Antidiabetic Med Classes- FINAL

Question 1

Insulin

Answer 1

-Polypeptide hormone secreted by B cells

-MOA:
-Triggered by glucose levels
-Exogenous in Type 1 to REPLACE absent insulin
-Exogenous in Type 2 to SUPPLEMENT insulin secretion

-Pharm: made by recombinant DNA
technology using strains of E. coli or yeast that are genetically altered
-Broken down in the GI tract, so it cannot be taken orally

-ADE: Low blood sugar
Weight gain
-Local injection site reactions (lipodystrophy)
-Bronchospasm can occur with
inhaled insulin

Question 2

Bolus Insulin Therapy

Answer 2

-A meal bolus is determined by: the amount of CHO to be ingested; this amount is divided by the insulin-to-CHO ratio [the number of grams of CHO that 1 unit of insulin covers]
-1 Unit covers approx 15 carbs

-Correction bolus is used: to quickly reduce BS back to normal; the dose is determined by the sensitivity factor
[the amount the BS will decrease with 1 unit of insulin]
-1 Unit covers approx 20mg/dl of blood sugar

-Sensitivity factor= is calculated by dividing 2000 by the total daily dose of insulin

Question 3

Basal Insulin Therapy

Answer 3

-This is the steady background insulin that controls BS in the fasting state [overnight and in between meals]

-Enables stored fat and glucose to be released in appropriate amounts to sustain metabolism during time when fuel is not being consumed and metabolized

-Can be added to orals for better BS control

Question 4

Considerations for insulins
(Functions)

Answer 4

-Secreted at a constant basal rate with intermittent bursts in response to stimuli

-Lowers blood sugar by enhancing transport of glucose into tissues

-Increases [NO] production in blood vessels

-Acts as a vasodilator; inhibits platelet aggregation

-In a person with normal insulin sensitivity, insulin plays a protective role against atherosclerosis

Question 5

Rapid and Short-Acting Insulins

Answer 5

-Are given to mimic mealtime release
of insulin and control postprandial glucose

-Usually used in conjunction with longer-acting basal insulin that
provides control of fasting BS

• Rapid acting should be injected 15 mins before meal (30 for regular insulin)

-Onset: 5-15 mins

-Peak levels: 60 mins approx

-Rapid duration: Approx 2 hours

-Ex: regular, inhaled insulin= SHORT lispro, aspart, glulisine= RAPID

NOTE– with REGULAR insulin, onset is 30 mins, peaks in 2 hours, but hangs around for 5-6 which is why we’re using it a lot more now in tube fed patients

Question 6

Side note for INHALED insulin (Abrezza)

Answer 6

-Most be older than 18

-Can use for type I or II

-eliminated more rapidly

-Provides higher insulin levels with peak effects in about 2 hours

-Dosed beginning with largest meal

-Can affect lung function contraindicated in COPD [risk of
acute bronchospasm]

-Patient must have baseline PFTs, then repeated every 6- 12 months

-Should not be used in smokers or in those with severe
asthma

Question 7

What are the goals of treatment for diabetes mellitus (DM)?

Answer 7

Maintain blood glucose within normal limits, prevent long-term complications, reduce insulin resistance through lifestyle modifications, and use pharmacologic interventions as needed.

Question 8

What is the action of insulin on the liver?

Answer 8

Insulin inhibits gluconeogenesis, promotes glycogen storage, and decreases hepatic glucose production.

Question 9

What is the action of insulin on muscle tissue?

Answer 9

Insulin stimulates glucose uptake, promotes glycogen storage, and enhances protein synthesis.

Question 10

What is the action of insulin on adipose tissue?

Answer 10

Insulin facilitates glucose uptake, promotes lipid synthesis, and inhibits lipolysis.

Question 11

What are the phases of insulin release in the body?

Answer 11

1) Fed State (Phase 1): Immediate insulin burst post-meal. 2) Postabsorptive State (Phase 2): Blood glucose from glycogen breakdown. 3) Early Starvation (Phase 3): Blood glucose from gluconeogenesis. 4) Preliminary Prolonged Starvation (Phase 4): Liver/kidney gluconeogenesis. 5) Secondary Prolonged Starvation (Phase 5): Reduced glucose use and gluconeogenesis.

