1. Sulfonylureas, Metformin

Question 1

MOA of sulfonylureas (SUs)

Answer 1

insulin secretagogue

Question 2

glipizide (brand, dosing)

Answer 2

Glucotrol: 5-10 mg daily or BID, max 40 mg/day

Glucotrol XL, Glipizide XL: 5-10 mg daily, max 20 mg/day

Question 3

glimepiride (brand, dosing)

Answer 3

Amaryl

1-2 mg daily, max 8 mg daily

Question 4

glyburide (brand, dosing)

Answer 4

DiaBeta: 2.5-5 mg daily, max 20 mg daily
Glynase: 1.5-3 mg daily, max 12 mg daily

DiaBeta ≠ Glynase: micronized tablet has better absorption

Question 5

sulfonylurea CIs (3)
one specific to glyburide

Answer 5

T1DM
DKA
glyburide: concurrent use with bosentan

Question 6

Sulfa allergies for sulfonylureas [are/aren’t] likely to cross-react

Answer 6

aren’t

Question 7

sulfonylurea SEs

Answer 7

moderate risk of hypoglycemia, wt gain, nausea

Question 8

sulfonylurea monitoring

Answer 8

BG, A1c

Question 9

SUs decrease A1c by ____%

Answer 9

1-2

Question 10

SUs are pregnancy category __

Answer 10

C

Question 11

Efficacy of SUs ____ after long-term us

Answer 11

decrease (low durability)

Question 12

(SUs) ______ has a weakly active metabolite that is _____ cleared, and is not a preferred agent

Answer 12

glyburide

renally

Question 13

Which SU can leave a ghost tablet in stool?

Answer 13

Glucotrol XL

Question 14

sulfonylurea DDI: ____ shares a similar MOA and should not be used concurrently

Answer 14

–meglitinides (repaglinide, nateglinide) due to increased hypoglycemia risk (share similar MOA as SUs)
–other drugs that can alter blood glucose (atypical antipsychotics, quinolones, systemic steroids; linezolid, non-selective beta-blockers, quinolones)
–insulin dose by

Question 15

sulfonylurea DDI: other drugs that can alter blood glucose; identify drugs that can raise and lower BG

Answer 15

Raise: atypical antipsychotics, posaconazole, cyclosporine, tacrolimus, sirolimus, protease inhibitors, quinolones, systemic steroids
Lower: non-selective beta-blockers (propranolol), quinolones, other anti-diabetic drugs (insulin, insulin secretagogues)

Question 16

sulfonylurea DDI: SU dose reduction may be required when these anti-diabetic agents are initiated (4)

Answer 16

TZD
GLP-1 receptor agonist
DPP-4 inhibitor
SGLT2 inhibitor

Question 17

sulfonylurea DDI: is a CYP___ substrate, use caution with CYP___ inducers and inhibitors

Answer 17

2C9

Question 18

sulfonylurea DDI: _______ may place pts with diabetes at an increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues

Answer 18

alcohol

Question 19

sulfonylurea major counseling points (5)

Answer 19

–swallow whole
–keep away from children
–take with breakfast (glipizide IR 30 min before breakfast)
–increased risk of low BG with skipped meal, excessive exercise, alcohol consumption, stress
–s/sx and management of hypoglycemia

Question 20

MOA of metformin

Answer 20

–decreases hepatic glucose production
–decreases intestinal glucose absorption
–increases insulin sensitivity

Question 21

metformin is ____-line in T2DM and is used in ______.

Answer 21

first

prediabetes

Question 22

metformin (brand, dosing)

Answer 22

Glucophage, Riomet: initial 500 mg BID or 850 mg daily
Glumetza, Fortamet, Glucophage XR: initial 500-1000 mg with dinner (swallow whole)

Titrate in 1-2 week intervals; max 2000-2550 mg/day

Question 23

metformin should be taken in a ____ to minimize ___ _____

Answer 23

meal

GI upset

Question 24

metformin BBW and risk factors

Answer 24

lactic acidosis: higher risk in acute HF, dehydration, excessive alcohol intake, hepatic/renal impairment or sepsis

Question 25

metformin CI (2)

Answer 25

–abnormal CrCl/SCr ≥1.5 males/SCr 1.4 females

–metabolic acidosis

Question 26

Metformin should be stopped in any case of _____, such as decompensated HF, respiratory failure, acute MI or sepsis.

Answer 26

hypoxia

Question 27

Temporarily discontinue metformin in patients receiving intravascular _____ _____ ______.

Answer 27

iodinated contrast media

Question 28

metformin SEs

Answer 28

N/V/D, flatulence, abdominal cramping, long-term vitamin B12 deficiency

Question 29

metformin is weight-_____ and is ___-risk for hypoglycemia when used as monotherapy

Answer 29

neutral

low

Question 30

metfomin monitoring

Answer 30

BG, A1c, renal function, B12

Question 31

metformin decreases A1c by ____%

Answer 31

1-2

Question 32

metformin is pregnancy category ___

Answer 32

B

Question 33

metformin ___ formulation may appear in stool

Answer 33

ER

Question 34

metformin DDIs

Answer 34

–increases risk for lactic acidosis: alcohol, iodinated contrast dye, topiramate

Question 35

metformin DDI: management for iodinated contrast dye

Answer 35

hold prior to procedure and wait 48 hrs after and restart only once renal function has been confirmed as normal

Question 36

metformin can decrease vitamin ___ absorption (and possibly _____ ____) leading to _____ anemia. Consider vitamin supplementation.

Answer 36

B12
folic acid
megaloblastic

Question 37

s/sx of lactic acidosis

Answer 37

weakness, somnolence, slow HR, shivers, muscle pain, SOB, stomach pain, lightheadedness and/or fainting