diabetes treatment

Question 1

Treatment of diabetes 1

5

Answer 1

1. at dx start insulin immediately
2. structured education programme
3. DAFNE- dose adjustment for normal eating
4. diet modify: restrict refined sugars+ saturated fats but calorific intake not reduced
5. exercise

Question 2

diabetes 2 general treatment escalation

5

Answer 2

1. diet +exercise
2. oral monotherapy
3. oral combination
4. oral + insulin
5. Insulin

Question 3

contraindication for oral monotherapy

Answer 3

ketoacidosis

severe intercurrent illness

Question 4

indications for insulin therapy with type 2 diabetes

3

Answer 4

1. persistently elevated blood glucose and HBA1C on maximum doses of anti-diabetic drugs (secondary failure to anti-diabetic drugs)
2. symptoms of hyperglycemia and/or infections (eg candidiasis) (severe intercurrent illness)
3. metabolic complications (non-fasting ketonuria and hyperosmolar state)

Question 5

3 classes of anti-diabetic drugs

mechanism

Answer 5

1. augment supply of insulin on pancreatic beta cells
2. enhance insulin action and reduce resistance-liver, fat & muscle
3. delay carbohydrate absorption- gut

Question 6

4 drugs that augment insulin supply

Answer 6

1. sulfonylureas eg -zide
2. prandial glucose receptors (end in glinides)
3. incretin mimics (-tide, exenatide)
4. gliptins: DPP4 inhibitors so incretin increased

Question 7

2 drugs that enhance insulin action and reduce resistance at liver, fat and muscle

Answer 7

1. biguanide eg metformin

2. thiazolidineoides (eg pioglitazone)

Question 8

3 drugs that delay carb absorption

Answer 8

1. alpha glucosidase inhibitors (eg acarbose, miglitol)
2. incretin mimics
3. glicretics, SGLT2 inhibitors

Question 9

what is gliplizide

Answer 9

sulphonylurea

Question 10

how does gliplizide work

Answer 10

stimulates secretion of endogenous insulin by closing the K-ATP channel

Question 11

pros of gliplizide

Answer 11

reduces blood glucose level

well tolerated generally

Question 12

cons of gliplizide

Answer 12

• promotes weight gain
• need reduced dose in renal impairment
• risk of hypoglycaemia
• increased appetite

Question 13

action of metformin

Answer 13

biguanide

decreases hepatic glucose production and increases sensitivity of insulin in muscle

Question 14

pros of metformin

Answer 14

encourage weight loss
old and cheap
good at controlling blood glucose

Question 15

what anti-diabetic drug is first line

Answer 15

metformin

Question 16

cons of metformin

Answer 16

nausea

diarrhoea

Question 17

when is metformin contraindicated

Answer 17

in renal impairment (risk of lactic acidosis <30 egfr)

Question 18

when is gliplizide contraindicated

Answer 18

hepatic failure

but also reduce dose in renal impairment

Question 19

what are the 2 glucose prandial regulators

Answer 19

repaglinide (meglitinide)

notglinide (amino acid derivative)

Question 20

what is the action of repaglinide

Answer 20

insulin secreatogogues-direct effect on beta cells they stimulate rapid endogenous insulin release when given with meals

Question 21

side effects of repaglinide

Answer 21

weight gain

hypoglycaemia but lower risk than sulfonylurea

Question 22

how does acarbose work

Answer 22

alpha-glucosidase inhibitors, delay digestion of carbohydrates and slow down postprandial absorption of glucose

Question 23

cons of acarbose and miglitol

Answer 23

limited weight efficacy but can be used in combination

• Bloating
• flactulence

Question 24

how does miglitol

Answer 24

inhibitors, delay digestion of carbohydrates and slow down postprandial absorption of glucose

Question 25

how does pioglitazone work

Answer 25

thiazolidenoides - activates PPAR gamma nuclear receptors on adipose tissue - reduces insulin resistance in liver and muscle by lowering plasma FFA and increases adiponectin - enhances actions of endogenous insulin

Question 26

what does PPAR

Answer 26

peroxisome proliferated activated receptors= family of nuclear transcription factors regulating expression of genes involved in lipid and carbohydrate metabolism

Question 27

pros of pioglitazone

Answer 27

- effective - rare hypo - sustained improvements in HbA1C - potential benefits in fatty liver

