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Flashcards in General Medicine Deck (33)
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1

Biguanide MoA

Decerase insulin resistance and hepatic glcose production.
Limit weight gain.

2

Biguanide Efficacy

• 1-2%
• Can be used with others
• Little side effects
• Low cost
• No hypoglycaemia

3

Biguanide side effect

• Little or no weight gain
• GI
• Lactic acidosis (with resp, CVD, Renal) HRH
• Vit B12 (absorption)

4

Sulphonylureas drugs used`

Gliclazide
Glibenclamide
Glimepiride
Tolbutamide

5

Sulphonylureas MoA

Stimulate B cells to release insulin. Antagonise B cell K/ATP channel activity, increase in K (as it accumulates) so depolarisation. Increased Ca, increased release

6

Sulphonylureas efficacy

• 1-2%
• Low cost
• Tolbutamide has good post prandial control as it has a short half life so taken 30mins before.
• Others have higher half life and more potent

7

Sulphonylureas side effect

• Weight gain
• Hypoglycaemia (especially CKD)

8

Glitazone (TZDs) example

Pioglitazone

9

Glitazone (TZDs) MoA

Increase sensitivity in muscle and adipose tissue. (via upregulation of signals/ genes)

10

Glitazone ADRs

• Wegith
• Fluid (HF)
• Bone metab (osteoporosis)
• Bladder cancer
• Hoever don’t get hypos
• Increase in LDL and HDL
Rarely used now

11

Describe Gliptins and e.gs

Sitagliptin
Vildagliptin
Saxagliptin
Linagliptin
• 0.5-0.8
• Weight loss

12

Gliptins ADRs

• GI symptoms
• High cost so 2nd line
• Infection
Pancreatitis
Hypos rare

13

GLP-1 agonists e.g.s MoA, efficacy

Exenatide Liraglutide
GLP from intestine increases insulin secretion and biosynthesis, decreases glucagon secretion, decreases liver glucose production (indirectly).
Decreases satiety, decreases gastric emptying.
Increases glucose uptake into muscles (indirect)
1-=1.5%

14

GLP-1 ADRS

• GI, nausea, loose stools, diarrhoea
• GORD
• Painful to inject

15

SGLT2 e.g.s

Dapagliflozin
Canagliflozin
Empagliflozin

16

SGLT2 MoA and efficacy

Prevents glucose absorption in the the PCT by SGLT2 (90%)
0.5-1%

17

SGLT2 ADRS

• Only one extra void a day
• UTI, thrush
• Polyuria
• Hypo (low risk)
Urosepsis
One one episode of above

18

Rapid acting insulin onset and name

Insulin Aspart (Novorapid)
Insulin Lispro (Humalog)
Insulin Glulisine (Apidra)
o 5-15
P: 30-60min
D: 3-4hr

19

Short acting

Humulin S
Actrapid
Insuman Rapid

O: 30-60
P: 2-3
D: 6-8

20

Intermediate acting

Humulin I
Insuman Basal
Insulatard
Isophane (NPH)

O: 1-2
P: 4-6
D: 14-16h

21

Long acting

Insulin glargine (Lantus); Abasaglar
O: 2-4h
No peak
D@ 20-24h

Insulin Detemir (levimer) Analogue
O:2-4
P: 6-14
D: 16-20

22

Importance of insulin Toujeo(R)

High strength insulin
Basal once daily
exlusive units
Glargine but flatter peak than other glargine products e.g. Lantus
Always prescribe by brand name and include the concentration of insulin

23

What is Degludec

Long acting
U100 and U200

24

What is Humulin R (resistant)

Very potent
U500 - 5x stronger than normal insulin
For insulin resistant patients
Normally TDS before meals
Prescribed in marks not U
Marks based on 0.3 or 0.5ml insulin syringe. 1 mark = 0.01ml = 5 units

25

Who needs insulin infusion?

DKA
HHS - Hypersmolar hyperglycaemic state
Surgical patients - NBM and missing more tna one meal
Vomiting
Major vasc event - ACS and Post CVA
TPN/ entral fed patients
Steroid use
Metabolically unwell not eating and drinking
-most cortisol related

26

Difficulties of IV insulin

x

27

Limitations to IV insulin

x

28

Practical aspects of IV insulin. What would you do?

To make 50 units of Human Actrapid
50 units of actrapid and 49.5ml of NaCl aline ina 50ml luer lock syringe so conc of 1unit/1ml
Non returnable valve
No more than 24 hrs as crystalises
Volumetric pump used
Rate used that gives 6-10mmols/L of glucose
Discard after 24hrs
In most cases needs substrate (glucose)
Different degrees of insulin sensitivity accounted for
Patients have different sensitivities to insulin to adjust accordingly related to weight, concurrent illness and medication (steroids)
Tables for rate guides
CBGs done hourly for first 24h

29

Ketone monitoring in IV insulin

Monitor ketones in T1 if glucose >12 on 2 readings 1 hr apart
T2 - Monitor if unwell, get a baseline

30

Treatmeny of hypos from IV insulin

CBG <4mmols/L
Stop insulin
Give 75mls of 20% glucose IV over 15 minutes or equivalent
Repeat CBG and if needed treatment
Once above 4mmol/L restart IV insulin with a review of dose