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12 - Oral Diabetes Medication 1 Flashcards

1
Q

Pregnancy? / ADR / Disadvantages

Meglitinides

A

Not Recommended in Pregnancy / Unknown if excreted in breast milk

caution w/ Clopidogrel or cyclosporine

Elderly / Adrenal-Pituitary Insufficiency

Severe Renal/hepatic impairment

not recommended to take with another secretagogue

Headache / Upper Respiratory Infection / Diarrhea / Weight gain

Hypoglycemia (Repaglinide) / Dizziness (Nateglinide)

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2
Q

Pregnancy? / ADR / Disadvantages

PiaglitaZone

TZD

A

Not Recommended in Pregnancy

Unknown if excreted in breast milk

Increased risk/exacerbation of CHF

Edema / Weight Gain

Upper Resiperatory INFECTION

incresed risk in women for bone fractures / ovulation

COST

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3
Q

Dose

DAPAgliflozin

SGL2-Inhibitor

A

FARXIGA

5mg qd AM

in morning with or w/o food

no dose adj for hepatic impairment

NOT RECOMMENDED for <45ml/min eGFR

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4
Q

ALOgliptin DOSE

Nesina

A

Nesina but generic

25mg QD

with or without food

Renal adjustments, CrCl of:

30-60ml/min = HALF 12.5mg qd

<30ml/min = half again 6.25mg qd

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5
Q

PK’s

SGLT2 Inhibitors​

C-D-E-E GLIFLOZIN​

A

All 4 Drugs have

>80% Glucuronidation metabolism

Peaks around 1-2 hours

Excreted split in urine & feces

  • no dose adjustment for HEPATIC impairment*
  • except for CANAgliflozin* (invokana)
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6
Q

SITAgliptin

A

Januvia

NO GI ADVERSE EFFECTS!

headache / upper respiratory infection / nasopharyngitis

  • Avg A1c reduction: 0.5-0.8%
  • FPG reduction: 20-40mg/dl
  • 2hrPPG reduction: 40-50mg/dl
  • DI:
    • ​increase digoxin
    • increase risk of hypoglycemia w/ sulfonylurea or insulin​
  • ​Peak/Elim = 1-4 hours / 12 hours
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7
Q

Disadvantages of

Metformin

A

GI adverse effects

Risk of lactic acidosis

Caution with alcohol

Not appropriate with

moderate-severe renal impairment

Acute/unstable CHF

Liver impairment

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8
Q

Products

Sulfonylureas

Insulin Secretagogues

A

Second Gen:

GLIPizide

5mg QD-BID

Glimepiride

0.5-1.0mg QD

Glyburide / Glyburide Micro

  • not seen much in practice, due to CKD / CVD risk*
    2. 5 / 1.5 QD or BID
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9
Q

Specific details of: SAXAgliptin

DPP4

LASS GLIPTIN

A

Onglyza

Active Metabolite - 2+4hour Peak

Peripheral Edema / UTI / symptoms of URI

headache / symptoms of upper respiratory infection

  • Reduce A1C by 0.5% monotherapy
  • Combo with sulfonylurea / metformin / TZD - 0.5-0.9%
    • increase risk of hypoglycemia w/ sulfonylurea or insulin​​
  • Along with ALOgliptin may increase risk of*
  • HEART FAILURE*
  • monitor SOB / fatigue / weight gain*
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10
Q

Which drugs are OKAY TO USE for pregnancy?

A

Alpha Glucosidase Inhibitors
Acarbose / Miglitol

DPP-4 Inhibitors
LASS-gliptin

Metformin

  • Bromocriptine mesylate = CYCLOSET*
  • Bile Acid Sequestrant = Colesevelam*
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11
Q

MoA / Advantages

DPP4 Inhibitors

SITAgliptin / SAXAgliptin / LINAgliptin / ALOgliptin

A

Enhances the INCRETIN SYSTEM

particularly GLP-1

oral agent –> incretin system

QD DOSE / WEIGHT NEUTRAL

well tolerated in most patients

Can be used in Renal Insufficiency

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12
Q

Not Recommended / Precautions

PiaglitaZone

TZD

A

Black Box Warning - CHF

Contraindicated in NYHA C3/4 CHF

Liver Disease

Monitor LFTs at start of therapy

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13
Q

Advantages / Benefits

Alpha-Glucosidase Inhibitors

Acarbose (precose) / Miglitol (glyset)

