Question 6
List the five classes of lipid–lowering drugs, mechanisms of action, major side effects, and their impact on lipids.
| Type of drug | Mechanism of action | Major side effects | Impact on lipids |
| Statins (rosuvastatin, atorvastatin*, simvastatin*, lovastatin*, pravastatin, fluvastatin) |
HMG CoA reductase inhibitor | Myositis (<0.1%) Rhabdomyolysis (<0.01%) Increased LFT (2-3%) CYP3A4 inhibition* |
LDL: 25-60% Atorvastatin and Rosuvastatin: TG lowers: 15-33% |
| Fibrates (gemfibrozil, fenofibrate, bezafibrate) |
PPAR α-agonist | GI, skin rash | TG: 30-50% |
| Ezitimibe | Cholesterol absorption inhibitor | LDL: 18% | |
| Nicotinic acid | Decreases FFA flux | Flushing PUD Gout Increased LFTs IGT |
HDL: 30-35% TG, LDL: 20% |
| Bile acid sequestrants, colesteryramine | Bile acid absorption inhibitor | Constipation | LDL: 25% TG if already high |
Question 7
You have started a patient on a sulfonylurea agent for her T2DM. How would you counsel them about recognizing and treating hypoglycemia?
Hypoglycemia means your blood sugar is less than…
4.
You may feel some or all of the following symptoms (list 5):
- Racing heart
- Sweating
- Shaking
- Headache
- Confusion
This can happen if (list 4):
- Medication is too strong
- Drinking alcohol
- Exercising
- Eating less carbohydrates than usual
This is what you should do (list 4):
Check blood sugar if possible. If <4 (or can’t check, but have symptoms), go on to the next step:
- Eat/Drink 15 g of carbohydrates (e.g. 3/4 cup juice or soft drink, 6 lifesavers, 1 Tbs honey, etc.) for a sugar of 2.5-4; 20 g for a lower sugar
- Recheck sugar every 15 minutes until >4 mmol/L
- Have snacks with carbohydrate and protein (e.g. half a sandwich, or crackers with peanut butter/cheese) if more than 1 hour until next meal
For the long-term, you should consider (list 2):
- Buying a Medic Alert bracelet
- Having a glucagon emergency kit on hand
- Always having a source of simple sugar available
Question 8
Mr. Chu is a 72 year-old man with long-standing T2DM, poor control on maximum metformin, glyburide, and pioglitazine. He agrees to start on MDI. He weighs 100 kg.
Write a reasonable order for insulin, including correction factor.
Weight (kg) * 0.5 = total daily dose of insulin (TDD)
= 100 * 0.5
= 50 units
Half of insulin as rapid acting, half as long acting:
Aspart or lispro or glulisine or regular: 8 units tid ac meals
Glargine or Detemir: 25 units OR 60% Regular;
40% NPH: 10 units Regular tid ac meals,
NPH 20 units qhs (NPH may need to be split into 2 doses)
Correction factor:
100 / TDD
= 100 / 50
= 2;
1 unit lowers glucose by 2 mmol/L.
If Pre-meal glucose is…
- 4-8 mmol/L, give 8 units Regular
- 8-10 mmol/L, give 9 units Regular
- 10-12 mmol/L, give 10 units Regular
- >12 mmol/L, give 11 units Regular
What medication(s) would you discontinue?
Glyburide and Pioglitazone will be stopped.
Metformin will be continued to reduce weight gain on insulin and lower the dose of insulin required.
Question 9
List 7 classes of drugs besides insulin that lower glucose, and their main mechanism of action.
| Drug Class | Mechanism of Action | |
| Biguanide (Metformin) | Reduces hepatic glucose production, Increases insulin sensitivity |
|
| Sulfonylureas | Insulin release via stimulation of the sulfonylurea receptor | |
| DPP-4 inhibitors (Sitagliptin/saxagliptin) |
Inhibit breakdown of GLP-1, GIP Incretins that stimulate insulin release in response to diet |
|
| GLP-1 analog (Liraglutide) | See above | |
| Thiazolidinediones (pioglitazone, rosiglitazone) |
PPARg agonist, Insulin sensitizer |
Question 10
How do you diagnose gestational diabetes?
During pregnancy, no prior diagnosis of diabetes mellitus:
Positive screening test:
50 g (non-fasting): 1 hour post glucose >10.3 mmol/L
2 hr OGTT 75 g (done if 1 hour screening glucose is between 7.8-10.2):
At least two glucose readings of the following:
Fasting glucose >5.3
1 hour glucose >10.6
2 hours glucose >8.9
What are the A1C and glucose targets for the patient with diabetes in pregnancy?
A1C <6%
Fasting glucose = 3.8-5.2 mmol/L
1 hr pc glucose = 5.5-7.7 mmol/L
2 hr pc glucose = 5.0-6.6 mmol/L
What is the glucose target during labour?
Glucose = 4.0-6.7
