Type 1 And Type 2 Diabtes Flashcards
(28 cards)
Aims of treatment
1)Use insulin regimens to achieve optimal blood glucose levels
2)avoid or reduce hypoglycaemic episodes
3)minimise risk of long term macro and microvascular complications
4)prevent disability from complications by early detection and active management of disease
5)the target for glycaemic control should be individualised for each patient
The optimal targets for glucose self monitoring in adults with type 1 diabetes
- monitor blood glucose at least 4 times a day (including before each meal and before bed)
Glucose targets
4-7mmol/l = be4 meals
5-7 mmol/L = I wake at 5-7 (waking)
5-9 mmol/L= I dine at nine (after food)
>5 mmol/l - five to drive
Less than or =11mmol/L - Random blood glucose levels
<= 48 = HBA1c
Type 1 diabetes overview
- type 1 requires insulin replacement
- also manages other CV risk factors as well(hypertension and high lipids)
- adjust dose of insulin according to eg. Planned excercise, intended food intake, current blood glucose levels
- Metformin added to insulin may benefit patients with BMI>= 25 or 23 and of south Asian or related ethnicity, who wish to improve glucose control but reduce insulin use
- Dietary advice should be given to type 1 and type 2 by dietician
- Advice should include info on weight control,CV risk, hyperglycaemic effect of different foods, changes in insulin according to food intake
Type 2 diabetes - Anti diabetic drugs: What are the different classes? (8)
1) Alpha Glucosidase inhibitors eg. Acarbose
2) Dipeptidylpeptidase-4-inhibitors (Gliptins) - Alogliptin, linagliptin
3) Glucagon-like peptide 1- receptor agonist (exenatide, liraglutide)
4) Mrglitinides - nateglinide
5) Sodium glucose co-transporter 2 inhibitors (canagliflozins, dapagliflozin)
6) Sulphonylureas (Gliclazide, tolbutamide,glipizide)
7)Thiazolidinediones(pioglitazone)
8)Biguanides (metformin)
What is type 2 diabetes
- insulin deficiency or resistance
- Associated with obesity, physical inactivity,raised blood pressure,dyslipidaemia and tendency to develop thrombosis, so it increases the risk of CVD)
- Associated with long term microvascular and macrovascular complications
- Typically develop later in life but is increasingly diagnosed in children
Aim of type 2 diabetes is to do what?
Minimise the risk of long term microvascular and macrovascular complications by effective blood glucose control
Step 1 - Life style advice and changes for 3 months
Step 2 - Antidiabetic drugs if lifestyle control is not adequate
The Biguanides - Metformin
- only available Biguanides
- first choice for all patients
- does not cause hypoglycaemia (does not stimulate insulin secretion)
- increase the dose slowly to prevent GI disturbances and side effects ( OD - BD- TDS)
- offer modified release if standard treatment is not tolerated
Side effects and contraindications of Metformin
- Gi side effects are the most common so take with or after food
- it can cause lactic acidosis (rare but discontinue)
Contraindications:
- Acute metabolic acidosis - including lactic acidosis and DKA
- ketoacidosis, renal failure general anaesthesia ( stop on morning of surgery)
- Lactic acidosis, avoid metformin if EGFR <30ml/min
-can cause renal failure which can increase the risk of lactic acidosis
Metformin- Pregnancy and breastfeeding? Cautions?monitoring? Patient and carer advice?
- can be used in pregnancy for both pre existing and gestational diabetes.Women with gestational should discontinue after birth.
It can be used in breastfeeding for pre-existing diabetes
Caution - conditions which worsen renal function and factors for lactic acidoses
Monitoring - renal function before starting treatment and at least annually
Patient and carer - inform patients at risk of lactic acidosis and how to recognise signs
What are the signs of lactic acidosis (metformin)
- Dyspnoea(difficult/laboured breathing)
- Muscle cramps
- Abdominal pain
- Hypothermia (low temp)
- Asthenia(weakness/lack of energy)
Sulphonylureas (eg.gliclazide, glimpepride, glipizide, tolbutamide)
- Causes hypoglycaemia
- Hypoglycaemia more likely with long acting Sulphonylureas eg. Gilbenclamide (discontinued),glimepride, chloropropamide
- causes weight gain
- generally avoid in pregnancy and breastfeeding feeding
- for patients who metformin is contraindicated or not overweight
- avoid before surgery and change to insulin
- greater risk of hypo with long acting. Avoid in elderly and give short acting instead (Gliclazide and tolbutamide)
Sulphonylureas side effects and cautions
- Gi (nausea,vomitting, diarrhoea and constipation)
- Hepatic impairment (Jaundice,hepatitis and hepatic failure)
- Allergic reaction in first 6-8 weeks(frequency unknown)
Contraindications and cautions = elderly patients and patients that have G6PD deficiency
- acute porphyria and ketoacidosis
- Avoid or reduce dose in renal and hepatic impairment
Alpha Glucosidase inhibitors - Acarbose
- poorer anti hyperglycaemic effect than other anti diabetics including sulfonylureas,metformin and pioglitazone
- Gi side effects - most common
- interferes with sucrose absorption ( if a patient that is hypo and needs sugar always give glucose not sucrose because it interferes with the absorption of sucrose)
Thazolidinediones - eg. Pioglitazone
- associated with heart failure (increased risk when given with insulin)
-MHRA advice = risk of bladder cancer
Continue treatment only if hb1Ac decreased by at least 0.5% within 6 months of starting treatment
Side effects = bone fractures, weight gain, visual impairments, increased risk of infection and numbness
Monitoring = monitor liver function and advice patients to report signs of liver toxicity
Dipeptidylpeptidase -4-inhibitor = the Gliptins
Alogliptin,linagliptin,sitagliptin,saxagliptin and vidagliptin
- contraindication = diabetic ketoacidosis
- side effects - Gi and skin reactions
- discontinue if symptoms of acute pancreatitis (eg. Severe abdominal pain)
= LIPTON TEA- DIP IN WATER - LIPTINS DIP
Sodium glucose co-transporter 2 inhibitors - SGLT3 inhibitors the flowing
Canagliflozin, emagliflozin and dapagliflozin
- associated with a risk of diabetic ketoacidosis = MHRA warning
- canagliflozin - increased risk of lower limb amputation(mainly toes)
- dapagliflozin - avoid if eGFR is less than 15
- Insulin and Sulphonylureas may need to reduce dose of these when given with flozins
- Adverse effects - weightloss, DKA,increased infection risk, urinary disorders
Glucagon-like peptide 1 receptor agonists
Exenatide, dulaglutide, liraglutide, lixisenatide and albiglutide
- for combination therapy when other treatment options have failed
- discontinue if acute pancreatitis
- effective contraception recommend for women of child bearing age (toxic)
Weight effects
Metformin = No effect
Sulfonylureas =Weight gain
SGLT2 = weight loss
Gliptins = no effect
GLP-1 = Weight loss
Pioglitazone = Weight gain
Alpha Glucosidase inhibitors mechanism of action
Acarbose = inhibits intestinal Alpha Glucosidases. Delays digestion and absorption of starch and sucrose has a small but significant effect on lowering glucose
Biguanides mechanism of action
Decreases glucogenesis and increases peripheral utilisation of glucose. Acts only in presence of insulin so only effective when there is some functioning of pancreas cells
Dipeptudylpeptidase- 4 inhibitors (eg.alogliptin)
Inhibits dipeptidylpeptidae - 4 to increase insulin secretion and lower glucagon secretion
Sulphonylureas mechanism of action
Augment insulin secretion and consequently only effective when some residual pancreatic beta cell activity is present