A

PROVIDES PPG CONTROL

does not cause hypoglycemia on its OWN

A1C reduction: 0.5-1%

FPG reduction: 20-40 mg/dl

PPG reduction: 40-70 mg/dl

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14
Q

Dose

EMPAgliflozin

SGL2-Inhibitor

A

JARDIANCE

First anti-DM agent –> REDUCE RISK OF CV DEATH​

10mg qd AM

same as DAPA, except for dose

in morning with or w/o food

no dose adj for hepatic impairment

NOT RECOMMENDED for <45ml/min eGFR

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15
Q

ALOgliptin

DPP4 Inhibitor

A

Nesina, but GENERIC NOW! (cheaper)

Peak = 1-2hrs / Elim = 21 hours

100% bioavailable

Along with SAXAgliptin may increase risk of

HEART FAILURE

monitor SOB / fatigue / weight gain

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16
Q

Products

Thiazolidinediones (TZDs)

Insulin sensitizers

A

Pioglitazone

(Actos)

Rosiglitazone

  • Avandia*
  • not used due to elevated CV risk, but ban was lifted*
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17
Q

Pregnancy? / ADR / Disadvantages

Sulfonylureas

A

Glipizide / Glimepiride / Glyburide

Not Recommended in Pregnancy

Hypoglycemia / Weight Gain

Caution in Elderly / Allergic Skin Reaction

No black box warning

GI disturbances : NVD (less than metformin)

Primary and Secondary Failure

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18
Q

Dose / Indication

GLYburide MICRONIZED

Sulfonylurea

A

GLYburide Micronized

1T (1.5mg) qd/bid

micronized = 1.5mg / MaxClinical=6mg / MaxDose=12mg

half life of 4 hours = can dose BID

Initial Response= 30 minutes, peak = 2-4 hours

CYP2C9

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19
Q

Dose

CANAgliflozin

SGLT1 Inhibitor

A

Invokana

100mg QD

BEFORE first meal

ONLY SGLT2-I that is

  • NOT recommended for severe hepatic impariment / K+ DI’s*
  • no titration needed for <60ml/min EGFR*

NOT recommended for <45ml/min eGFR

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20
Q

Advantages / Benefits

SGLT2 Inhibitors​

A

Treat hyperglycemia in a NEW PATHWAY

Once daily Dosing + Weight Loss

EMPAgliflozin = indicated for reducing death in CV DISEASE!

FPG reduction of: 25-40mg/dl

0.5-0.9% A1C reduction

(but with baseline of 8%)

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21
Q

Examples of Fast Acting Carbs

A

All have ~15g of Carbs

3-4 glucose tablets

5-6 hard candies (chewed)

4 ounces (1/2 glass) of juice/ soda

1 Cup milk

Glucose Gel

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22
Q

Indication / MoA

SGLT2 Inhibitors

A

Treatment for T2DM as adjunct to diet + exercise

SGLT2 Inhibitors

Block the REABSORPTION of

filtered glucose

leading to glucosuria (urinating glucose)

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23
Q

Disadvantages / ADR

SGLT2 Inhibitor

A

CI = END STAGE RENAL DISEASE

Cost / Need for LAB monitoring

NOT REC pregnancy / breast feeding

  • NUMEROUS Side effects
    • UTI - glucose in urine
    • Kidney injury / decrease in eGFR
    • BONE FRACTURES
    • KETOACIDOSIS
    • CANAgliflozin
      • –> lower limb amputation
        • also hyperkalemia
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24
Q

What ORAL drugs are insulin

SENSITIZERS?

