LSB384 Pharmacology for Health Professionals

Case studies in diabetes

Brett S developed diabetes when he was a child. Bretts father developed diabetes when he
was 55 years old.
(i)

Which types of diabetes do Brett and his father have? Explain

Brett S has type 1 diabetes, also knows as insulin dependent diabetes mellitus or
juvenile onset. He is reliant on exogenous insulin in order to metabolise glucose.
Brett's father has type 2 diabetes, which mean his pancreas secretes lower amounts
of insulin, or there is insensitivity to insulin. This is more common in adults, but can occur in
children if they are obese.
both types result in poor glycaemic control

Brett is using injections to control his diabetes.

(ii)

What do these injections contain? How do they work?

These injections contain insulin. However, this is exogenous insulin. Similar to

endogenous insulin who's highest concentrations are in the live, a major site of
action is at the liver. However, exogenous insulin's highest concentrations are at
the site of administration. There are both normal and long acting forms of insulin
replacement therapy in an attempt to mimic the kinetics of endogenous insulin.
Ultimately insulin acts to lower blood glucose.

One day, Brett forgot to eat after taking his injection, and became hypoglycaemic.
Unfortunately, Brett did not recognise this, and went into a coma. Bretts friends called the
ambulance, and told the paramedics that Brett was diabetic. The paramedics gave Brett
something, which aided his recovery.
(iii)

What are the symptoms of hypoglycaemia? What could Brett have done if he
had recognised the hypoglycaemia? Which agents could the paramedics have
used to overcome the hypoglycaemic diabetic coma? How were they
administered? How do the agents overcome hypoglycemia?

The symptoms of hypoglycaemia include sweating, hunger, palpitations, tremor, anxiety,

convulsions, and coma.
Brett could have ingested a fast acting glucose which would have raised his bgl. The
paramedics could have used glucose or glucagon, administered intravenously.
Glucose directly enters the blood and raises the blood glucose level. Glucagon stimulates the
1

liver to convert glycogen into glucose, a process known as glycogenolysis.

In addition to taking medication of diabetes, Brett is also asthmatic. One day, his asthma was
particularly bad and he used his inhaler to a great extent to treat the asthma. Brett took his
regular injections for diabetes. Brett became hyperglycaemic.
(iv)

Explain the drug interaction/s between insulin and anti-asthma drugs? Antiasthma drugs stimulate b adrenoceptors on the pancreas to secrete glucagon.
This increases the blood sugar level. They also directly affect the liver to induce
glycogenolysis, which also increases blood glucose. Brett's insulin dose would
not be large enough for such a massive increase in blood glucose and would
manifest as hyperglycaemia.

Bretts father is not having injections for his diabetes. The first medicine he is given for
diabetes is metformin, and when this does not lower blood glucose by a satisfactory amount,
he is also given gliclazide
(v)

Why is Bretts father not having injections? How do metformin and gliclazide
work? Do they cause weight gain and/or hypoglycaemia?

Brett's father is not having injections as he may still be able to produce insulin or his body
may be insensitive to it. Therefore, metformin works by increasing the body's
sensitivity to insulin, increasing the uptake of glucose. Gliclazide works by
increasing pancreatic secretion of insulin as well as increasing sensitivity to that
insulin. There is no weight gain or hypoglycaemia associated with metformin.
These adverse effects are associated with sulfonylureas.

When attending the diabetes clinic, the nurse asked Bretts father if he would like to take part
in a long term trial comparing two new treatments of diabetes. One treatment was the
combination of exenatide and sitagliptin and the other was dapagliflozin.
(vi) How do these drugs work? How are these drugs administered? Do these drugs cause
hypoglycaemia?
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exenatide - is an agonist at GLP-1 receptors mimicking the effects of glucagon peptide like 1
in that it increases insulin secretion and decreases glucagon secretion, thus lowering blood
glucose. Administered subcutaneously before a meal. It does cause hypoglycaemia
sitagliptin inhibits DPP4, the enzyme that breaks down GLP-1. This results in the build up of
GLP-1 and has the same effect as exenatide. Administered orally. Can cause hypoglycaemia
if administered with a sulfonylurea.
dapagliflozin - limits the reabsorption of glucose from the kidneys, and promotes glucose
excretion. This drug does not cause hypoglycaemia.