Chapter 60 Drugs for Diabetes Mellitus Flashcards
Type 1 Diabetes (Insulin dependent) vs. Type 2 Diabetes (Insulin Resistant)
Type 1:
Onset - usually autoimmune childhood or adolescence with abrupt onset
Patho - Primary defect is loss of pancreatic beta cells
Requires insulin therapy
Patients are usually thin and undernourished at diagnosis
Symptoms - 3 Ps =Polyuria, polydipsia, polyphagia, & weight loss
Diabetic ketoacidosis (DKA) is common if insulin dosage is insufficient
Type 2:
Most prevalent
40+ with gradual onset, may run in the family, insulin resistance, comorbidity obese
Short term vs. Long term complications (micro-vascular vs. macro-vascular complications) are?
Short term: Hyperglycemia & hypoglycemia
Long term:
Macro-vascular: Heart dz, HTN, stroke
Microvascular: Retinopathy, nephropathy, neuropathy, ED
Diagnostic criteria for diabetes? Fasting? Random? OGTT? HgbA!C?
Fasting plasma glucose ≥ 126mg/dL
OR
Random glucose ≥ 200mg/dL + S&S of DM
OR
OGTT: 2-hr plasma glucose ≥ 200mg/dL
OR
HgB A1C 6.5% or higher
What is the treatment goal for a patient with diabetes?
HgB A1C < 7%
Fasting glucose 70-130mg/dL
Post Prandial glucose < 180 mg/dL
What does Insulin do?
Increases glucose transport into skeletal muscle and adipose tissue
How?
Increases glycogen synthesis
Decreases gluconeogenesis
What does glucagon do?
Promotes liver glycogen breakdown
* Increases gluconeogenesis
What other hormones affect blood glucose?
Catecholamines
Epinephrine and norepinephrine
Help to maintain blood glucose levels during periods of stress (fight or
flight would need the glucose for energy)
Growth hormone
Increases protein synthesis in all cells of the body, mobilizes fatty acids
from adipose tissue, and antagonizes the effects of insulin
Glucocorticoids
Critical to survival during periods of fasting and starvation
Stimulate gluconeogenesis by the liver
What types of insulin perform which action?
Short duration, fastest acting (Insulin lispro, aspart, glulisine)
Short duration, slower acting (Regular insulin)
Intermediate duration, slow acting (NPH insulin)
Long duration, slowest acting (Glargine, detemir)
How do you calculate insulin dosing?
0.6 units/kg/day = total daily dose (TDD)
50% of TDD = basal
50% 3 = prandial
Example:
160 lb = 72.7kg
0.6 units/73kg/day= Round to 44 units per day = TDD
½ of 44 = 22 units of basal insulin
*½ of 44 divided by 3= 7 units per meal
Side effects of insulin? Interact with?
Hypoglycemia, hypokalemia, lipohypertrophy, allergic rx
Interact with beta blockers, steriods, why?
What should you do to prevnent injection site lipohypertrophy?
Rotate injection sites around the back of the arms, stomach folds, outer thighs, buttocks, lower lateral back
What is Glucophage (Metformin®)? A/e? What should you monitor for? Do not use with?
Used for weight loss and T2DM; increases insulin sensitivity
Few a/e initially, but can result in lactic acidosis IF renal failure is present
Monitor for GFR
Can start medication in pts who GFR >45; contraindicated <30
DO NOT USE WITH ETOH
Can increase fertility (good or bad)
What dosing would you start with and why for Glucophage (Metformin®)?
500 mg daily and advanace to 1,000 mg BID
ER tablet has less GI side effects
What is a 2nd line drug for T2DM? Why? Take when?
Sulfonylureas as they stimulate insulin release from the pancreatic B cells
(Ex: glipizide, glyburide, Glimepiride)
30 mins before meal
Pros: Effective at reducing HGBA1C by 1.25%, very cheap
Cons: hypoglycemia risk, weight gain, N/v
What are Meglitinides used for? Ex? Who will this not work for? Give when?
T2DM Ex: repaglinide; nateglinide
WILL NOT WORK IN PTS WHO DO NOT REPSOND TO SULFONYLUREAS
Give 30 mins before meals, skip dose if meal is skipped, add dose if added meal, do not exceed 4x/day
What are Thiazolidinediones (TZDs) used for? What do they do? Ex?
T2DM
Increase glucose uptake by skeletal muscle and adipose
cells and decrease gluconeogenesis in liver
Ex: pioglitazone (Actos)
Pros:
Effective in reducing HgbA1c
Lower risk of hypoglycemia than sulfonylureas
Cons:
Some weight gain
Risk of edema and heart failure
More expensive
What are TZDs (Glitazones) used for? Given when? Adjunct? Follow what labs?
T2DM
Given with or without food
Used with insulin availability (adjunct with metformin, sulfonylurea or insulin)
LFTs and lipids q 6 months (d/t decreasing triglycerides and elevation of LDLs and HDLs)
TZDs (Glitazones -Actos®) and inuslin can cause what when used together?
Both promote fluid retention thus increased risk for CHF
Alpha-Glucosidase Inhibitors do what? Ex? Give when? Monitor for? Drug interactions?
T2DM - Act in the intestine to delay absorption of carbohydrates
Reduces rise of blood glucose after meals
Ex: Acarbose, Miglitol
Given with first bite of food, skip dose if meal is skipped
Monitor - Hypoglycemia, LFTs (especially w/ liver impairment), GI issues
Must use dextrose to treat hypoglycemia
DI - Insulins, sulfonlyureas, ginseng, metformin, estrogen, diuretics, steriods, phenothiazines
What do DDP-4 Inhibitors do? Ex? A/e?
Sitagliptin (Januvia®); saxagliptin (Onglyza®); Linagliptin (Tradjenta®)
Enhances action of incretin hormones
Stimulate glucose-dependent release of insulin
Suppress post prandial release of glucagon
Adverse effects
Pancreatitis
Hypersensitivity reactions
SGLT2 Inhibitors (Sodium-Glucose co-transporter 2) do what?
SGLT2 is a protein in humans that facilitates glucose reabsorption in the kidney. SGLT2
inhibitors block the reabsorption of glucose in the kidney, increase glucose excretion,
and lower blood glucose levels
SGLT2- Inhibitor examples? A/e? Monitor for?
Canagliflozin (Invokana®); Dapagliflozin (Farxiga®); & Empagliflozin
(Jardiance®); Ertugliflozin (Steglatro®)
Yeast infx, UTIs, hypotension, dehydration.
Monitor for?
Renal function impairment (contraindicated w/ GFR <30)
DKA
Hypoglycemia
SGLT2 Inhibitors for T2DM end in?
-florzin
Glucagon-like Peptide-1 Receptor Agonist (GLP-1) do what? A/e?
Activaite GLP-1 receptors and cause same effects as incretins:
Slows gastric emptying
*Stimulate glucose dependent release of insulin
*Inhibit post prandial release of glucagon
*Suppresses appetite
N/V r/t pancreatitis
