ada3 Flashcards
Describe the characteristics of Metformin.
Metformin has high efficacy in lowering glucose levels, no cardiovascular effects, no renal effects, and a potential for weight loss. It is taken orally and has low cost. However, it is contraindicated in patients with an estimated glomerular filtration rate (eGFR) less than 30 mL/min.
What are the clinical considerations for Metformin?
When prescribing Metformin, clinicians should be aware of the potential for gastrointestinal side effects and consider slow dose titration, extended-release formulations, and administration with food to mitigate these effects. Regular monitoring for vitamin B12 deficiency is also recommended.
What are the characteristics of SGLT2 inhibitors?
SGLT2 inhibitors have intermediate efficacy in lowering glucose levels, no cardiovascular effects, no renal effects, and a potential for weight loss. They are taken orally and have high cost. However, they carry a risk of diabetic ketoacidosis (DKA) and genital mycotic infections. Renal dose considerations should be followed.
How do SGLT2 inhibitors affect glucose-lowering effect at lower eGFR?
The glucose-lowering effect of SGLT2 inhibitors is lower at lower eGFR. Therefore, caution should be exercised when using these medications in patients with reduced kidney function.
Describe the characteristics of GLP-1 RAs.
GLP-1 RAs have high to very high efficacy in lowering glucose levels, no cardiovascular effects, no renal effects, and a potential for weight loss. They can be administered subcutaneously or orally. However, there is a risk of thyroid C-cell tumors in rodents, and the human relevance is not determined. Renal dose considerations should be followed.
Describe the characteristics of GLP-1 RAs.
GLP-1 RAs have high to very high efficacy in lowering glucose levels, no cardiovascular effects, no renal effects, and a potential for weight loss. They can be administered subcutaneously or orally. However, there is a risk of thyroid C-cell tumors in rodents, and the human relevance is not determined. Renal dose considerations should be followed.
What are the clinical considerations for GLP-1 RAs?
When prescribing GLP-1 RAs, clinicians should monitor for thyroid C-cell tumors, counsel patients on potential gastrointestinal side effects, and provide guidance on dietary modifications to mitigate these effects. Renal function should be monitored when initiating or escalating doses in patients with renal impairment.
Describe the recommended glucose-lowering regimen for people with reduced estimated glomerular filtration rates (eGFR).
Table 10.3C and Section 10 recommend a glucose-lowering regimen independent of A1C, independent of metformin use, and considering person-specific factors.
What are the potential side effects associated with metformin use?
Metformin use is associated with vitamin B12 deficiency and worsening symptoms of neuropathy.
What are the potential side effects associated with metformin use?
Metformin use is associated with vitamin B12 deficiency and worsening symptoms of neuropathy.
What does the VERIFY trial suggest about initial combination therapy for type 2 diabetes?
The VERIFY trial suggests that initial combination therapy with metformin and the dipeptidyl peptidase 4 (DPP-4) inhibitor vildagliptin has a slower decline of glycemic control compared to metformin alone.
Define the term ‘glycemic targets’.
Glycemic targets refer to the desired levels of blood glucose control in individuals with diabetes.
How should medication choice be guided when selecting a glucose-lowering regimen?
Medication choice should be guided by efficacy in achieving individualized glycemic and weight management goals, avoidance of side effects, cost/access, and individual preferences.
How should medication choice be guided when selecting a glucose-lowering regimen?
Medication choice should be guided by efficacy in achieving individualized glycemic and weight management goals, avoidance of side effects, cost/access, and individual preferences.
Describe the principles in Figure 9.3 for pharmacologic approaches to glycemic treatment.
The principles in Figure 9.3 include reinforcement of behavioral interventions such as weight management and physical activity, as well as provision of DSMES (Diabetes Self-Management Education and Support) to meet individualized treatment goals.
What are the recommended injectable therapies to reduce A1C in most individuals prior to insulin?
GLP-1 RA (Glucagon-Like Peptide-1 Receptor Agonist) or GIP/GLP-1 RA (Glucose-Dependent Insulinotropic Polypeptide/Glucagon-Like Peptide-1 Receptor Agonist) are recommended prior to insulin in most individuals.
