Diabetes

Question 1

Metformin

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 1

1. Biguanide
2. T2DM, anovulatory infertility in PCOS
3. Conv. tab: 500-1000mg TDS (3g max).
   CR tab: 500-2000mg OD. If >2g use conv. tab.
4. Renal fn - renally eliminated, must reduce if CrCL<90mL/min & increased risk of lactic acidosis due to accumulation of metformin.
   Liver fn - avoid in severe hepatic impairment due to MOA.
   VitB12
   Blood glucose, esp when switching to fixed dose combo w/glibenclamide bc not bioequivalent.
   Lactic acidosis signs
5. Take with food.
   LABELS: 10a, B, A- for CR tabs,
   Alcohol - limit, have with food, avoid binge drinking.
   Weight loss
   Exercise and diet benefits.
   Hypoglycaemia
   Tell Dr immediately if you have loss of appetite, N&V, abdo pain, cramps, extreme fatigue, diarrhoea or weight loss (Lactic acidosis signs).
   S/Es: malabsorption vitB12, anorexia, lactic acidosis, acute hepatitis

Question 2

Gliclazide, Glibenclamide, Glipizide, Glimepramide

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 2

1. Sulfonylureas
2. T2DM, C/I in T1DM as increases pancreatic insulin, FIRST LINE for maturity-onset diabetes of the young.
3. 40-320mg d in 1-2 doses.
   CR tabs: 30mg OD, increase by 30mg at 2-weekly to max 120mg.
   Glibenclamide - in combo w/metformin 1.25-5mg
   Glipizide - 2.5-40mg d in 1-2 doses, >15mg d should be divided.
   Glimepramide - 1mg OD, increase by 1mg at 1-2-weekly to max 4mg OD.
   Increasing dose doesn’t do much better to combine agents.
4. Renal fn - increased risk of hypoglycaemia
   Liver fn - avoid in severe hepatic impairment, can cause heptotoxicity.
   Hypoglycaemia - risk increased by elderly, renal or hepatic impair and interacting drugs.
   Bloods - can cause blood disorders (thrombocytopaenia, agranulocytosis, etc)
   SJS, photosensitivity
   Avoid in bfeeding.
5. Can cause weight gain, hypoglycaemia- watch out for signs and smx, metallic taste in mouth
   With food- for hypo.
   Alcohol - limit, have with food, avoid binge drinking.
   Weight loss
   Exercise and diet benefits.
   HYPOGLYCAEMIA
   Tell Dr immediately if you have pale stools, dark urine, jaundice.
   LABELS: 10a. B

Question 3

Linagliptin, Saxagliptin, Sitagliptin, Alogliptin, Vildagliptin

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 3

1. DPP4-Inhibitors (dipeptidyl peptidase 4 inhibitors) - increase incretin thus increase glucose dependent insulin secretion and reduce glucagon production.
2. T2DM
3. All given OD except vitagliptin OD-BD.
   Sitagliptin (Januvia) - 100mg OD, (Janumet) - 1 tab BD or XR 1 tab OD
   Linagliptin (Trajentamet, Trajenta) - 5mg OD
   Alogliptin= 25 mg once daily.
   CrCl 30–50 mL/minute, 12.5 mg once daily.
   CrCl <30 mL/minute, 6.25 mg once daily.
   Fixed-dose combination with metformin= 1 tablet (of any strength) twice daily.
   Vildagliptin= 50 mg BD.
   CrCl <60 mL/minute, 50 mg once daily.
   With metformin, pioglitazone or insulin, 50 mg once or twice daily.
   With a sulfonylurea, 50 mg once daily.
   With metformin and a sulfonylurea, 50 mg twice daily.

Fixed-dose combination with metformin= 1 tablet (of any strength) twice daily.

Patients stabilised on each drug separately, start with the current daily doses of vildagliptin and metformin.

To add vildagliptin, start with the tablet corresponding to the current metformin dose.

4. Renal fn - reduces excretion of DPP4Is.
   Sitagliptin - most renally CLd (Janumet, Januvia)
   Linagliptin- Trajentamet, Trajenta
   Liver fn - avoid in severe hepatic impairment, can cause heptotoxicity.
   Avoid in bfeeding and preg.
   Bullous pemphigoid
   Hypoglycaemia -ONLY w/sulfonylureas or insulin and by elderly, renal or hepatic impair and interacting drugs.
   musculoskeletal pain
   pancreatitis
5. Can cause hache, constipation, stomach discomfort, muscle pain.
   With (combo w/metformin) OR without food.
   Alcohol - limit, have with food, avoid binge drinking.
   Weight loss
   Exercise and diet benefits.
   Hypoglycaemia
   Tell Dr if you have severe joint or abdo pain, low blood sugar smx, develop blisters (bullous pemphigoid).
   LABELS: 10a.