Question 12

What is the role of Amylin in the body?

Answer 12

Amylin delays gastric emptying, decreases postprandial glucagon secretion, and enhances satiety.

Question 13

What is the difference between basal and prandial (bolus) insulin?

Answer 13

Basal insulin provides steady background insulin levels for fasting states, while prandial (bolus) insulin is used to manage post-meal glucose spikes.

Question 14

What are the types of insulin based on their action?

Answer 14

1) Rapid-acting (onset: 5-15 min, peak: 1-3 hrs, duration: 2-4 hrs).

2) Short-acting (onset: 30-60 min, peak: 2-4 hrs, duration: 6-12 hrs).

3) Intermediate-acting (onset: 2-4 hrs, peak: 6-10 hrs, duration: 10-16 hrs).

4) Long-acting (onset: 2 hrs, no peak, duration: 20-24 hrs).

Question 15

Which types of insulin target fasting blood sugar (FBS) vs. postprandial blood sugar (PPBS)?

Answer 15

Basal insulins (intermediate, long-acting) target FBS. Lantus/glargine

Prandial insulins (rapid, short-acting) target PPBS.

Question 16

Which insulins may be given IV?

Answer 16

Short-acting and rapid-acting insulins (Regular insulin, Insulin Aspart, Insulin Lispro, and Insulin Glulisine).

Question 17

What laboratory monitoring is important for diabetic patients?

Answer 17

Hemoglobin A1C (every 3 months), fasting blood glucose, postprandial glucose, kidney function (creatinine, albuminuria), lipid profile, and blood pressure monitoring.

Question 18

Which insulins can be used in pregnancy?

Answer 18

Regular insulin, NPH, Insulin Lispro, Insulin Aspart, Insulin Detemir, Insulin Glargine.

Question 19

How do you adjust insulin dosage when switching between types? How do you convert intermediate insulin to base insulin?

Answer 19

Switching from rapid to basal insulin requires dose calculation based on total daily insulin needs. Switching from intermediate to basal insulin requires a 20% dose reduction for starting dose.

Question 20

What are common complications and side effects of insulin use?

Answer 20

Hypoglycemia, weight gain, injection site reactions, lipodystrophy, and risk of bronchospasm with inhaled insulin.

Question 21

How do Biguanides (Metformin) work?

Answer 21

Decreases hepatic glucose production, increases insulin sensitivity, and decreases intestinal glucose absorption.

Question 22

What are the advantages and disadvantages of Biguanides?

Answer 22

Advantages: No hypoglycemia, weight neutral, cardiovascular benefits. Disadvantages: GI disturbances, risk of lactic acidosis, contraindicated in renal impairment.

Question 23

What is the mechanism of action of Sulfonylureas and Glinides?

Answer 23

Stimulate insulin release from pancreatic beta cells by closing ATP-sensitive potassium channels.

Sulfonylureas Glipizide
Glinides repaglinide

Question 24

What are the advantages and disadvantages of Sulfonylureas?

Answer 24

Advantages: Effective in reducing blood glucose. Disadvantages: Risk of hypoglycemia, weight gain, and loss of efficacy over time.

Question 25

What are the indications for IV insulin use?

Answer 25

DKA, HHS, perioperative glycemic management, and severe hyperglycemia in hospitalized patients.

Question 26

Metformin MOA, A1C reduction, targets fasting or postprandial? Can be used in children? Pregnancy?

Answer 26

MOA: Decreases hepatic glucose production, increases insulin sensitivity A1C: 1-1.5% Fasting. Children: Yes > 10 Pregnancy Yes (B)

Question 27

Metformin Advantages, disadvantages, side effects and drug interactions

Answer 27

Adv: Weight neutral, CV benefits, no hypoglycemia. Disadv: GI side effects, lactic acidosis risk. Side effects: diarrhea, nausea, B12 deficiency, lactic acidosis (rare). Interactions: Contrast, alcohol, cimetidine

Question 28

Sulfonylureas/Meglitinides MOA, A1C reduction, targets fasting or postprandial? Can be used in children or pregnancy?