How should the basal insulin dose be initiated and titrated?
The basal insulin dose should be initiated at an appropriate starting dose for the selected agent and titrated to a maintenance dose. The specific starting and titration doses vary within the class of basal insulin.
When should prandial insulin be considered and how should it be dosed?
Prandial insulin should be considered if A1C remains above target and the individual is not already on a GLP-1 RA or dual GIP and GLP-1 RA. It can be dosed individually or mixed with NPH as appropriate, usually with the largest meal or the meal with the greatest postprandial glucose excursion.
Describe the pharmacologic approaches to glycemic treatment.
Pharmacologic approaches to glycemic treatment involve the use of medications such as insulin therapy, GLP-1 receptor agonists, and SGLT2 inhibitors to manage blood sugar levels in individuals with diabetes.
What are the benefits associated with GLP-1 receptor agonists?
GLP-1 receptor agonists have been shown to have greater efficacy and durability of glycemic treatment compared to NPH insulin. They also reduce the risk of symptomatic and nocturnal hypoglycemia.
How do longer-acting basal insulin analogs differ from U-100 glargine or detemir?
Longer-acting basal insulin analogs, such as U-300 glargine or degludec, have a lower hypoglycemia risk when used in combination with oral agents compared to U-100 glargine.
Define overbasalization in insulin therapy.
Overbasalization in insulin therapy refers to the excessive use of basal insulin, which can lead to high bedtime-morning or postprandial glucose differentials, hypoglycemia, and high variability in blood sugar levels.
Describe the impact of chronic kidney disease (CKD) on treatment choices for diabetes.
Chronic kidney disease (CKD) can impact treatment choices for diabetes. Some medications, such as SGLT2 inhibitors, have been shown to have beneficial effects on indices of CKD. Clinicians should consider CKD when selecting treatment options.
What is the median AWP of metformin 850 mg (IR)?
$106 ($5, $189)
Describe the dosage strength of glimepiride.
4 mg
What is the maximum approved daily dose of glyburide?
5 mg
Define NADAC.
National Average Drug Acquisition Cost
How much does a 30-day supply of dulaglutide 4.5 mg mL pen cost according to NADAC?
$852
Do SGLT2 inhibitors lower blood glucose levels?
Yes
Describe the dosage strength of exenatide (extended release).
2 mg powder for suspension or pen
What is the median NADAC of miglitol 100 mg?
NA
How much does a 30-day supply of bromocriptine 0.8 mg cost according to AWP?
$1,118
Describe the median cost of Lispro follow-on product in U-100 vial calculated as AWP.
The median cost of Lispro follow-on product in U-100 vial calculated as AWP is $118.
What is the median cost of Glulisine in U-100 prefilled pen calculated as NADAC?
The median cost of Glulisine in U-100 prefilled pen calculated as NADAC is $351.
How much does the U-500 prefilled pen of concentrated human regular insulin cost?
The U-500 prefilled pen of concentrated human regular insulin costs $230.
Do the AWP and NADAC data presented include vials of regular human insulin and NPH available at Walmart?
No, the AWP and NADAC data presented do not include vials of regular human insulin and NPH available at Walmart.
What is the recommended spirometry testing for individuals who smoke or recently stopped smoking?
All individuals require spirometry (FEV1) testing to identify potential lung disease.
When initiating combination injectable therapy, what medication should be maintained?
When initiating combination injectable therapy, metformin therapy should be maintained.
What adjunctive medication may help improve control and reduce the amount of insulin needed in individuals with suboptimal blood glucose control?
In individuals with suboptimal blood glucose control, especially those requiring large insulin doses, adjunctive use of a thiazolidinedione or an SGLT2 inhibitor may help to improve control and reduce the amount of insulin needed.
Describe the importance of dose titration in a basal-bolus insulin regimen.
Once a basal-bolus insulin regimen is initiated, dose titration is important, with adjustments made in both mealtime and basal insulins based on the blood glucose levels and an understanding of the individual’s glycemic goals.
