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RED - Clinical and Pharmacy Practice > Prescribing Issues in Diabetes > Flashcards

Prescribing Issues in Diabetes Flashcards

1
Q

How is DM classed?

A
  • Type 1; pancreas not producing enough insulin (often none) - autoimmune
  • Type 2; cells are not responding the the insulin that is produced often presenting later in life, and progressing to complete loss of β-cell function
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2
Q

How is DM characterised?

A

Hyperglycaemia (high blood glucose)

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3
Q

What are the aims for the therapetutic managment of diabetes?

A
  • Control symptoms of hyperglycaemia
  • Prevent diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS)
  • Prevent both long-term microvascular and macrovascular complications
  • Enable patients to maintain a close to normal lifestyle
  • Establish medication concordance with patient (importance of using/adhering to medication)
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4
Q

When is insulin therapy considered for T2DM?

A

When HbA1c levels remain above 59 mmol/mL (7.5%) despite other interventions (diet/lifestyle/metformin/SHs etc.)

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5
Q

What is the aim of insulin therapy?

A

To try and mimic normal physiological insulin release from the pancreas.

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6
Q

Why has human insulin replaced porcine/bovine?

A

Higher chance of hypersensitivity with animal-derived insulin.

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7
Q

What is the brand name for insulin aspart and what type of insulin does it belong to?

A
  • Novorapid

- Rapid-acting

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8
Q

What is the onset, peak and duration of action of rapid-acting insulin?

A

Onset: 10 - 20 minutes
Peak: 30 - 180 minutes
Duration: 2 - 5 hours

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9
Q

What are the generic names for Humalog and Apidra and what type of insulin are they?

A
  • Humalog; insulin lispro

- Apidra; insulin glulisine

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10
Q

What is the onset, peak and duration of action of short-acting insulin?

A

Onset: 30 - 90 minutes
Peak: 2 - 4 hours
Duration: 6 - 8 hours

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11
Q

Give two examples of short-acting insulin (brand names) and their one corresponding generic name.

A
  • Actrapid
  • Humulin S

Human sequence soluble insulin

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12
Q

What is the onset, peak and duration of action of intermediate-acting insulin?

A

Onset: 30 - 90 minutes
Peak: 6 - 8 hours
Duration: 11 - 24 hours (mostly 24)

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13
Q

Give two examples of intermediate-acting insulin (brand names) and their one corresponding generic name.

A
  • Insulatard
  • Humulin I

Human sequence isophane insulin

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14
Q

What is the onset, peak and duration of action of long-acting insulin?

A

Onset: 1 -2 hours
Peak: No peak
Duration: 20 - 26 hours

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15
Q

What are 3 examples of long-acting insulins and their brand names?

A 
Insulin glargine (Lantus)
Insulin detemir (Levemir)
Insulin degludec (Tresiba)
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16
Q

What is biphasic insulin and its advantage?

A
  • Insulin pen/vial with a mixture of rapid or short-acting insulin and an intermediate-acting insulin.
  • Reduces number of injections required
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17
Q

What is the onset, peak and duration of action of biphasic insulin?

A

Onset: 10 - 90 minutes
Peak: 2 - 4 hours
Duration: 11 - 24 hours

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18
Q

Name some biphasic insulins and their corresponding brand name.

A
  • Biphasic insulin aspart (Novomix 30)
  • Biphasic insulin lispro (Humalog Mix25, Humalog Mix50)
  • Biphasic isophane insulin (Humulin M3, Insuman Comb)
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19
Q

What does the basal-bolus insulin regimen entail?

A
  • Basal; OD injection of long-acting insulin (e.g. insulin detemir) for background level of insulin
  • Bolus; TDS injection of short-acting insulin (e.g. soluble insulin) giving big spike that lasts a few hours to tackle big blood glucose spikes at breakfast/lunch/dinner
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20
Q

What is a common regimen for young patients diagnosed with T1DM?

A
  • Basal-bolus

- Gives good control of blood glucose

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21
Q

What are the advantages and disadvantages of the basal-bolus regimen?

A

+ Best at mimicking normal physiological insulin release (best control)
- Most complex (4 injections required a day)

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22
Q

What does the twice-daily insulin regimen of short and intermediate acting insulins entail?

