Combination Therapy

Question 1

What are the initial considerations for selecting combination therapy in type 2 diabetes?

Answer 1

Assess if the patient has ASCVD, heart failure, or CKD.

Question 2

Which class of drugs is preferred for patients with type 2 diabetes and established cardiovascular disease (ASCVD)?

Answer 2

GLP-1 receptor agonists with proven CVD benefits.

Question 3

What are some examples of GLP-1 receptor agonists approved for reducing cardiovascular events in patients with type 2 diabetes?

Answer 3

Liraglutide (Victoza®), Semaglutide (Ozempic®), Dulaglutide (Trulicity®).

Question 4

What is the primary goal when using combination therapy in patients without ASCVD, CKD, or heart failure?

Answer 4

Focus on efficacy, weight loss, and cost/access considerations.

Question 5

Which class of drugs is recommended for patients with type 2 diabetes and heart failure?

Answer 5

SGLT2 inhibitors like Empagliflozin and Dapagliflozin.

Question 6

What is the effect of SGLT2 inhibitors on heart failure outcomes in patients with type 2 diabetes?

Answer 6

They reduce the risk of hospitalization for heart failure.

Question 7

Which trial demonstrated the cardiovascular benefits of Empagliflozin (Jardiance®)?

Answer 7

The EMPA-REG trial.

Question 8

What are the key renal benefits of Canagliflozin (Invokana®) shown in the CREDENCE trial?

Answer 8

Reduced risk of end-stage kidney disease, cardiovascular death, and hospitalization for heart failure.

Question 9

Which drugs are recommended for reducing the risk of cardiovascular death in patients with heart failure and reduced ejection fraction?

Answer 9

Empagliflozin and Dapagliflozin.

Question 10

What is the typical A1C lowering range for GLP-1 receptor agonists?

Answer 10

1 – 1.5%+.

Question 11

What are the side effects of GLP-1 receptor agonists?

Answer 11

GI issues like nausea and vomiting, weight loss, and potential pancreatitis.

Question 12

Which GLP-1 receptor agonist is known for having the highest weight loss effects?

Answer 12

Semaglutide.

Question 13

What is a major side effect of Sulfonylureas?

Answer 13

Hypoglycemia and weight gain.

Question 14

What are the clinical pearls when using Sulfonylureas in therapy?

Answer 14

Careful with sulfa allergies, avoid glyburide in older adults.

Question 15

What is the maximum recommended dose of Glimepiride?

Answer 15

8 mg/day.

Question 16

What is a key precaution when prescribing Glipizide?

Answer 16

Take within 15-30 minutes of meals to prevent hypoglycemia.

Question 17

What should be avoided when using Glyburide in elderly patients?

Answer 17

It should be avoided due to the risk of prolonged hypoglycemia.

Question 18

Which SGLT2 inhibitor has been shown to reduce the risk of hospitalization for heart failure in patients with diabetes?

Answer 18

Empagliflozin.

Question 19

What is the A1C lowering effect of SGLT2 inhibitors?

Answer 19

0.5 – 1%.

Question 20

What are the renal dose adjustments for Canagliflozin (Invokana®)?

Answer 20

Do not initiate in patients with eGFR <30 mL/min, adjust dose based on eGFR.

Question 21

What are some common side effects of SGLT2 inhibitors?

Answer 21

Genital mycotic infections, urinary tract infections, hypotension.

Question 22

Which DPP-4 inhibitor does not require dose adjustment for renal function?

Answer 22

Linagliptin (Tradjenta®).

Question 23

What are the common side effects of DPP-4 inhibitors?

Answer 23

Joint pain and pancreatitis.

Question 24

Which DPP-4 inhibitors should be avoided in patients with heart failure?

Answer 24

Saxagliptin and Alogliptin due to increased risk of heart failure hospitalization.

Question 25

Which DPP-4 inhibitor is weight neutral and has modest A1C lowering?

Answer 25

Sitagliptin.

Question 26

What is the typical A1C lowering effect of DPP-4 inhibitors?

Answer 26

~0.7%.

Question 27

Which drug combinations should be avoided in type 2 diabetes therapy?

Answer 27

DPP-4 inhibitors with GLP-1 receptor agonists, and Sulfonylureas with Meglitinides.

Question 28

What are some common combination pills for type 2 diabetes?

Answer 28

Glipizide/metformin (Metaglip), Pioglitazone/metformin (Actoplus Met), Sitagliptin/metformin (Janumet).

Question 29

Which drug classes are associated with weight loss in patients with type 2 diabetes?

Answer 29

GLP-1 receptor agonists and SGLT2 inhibitors.

Question 30

Which drug classes are weight-neutral in type 2 diabetes?

Answer 30

Metformin and DPP-4 inhibitors.

Question 31

Which drug classes are associated with weight gain in type 2 diabetes?

Answer 31

Sulfonylureas, Thiazolidinediones (TZDs), and Insulin.

Question 32

What is the Rule of 15 for managing hypoglycemia?

Answer 32

Consume 15-20g of glucose, recheck in 15 minutes, and repeat if necessary.

Question 33

Which carbohydrate options are used to treat hypoglycemia?

Answer 33

Glucose tablets, fruit juice, regular soda, or honey.

Question 34

What is the maximum dose of Dulaglutide (Trulicity®)?

Answer 34

4.5 mg once weekly.

Question 35

What is the titration schedule for Semaglutide (Ozempic®)?

Answer 35

Start with 0.25 mg once weekly, increase to 0.5 mg after 4 weeks, and titrate up to 1 mg or 2 mg.

Question 36

Which patients should avoid GLP-1 receptor agonists?

Answer 36

Patients with a personal or family history of medullary thyroid carcinoma.

Question 37

What are the contraindications for using GLP-1 receptor agonists?

Answer 37

History of pancreatitis or thyroid cancer.