1. DPP-IV Inhibitors, SGLT-2 Inhibitors, GLP-1 Receptor Agonists

Question 1

MOA of dipeptidyl peptidase 4 inhibitors

Answer 1

prevent enzyme DPP-4 from breaking down incretin hormones, GLP-1 and glucose dependent

Question 2

sitagliptin (brand, dosing, renal adjustments)

Answer 2

Januvia
100 mg daily
CrCl 30-49: 50 mg daily
CrCl

Question 3

saxagliptin (brand, dosing, renal adjustments)

Answer 3

Onglyza
2.5-5 mg daily
CrCl

Question 4

linagliptin (brand, dosing, renal adjustments)

Answer 4

Tradjenta
5 mg daily
No renal dose adjustment necessary

Question 5

alogliptin (brand, dosing, renal adjustments)

Answer 5

Nesina
25 mg daily
CrCl 30-59: 12.5 mg daily
CrCl

Question 6

DPP-4 warning: hypoglycemia when used with _____ or _____ ______; consider their dose reduction

Answer 6

insulin

insulin secretagogue

Question 7

DPP-4 warning: acute _____ has been reported - d/c if suspected

Answer 7

pancreatitis (s/sx: severe, unresolving stomach pain ± vomiting; pain can radiate from abdomen to the back)

Question 8

DPP-4 warning: severe and disabling _____ (____ pain) has been reported

Answer 8

arthralgia

joint

Question 9

DPP-4 warning for aloglitpin

Answer 9

hepatotoxicity

Question 10

DPP-4 SEs

Answer 10

nasopharyngitis, upper respiratory tract infections, UTIs, peripheral edema (especially if combined with a TZD), rash

Question 11

DPP-4s are weight _____

Answer 11

neutral

Question 12

DPP-4 monitoring (3)

Answer 12

BG, A1c, renal function

Question 13

DPP-4s decrease A1c by ___%

Answer 13

0.5-0.8

Question 14

DPP-4s target [pre/post]prandial BG

Answer 14

post

Question 15

DPP-4s are pregnancy category __

Answer 15

B

Question 16

DPP-4 note: possible risk of HF and death with _____ and _____

Answer 16

saxagliptin

alogliptin

Question 17

DPP-4 DDI: with insulin or insulin secretagogue (management)

Answer 17

consider decreasing dose of insulin or insulin secretagogue; monitor BG closely after initiation of therapy

Question 18

DPP-4 DDI: saxagliptin, a major ___ and ___ substrate (management)

Answer 18

3A4, Pgp

Limit dose to 2.5 with strong 3A4 inh. (atazanavir, clarithromycin, indinavir, triazole antifungals, telithromycin)

Question 19

DPP-4 DDI: linagliptin, a major ___ and ___ substrate (management)

Answer 19

3A4, Pgp

linagliptin levels are decreased by strong inducers (carbamazepine, efavirenz, phenytoin, rifampin, St. John’s wort)

Question 20

MOA of sodium glucose cotransporter-2 inhibitors

Answer 20

SGLT-2, expressed in the proximal renal tubules, is inhibited; this prevents the reabsorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose, increasing urinary glucose excretion

Question 21

canagliflozin (brand, dosing, renal adjustments)

Answer 21

Invokana
100 mg daily prior to first meal of the day; max 300 mg daily
CrCl 45-60: 100 mg daily max
CrCl 30-44: not recommended
CrCl

Question 22

dapagliflozin (brand, dosing, renal adjustments)

Answer 22

Farxiga
5 mg daily in the morning; max 10 mg daily
CrCl 30-59: not recommended
CrCl

Question 23

empagliflozin (brand, dosing, renal adjustments)

Answer 23

Jardiance
10 mg daily in the morning; max 25 mg daily
CrCl 30-44: not recommended
CrCl

Question 24

SGLT-2 inh. CI

Answer 24

severe renal impairment (CrCl

Question 25

SGLT-2 inh. warnings (all-6, cana-3, dapa-1)

Answer 25

all: genital mycotic infections, symptomatic hypotension 2/2 intravascular volume depletion, inc. LDL, UTIs, ketoacidosis, renal insufficiency
canagliflozin: increased risk of hyperkalemia, fractures and decreased bone mineral density
dapagliflozin: increased risk of bladder cancer

Question 26

SGLT-2 inh. SEs

Answer 26

genital mycotic infections, serious UTIs, hypoglycemia, increased urination, hypotension, thirst

Question 27

SGLT-2 inh. cause weight _____

Answer 27

loss

Question 28

SGLT-2 inh. monitoring (5)

Answer 28

renal function, BG, A1c, LDL, BP

Question 29

SGLT-2 inh. decrease A1c by ____%

Answer 29

0.7-1

Question 30

SGLT-2 inh. are pregnancy category ___

Answer 30

C

Question 31

_____ glucose tests are not recommended in patients taking SGLT-2 inh.

Answer 31

Urine

Question 32

SGLT-2 inh. DDI: with insulin or insulin secretagogue (outcome, management)

Answer 32

risk of hypoglycemia, consider reducing their dose and monitor BG closely after initiation of therapy

Question 33

SGLT-2 inh. DDI: with UGT inducers like rifampin (outcome, management)

Answer 33

decreases level of canagliflozin, consider 300 mg

Question 34

SGLT-2 inh. DDI: digoxin with canagliflozin (outcome, management)

Answer 34

increases AUC of digoxin, monitor levels

Question 35

SGLT-2 inh. DDI: diuretics (outcome)

Answer 35

worsen volume depletion, increasing risk of hypotension

Question 36

SGLT-2 inh. DDI: canagliflozin and ACEi, ARBs.. (outcome, management)

Answer 36

canagliflozin and other K+ retaining/sparing drugs increase risk for hyperkalemia, monitor K+ closely