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303 - Medicine > Non-insulin agents in T2DM > Flashcards

Non-insulin agents in T2DM Flashcards

1
Q

Diabetes mellitus

A
  • A syndrome of chronic hyperglycaemia due to relative insulin deficiency, resistance or both
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2
Q

Optimal blood glucose control

A

4-7 mmol/l before meals

<10 mmol/l 2 h after meals

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3
Q

When is HbA1c not appropriate

A
  • Young/pregnant
  • T1DM
  • Diabetes symptoms<2 months
  • Medication causing rapid glucose rise e.g. steroids, antipsychotics
  • Acute pancreatic damage inc. surgery
  • Genetic and haematologic factors
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4
Q

What can low HbA1c levels indicate

A
  • Deteriorating renal function

- Sudden weight loss

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5
Q

Metformin pharmacodynamics

A
  • Reduces hepatic production of glucose
  • Decreases intestinal absorption of glucose
  • Enhances insulin sensitivity by increasing both peripheral glucose uptake and utilisation
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6
Q

Metformin benefits

A
  • No hypoglycaemia

- Weight neutral

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7
Q

Metformin side effects

A
  • Anorexia
  • Abdominal pain
  • Metallic pain
  • Decreased vit B12 absorption
  • Metabolic acidosis
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8
Q

Metformin contraindication

A
  • Acute metabolic acidosis(including lactic acidosis and DKA)
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9
Q

Sulfonylureas pharmacodynamics

A
  • Stimulates beta cells of the islet of langerhans in the pancreas to release insulin
  • Enhances peripheral insulin sensitivity
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10
Q

Sulphonylureas side effects

A

Hypos, GI, weight gain, deranged LFTs

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11
Q

Thiazolidinediones (glitazones) pharmacodynamics

A

Pioglitazone enhances cellular responsiveness to insulin, increases insulin-dependent glucose disposal, and improves impaired glucose homeostasis

Pioglitazone is a selective agonist at peroxisome proliferator-activated receptor-gamma (PPARγ) in target tissues for insulin action such as adipose tissue, skeletal muscle, and liver.

Activation of PPARγ increases the transcription of insulin-responsive genes involved in the control of glucose and lipid production, transport, and utilization

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12
Q

What is pioglitazone associated with

A

Assoc. w increased risk of HF, bladder cancer + bone fracture – cautioned

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13
Q

How long does it take for pioglitazone to take full effect

A

8 weeks

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14
Q

Pioglitazone side effects

A

GI, headache, anaemia, weight gain, oedema, hypoglycaemia, altered lipids

Cont. if reduction of at least 0.5% HbA1c in 6 months

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15
Q

DPP-4 inhibitors and incretin analogues mechanism

A

Vildagliptin inhibits dipeptidyl peptidase-4 (DPP-4)

This in turn inhibits the inactivation of GLP-1 by DPP-4, allowing GLP-1 to potentiate the secretion of insulin in the beta cells.

Dipeptidyl peptidase-4’s role in blood glucose regulation is thought to be through degradation of GIP and the degradation of GLP-1

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16
Q

What is GIP synthesised by

A

K cells which are found in the mucosa of the duodenum and the jejunum of the GI tract

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17
Q

Effects of GIP

A
  • Weak inhibitor of gastric acid secretion

- Stimulates insulin secretion

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18
Q

Examples of glucagon-like peptide-1 receptor agonists

A
  • Exenatide, lireglutide, lixisenatide
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19
Q

When should GLP-1 agonists be continued

A
  • Only continue if beneficial metabolic response in 6 months
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20
Q

Features of glucagon-like peptide-1 receptor agonists

A

S/C injection
Caution in elderly + renal
Interaction - meds 1 hr before or 4 hrs after inj

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21
Q

Side effects of GLP-1 agonists

A

GI, weight loss, hypoglycaemia, pancreatitis, AKI

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22
Q

Examples of dipeptidylpeptidase-4 inhibitors

A
  • Alogliptin, vildagliptin
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23
Q

When should DPP-4 inhibitors be continued

A
  • Sitagliptin/vildagliptin should cont. if reduction of at least 0.5% HbA1c in 6 months
  • Liver + renal reduce dose
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24
Q

Side effects of DPP-4 inhibitors

A

GI, peripheral oedema, pancreatitis

25
Q

SGLT2 inhibitors mechanism

A
  • SGLT2 inhibitors inhibit sodium glucose 2 co-transporters
  • The results are decreased kidney reabsorption of glucose, glucosuria effect increases with higher level of glucose in the blood circulation
  • Therefore, dapagliflozin reduces the blood glucose concentration with a mechanism that is independent of insulin secretion and sensitivity, unlike many other antidiabetic medications
  • Functional pancreatic β-cells are not necessary for the activity of the medication so it is convenient for patients with diminished β-cell function
26
Q

Where are SGLT1 proteins expressed

A
  • Intestine, trachea, kidney, heart, brain, testes, prostate
27
Q

Where are SGLT2 proteins expressed

A
  • Kidney, brain, liver, thyroid, muscle, heart
28
Q

Where is SGLT2 primarily expressed

A

SGLT2 is mainly expressed in the kidneys on the epithelial cells lining the first segment of the proximal convoluted tubule

