13 - Oral Diabetes Medication 2 Flashcards
Signs & SYmptoms of
hypoglycemia
Shakey / Sweaty
Blurred Vision / Headache
Hunger / Weakness / Fatigue
CONFUSION
IRRITABILITY
FAST HEART BEAT
Dose
Bile Acid Sequestrant
Colesevelam = Welchol
MoA = unknown, maybe incretins and hepatic glucose
3.75g QD WF
may divide into BID
650mg tablets = huge
hypoglycemia
Definition
Since some meds can cause hypoglycemia
BG of <70mg/dl
S/S may appear in normal ranges
esp if they had CHRONIC HYPERglycemia
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
Advantages / Benefits
SGLT2 Inhibitors
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%)
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!
Dose
DAPAgliflozin
SGL2-Inhibitor
FARXIGA
5mg qd AM
in morning with or w/o food
no dose adj for hepatic impairment
NOT RECOMMENDED for <45ml/min eGFR
Which drugs are OKAY TO USE for pregnancy?
Alpha Glucosidase Inhibitors
Bromocriptine mesylate = CYCLOSET
Bile Acid Sequestrant = Colesevelam
all except SGLT inhibitors -gliflozin
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
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
Advantages / Benefits
Alpha-Glucosidase Inhibitors
Acarbose (precose) / Miglitol (glyset)
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
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
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
PK’s
SGLT2 Inhibitors
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*
Products
Alpha-Glucosidase Inhibitors
Acarbose (precose)
Miglitol (glyset)
BOTH SAME DOSE
SLOW TITRATION
TAKE IN MORNING WITH FOOD TID
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
-
various GI related diseases
- Flatulence / Ab Pain / Diarrhea
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%
Examples of Fast Acting Carbs
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
Dose
CANAgliflozin
SGLT1 Inhibitor
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
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*
Indication / MoA
SGLT2 Inhibitors
Treatment for T2DM as adjunct to diet + exercise
SGLT2 Inhibitors
Block the REABSORPTION of
filtered glucose
leading to glucosuria (urinating glucose)
Dose
EMPAgliflozin
SGL2-Inhibitor
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
Disadvantages / ADR
SGLT2 Inhibitor
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
-
–> lower limb amputation
Why Combination Products?
Useful when BG is STABLE
can REDUCE Pill BURDEN
usually not recommended for INITIAL Therapy
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
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
- patient should eat a meal / snack
Products
SGLT2 Inhibitors
C-D-E-E
CANAgliflozin
Invokana - 100mg
DAPAgliflozin
Farxiga - 5mg
EMPAgliflozin
Jardiance - 10mg
ERTUgliflozin
Steglatro - 5mg
