening and fatal cases of DKA
- in several cases, presentation of DKA was atypical (pt only had moderately elevated BG)
- inform pt about signs and symptoms of DKA and advice them to seek medical advice if they have any
- test for raised ketones in pt with signs and symptoms, even if plasma glucose levels are nearvnormal
- use with caution in pt with RF for DKA
- stop if DKA suspected or diagnosed
- do not restart with any SGLT2i in pt who had DKA during use, unless another cause was identified and resolved
- interrupt SGLT2i treatment in pt who are hospitalised for major surgery or acute serious illness, restart once pt condition stable
33
what are the signs and symptoms of DKA
- rapid weight loss
- n/v
- abdominal pain
- fast and deep breathing
- sleepiness
- sweet breath
- sweet or metabolic taste in mouth
- different odour to urine or sweat
34
a pt presents to A&E with suspected DKA as they have a sweet breath, are vomiting and have fast and deep breathing. you check their plasma glucose levels but they are only slightly raised so you are unsure if this is DKA. however, when you look at what drugs they are taking you check for high ketones and commence DKA treatment. what class of drugs is it and why?
SGLT2 inhibitors have had cases of DKA with atypical symptoms e.g. moderately elevated blood glucose levels
test for raised ketones in pt with signs and symptoms, even If plasma GC is near normal
35
MHRA advice on monitoring ketones in blood during SGLT2 inhibitor treatment interruption for surgical procedures or acute serious medical illness
- monitor ketone levels during SGTL2i treatment interruption in pt who have been hospitalised for major surgery or acute serious illness
- measuring blood ketone levels is preferred to urine
- treatment can be restarted once ketone normal and pt stable
36
Canagliflozin MHRA advice on increased risk of lower limb amputation
- mainly toes in pt with T2D
- preventative foot care
- consider stopping if pt develops significant lower limb complication e.g. skin ulcer, gangrene, osteomyleitits
- carefully monitor pt with RF for amputation e.g. previous amputation, existing peripheral vascular disease, neuropathy
- monitor all pt for signs and symptoms of water or salt loss, ensure pt are sufficiently hydrated to prevent volume depletion in line with manufacturer recommendations
- advice pt to stay well hydrated, carry out routine preventative foot care and see medical advice if skin ulceration, discolouration, new pain or tenderness
- start treatment for foot problems as early as possible
37
MHRA advice - risk of Fournier's gangrene with SGLT2 inhibitors
- rare but serious and potentially life threatening infection
- if suspected, stop and urgently start treatment (incl abx and surgical debridement)
- seek urgent medical attention if severe pain, tenderness, erythema, swelling in genital or perineal area, accompanied by fever or malaise
- urogenital infection or perineal abscess may precede necrotising fasciitis
38
a pt comes in to the pharmacy and asks says she has fever and feels unwell and had pain and tenderness in the genital region. you know that she is a T2D. what medication could have caused this and what do you do?
SGLT2 inhibitors - associated with Fournier's gangrene
seek urgent medical attention
39
contraindications of SGLT2i
DKA
T1D (due to increased risk of DKA)
40
when should you discontinue a SGLT2 inhibitor immediately
DKA
Fourniers gangrène
41
cautions for SGLT2 inhibitors
- elderly (risk of volume depletion)
- elevated haematocrit
- hypotension
- risk of volume depletion - correct hypokalaemia before starting treatment
42
common SE SGT2 inhibitors
- inflammation of penis
- constipation
- dyslipidaemia
- hypoglycaemia (in combo with insulin or SU)
- increased risk of infection
- nausea
- thirst
- urinary disorders
-urosepsis
43
hepatic impairment SGLT2 inhibtors
avoid in severe impairment
44
renal impairment in SGLT2 inhibitors
caution if eGFR less than 60
avoid initiation when baseline eGFR less than 30
45
monitoring requirements for SGLT2 inhibitors
- renal function before treatment and at least annually after
- renal function before initiating concomitant drugs that reduce renal function and periodically thereafter
46
pt and carer advice SGLT2 inhibitors
- report symptoms of volume depletion including postural hypotension and dizziness
- inform of signs of DKA to look out for
47
can forgixa 5mg tabs be used for treatment of T1DM
not anymore. not authorised.
48
which SGLT2 inhibitor can increase risk of lower limb amputation (mainly toes)
Canagliflozin
49
what to do if complicated UTI occurs during treatment with empagliflozin
cautioned in complicated UTIs, consider temporarily interruption treatment
50
there is greater uncertainty about the CV benefits associated with with SGLT2 inhibitor?
ertugliflozin
51
what are the GLP-1 receptor agonists and when should they be used and what are their features
- dulaglutide, eventide, lirglutide, lixisenatide, semaglutide
- reserve for combo therapy hen other treatment options failed
- can promote weight loss and for some pt may improve CV outcomes
52
what treatment should you offer to diabetic pt with chronic HF or established atherosclerotic CVD?
metformin + SGLT2 inhibitor (with proven CV benefit) as initial drug treatment
start metformin first, then start the other as soon as tolerability to metformin is confirmed
53
what treatment for diabetes can you consider for pt at high risk of developing CVD
SGLT2i with proven CV benefit
54
how does metformin work
- decreases gluconeogensis and increases peripheral utilisation of glucose
55
why can metformin only be used in T2D
since it acts only in the presence of endogenous insulin it is effective only if there are some residual functioning pancreatic islet cells. Works by increasing insulin senstivity and reducing gluconeogenesis by the liver.
56
max dose metformin
2g daily
57
metformin renal impairment
avoid if eGFR <30
58
metformin MHRA safety advice - vitamin B12 levels
- B12 deficiency is a common SE in pt taking metformin, esp higher dose or longer treatment duration and RF
- check serum B12 levels if deficiency suspected and consider periodic monitoring in pt with RF
- counsel pt on signs and symptoms of B12 deficiency
## Footnote
fatigue, weakness, pale skin, numbness or tingling (especially in hands and feet), balance issues, memory problems, mood changes
59
which anti diabetic drug is safe to use in pregnancy and BF
metformin
60
common side effects of metformin
b12 deficiency, taste altered, GI disorder, abdominal pain, appetite decreased, diarrhoea, nausea, vomiting
61
metformin is contraindicated in
acute metabolic acidosis - incl lactic acidosis and DKA
62
metformin should be used with caution in pt with
risk factors for lactic acidosis
e.g. chronic stable HF (monitor cardiac function), concomitant use of drugs that can acutely impair renal function, interrupt treatment if dehydration occurs, avoid in conditions that can acutely worsen renal function, or cause tissue hypoxia
63
which drug has poorer anti-hyperglycaemic effect than many other anti diabetic drugs?
acarbose
64
meglitinides characteristics & name the one licensed for use in UK
- rapid onset of action and short duration of activity
- can be used flexibly around mealtimes and adjusted to fit around individual eating habits which may be beneficial to some pt
but generally they are less preferred than the SU
- repaglinide