29
Q

SGLT1 vs SGLT2 in terms of responsibility for glucose reabsorption

A

SGLT2 - 90%

SGLT1 - 10%

30
Q

Examples of SGLT2 inhibitors

A
  • canagliflozin, dapagliflozin
31
Q

SGLT2 cautions

A
  • Caution in volume depletion, CVD, liver, renal
32
Q

SGLT2 side effects

A
  • GI, dyslipidaemia, urinary, dehydration
33
Q

What is dapaglifozin not recommended in combination with

A
  • Not recommended in combination with pioglitazone
34
Q

What is alpha glucosidase

A
  • Enzyme located in the brush border of the small intestine that acts on alpha(1-4)bonds
  • Alpha glucosidase breaks down starch and disaccharides into glucose
35
Q

Example of alpha glucosidase inhibitor

A
  • Acarbose
36
Q

Mechanism of acarbose

A
  • Inhibits alpha glucosidase
  • Also blocks pancreatic alpha-amylase
  • Delays glucose absorption from gut after CHO meal
  • In diabetic patients, the short-term effect of these drug therapies is to decrease current blood glucose levels; the long-term effect is a reduction in HbA1c level.
37
Q

When should acarbose be avoided

A
  • Liver and renal impairment
38
Q

Side effects of acarbose

A
  • Nausea and vomiting
  • Diarrhoea
  • Flatulence
  • Hypos with sulphonylureas
39
Q

What should be monitored with acarbose usage

A
  • Hepatic function
40
Q

Meglitinides mechanism of action

A
  • Bind to an ATP-dependent K+(Katp) channel on the cell membrane of pancreatic beta cells in a similar manner to sulphonylureas
  • Have a weaker binding affinity and faster dissociation from the SUR1 binding site
  • This increases the concentration of intracellular potassium, which causes the electric potential over the membrane to become more positive.
  • This depolarization opens voltage-gated Ca2+ channels. The rise in intracellular calcium leads to increased fusion of insulin granula in the cell membrane, and therefore increased secretion of (pro) insulin.
41
Q

Effect of meglitinides

A
  • Stimulate insulin secretion in presence of glucose

- Rapid onset and short duration

42
Q

Meglitinides cautions

A
  • Elderly

- Driving

43
Q

Side effects of meglitinides

A
  • Hypoglycaemia(lower risk than SU)

- GI

44
Q

When are meglitinides more effective

A
  • Nateglinide activity is dependent on the presence functioning β cells and glucose(no effect in the absence of glucose)
  • Potentiates the effect of extracellular glucose on ATP-sensitive potassium channel and has little effect on insulin release between meals and overnight
  • More effective at reducing postprandial blood glucose levels and requires a longer duration of therapy(>1 month) before decreases in fasting blood glucose are observed
45
Q

First line management of adult with type 2 diabetes

A

If HbA1c rises to 48 mmol/mol(6.5%) on lifestyle interventions:

  • Offer standard-release metformin
  • Support the person to aim for an HbA1c level of 48 mmol/mol(6.5%)
46
Q

What should be considered if standard-lrelease metformin not tolerated

A
  • Consider a trial of modified-release metofrmin
47
Q

DM II - first intensification

A 
If HbA1c rises to 58 mmol/mol(7.5%) 
Consider dual therapy with: 
- Metformin and a DPP-4i
- Metformin and pioglitazone 
- Metformin and an SU 
- Metformin and an SGLT-2i

Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%)

48
Q

DM II - second intensifcation

A 
If HbA1c rises to 58 mmol/mol(7.5%) 
Consider triple therapy with: 
- Metformin, a DPP-4i and an SU 
- Metformin, pioglitazone and an SU 
- Metformin, pioglitazone or an SU, and an SGLT-2i
  • Insulin-based treatment

Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%)

49
Q

Management if triple therapy not effective in DM II

A
  • Consider combination therapy with metformin, an SU and a GLP-1 mimetic for adults who:

1) Have a BMI of 35 kg/m^2 or higher and
2) Have specific psychological or other medical problems associated with obesity or
3) Have a BMI lower than 35 kg/m^2 and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related co-morbidities

50
Q

First line management of DM II - if metformin contraindicated

A

If HbA1c rises to 48 mmol/mol (6.5%) on lifestyle interventions:

Consider one of the following

  • A DPP-4i, pioglitazone or an SU
  • Support the person to aim for an HbA1c level of 48 mmol/mol (6.5%) for people on a DPP-4i or pioglitazone or 53 mmol/mol(7%) for people on an SU
51
Q

First intensification DM II - if metformin contraindicated

A

If HbA1c rises to 58 mmol/mol(7.5%):

Consider dual therapy with

  • A DPP-4i and pioglitazone
  • A DPP-4i and an SU
  • pioglitazone and an SU

Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%)

52
Q

Second intensification DM II - if metformin contraindicated

A

If HbA1c rises to 58 mmol/mol(7.5%):

  • Consider insulin-based treatment
  • Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%)
53
Q

When should DM II meds be stopped

A
  • Omit drugs on morning of surgery + use insulin
54
Q

What is gestational diabetes

A
  • When a woman without diabetes develops high glucose levels during pregnancy
  • Thought to be linked to increased insulin resistance during pregnancy
55
Q

What can gestational diabetes increase the risk of developing

A
  • Pre-eclampsia, depression and requirement for caesarean section
56
Q

Risk factors for gestational diabetes

A
  • Being overweight
  • Previous history of gestational diabetes
  • Family history of DM II
  • PCOS
57
Q

Which drug can be used in gestational diabetes

A
  • Metformin can be used in pre-existing and gestational diabetes
  • All other drugs to be avoided
58
Q

DVLA regulations on diabetes and driving

A

Inform DVLA if conditions apply

Fine if not informed

Insulin, sulfonylureas, meglitinides

Test blood glucose max 2 hours before start of journey and every 2 hours

303 - Medicine (10 decks)

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