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Gen med ends > T2DM pharm > Flashcards

T2DM pharm Flashcards

1
Q

Dietary advice for T2DM

A

encourage high fibre, low glycaemic index sources of carbohydrates
include low-fat dairy products and oily fish
control the intake of foods containing saturated fats and trans fatty acids
limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
discourage the use of foods marketed specifically at people with diabetes
initial target weight loss in an overweight person is 5-10%

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2
Q

HbA1c target - with just lifestyle measures

A

48mmol/mol

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3
Q

HbA1c target - lifestyle measures + metformin

A

48 mmol/mol

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4
Q

HbA1c target - includes any drug which may cause hypoglycaemia

A

53mmol/mol

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5
Q

1st line agent if HbA1c > 48mmmol/mol

A

metformin

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6
Q

Options HbA1c has risen to 58mmol/mol already on metformin

A

sulfonylurea
gliptin
pioglitazone
SGLT-2 inhibitor

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7
Q

Criteria for GLP1 mimetic

A

if triple therapy is not effective, not tolerated or contraindicated then consider combination therapy with metformin, a sulfonylurea and a glucagon-like peptide1 (GLP1) mimetic if:

BMI >= 35 kg/m² and specific psychological or other medical problems associated with obesity or

BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities

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8
Q

Should metformin be continued when starting insulin

A

Yes

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9
Q

Example of GLP-1 mimetic and how does it work

A

Exenatide

Increases insulin secretion and inhibits glucagon secretion

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10
Q

what is a potentially beneficial effect of GLP-1 mimetics

A

Typically result in weight loss

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11
Q

How is exenatide usually given

A

Exenatide must be given by subcutaneous injection within 60 minutes before the morning and evening meals. It should not be given after a meal.

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12
Q

Major adverse effect of GLP-1 mimetics

A

Nausea and vomiting

Link to severe pancreatitis

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13
Q

How do DPP-4 inhibitors work

A

dipeptidyl peptidase-4, DPP-4 inhibitors increase levels of incretins (GLP-1 and GIP) by decreasing their peripheral breakdown

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14
Q

When do NICE recommend use of DPP-4 inhibitors

A

NICE suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated or the person has had a poor response to a thiazolidinedione

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15
Q

Adverse effects of DPP-4 inhibitors

A

GI problems
Dizziness
Peripheral oedema
Pancreatitis

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16
Q

How do SGLT-2 inhibitors work

A

SGLT-2 inhibitors reversibly inhibit sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.

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17
Q

Examples of SGLT-2 inhibitors

A

Examples include canagliflozin, dapagliflozin and empagliflozin.

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18
Q

Important adverse effects of SGLT-2 inhibitors

A

urinary and genital infection (secondary to glycosuria). Fournier’s gangrene has also been reported
normoglycaemic ketoacidosis
increased risk of lower-limb amputation: feet should be closely monitored

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19
Q

Key potential beneficial side effect of SGLT-2 inhibitors

A

Weight loss

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20
Q

Metformin mechanism of action

A

increases insulin sensitivity
decreases hepatic gluconeogenesis
may also reduce gastrointestinal absorption of carbohydrates

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21
Q

Adverse effects of metformin

A

gastrointestinal upsets are common
reduced vit b12 absorption
lactic acidosis with severe liver disease or renal failure

22
Q

Metformin contraindications

A

CKD(review)
Periods where there is tissue hypoxia(MI, AKI, severe dehydration)
iodine-containing x-ray contrast media

23
Q

Advice regarding stopping metformin in imaging procedures using iodine-containing contrast

A

metformin should be discontinued on the day of the procedure and for 48 hours thereafter

24
Q

Fasting glucose and HbA1c which indicate pre diabetes

A

a fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk

25
Q

Mx of pre diabetes

A

Lifestyle modification: weight loss, increased exercise, change in diet
at least yearly follow-up with blood tests is recommended

NICE recommend metformin for adults at high risk

26
Q

What are the two main types of impaired glucose regulation

A

impaired fasting glucose (IFG) - due to hepatic insulin resistance
impaired glucose tolerance (IGT) - due to muscle insulin resistance

patients with IGT are more likely to develop T2DM and cardiovascular disease than patients with IFG