A

TZDs
PioglitaZone / RosiglitaZone –> PPAR-Y

Metformin

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25
**Dose** **Bile Acid Sequestrant**
**_Colesevelam = Welchol_** MoA = *unknown, maybe incretins and hepatic glucose* **3.75g QD WF** *may divide into **BID*** **650mg tablets = huge**
26
**15/15 Rule** **for *Hypoglycemia*** **Treatment**
* 1st check BG, **_if \<70mg/dl_** * Tak_e **15g of SIMPLE carb**_ (FAST acting sugar) * monitor the **_BG in 15 Minutes_** * **REPEAT if \<70mg/dl STILL** * *but if its **\<50mg/dl --\>*** **_GIVE 30g of simple carb_** * **_Prefer \>80mg/dl_** * After initial treatment: * patient should **eat a meal / snack** * to **maintain BG level**
27
**Products** **Meglitinides** Insulin Secretagogues
**_Repaglinide_** ADR of hypoglycemia (Prandin) **_Nateglinide_** ADR of Dizzinesss (Starlix) Indicated for adult patients with: **T2DM** as **monotherapy** or **combo** with a **INSULIN SENSITIZER**
28
**MoA / Advantages** **Sulfonylureas​**
**_INSULIN SECRETAGOGUE_** Stimulates **_insulin secretion_** from _pancreatic beta cells_ Improve **insulin sensitivity** + *Reduce **glucose output** from liver* **Relatiely *INEXPENSIVE*** For recent onset **_T2dm and FBG \>200mg/dl_** *Decreases **A1C 1-2%***, *reduces **FBG 50-70 mg/dl*** _similar effects of Metformin(biguanide) on Hba1c & FPG_
29
**Dose / Indication** **PioglitaZone** **TZD**
**1T QD** ## Footnote **start w/ 15 mg, can titrate to** **_MAX 45mg/day_** Titration \>4 weeks, may take up to 12 weeks. **Mono/Combo therapy for T2DM** **\<8% A1c** + **Need for Combo therapy**
30
**Which 2 drugs had a FDA alert saying that they:** * *INCREASE risk of** * *_HEART FAILURE_** (esp those with preexistant **heart / kidney disease**) monitor **SOB / fatigue / weight gain**
**SAXAgliptin** Onglyza **ALOgliptin** Nesina Both are DPP4 - LASS Gliptin
31
**PK's** **Alpha-Glucosidase Inhibitors** **Acarbose (precose) / Miglitol (glyset)**
Onset: **\<1 hour** Duration \<**6 hours** need to take **TID** *very low **bioavailability \<2%*** acarbose miglitol **bioavailability of 100%**
32
**Products** **DPP-4 Inhibitors** (LASS)
**_Sitagliptin_** Januvia - 100mg qd **_Saxagliptin_** Onglyza - 2.5-5mg qd **_Linagliptin_** Tradjenta - 5mg qd, *no dose adjustment* **_Alogliptin_** Nesina - 25mg qd
33
**Products** **Alpha-Glucosidase Inhibitors**
**Acarbose (precose)** **Miglitol (glyset)** **BOTH SAME DOSE** ***SLOW TITRATION*** ***TAKE IN MORNING WITH FOOD TID***
34
**Doses for JANUVIA** Sitagliptin = DPP4-I
**_100mg QD_** ***with or without food*** mono or combo therapy w/ **metformin or PPARy agonist** Pts with renal insufficiency: Moderate, _**CrCl 30-50 ml/min** - **50mg qd**_ Severe & ESRD, ***CrCl \<30 ml/min** - **25mg qd***
35
**Why choose a Sulfonylurea?** Glipizide or Glimepiride
_insulin **S**__ecretagogue_ Preferred for patients with: **Chronic Kidney Disease** **Cardiovascular Disease**
36
**Dose** **Alpha-Glucosidase Inhibitors** Acarbose (precose) / Miglitol (glyset)
**_TAKE WITH FIRST BITE OF MEAL_** ***very slow titration***, same dose both drugs **25 mg** daily for **2-4 weeks** 25 mg **BID** for 2-4 weeks 25 mg **TID** for 2-4 weeks ***50 mg TID, if needed***
37
**Dose / Indication** **Repaglinide, if A1C \<8%** Meglitinide
**_Repaglinide_** **_HbA1c \<8%_ or** renal impairment **_CrCl 20-40mL_** **0.5mg TID** Administer **_within 30 min prior to meal_** *\<4 doses/day, **titrate according to BG​*** **MAX = 16mg/day** (depending on meal pattern)
38
