Sunday, 19 September 2021
Medications in DM
- Pathophysiology of T2M: impaired insulin secretion and loss of Beta cell mass but
insulin resistance also. The liver & gut are included.
- HBA1C- glycaemic control over 3 M
• before percentages but now di erent units. threshold of 6.5% or 48 mmol/mol
the dx stands
• HBA1c used for monitoring to see when to add meds/ to see if working
• Monitoring emphasised in pts: insulin pts, prone to have hypoglycaemia,
drivers machinery occupation
• Previous studies show that better HBA1c control reduces micro/ macrovascular
causes.
Q: Miss AC, 62 y/o lady attends annual diabetes follow-up appointment. Latest
HbA1C: 75 mmol/mol (9%)
What average blood glucose level for the last 3 M’s is the most likely present?
Want it to be from 7-9 for stringent control; anything between 11-12 increases
HBA1c
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Sunday, 19 September 2021
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Sunday, 19 September 2021
Risk of osteoporosis: eventide & SGLT-2 inc risk. Gliclazide could ppt hypos thus
avoided. DPP-4 inhibitor may be more safe.
DPP-4 inhibitors: Linagliptin, sitagliptin
Linagliptin is hepatically excreted thus not adjusted for renal dysfunction unlike
sitagliptin.
HBA1c target is 7-7.5 and if over 7.5 or 58 mmol/mol we add more meds like
pioglitazone.
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Sunday, 19 September 2021
Thiazolidinediones (TZD)—Glitazones—Pioglitazones
Gliclazide is the answer
Sulphonylureas—insulin secretagogues —Cliclazide, Glimepiride, Glibenclamide
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Sunday, 19 September 2021
Sodium-glucose co-transporter 2 inhibitors—Gli ozins—Dapagli ozin,
Empagli ozin, Canagli ozin: bene t in HF even w/o DM. Also renal portection.
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GLP-1—Ezenatide, Liraglutide, Dulaglitide
Insulin:
Insulin is usually started when the HbA1c remains above 58 mmol/mol despite
maximum tolerated oral agents. Starting insulin is no easy task for a patient or a
medical professional. The patient or carer is required to inject the medication, selfmonitor, have support in titrating the dose, learn how to manage hypoglycaemia &
inform the DVLA if they drive.
If insulin is started, sulphonylureas like gliclazide are usually stopped due to the risk
of profound hypoglycaemia or because the treatment is clearly failing – the
pancreas is simply unable to release any more insulin.
There are multiple potential regimes:
Basal only (once or twice daily injection) given at a set time to give a long-acting
insulin lasting at least 12-16 hours
Biphasic (or pre-mixed) insulin given twice daily with meals which contains shortacting & long-acting insulin mixed into one vial
Basal-bolus insulin where there is a long-acting basal agent with short-acting bolus
doses with each meal
Patients will be usually started on a basal-only regime with insulin types such as
NPH insulin (Humulin I), Insulin Glargine (Lantus/Abasaglar), or Insulin Detemir
(Levemir) typically with a dose that is about 10-20 units per day depending on
insulin resistance. If they have high CBGs post-meals then the other two regimes
may be considered or if their HbA1c is very elevated (above 75 mmol/mol) as per
NICE.
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Sunday, 19 September 2021
In T1DM, most patients will be on a basal-bolus regime as this allows greater
exibility of meal times & doses can be adjusted for each meal.
We usually start around 0.3 units/kg/day to begin with and titrate this up based on a
patient’s blood sugars. Usually patients will need around 0.7-1 unit/kg/day but it is
important to avoid hypoglycaemia as this will often scare patients into running their
blood sugars high.
Sick day rules: Never stop insulin as illness often results in increased insulin
requirement. If in hospital & not eating/drinking, the patient may need to switch to
variable rate insulin infusion usually alongside their basal insulin. You should check
your local guidelines.
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