Answer 28

MOA: Stimulates pancreatic beta cells to release insulin. A1C: 1-2%. Suldonylreas both fasting and post prandial, Meglitinides: post prandial Children: Limitied to Glyburide. Pregnancy: limited to glyburide (not first line)

Question 29

Sulfonylureas/Meglitinides (Glinides) Advantages, disadvantages, side effects and drug interactions

Answer 29

Adv: rapid action, effective early on. Disadv: hypoglycemia, weight gain, loss of efficacy over time. Interactions: Betablockers, ETOH, CYP2C9 inhibitors

Question 30

Thiazolidinediones MOA, A1C reduction, targets fasting or post prandial can be used in children? Pregnancy?

Answer 30

MOA: increases insulin sensitivity. Fasting. A1C 1-1.5%. Children: No Pregnancy: No

Question 31

Thiazolidinediones Advantages, disadvantages, side effects, and drug interactions

Answer 31

Adv: no hypoglycemia Disadv: weight gain, edema, CHF risk, fractures. ADE: bladder cancer (with pioglitazone). Interactions: CYP2C8, Insulin

Question 32

Alpha-Glucosidase Inhibitors MOA, A1C, targets fasting or post prandial. Children? Pregnancy?

Answer 32

MOA: inhibits intestinal alpha-glucosidase, delays carb digestion. Postprandial. A1C: 0.5-0.5%. Children: No. Pregnancy: No. Acarbose

Question 33

Alpha-Glucosidase Inhibitors Advantages, disadvantages, side effects and drug interactions

Answer 33

Adv: no systemic effects, weight neutral. Disadv: GI issues, frequent dosing. Side effects: flatulence, bloating, diarrhea. Interactions: Affects absorption of other drugs

Question 34

DDP-4 Inhibitors MOA, A1C, targets fasting or postprandial, Children? Pregnancy?

Answer 34

Inhibiting DDP-4 anzyme increases incretin hormones. Post prandial. A1C: 0.5-1%. Children: No. Pregnancy: No Gliptin: sitagliptin

Question 35

DDP-4 Inhibitors Advantages, disadvantages, side effects, drug interactions

Answer 35

Adv: Weight neutral, low hypoglycemia risk. Disadv: Pancreatitis risk, only modest A1C reduction. Side Effects: N/V/D, pancreatitis, thyroid cancer?? Interactions: delays gastric emptying affecting oral drug absorption Increase GLP1& GIP = sitagliptin

Question 36

GLP-1 Agonists MOA, A1C, targets fasting or postprandial, Children? Pregnancy?

Answer 36

Mimics GLP-1, enhances insulin, decreases glucagon and appetite. Both fasting and postprandial. A1C: 1-2%. Children: Liraglutide in >10 only. Pregnancy: No

Question 37

GLP-1 Agonists Advantages, disadvantages, side effects, drug interactions

Answer 37

Adv: weight loss, decreased CV risk, low hypoglycemia risk. Disadv: injection, N/V/D. Side effects: N/V/D, pancreatitis, thyroid cancer risk. Interactions: Delays gastric emptying affecting absorption of other drugs

Question 38

Amylin Mimetics MOA, A1C, targets fasting or postprandial, Children? Pregnancy?

Answer 38

MOA: slows gastric emptying, reduces glucagon. Postprandial. A1C: 0.5-1%. Children: No. Pregnancy: No

Question 39

Amylin Mimetics Advantages, disadvantages, side effects, drug interactions

Answer 39

Adv: Weight loss, adjunct to insulin. Disadv: Injection, hypoglycemia risk with insulin. Side effects: N/V, hypoglycemia. Interactions: delays oral drug absorption, enhances insulin effects

Question 40

SGLT2 Inhibitors MOA, A1C, targets fasting or postprandial, Children? Pregnancy?

Answer 40

MOA: inhibits renal SGLT2 increasing urinary excretion of glucose. Fasting. A1C: 0.5-1%. Children: Yes >10. Pregnancy: No

Question 41

SGLT2 Inhibitors Advantages, disadvantages, side effects, drug interactions

Answer 41

Adv: weight loss, CV and renal benefits, low hypoglycemia risk. Disadv/side effects: UTIs, dehydration, ketoacidosis, amputations?! Interactions: Diuretics, RAAS inhibitors (hyperkalemia)

Question 42

What is the role of bromocriptine (Cycloset) and colesvelam (Welchol) in diabetes management?