Question 28

cons of pioglitazone

Answer 28

- slow onset of action 2-3 months - promotes weight gain - redistributes body fat to reduce visceral deposits - fluid retention- oedema - bladder cancer increase risk

Question 29

contraindication of pioglitazone

Answer 29

ci in cardiac failure and hepatic failure as may cause fractures

Question 30

what is the action of exenatide and liraglutide

Answer 30

mimics Glucagon like peptide 1 incretin mimic potent insulinotrophic hormone is released in response to meals, but lower in IGT stimulate glucose-dependent insulin secretion, suppresses glucagon secretion, slow gastric emptying, reduces food intake and improves insulin sensitivity

Question 31

how is exenatide given

Answer 31

injected

Question 32

pros of exenatide

Answer 32

- promotes weight loss - reduces appetite as feel fuller for longer - reduces risk of cardiac disease

Question 33

cons of exenatide

Answer 33

- nausea - hypo risk but rare unless given with SU - risk of pancreatitis - only available as injection

Question 34

how do gliptins work

Answer 34

DPP4 inhibitors dipeptidyl pepitdase enzyme so get more GLP-1 so enhance action on insulin

Question 35

what are gliptins given with

Answer 35

metformin

Question 36

what is exenatide often given with

Answer 36

metformin and SU

Question 37

Pros of gliptins

Answer 37

weight neutral safe in renal impairment modest reduction in HBa1C oral taken

Question 38

cons of gliptins

Answer 38

minimal hypo

Question 39

what action empaglifozin, canglifozin have

Answer 39

act at kidney to prevent glucose resorption | SGLT2 inhibitors

Question 40

pros of empaglifozin

Answer 40

``` weight loss BP reduction not assoc. to hypos CV mortality improved moderately effective ```

Question 41

cons of canglifozin

Answer 41

- can't be used if eGFR <45 or >60 - polyuria - care with hypoloaemia/ loop diuretics - glycosuria: leads to UTI and genital infections

Question 42

contraindication of canglifozin

Answer 42

>85

Question 43

what are the ultra short acting drugs insulin

Answer 43

novorapid humalog apidra

Question 44

how long are ultra short acting drugs

Answer 44

4 hours

Question 45

what are the short acting drugs

Answer 45

actrapid, humulin s, hypurin neutral

Question 46

what length are short acting drugs

Answer 46

6 hours

Question 47

what are the intermediate acting insulin drugs

Answer 47

insulatard humulin I hypurin isophane

Question 48

how long are intermediate acting insulin drugs

Answer 48

12 hours

Question 49

what are the fixed mixed insulin drugs

Answer 49

humulin M3 novomix 30 humalog mix 25 humalog mix 50

Question 50

what are the long acting insulin drugs

Answer 50

glargine (lantus) levemir (detemir) degludec

Question 51

long acting insulin drugs how long

Answer 51

18-36 hours

Question 52

what is an insulin analogue

Answer 52

substitution of single amino acid in insulin chain alters absorption characteristics of insulin time-action profile is modified by amino acid

Question 53

sick day rule

Answer 53

take 10% of insulin every 2 hours when ill

Question 54

what regimens of insulin are there

Answer 54

- basal-bolus (multiple injections) : short or fast acting insulin before meals then intermediate or long acting once daily - Twice daily: soluble or fast acting and isophane (NPH) insulins combined; free or fixed mix - once daily: intermediate or long acting insulin with diabetic drug

Question 55

when is intraperitoneal insulin used

Answer 55

in dialysate or renal failure

Question 56

complications of insulin

Answer 56

lipohypertrophy at insulin site

Question 57

side effects on insulin

Answer 57

``` hypoglycaemia weight gain lipohypertrophy peripheral oedeam insulin antibody form local allergy ```

Question 58

when is islet transplantation used

Answer 58

-impaired awareness of hypo in 1dm

Question 59

how is islet transplantation done

Answer 59

double donor transplants

Question 60

benefits of islet transplantation

Answer 60

insulin independence | establish awareness of hypos and glycaemic stability

Question 61

what add's have the highest efficacy

Answer 61

insulin 1st | SU, tzd, glp1

Question 62

highest hypo risk

Answer 62

insulin then su

Question 63

highest weight gain

Answer 63

insulin, SU, TZDs