What devices/forms are insulins commonly available in? What are the major types of insulin by onset/duration of action?

MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.

MAJOR THEMES;DIABETES MELLIUS, TYPES 1 and 2.DIETARY MANAGEMENT ORAL HYPOGLYCAEMICS INSULIN THERAPY.

LEARNING OBJECTIVES

Following the workshop, directed and background reading, students should be able to:
1)    Outline the dietary recommendations given to patients with diabetes
2)    Discuss the place in therapy of the different oral hypoglycaemic agents
3)    Describe the different insulins available
4)    List the factors influencing choice of insulins and insulin delivery devices in diabetic patients.

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DIRECTED READING

BNF Section 6.1.1-6.1.4 Drugs used in diabetes (Introduction and section headings)

National Institute for Health and Clinical Excellence. Clinical Guideline 87 Management of type 2 diabetes. May 2009.

Jacques N. New NICE guidelines for type 2 diabetes treatment. Br J Clin Pharmacy 2009;1:167-8.

Questions:

What devices/forms are insulins commonly available in?

What are the major types of insulin by onset/duration of action?

BACKGROUND READING
National Institute for Health and Clinical Excellence. Clinical Guideline 15. The diagnosis and management of type 1 diabetes in adults. July 2004. (Look at pages 5-

10)

Hackett E, Jacques N, Gallagher A. Type 1 Diabetes: Pathophysiology and diagnosis. Clinical Pharmacist 2013;5:69-72.

Hackett E, Jacques N. Type 1 Diabetes: Insulin management. Clinical Pharmacist 2013;5:69-72.

WORKSHOP EXERCISE
Example of medicine    Typical starting and maximum dose    Class    How it works to lower blood glucose    Any other notes (place in therapy, common adverse

events, contra-indications etc.)
Insulin

Metformin

500mg od-max 2g OD

.
Gliclazide

40mg OD-max 320mg in divided doses

.
Pioglitazone

15mg OD- max 45mg OD

Nateglinide

60mg TDS to max 180mg TDS

Exenatide

5mcg BD top max 10mcg BD

Sitagliptin

100mg OD

Dapagliflozin     10mg OD

ANSWER ALL THESE QUESTIONS IN DETAIL AND USE THE READING LIST ON THE PREVIOUS PAGE TO HELP ANSWER THESE QUESTIONS

Miss HH is a 65 yr old lady weighing 83kg who presents to a community pharmacy, where you regularly do a locum, asking for “something stronger for thrush which keeps

coming back”. On further questioning she is feeling increasingly lethargic recently and is complaining of going to the toilet more often. You suspect she may have

diabetes mellitus and refer her to a G.P.

She has mild osteoarthritis and is only on ibuprofen and co-codamol.

1)    What signs and symptoms of diabetes mellitus does Miss HH have? What other initial symptoms may also be present?

2)    Miss HH has heard that in one type of diabetes she will need injections. She asks you how the G.P. will determine she has diabetes and which type she has?

What are the two types and is there a precise diagnosis for diabetes?

3)    What complications can arise in someone with diabetes mellitus?

4)    What are the aims of treating diabetes?

5) The G.P. diagnoses Miss HH with type 2 diabetes and gives her dietary advice. What type of diet is recommended in diabetic patients, and why?

6)    The GP also starts Miss HH on metformin 500mg TDS. In general, is this a reasonable initial therapy? What would make it not so?

7)    A year later Miss HH is seen in clinic and it is clear her diabetes is uncontrolled. She is admitted for review of her therapy. She is on metformin 1g bd for

her diabetes and usual painkillers. Blood tests came back as:
U&Es    FBCs
Glucose    22.3 mmol/L (3.6-8)    Hb     12.1 g/dl (11.5-16.5)
HbA1c     105mmol/mol
(<48mmol/mol/6.5%)     WBC 10.2×109/l (4-11)
Na            136 mmol/L (135-145)    Plts    293×109/l (150-450)
K               4.8 mmol/L (3.5-5.0)
Urea         11.7 mmol/L (2.5-7.5)
Creatinine 250micromol/l (60-120)

Wgt  80kg    Temp. 37.1 degrees
Hgt   5’6’’    BP 147/85mmHg

a)    Comment on Miss HH’s glucose and HbA1c in relation to NICE guidance.
You can use the 2112 rule to convert old HbA1c to new units and vice versa:
old to new:  -2 x 11 -2;
new to old: +2 divided by 11 +2.

b)    Work out Miss HH’s B.M.I. and ideal body weight. Are these relevant?
BMI = wt (kg)                IBW= 50kg (men)/45.5kg (women)
Ht2(m2).                 + 2.3kg for each inch > 5 feet.

c)    Comment on Miss HH’s creatinine and urea: use Cockcroft and Gault’s method to estimate her renal function.

8)    According to the BNF, and the latest NICE guidelines (2009), should we change Miss HH’s therapy? What is your suggestion?

9)    A nursing student comes to you and tells you Miss HH’s “BMs are 2.3” (Random peripheral blood glucose is 2.3 mmol/L). What are the symptoms of a hypoglycaemic

attack and how would you would treat it? Why do some patients not exhibit any symptoms?

10)    Three months later, Miss HH is taking gliclazide 160mg BD but her blood sugar remains at least 11.5mmol/L most of the day. Three possible options exist other

than starting insulin. Which of the three possibilities below might or might not be suitable for Miss HH? Which would you support? Refer to the NICE algorithm.

a) Exenatide

b) sitagliptin

c) pioglitazone

 

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