**What ORAL medications are dosed TID?**
**_Meglitinides_** Repa**glinide** / Nate**glinide** **_Alpha Glucosidase Inhibitors_** Acarbose / Miglitol *after TITRATION, QD -\> BID -\> TID -\> TID* *Dopamine Receptor Agonist = **_Bromocriptine_*** ​taken with ALL meals
39
**Dopamine Receptor Agonist** **DOSE**
**Bromocriptine = Cycloset** **0.8mg qd** **_within 2 hours after AWAKENING_** **Titrated weekly** by 1 tablet to therapeutic dose of **_1.6-4.8mg qd_**
40
**Dose** **ERTUgliflozin** **SGLT2-Inhibitor**
_STEGLATRO_ **5mg qd** * doesnt have to be AM,* **_with or without food_** * No dose adj for HEPATIC impairment, **but not studied in severe*** ***not rec for \<60ml/min*** */ **condraindicated \<30ml/min***
41
**Products** **SGLT2 Inhibitors**
**_C-D-E-E GLIFLOZIN_** **CANAgliflozin** Invokana - 100mg **DAPAgliflozin** Farxiga - 5mg **EMPAgliflozin** Jardiance - 10mg **ERTUgliflozin** Steglatro - 5mg
42
**What ORAL medications are dosed** **BID?**
**_Alpha Glucosidase Inhibitors_** Acarbose / Miglitol titration = QD -\> BID -\> tid -\> tid TZD: Just **Rosiglitazone** Sulfonylurea: Just **MicronizedGlyburide** Dopamine Receptor Agonist = Bromocriptine taken with ALL meals *May divide BID - _Bile Acid Sequestrant = **Colesevelam**_*
43
**Adv / Disadvantages** **Dopamine Receptor Agonist** **Bromocriptine = Cycloset**
**_Appropriately timed daily admin of drug_** ***decreases BOTH FPG & PPG***, _but ONLY with other **t2dm drugs**_ need to be taken w/ food & weekly titration ***NOT TYPICALLY USED TO TO ADR & DIFFICULTY OF USE*** *nausea / fatigue / dizziness / constipation / headache*
44
**Dose / Indication** **Glipizide** Sulfonylurea
**_Glipizide_** Drug of choice in **_Moderate Renal Insufficiency (IR)_** **1T (5mg) QD - BID** **_Take 30min BEFORE food_** **5mg** / MaxClinical=**20mg** / MaxDose=**40mg** Initial Response (IR) = **30 minutes**, peak = **1-3 hours** *XR = **2-3 hours**, peak = **6-12 hours***
45
**Indication / MoA** **Alpha-Glucosidase Inhibitors** Acarbose (precose) / Miglitol (glyset)
*monotherapy or* in **COMBINATION WITH _SULFONYLUREA_** *not recommended for intestinal or liver disease* *Competitive inhibitor of :* **pancreatic alpha amylase & brush border alpha glucosidases** *delay carb hydrolysis & **absorption of glucose*** **_PPG REDUCTION!_**
46
**Why Combination Products?**
Useful when **_BG is STABLE_** can ***REDUCE Pill BURDEN*** *usually not recommended for INITIAL Therapy*
47
**Dose / Indication** **Glimepiride** Sulfonylurea
***_reduced dose in RENAL INSUFFICIENCY (1mg)_*** **1T QD** **0.5-1.0mg** / MC = **4mg** / MAX = **8mg**
48
**Onset / PK** **Meglitinides**
FAST onset: **\<30 minutes** Mainly **liver metabolism**: Rapaglinide = CYP3A4 / CYP2C8 Nateglinide: CYP3A4 / CYP2C9 Duration = **4-6 hours** need to take **MULTIPLE DOSES** **within 30min of each meal**
49
**Signs & SYmptoms of** ***hypoglycemia***
Shakey / Sweaty Blurred Vision / Headache Hunger / Weakness / Fatigue **CONFUSION** **IRRITABILITY** **FAST HEART BEAT**
50
**MoA / Advantages** **Meglitinides** Repaglinide / Nateglinide
**_INSULIN SECRETAGOGUE_** MOA: Stimulate **insulin release from pancreas** ***_low risk of severe hypoglycemia_** vs sulfonylureas* * Flexibility in lifestyle - **dose coupled w/ meals** * high initial response rate * Can be used in: * **mild-moderate RENAL INSUFFICIENCY** * **Hepatic DYSFUNCTION** * _Repaglinide_ with slow dose titration
51