What is the purpose of advancing to combination injectable therapy?
If basal insulin has been titrated to an acceptable fasting blood glucose level and A1C remains above target, advancing to combination injectable therapy can help improve glycemic control.
Describe the importance of dose titration in a basal-bolus insulin regimen.
Once a basal-bolus insulin regimen is initiated, dose titration is important, with adjustments made in both mealtime and basal insulins based on the blood glucose levels and an understanding of the individual’s glycemic goals.
What is the purpose of advancing to combination injectable therapy?
If basal insulin has been titrated to an acceptable fasting blood glucose level and A1C remains above target, advancing to combination injectable therapy can help improve glycemic control.
Describe the importance of dose titration in a basal-bolus insulin regimen.
Once a basal-bolus insulin regimen is initiated, dose titration is important, with adjustments made in both mealtime and basal insulins based on the blood glucose levels and an understanding of the individual’s glycemic goals.
What is the purpose of advancing to combination injectable therapy?
If basal insulin has been titrated to an acceptable fasting blood glucose level and A1C remains above target, advancing to combination injectable therapy can help improve glycemic control.
Describe the purpose of the study published in the Lancet Diabetes Endocrinol in 2017.
To evaluate the efficacy and safety of liraglutide added to insulin treatment in type 1 diabetes.
What is the duration of the multicenter trial of closed-loop control in type 1 diabetes published in the New England Journal of Medicine in 2019?
12 weeks.
Define metformin.
A medication commonly used for the treatment of type 2 diabetes that helps control blood sugar levels.
How long was the trial in which the long-term treatment with metformin in type 2 diabetes and methylmalonic acid was analyzed?
4.3 years.
Describe the aim of the DEPICT-1 trial.
To assess the efficacy and safety of dapagliflozin in patients with inadequately controlled type 1 diabetes.
What organization published the American Diabetes Association/JDRF Type 1 Diabetes Sourcebook?
American Diabetes Association.
Do the FDA warnings regarding the use of diabetes medicine metformin apply to all patients?
No, the warnings are specific to certain patients.
Describe the findings of the randomized trial published in Diabetes Care in 2016 regarding the efficacy and safety of liraglutide added to capped insulin treatment in subjects with type 1 diabetes.
The trial found that liraglutide added to capped insulin treatment improved glycemic control and was well-tolerated.
Describe the TITRATE study.
The TITRATE study assessed the efficacy and safety of patient-directed titration for achieving glycemic goals using a once-daily basal insulin analogue.
What is the purpose of the PIONEER 4 study?
The PIONEER 4 study aimed to compare the efficacy and safety of oral semaglutide versus subcutaneous liraglutide and placebo in type 2 diabetes.
Define network meta-analysis.
Network meta-analysis is a statistical technique that combines direct and indirect evidence from multiple studies to compare the effectiveness of different interventions.
How does insulin degludec compare to insulin glargine in the BEGIN Once Long trial?
The BEGIN Once Long trial found that insulin degludec was non-inferior to insulin glargine in terms of glycemic control in insulin-naive subjects with type 2 diabetes.
Describe the STAT study.
The STAT study investigated the efficacy of glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy in combination with titrated insulin glargine for glycemic control in patients with type 2 diabetes.
What is the purpose of the SURPASS-5 trial?
The SURPASS-5 trial aimed to compare the efficacy and safety of technosphere insulin versus insulin aspart in patients with type 2 diabetes over a 24-week period.
Define pharmacokinetics and pharmacodynamics.
Pharmacokinetics refers to the study of how a drug is absorbed, distributed, metabolized, and excreted by the body. Pharmacodynamics refers to the study of the drug’s effects on the body and the mechanisms of action.
How does LixiLan-L simplify insulin regimens?
LixiLan-L is a titratable fixed-ratio combination of insulin glargine and lixisenatide that simplifies insulin regimens by providing both basal and prandial insulin in a single injection.
What is the purpose of the American Diabetes Association (ADA) Standards of Care in Diabetes?
To provide clinical practice recommendations and tools for evaluating quality of care in diabetes.
