Diabetes drugs

Question 1

What insulin syringes are in common use

Answer 1

1 ml syringes, containing a maximum of 100 units insulin

• 0.5ml containing a maximum of 50 units
• 0.3ml Paediatric syringes containing a maximum of 30 units insulin

Question 2

why is it important to use a specific insulin syringe to give insulin

Answer 2

If an ordinary syringe is used and 1ml is drawn up for each unit of insulin, 100 x the intended dose will be given, carrying a high risk of a fatal error.

0.1ml carries 10 units
1ml carries 100 units

Insulin syringes have graduations only suitable for calculating doses of standard 100 units/mL

Question 3

what information do you need to prescribe a pts insulin

Answer 3

need the box to see the exact name - they may refer to ‘humalog’ but mean humalog 25’ which are very different

Question 4

should pts self-administer insulin whilst in hospital

Answer 4

Many patients are competent to self - administer their insulin. Self administration of insulin will ensure that that the patient receives

• The right insulin
• At the right time
• In the right dose

Self administration of insulin should be encouraged providing:

• The patients is assessed and considered competent
• The insulin is stored in a locked medicine cabinet (by the patient’s bed if available)
• Sharps disposal is available to the patient
• The nurse checks that each dose has been administered and documents code 7 in the administration record

Question 5

sites for subcut insulin inj

Answer 5

abdomen, buttocks, thighs

Avoid arms as there is a risk of intramuscular injection which may lead to hypoglycaemia
Avoid fatty/lumpy injection sites, as these will interfere with insulin absorption

Question 6

what to do if an insulin pump becomes disconnected

Answer 6

• if an insulin pump becomes disconnected, the patient will lack insulin very quickly and is at risk of developing ketoacidosis
• subcutaneous insulin should be given promptly if pump disconnected or malfunction suspected
• all patients should be referred promptly to the diabetes team

Question 7

if a person has DKA and has a pump, how do you deliver insulin?

Answer 7

if a patient is admitted with diabetic ketoacidosis he/she should be treated as usual with intravenous insulin

• do not rely on the pump to deliver insulin, it may not be functioning

Question 8

Which diabetes drugs are biguanides

Answer 8

metformin

Question 9

moa metformin

Answer 9

Increases insulin sensitivity. Activates AMP kinase in the liver which reduces gluconeogenesis and increases insulin sensitivity

Question 10

benefit of metformin over other diabetes drugs

Answer 10

Doesn’t cause weight gain or hypos

Question 11

adverse effects metformin

Answer 11

diarrhoea, vomiting, nausea, anorexia, taste disturbance, lactic acidosis

Question 12

in what scenarios should you stop metformin

Answer 12

Can cause lactic acidosis - this is amplified during aki as it builds up.

Withhold metformin in aki, 48 hours prior to having IV radio contrast (as can cause aki), not eating and drinking, if raised lactate

Question 13

dosing metformin

Answer 13

500mg 2-3 times per day

Question 14

drug monitoring metformin

Answer 14

U&E and eGFR should be checked before starting metformin and at least once per year (twice in renal imp)

Question 15

patient communication metformin

Answer 15

Take metformin with food to reduce the chances of feeling sick. It may also help to slowly increase your dose over several weeks.

Question 16

name some SGLT-2 inhibitors

Answer 16

canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin,

think S = Z

Question 17

dapagliflozin, drug class?

Answer 17

SGLT-2 inhibitor

Question 18

pioglitazone drug class?

Answer 18

glitazones

Question 19

gliclazide drug class

Answer 19

sulfonylurea

Question 20

tolbutamide drug class

Answer 20

sulfonylurea

Question 21

sitagliptin drug class

Answer 21

DPP4 inhibitor

Question 22

metformin drug class

Answer 22

biguanide

Question 23

epagliflozin drug class

Answer 23

SGLT-2 inhibitor

Question 24

name DPP4 inhibitors

Answer 24

Alogliptin, Linagliptin, Sitagliptin, Saxagliptin, Vildagliptin

D=T

Question 25

name 3 sulfonylureas

Answer 25

gliclazide, Glibenclamide, Tolbutamide

Question 26

Glibenclamide, drug class?

Answer 26

sulfonylurea

Question 27

MoA SGLT-2 inhibitors

Answer 27

eg canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin,

Reversibly inhibits sodium-glucose co-transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.