***Not Recommended / Precautions*** **DDP4 Inhibitors** SITAgliptin / SAXAgliptin / LINAgliptin / ALOgliptin
*Caution with **_ANTIRETROVIRALS_*** (SAXA/LINAgliptin) Patients with **Arthralgia** Risk for ***Pancreatitis***
52
**DPP4 Inhibition** **MoA**
**DPP4 normally *BREAKS DOWN*** **_incretin_** hormone quickly *inhibiting it --\>* **_MORE INCRETIN AVAILABLE_** ***lower Fasting BG & Postprandial BG*** * Incretin Hormones: * **_GLP-1_** * ***less GLUCAGON*** * _​_*decreases **HEPATIC GLUCOSE** production* * **_GIP_** _+ GLP-1_ * **_MORE INSULIN_** * increases **_GLUCOSE UPTAKE_** by peripheral tissue
53
**Primary Failure** **of Sulfonylurea**
**Patient NEVER responds to the drug** Glipizide / GLYburide / Glimepiride
54
**Onset / PK** **PioglitaZone** TZD
*Delayed onset:* ***4 weeks, up to 12 weeks*** Mainly **liver metabolism**: CYP3A4 / CYP2C8 both **active & *inactive* metabolites** Peak @ **2-4 hours** *vs 1 hour for Rosiglitazone*
55
**Pregnancy? / ADR / Disadvantages** **DPP4 Inhibitors** SITAgliptin / SAXAgliptin / LINAgliptin / ALOgliptin
**_Okay for pregnancy_** (only other is metformin) **COST** ***A1c reduction may be lower*** Increased risk of ***hypoglycemia*** w/ insulin or secretagogues _FDA Warning / Post-Market Cases:_ **Severe Joint Pain** (within 1 month of initiation) **Pancreatitis / Hypersensistivity RXN**
56
**Secondary Failure of** **Sulfonylurea**
_Glipizide / GLYburide / Glimepiride_ **_Drug USED TO WORK_** **initially controlled** on the drug,but control is ***LOST OVER TIME*** * Signs: **FPG\>140mg/dl - HbA1c \> 8%** * ​**Addition or switch** to another medication * after _6 months of therapy_ * _​​_Causes: * ***Decreasing Beta cell fxn or NON ADHERENCE***
57
**SAXAgliptin Dose** Onglyza
**2.5-5mg QD** ## Footnote **normally 5mg** ***For Renal insufficiency*** ***(CrCl \<50ml/min)*** *half dose to **_2.5mg QD_***
58
**SEVERE** ***hypoglycemia* treatment**
**_GLUCAGON EMERGENCY KIT_** **0.5-1mg** **IM, SC or IV** into _Buttocks / upper arm / thigh_ **_may be repeated in 15 min if needed_** * ***if no response in 15 minutes*** * **_CALL AMBULENCE 911_** * *may cause **N/V**_,_ turn patient on **side*** * **give CARB SNACK** **​_DEXTROSE IV 25G okay in inpatient or clinic setting_**
59
***Not Recommended / Precautions*** **PiaglitaZone** TZD
**_Black Box Warning - CHF_** ## Footnote Contraindicated in NYHA C3/4 CHF **_Liver Disease_** Monitor **LFTs** at start of therapy
60
**Dose / Indication** **Repaglinide, if A1C \>8%** **GREATER THAN 8%** Meglitinide
**_Repaglinide_** **HbA1c greater than \>8%** **1-2mg TID** Administer **_within 30 min prior to meal_** *\<4 doses/day, **titrate according to BG*** **MAX = 16mg/day** (depending on meal pattern)
61
**SGL2** **Sodium Glucose Co-transporter 2**
180g of glucose is filtered daily in **glomeruli** **almost ALL (99%) is REABSORBED** **_through SGLT2_** low-affinity transporter expressed mainly in the KDNEY *inhibition --\> **glucose in URINE***
62
**LINAgliptin Dose**
**Tradjenta** **5mg QD** ***_NO DOSAGE ADJUSTMENT!_***
63
**Why choose Meglitinide over Sulfonylurea?**
_Repaglinide/Nateglinide \> Glyburide/Glimepiride/Glyburide_ ***_Lower risk of SEVERE hypoGLYCEMIA_*** *compared to sulfonylureas*
64
**Advantages of** **Metformin**
Insulin Sensitizer ***No Direct action on PANCREAS*** *MoA not likely to cause **hypoglycemia*** ***Weight loss*** ***Inexpensive*** *used in **combination** w/ other orals or Injectables*
65
**Onset / PK** **DPP4 Inhibitor** SITAgliptin / SAXAgliptin / LINAgliptin / ALOgliptin
***Varies between the drugs*** Typically 1-4 hours _**SAXAgliptin** has an **active metabolite**_ its bioavailability is still unknown due to this
66
