Basic class of treatments use for:
A. T1DM
B. T2DM
A. T1DM -> insulin
B. T2DM -> oral hypoglycaemic agents, noninsulin injectable therapies, insulin
Target of fasting and pre-meal capillary blood glucose readings
4 - 7 mmol/l
The target of HbA1c (glycated hemoglobin) - for a diabetic person
48-53 mmol/mol
(but should be individualized - e.g. more tight for a young person with many years ahead to live with diabetes)
short-acting insulin: (times)
- duration of action
- onset of action
Duration: 3-5 hrs
Onset: 30 mins
Rapid-acting insulin (times):
- duration of action
- onset of action
Duration 3-5 hrs
onset 15 mins
Intermediate-acting insulin (times):
- duration of action
- onset of action
Duration: 12-16 hrs
Onset: 1-3 hours
Long-acting insulin - times:
- duration of action
- onset
Duration: 20-24 hrs
Onset: 1hr
Pre-mixed insulin (times)
- duration of action
- onset
- duration 12-16 hours
- onset 30 mins
What types of insulin are mixed in pre-mixed insulin? (2)
rapid + intermediate
What are the characteristics of rapid-acting insulin?
Act faster and have shorter lasting effects (than soluble insulin)
What’s a basal-bolus regimen?
- rapid/short-acting ‘bolus’ insulin before meals
WITH
- intermediate/long-acting ‘basal’ insulin once or twice daily
What is a typical therapy with insulin?
Basal-bolus
(2) names of rapid-acting insulin
- insulin aspart: NovoRapid
- insulin lispro: Humalog
(2) names of short - acting insulin
soluble insulin examples:
- Actrapid
- Humulin S
(1) type of immediate - release insulin
- isophane insulin
(2) names of long-acting insulin
- insulin determir (Levemir): given once or twice daily
- insulin glargine (Lantus): given once daily
What pre-mixed preparations contain in general?
combine intermediate-acting insulin with either a rapid-acting insulin analogue or soluble insulin
Name (4) examples of pre-mixed preparations
- Novomix 30
- Humalog Mix25
- Humulin M3
- Insuman Comb 15
Possible routes of administration of insulin
- SC- the majority of the patients, I rotate injection sites to prevent lipodystrophy
- Insulin pumps - ‘continuous subcutaneous insulin infusions’ which delivers a continuous basal infusion and a patient-activated bolus dose at meal times
- Intravenous insulin - used for patients who are acutely unwell (e.g. DKA) w
- Inhaled insulin is available but not widely used
- Oral insulin analogues are in development but have considerable technical hurdles to clear
What are (2) insulin regimens used in the management of diabetes type 1 - general names of regimens
- twice daily (rarely)
- basal bolus
What insulins are used in once daily insulin regimen
- long acting
- intermediate acting
What insulins are used in twice daily insulin regiment? (1)
Pre-mixed (with breakfast and main evening meal)
What insulin is used in a basal-bolus insulin regimen?
- Basal - once daily (rarely twice daily)
- Bolus - with each meal
What’s the disadvantage of twice daily insulin?
Twice daily insulin = pre-mixed insulin
Disadvantage: patient needs to have 4 regular meals, roughly at the same time, every day without fail
How much insulin do you give in ‘carbohydrate counting’
Carbs counting - possibly with basal-bolus
1 unit of insulin with 10 units of carbs
Do we worry about kidney in the insulin Rx?
Yes, in AKI, then we need dose reduction (otherwise hypoglycaemia) due to reduced excretion by kidney
Do we need to worry about LFTs in insulin use?
No
(the only contraindication to insulin use is if someone is allergic to insulin)
What med belongs to biguanide class?
How does it work?
Metformin
MoA: reduces insulin resistance
SEs of Metformin use (3)
- GI upset
- lactic acidosis
- B12 deficiency
What meds belong to Sulphonylurea class? (3)
- Gliclazide
- Glimepiride
- Glibenclamide
MoA of Sulphonylureas
Increase insulin secretion
SE (1) of sulphonylureas
hypos
What drug belongs to Thiazolidinedione class?
Pioglitazone
MoA of Pioglitazone
decrease insulin resistance
SEs of Pioglitazone (2)
- fluid overload
- fractures
Drugs that belong to DPP4 inhibitors class (3)
- Sitagliptin
- Saxagliptin
Linagliptin
How do DPP4 inhibitors work?
Decrease incretin hormone degradation (so more incretins as a result)
What drugs belong to class SGLT2 inhibitors? (3)
- Dapagliflozin
- Canagliflozin
- Empagliflozin
SEs of SGLT2 inhibitors (3)
- UTI
- Trush
- DKA
What class of drugs is a non-insulin injectable therapy?
GLP-1 agonist
e.g. exenatide, lixisenatide etc
MoA of GLP-1 agonist
Example: GLP-1 agonist is Exenatide
MoA: Mimic incretin hormone (GLP-1)
so: increase in insulin, decrease in glucagon, decrease in gut motility, decrease food intake
Benefits of use of Exenatide (2)
- cardioprotective
- weight loss
Exenatide
- SEs
- cautions
- GI disturbance
- caution: bowel disease, liver disease
What are NICE criteria for initiation of Exenatide
poor control + BMI >35
OR
BMI <35 but: weight loss would be beneficial, occupational consideration
AND continuation of targets (different flashcard)
What are targets for continuation of Exenatide Rx
HbA1c reduction of 11 mmol/mol + weight loss 3% in 6 months