27
Q

Definition of impaired fasting glucose

A

a fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

28
Q

Definition of impaired glucose tolerance

A

impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

29
Q

What should patients with IFG be offered

A

people with IFG should then be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn’t have diabetes but does have IGT

30
Q

Example of a sulfonylurea

A

Gliclazide

31
Q

Sulfonylureas mechanism of action

A

Sulfonylureas bind to and close ATP-sensitive K+ (KATP) channels on the cell membrane of pancreatic beta cells, which depolarizes the cell by preventing potassium from exiting. This depolarization opens voltage-gated Ca2+ channels. The rise in intracellular calcium leads to increased fusion of insulin granules with the cell membrane, and therefore increased secretion of mature insulin

32
Q

Side effects of sulfonylureas

A

Abdominal pain; diarrhoea; hypoglycaemia; nausea

Weight gain

33
Q

Which conditions cause lower than expected levels of HbA1c

A

Sickle cell anaemia
GP6D deficiency
Hereditary spherocytosis

34
Q

Which conditions cause higher than expected levels of HbA1c

A

Vitamin B12/folic acid deficiency
IDA
Splenectomy

35
Q

What is hyperosmolar hyperglycaemic state

A

Very high blood glucose levels (often over 40 mmol/L) develop as a result of a combination of illness, dehydration and an inability to take normal diabetes medication due to the effect of illness

Characterised by severe hyperglycaemia with marked serum hyperosmolarity, without evidence of significant ketosis

36
Q

Characteristic features of HHS that differentiate it from DKA

A

Hypovolaemia.
Marked hyperglycaemia (30 mmol/L or more) without significant hyperketonaemia (<3 mmol/L) or acidosis (pH>7.3, bicarbonate >15 mmol/L).
Osmolality usually 320 mosmol/kg or more

37
Q

Illnesses which can precipitate HHS

A 
MI
Infections 
Strokes
Hyper/Hypothermia 
Pancreatitis 
PE
38
Q

HHS symptoms

A

Signs of gross dehydration
Focal or global neurological dysfunction
Generalised weakness + visual impairment
Nausea and vomiting(less than dka)
Confusion
Seizures

39
Q

IX in HHS

A

Urinalysis shows marked glycosuria with normal or slightly elevated ketones

Capillary glucose

Serum osmolarity usually >320mmol/L

ABG

40
Q

Initial general measures in HHS mx

A

A-E
NG tube if impaired consciousness and risk of aspiration
Consider transfer to HDU
Alert acute med/diabetic team

41
Q

Main principles of HHS management

A

Measure osmolality to monitor response to treatment

IV 0.9% NaCl

Low-dose IV insulin only once blood glucose no longer falling with iv fluids alone

Monitor for complications(fluid overload, cerebral oedema)

Prophylactic anticoagulation

42
Q

Complications of HHS

A 
Ischaemia or infarction 
VTE
ARDS 
DIC 
Rhabdymylosis 
Cerebral oedema
43
Q

How can serum osmolality

A

it can be estimated by 2 * Na+ + glucose + urea

44
Q

criteria for bariatric surgery

A

BMI 40-50

Other conditions such as T2DM and HTN

45
Q

What is whipple’s triad

A

should be present in cases of true hypoglycaemia:

hypoglycaemic symptoms, accompanying low blood glucose concentration, and resolution of symptoms after raising the blood glucose concentration to normal

46
Q

When should fast-acting carbohydrates be used via mouth for mx of hypoglycaemia

A

Any patient with a blood-glucose concentration less than 4 mmol/litre, with or without symptoms, and who is conscious and able to swallow

47
Q

Mx of hypoglycaemia which does not respond to fast-acting carbohydrates

A

intramuscular glucagon or glucose 10% intravenous infusion

Thiamine supplementation in alcoholics

48
Q

When is glucagon not appropriate

A

Ineffective in patients whose liver glycogen is depleted(should not be used in anyone who has fasted for a prolonged period or has adrenal insufficiency)

Glucagon may be less ineffective in patients taking a sulfonylurea

49
Q

Why is glucose 50% not recommended

A

it is hypertonic, thus increases the risk of extravasation injury, and is viscous, making administration difficult

50
Q

Mx of hypoglycaemia if unresponsive to glucagon

A

glucose 10% intravenous infusion, or alternatively glucose 20% intravenous infusion should be given.

Gen med ends (9 decks)

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