Question 4

Dulaglutide, exenatide (60 doses= lasts a month_, liraglutide

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 4

1. GLP1-analogues (glucagon-like peptide 1 analogues) - act like incretin to increase glucose dependent insulin secretion and reduce glucagon production.
   Delay gastric emptying, which slows glucose absorpiton and decrease appetite.
2. T2DM, SAXENDA used as an adjunct to lifestyle modification in obesity BMI>30.
3. Trulicity (ready to use dulaglutide) - 1.5mg subcut once a week.
   Byetta (ready to use exenatide) - 5-10microg BD within 60mins before morn and even meals. Increase if tolerated after 1/12. meals need to be >6 hours apart
   Bydureon (need to mix beforehand exenatide)- 2 mg inject once a week at the same time each week with or without a meal.
   T2DM - Victoza (liraglutide) - subcut 0.6mg OD at same time each day. Max 1.8mg d.
   OBESITY - Saxenda (liraglutide) - subcut 0.6mg OD at same time each day. Max 3mg d.
4. Avoid in bfeeding and preg.
   Hypoglycaemia - ONLY risk increased when used with sulfonylureas or insulin and by elderly, renal or hepatic impair and interacting drugs.
   Stop SAXENDA if after 12 weeks <5% weight loss
   GORD, dyspepsia, fatigue, hypoglycaemia, small increase in HR and anti-drug antibodies - may not be clinically sig, weight loss (decreased appetite).
   Rarely pancreatitis, cholecytitis, cholelithiasis, acute renal failure and worsen CKD.
5. Commonly causes nausea and sometimes vomiting or diarrhoea when you start taking it, but this usually reduces/stop within a short time. If affected, drink plenty of fluids to avoid dehydration.
   With or without food.
   Alcohol - limit, have with food, avoid binge drinking.
   Weight loss
   Exercise and diet benefits.
   Hypoglycaemia
   Tell Dr if you have develop unexplained severe abdo pain.
   LABELS: 6, 7b 10a.
   Exenatide can make you feel jittery, taste disturbance and alopecia. Antibodies develop in 50% of pts.

Question 5

Dapaglifozin, empaglifozin, ertuglifozin

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 5

1. SGLT2 inhibitors (sodium glucose co-transporter 2 inhibitors) - reduce glucose reabsorption in the kidneys and increasing excretion in urine
2. T2DM
3. Dapa - 10mg OD (FORGIXA) or Xigduo
   Empag - 10mg OD, max 25mg (JARDIANCE, JARDIAMET)
   ertuglifozin= initially 5-15 mg once daily.
4. Renal fn - efficacy dependent bc of MOA. Check before start tx. Increased risk of #s.
   Avoid in bfeeding and preg.
   Hypoglycaemia - risk increased when used with sulfonylureas or insulin and by elderly, renal impair and interacting drugs.
   Avoid in ppl taking loop diuretics, elderly due to increased risk of volume depletion.
   VERY IMPORTANT= euglycaemic ketoacidosis - CAUSED BY DEHYDRATION, renal impair, constipation, UTI, dehydration.
   Euglycaemic ketoacidosis
   Empagliflozin ↓ risk of hospitalisation for HF failure, CV death and overall mortality, and slowed the progression of kidney disease.
5. Hypoglycaemia
   Your urine will test +ve for glucose while you take this.
   Make sure you drink enough water to control your thrist, in order to avoid dehydration.
   Both men and women may be more likely to get genital infections eg: thrush. Maintaining good hygiene is important to reduce this chance.
   With or without food.
   May increase effects of diuretics.
   Alcohol - limit, have with food, avoid binge drinking.
   Weight loss
   Euglycaemic ketoacidosis

Exercise and diet benefits.
LABELS: 10a. 21, A

Question 6

Acarbose

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

Answer 6

1. Antihyperglycaemic
2. T2DM
3. 50mg OD- 100mg TDS, MAX 600mg d. Swallow whole immediately before or w/first few mouthfuls of food
4. HYPOGLYCAEMIA - GIVE GLUCOSE NOT SUCROSE ABSORPTION IS DELAYED.
   C/I in pts w/intestinal obstruction, IBD, GI/malabsorption disorders.
   Renal fn
   Hepatic fn - hepatotoxic
   Avoid preg, low BA in breastf but should be safe.
   Plasma aminotransferase concs each month of first 6/12. Decrease dose if they are high, monitor weekly until concs return to normal. Stop tx if elevations persist.

5. LABEL: A, 10a, B
Hypoglycaemia
Abdo discomfort (farts, diarrhoea, pain)
Weight loss
Exercise and diet benefits.
skin reactions
Tell dr if swellin in legs or face, you are not going to the toilet (ileus).