Question 28

adverse effects SGLT-2 inhibitors

Answer 28

such as dapagliflozin

genital candida, increased risk of UTI, mild diuretic, DKA, EKA. Back pain; balanoposthitis; cystitis; dizziness; dyslipidaemia; hypoglycaemia

Question 29

when to stop an SGLT-2 inhibitor such as dapagliflozin

Answer 29

UTI/pyleonephritis

If admitted to hospital when unwell - as associated with DKA and EKA!!!!!

dehydrationm diarrhoea etc

Question 30

benefit of SGLT2 inhibitors over other diabetes drugs

Answer 30

improves cardiovascular outcomes and promotes weight loss

Question 31

drug monitoring and patient communication SGLT-2 inhibitors

Answer 31

check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if:
They have had a previous episode of DKA.They are unwell with intercurrent illness. They are following a very low carbohydrate or ketogenic diet. Advise adults with type 2 diabetes who are taking an SGLT-2 inhibitor about the need to minimizse their risk of DKA by not starting a very low carbohydrate or ketogenic diet without discussing it with their healthcare professional, because they may need to suspend SGLT-2 inhibitor treatment.

Monitor renal function

Question 32

MoA DPP4 inhibitors

Answer 32

Inhibits dipeptidylpeptidase-4 to increase insulin secretion and lower glucagon secretion. (increase the incretin effect)

Question 33

contraindications to DPP4 inhibitors

Answer 33

Ketoacidosis.

Hepatic impairment — avoid vildagliptin; avoid saxagliptin and alogliptin if severe hepatic impairment.

Heart failure — avoid vildagliptin if severe heart failure; avoid alogliptin if moderate-to-severe heart failure.

Question 34

drug monitoring DPP4 inhibitors

Answer 34

LFT and U&E

Before starting treatment with saxagliptin, vildagliptin, or alogliptin:Check liver and kidney function. For vildagliptin, monitor LFTs at 3 monthly intervals. For saxagliptan and alogliptan, monitor renal function.

Question 35

what dpp4 inhibitors are contraindicated in heart failure

Answer 35

avoid vildagliptin if severe heart failure; avoid alogliptin if moderate-to-severe heart failure.

Question 36

adverse effects dpp4 inhibitors

Answer 36

PANCREATITIS

GI constipation, vomiting, nausea, diarrhoea, dyspepsia, gastritis, and gastro-oesophageal reflux. Acute pancreatitis (pancreas is stimulated)Hepatic — hepatitis and hepatic failure (with vildagliptin and alogliptin, rare).Nervous system — headache, dizziness, and tremor (common with sitagliptin, saxagliptin, vildagliptin, and alogliptin).

Question 37

what is the incretin effect

Answer 37

The incretin effect describes the phenomenon whereby oral glucose elicits higher insulin secretory responses than does intravenous glucose, despite inducing similar levels of glycaemia, in healthy individuals. Type 2 diabetics have a decreased incretin effect

Question 38

MoA glitazones

Answer 38

reduces peripheral insulin resistance, leading to a reduction of blood-glucose concentration.

Question 39

adverse effects glitazones

Answer 39

fluid retention, heart failure, fluid retention, increased risk of bladder cancer, weight gain, Numbness, visual impairment, weight increase, insomnia.
Increased risk of bone fractures.

Question 40

when should you stop glitazones

Answer 40

stop in fluid overload and known or suspected bladder cancer

Question 41

drug monitoring glitazones

Answer 41

Before initiation monitor LFTs, risk of heart failure and bladder cancer and osteoporosis.

Monitor LFTs periodically, based on clinical judgement.

Monitor for signs and symptoms of heart failure, such as weight gain or oedema.
Monitor LFTs periodically, based on clinical judgement.

Question 42

contraindications glitazones

Answer 42

heart failure as can cause fluid retention, uninvestigated macroscopic haematuria, previous or active bladder cancer, hepatic impairment.

Question 43

MoA sulfonylureas

Answer 43

Insulin secretagogues “spanc the panc” -They work by increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present. On a molecular level they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells.

Question 44

adverse effects sulfonylureas

Answer 44

hypoglycaemic episodes (more common with long-acting preparations such as chlorpropamide), weight gain, hyponatraemia secondary to syndrome of inappropriate ADH secretion, bone marrow suppression, hepatotoxicity (typically cholestatic), peripheral neuropathy

Question 45

when to stop sylfonylureas

Answer 45

hypoglycaemia

Question 46

insulin route

Answer 46

always s/c

except:
- iv in sliding scale using short acting insulins