A
  • Short and intermediate-acting insulins (e.g. insulin aspart + isophane insulin)
  • One of each given at breakfast and dinner; intermediate giving background level
23
Q

What are the advantages and disadvantages of the twice-daily regime w/short + intermediate acting insulins?

A

+ BD not QDS

  • But still two injections each time
  • Poor insulin cover at lunchtime spike (only background intermediate insulin available)
24
Q

How does the twice daily regimen of bi-phasic insulin differ from the twice daily of short and intermediate-acting insulin and what are its advantages?

A
  • Same insulin cover

+ Only one injection each time at breakfast and dinner instead of two

25
Q

When is the OD regime of insulin used and why?

A
  • In T2DM ONLY
  • Basal level of long-acting insulin e.g. insulin determir
  • Patient probably supplementing breakfast/lunch/dinner peaks w/oral antidiabetic e.g. metformin
26
Q

Why should patients rotate areas for SC injection insulin?

A

To prevent lipohypertrophy and lipoatrophy (hardening/soreness)

27
Q

Where is suitable for SC injection of insulin?

A
  • Lower abdomen
  • Upper outer thighs
  • Buttocks
  • Upper outer arm
28
Q

What devices are available for insulin SC and why is it important to check as a pharmacist?

A
  • Vials
  • Cartridges
  • Disposable pens
  • Innolet device (fancy pen)
  • Continuous subcutaneous insulin infusion (CSII); device giving continuous insulin maintaining blood glucose within tight range

Show patient if unsure which device is used.

29
Q

What is variable rate insulin infusion (VRII)?

A
  • Consists of continuous intravenous (IV) insulin infusion (via cannula) and constant glucose infusion
  • Allows for very tight/close control
30
Q

When is VRII used?

A
  • In DM patients that are nil by mouth (NBM) for a sustained period e.g. going for surgery, or have uncontrolled hyperglycaemia
  • In critical care; tight glucose control beneficial for critically ill (better outcomes/recovery)
  • Fixed-rate infusion given for patients admitted with DKA or HHS
  • If patient is hyperglycaemic following an MI (studies shown better recovery w/tightly controlled glucose)
31
Q

What must VRII treatment be given with/cautions are there?

A
  • Blood glucose monitoring essential (every one or two hours); too much insulin = seizures/comas
  • Adjust insulin infusion according to blood glucose
  • Insulin closes ATP-dependent K+ channels; K+ retained in cells therefore hypokalemia risk = give K+ fluids as well as glucose (K+ monitored once or twice daily)
32
Q

What does a variable rate insulin infusion scale entail?

A
  • Blood glucose measured upon submission to ward
  • Refernce to a column/scale (e.g. Scale 2) describes how much insulin to infuse an hour for particular blood glucose measurement
  • Reducing insulin infusion to lower units
  • Want to be off IV insulin ASAP
33
Q

Where are areas that errors can potentially occur with VRII?

A
  • IV Glucose co-infusions; unless patient is very hyperglycaemic, glucose IV should always be prescribed
  • Monitoring; glucose levels to be monitored every 1-2 hours and hourly if unstable (avoid hypoglycaemia)
  • Labelling of insulin synringes; knowing the rate, mls and hour etc.
  • Discontinuation of insulin and recommencement of usual hypoglycaemic medicines; IV insulin to be stopped 30-60 minutes after restarting usual SC insulin and/or anti-diabetics
  • Long-acting insulin SC to be continued whilst patient is on VRII giving background level and to prevent rebound hyperglycaemia (blood glucose shooting back up) when infusion stopped (but stop biphasic/short acting SC insulin w/IV)
34
Q

How is VRII given in DKA?

A
  • Fixed rate insulin

- Vary fluid rate

35
Q

What would a pharmacist check on a sliding scale insulin prescription (VRII)?

A
  • Insulin appropriately made up and labelled
  • If suitable concomitant fluid is prescribed (glucose/K+)
  • Blood sugar levels; in range? If not is insulin rate being altered as per scale/protocol?
  • Can the sliding scale insulin be stopped? (switch back to SC?)
36
Q

What factors should the doctor be considering when reviewing the patient’s normal insulin regime?

A
  • Patient preference
  • Lifestyle
  • Eating patterns (e.g. extra injection at lunch if on BD?)
  • Insulin device used
  • Ability to self-monitor (issue w/eldery who have dementia etc.)
  • Risk or previous history of hypoglycaemia (seizure/coma risk)
  • Knowledge of conditions and awareness of complications
37
Q

How is sliding scale insulin stopped in a patient normally on rapid-acting + intermediate-acting SC?