***hypoglycemia*** **Definition**
Since some meds can cause ***hypo*glycemia** **BG of \<70mg/dl** **S/S** *may appear in **normal ranges*** *_esp if they had CHRONIC HYPERglycemia_*
67
**What drug class has a....** **_Black Box Warning - CHF_** *Contraindicated in NYHA C3/4 CHF* **Liver Disease / Hepatotoxicity** *Monitor LFTs at start of therapy*
**TZDS** Pioglitazone Rosiglitazone
68
**Which ORAL medications can be used with patients with** **_RENAL INSUFFICIENCY?_**
**_DPP-4 Inhibitors_** Renal Dose adjustments, *except LINAgliptin = Tradjenta* ***Meglitinides** can be used in mild to moderate renal insufficiency no adjustment in NATEglinide* Not ideal but **GLIPIZIDE** is the sulfonylurea that is preferred in moderate renal insufficiency.
69
**LINAgliptin** DPP4 Inhibitor 5mg QD, *no dose adjusting*
**Tradjenta** ***_NO DOSAGE ADJUSTMENT!_*** *Low BV of 30%* Peak @ **1.5 hour**s / Elim **12 hours** ***Hypoglycemia***
70
**Adv / Disadv** **Bile Acid Sequestrant** **Colesevelam**
Effects not seen until **_4-18 weeks_** Reduction of A1C is **ONLY 0.3-.54%** ***_TAKES TOO LONG & NOT AS EFFECTIVE_*** * also **need to SPACE OUT FROM OTHER DRUGS*** * GI obstruction / Constipation / Headace / Dypepsia*
71
**Dose / Indication** **Nateglinide** Meglitinide
**_Nateglinide_** ***_no RENAL or HEPATIC dose adjustment_*** **120mg TID** Administer **_within 30 min prior to meal_** *if closer to A1C goal (\<8%), can start at **60mg TID***
72
**MoA / Advantages** **Pioglitazone** **TZD**
**_INSULIN SENSITIZER_** - Selective agonist for **PPAR-Gamma** Improve **insulin sensitivity** + Enhance **glucose uptake** * Lower **BP / Lipid profile*** * Reduced **C-Reactive protein + PAI-1 levels*** * Decreases **A1C 0.5-1.5%***, *reduces **FBG 30-60 mg/dl***
73
**What ORAL drugs are insulin** **_SECRETAGOGUES?_**
**_Sulfonylurea_** Glipizide / Glyburide / Glimepiride **_Meglitinides_** repaGLINIDE / nateGLINIDE
74
**Dose / Indication** **GLYburide *nonmicronized*** Sulfonylurea
**_GLYburide_** *NOT recommended for **CrCl \<60ml/min*** **1T (2.5mg) QD** normal = **2.****5mg**/ MaxClinical=**10****mg** / MaxDose=**20mg** Initial Response= **30 minutes**, peak = **2-4** **hours** CYP2C9, half life = 10hrs
75
**Disadvantages / ADR** **Alpha-Glucosidase Inhibitors** **Acarbose (precose) / Miglitol (glyset)**
**_GI EFFECTS!_** **TID Dosing + *slow titration*** (2-4 weeks) need **glucose treatment** if taken with hypoglycemic drug (liver labs) **​LFT testing EVERY 3 MONTHS** * *_Contraindications_* * ***_various GI related diseases_*** * IBS / Ulcers / Cirrhosis / Intestinal obstruction * ***Liver Disease*** * ***​*Flatulence / Ab Pain / Diarrhea**
76
**C D E E** -**g****liflozin**
**SG**LT2 Inhibitors **Cana** / **Dapa** / **_Empa_** / ***Ertu*** **100 / 5 / 10 / 5** Invok(c)ana / Farxiga / _Jardiance_ / *Steglatro* b4 first meal / AM / _AM_ / *no need for AM or food*
77
**L A S S -gliptin**
**DPP4**-Inhibitors ***Lina* / Alo / Saxa / Sita** ***5* / 25 / _5_ _(2.5)_ / 100** * Tradjenta* / NesinA / _Onglyza_ / Januvia * no dose adj* / risk of Heart failure + _active metabolite_ /
78
**Which medication was the FIRST ANTI-DM AGENT with the additional indication to** ***reduce risk of*** ***_CV DEATH_***???
**_EMPAgliflozin_** = **Jardiance** 25mg QD AM CDEE-gliflozin = SGLT2 Inhibitor

PDAT2 (22 decks)

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