Answer 42

Neither are first line agents. They are used with patients need additional A1C lowering but can't tolerate other medications. They are usually adjuncts to metformin whe other options are contraindicated. Bromocriptine is helpful for patients with diabetes and CV disease, while colesevelam is helpful for patients with diabetes and dyslipidemia.

Question 43

What are some complications of insulin use that could decrease patient compliance?

Answer 43

Injection site reactions, allergies, complexity of regimens, fear of needles, social stigma, weight gain, hypoglycemia.

Question 44

Why is Urine albumin to creatinine ratio important to monitor in DM patients?

Answer 44

Screens for diabetic nephropathy. Should be done annually. Indicates the need for ACE inhibitors or ARB.

Question 45

Why are LFTs important to monitor in DM patients?

Answer 45

Screens for fatty liver disease or medication toxicity. Should be done annually. Adjust TZDs or statins as needed.

Question 46

Why is TSH important to monitor in DM patients?

Answer 46

Detects thyroid disfuction that is common in DM. Hypothyroidism can affect blood glucose control. Should be done annually.

Question 47

Why is C-peptide & Autoantibody (GAD, IA-2, ZnT8) checked in a DM patient?

Answer 47

Differentiates type 1 from type 2 DM. Only needed at the time of diagnosis. Helps determine if the patient is insulin dependent.

Question 48

Intermediate acting insulin

Answer 48

-Only one formulation available in US (NPH--Novolin N or Humulin N) -Is usually given with rapid or short acting insulin to cover mealtime—it can only be given SQ -Should never be used when rapid BS lowering in needed -Onset of action—2 hours; peaks in 5-6 hours, duration of action 12 hours (has a wide variation in effective action time—hypoglycemia risk) -CLOUDY (and CAN be mixed with short acting)

Question 49

Examples of Biguanides

Answer 49

Metformin (first line type 2)

Question 50

Example of Sulfonylureas & Glinides

Answer 50

Sulfonylureas: Glipizide Glinides: Repaglinide

Question 51

Example of Thiazolidinediones (TZDs)

Answer 51

Pioglitazone

Question 52

Example of Alpha glucosidase inhibitors

Answer 52

Acarbose

Question 53

Example of DDP4 Inhibitors/Gliptins

Answer 53

Sitagliptin

Question 54

Example of GLP-1 AGONISTS

Answer 54

Exenatide, liraglutide, semaglutide

Question 55

Example of GLP-1/GIP agonist

Answer 55

Tirzepatide

Question 56

Example of Amylin Mimetics

Answer 56

Pramlintide

Question 57

Example of SGLT2 Inhibitors

Answer 57

Empaglifozin

Question 58

Long acting insulins

Answer 58

-Lantus=PROTOTYPE -Are used for basal control and should only be given SQ—they should not be mixed with any other insulin -Releases insulin over an extended time— slower onset and a flat prolonged blood sugar lowering effect with NO peak -Onset of action in 2-3 hours; duration of action near 24 hours -To initiate: Adding to oral agents—start 10 units evening dose—14 hours before first meal of the day -↑Glargine until fasting glucose target of 100 mg/dL reached; then stop—that is the maximum dose -Ex. Glargine, Detemir, Degludec

Question 59

Mixed Insulins

Answer 59

-Targets both basal & postprandial glucose levels -Cloudy suspension -Pro: Limits number of injections -Con: More difficult to adjust components as needed

Question 60

Standard vs. Intensive Insulin Treatment

Answer 60

-Standard; injections twice per day -Intensive: 3 or more injections per day (not recommended for those with long standing DM, microvascular issues, old age, hypoglycemia unawareness) -Intensive therapy much more likely to achieve ADA goals of A1C of < 7% with target BS < 154

Question 61

Insulin Prescribing guidelines

Answer 61

-Ketotic, infected, stressed—larger doses needed -Decreased renal function requires less insulin -Starting dose—0.6U/kg/day for adults [0.25-0.5 U/kg/day for children] -Teenagers may need more—1-1.5 u/kg/day -Each insulin pen delivers 300 units -ALWAYS order in Units NOTE* MOST all insulins are pregnancy safe*