A
  • Give the SC insulin (Humalog) w/meal e.g. breakfast or lunch (can’t monitor patient at night as closely) and stop IV insulin 30-60 minutes after meal (gives time for SC insulin absorption)
  • Humulin I (intermediate) to give that night as doesn’t need to be given with food; doesn’t really have peak/24 hrs
  • Don’t stop IV insulin at night; patient can be monitored for hypoglycaemia during the day when stopping with breakfast/lunch
38
Q

What does metformin do?

A
  • Biguanide
  • Decreases gluconeogenesis
  • Increases peripheral utilisation of glucose
39
Q

What are the advantages of using metformin?

A
  • Gold-standard
  • Lower incidence of weight gain
  • Unlikely to cause hypoglycaemia (elderly patients at risk; not as aware of symptoms of dizziness etc, can lead to falls from loss of consciousness)
40
Q

What are the main side effects of metformin and how can they be avoided?

A
  • GI disturbances (bloating/abdominal pain/diarrhoea); avoid by stepping up gradually/consider trial of MR preparation if GI tolerability an issue
  • Lactic acidosis (rare); caution in renal impairment, or if tissue hypoxia likely (e.g recent MI)
  • Taken w/meals to tackle peaks in glucose
41
Q

What do sulphonylureas do and when can they considered 1st line?

A
  • Stimulates insulin secretion
  • Consider for first line if patient:
    > not overweight (causes weight gain)
    > metformin not tolerated/contraindicated (poor renal function etc)
    > rapid therapeutic response required because of hyperglycaemic symptoms (can bring down blood glucose quickly)
42
Q

What are the risks/side effects of sulphonylureas?

A
  • Risk of hypoglycaemia; use short-acting preparations e.g. gliclazide (main one) especially in renal impairment/elderly - short acting less likely to build-up and cause hypo
  • Weight gain
  • Choose lowest cost/shortest acting
43
Q

What are the notable adverse effects of acarbose and the main counselling point?

A
  • Flatulence (but decreases over time)

- Tablets should be chewed with 1st mouthful of food or swallowed whole with a little liquid immediately before food

44
Q

What are the notable adverse effects of pioglitazone and the main counselling point?

A
  • Increased risk of bladder cancer, heart faiure and bone fractures
  • May cause weight gain
  • Monitor liver function
45
Q

What are the notable adverse effects of DPP-4 inhibitors/gliptins and the main counselling point?

A
  • GI upset
  • Peripheral oedema
  • May enhance risk of hypoglycaemia when given with sulphonylureas
46
Q

What are the notable adverse effects of SGLT-2 inhibitors e.g. dapagliflozin and the main counselling point?

A
  • Polyuria
  • Dysuria
  • Contra-indicated in renal impairment, CrCl
47
Q

How do target blood glucose levels compare between T1DM adults/children and T2DM?

A
  • Most lax for T1DM children
  • Then T1DM adults
  • But T2DM v. tightly controlled
48
Q

How often are HbA1c levels measured in DM?

A
  • Monitor 2-6 monthly until stable on unchanging therapy

- Then monitor 6-monthly once blood glucose level and therapy stable.

49
Q

What are HbA1c target for DM patients?

A

48 - 59 mmol/mol (6.5 - 7.5%)

50
Q

Why is the sulphonylurea gliclazide appropriate for an elderly lady already on metformin?

A
  • 80mg OD; lower dose for elderly
  • Lowest cost
  • Short-acthing sulphonylurea appropriate due to increased risk of hypoglycaemia
51
Q

How can metformin MR relieve abdominal pain from metformin 1g BD?

A

Released more gradually into GI tract = more tolerable?

52
Q

Should short-acting insulin be given at night without food?

A

No; only long-acting to provide basal level, short-acting should always be given with food.

53
Q

What interventions should be made if a DM patient was hypertensive?

A
  • Start on hypertensives to reduce CVD risk; 130/90 mmHg target for DM
  • Start on statin to reduce CVD risk (even on normal cholesterol level); can have anti-inflammatory effect
  • Antiplatelet therapy e.g. low-dose aspirin

RED - Clinical and Pharmacy Practice (3 decks)

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