Question 7

Insulins

1. Drug class
2. Indication
3. Dosage range, Frequency and best admin time
4. Monitoring
5. Counselling

↑↓△

mixed= bolus and basal

Answer 7

1. Insulins
2. T1DM, T2DM, Gestational diabetes- safe to use in preg and bfeeding
3. Dosage range, Frequency and best admin time
   All 100 units/mL except- Humalog U200 KwikPena= 200 units/mL AND Toujeo SoloStara= 300 units/mL

4. Monitoring
BSLs
HBA1c
Diabetic ketoacidosis
Hypoglycaemia (below), weight gain, allergic reactions, Local reactions including erythema, itching, Lipodystrophy, lipoatrophy
Safe in preg and breastfeeding.

5. Counselling
   Alcohol- ↑ BSLs, mask warning smx of hypoglycaemia, Avoid binge drinking, eat, limit.
   Weight gain
   Exercise and diet benefits.
   Hypoglycaemia- family, friends, signs- recognise and tx
   Hypoglycaemia-
   The most frequent and serious adverse effect; may occur with excessive dosage, delayed or insufficient food, increased physical activity. Warning symptoms may include sweating, hunger, faintness, palpitations, tremor, lip tingling, headache, visual disturbance, confusion and altered mood.
   Diabetes educator

Check BSLs before driving, long trips, and recheck at least Q2H.

Insulin is injected under the skin (subcutaneous injection) usually in the abdomen, or less commonly in the thigh, upper arm or buttock.
Rotate injection sites in the same general area to prevent damage to the fat and tissues under the skin (called lipodystrophy).

Use short-acting insulin 30 minutes before meals. Use ultra-short-acting insulin immediately before a meal (within 15 minutes) unless your doctor tells you otherwise.

If your insulin has been in the fridge, allow it to stand at room temperature for about 30 minutes before using it (cold insulin may be more painful to inject).

Gently roll and invert vials and cartridges of cloudy insulin in hands before use to ensure it is evenly mixed (it should look white and uniformly cloudy).

When mixing insulins, draw up short-acting insulin into the syringe first to avoid contaminating the vial with long-acting insulin.
Do not mix insulin detemir, insulin glargine or faster-acting insulin aspart with other insulins.

storage of insulin is in the fridge. can stay out of the fridge for 28 days <25 degrees.
Mixed= you must role, they are cloudly.
Normal ones short or long should be clear.
Inject at 90 degrees. Don’t rub after.

Question 8

General counselling

Answer 8

HBA1c 
BSLs
hypoglycaemia
renal fn
feet 
eyes 
BP
lifestyle
exercise
alcohol
Diabetes educator
Label 10a- pressure on kidneys

Question 9

Pioglitazone

Answer 9

Makes body more sensitive to insulin.

2. Type 2 diabetes, alone or with: metformin and/or a sulfonylurea or insulin
3. Oral, 15–30 mg once daily; may be increased to a maximum dose of 45 mg once daily after 6–8 weeks of treatment if effect is inadequate.
4. Tell your doctor immediately if you have swollen feet or ankles, breathlessness, nausea, vomiting, abdominal pain, fatigue, loss of appetite or dark urine. Also tell your doctor if you notice blood in your urine or painful urination.
   Can cause HF, or worsen existing HF.
   Osteoporosis (or risk factors)—pioglitazone may increase risk of fracture.
5. Women, the manufacturer recommends starting with 15 mg once daily (because oedema has been reported more frequently in females).

With insulin, start with 15 mg once daily and monitor carefully.

Heart failure (NYHA class I), start with 15 mg once daily; wait several months before increasing dose.

5. Common (>1%)
   peripheral oedema, weight gain, headache, dizziness, arthralgia, decrease in haemoglobin and haematocrit, myalgia

Infrequent (0.1–1%)
fractures (particularly non-vertebral fractures in women)

Rare (<0.1%)
elevated liver enzymes, hepatocellular injury, heart failure, pulmonary oedema, macular oedema, elevated creatine kinase

Question 10

Glucagon

Answer 10

Hypoglycaemia

3. Hypoglycaemia
   Adult, child >25 kg, SC/IM/IV 1 mg.

Child <25 kg, SC/IM/IV 0.5 mg.

Diagnostic aid
Adult, IV/IM 0.2–2 mg depending on radiological technique and route.
Must be reconstituted

4. Vital signs
BSLs
HBA1C
GP/DIabetesPregnancy
Safe to use.

Breastfeeding
Safe to use.
Insulinoma—contraindicated; hypoglycaemia may be exacerbated by glucagon-induced insulin secretion.

Phaeochromocytoma—contraindicated; may stimulate release of catecholamines causing acute severe hypertension.

Glucagonoma—contraindicated.

Chronic hypoglycaemia, adrenal insufficiency, starvation, alcohol-induced hypoglycaemia—glucagon is ineffective.

5. Make sure that your friends and family know how to recognise low blood glucose (hypoglycaemia) and how to give glucagon injection; ask your doctor or diabetes educator if you are unsure.

Hypoglycaemia
response to glucagon should occur within 10 minutes; if there is no response, give IV glucose
give complex carbohydrates orally when person has responded to prevent recurrent hypoglycaemia

nausea, vomiting, hypokalaemia (large doses), allergic reactions