Combination Therapy Flashcards
What are the initial considerations for selecting combination therapy in type 2 diabetes?
Assess if the patient has ASCVD, heart failure, or CKD.
Which class of drugs is preferred for patients with type 2 diabetes and established cardiovascular disease (ASCVD)?
GLP-1 receptor agonists with proven CVD benefits.
What are some examples of GLP-1 receptor agonists approved for reducing cardiovascular events in patients with type 2 diabetes?
Liraglutide (Victoza®), Semaglutide (Ozempic®), Dulaglutide (Trulicity®).
What is the primary goal when using combination therapy in patients without ASCVD, CKD, or heart failure?
Focus on efficacy, weight loss, and cost/access considerations.
Which class of drugs is recommended for patients with type 2 diabetes and heart failure?
SGLT2 inhibitors like Empagliflozin and Dapagliflozin.
What is the effect of SGLT2 inhibitors on heart failure outcomes in patients with type 2 diabetes?
They reduce the risk of hospitalization for heart failure.
Which trial demonstrated the cardiovascular benefits of Empagliflozin (Jardiance®)?
The EMPA-REG trial.
What are the key renal benefits of Canagliflozin (Invokana®) shown in the CREDENCE trial?
Reduced risk of end-stage kidney disease, cardiovascular death, and hospitalization for heart failure.
Which drugs are recommended for reducing the risk of cardiovascular death in patients with heart failure and reduced ejection fraction?
Empagliflozin and Dapagliflozin.
What is the typical A1C lowering range for GLP-1 receptor agonists?
1 – 1.5%+.
What are the side effects of GLP-1 receptor agonists?
GI issues like nausea and vomiting, weight loss, and potential pancreatitis.
Which GLP-1 receptor agonist is known for having the highest weight loss effects?
Semaglutide.
What is a major side effect of Sulfonylureas?
Hypoglycemia and weight gain.
What are the clinical pearls when using Sulfonylureas in therapy?
Careful with sulfa allergies, avoid glyburide in older adults.
What is the maximum recommended dose of Glimepiride?
8 mg/day.
What is a key precaution when prescribing Glipizide?
Take within 15-30 minutes of meals to prevent hypoglycemia.
What should be avoided when using Glyburide in elderly patients?
It should be avoided due to the risk of prolonged hypoglycemia.
Which SGLT2 inhibitor has been shown to reduce the risk of hospitalization for heart failure in patients with diabetes?
Empagliflozin.
What is the A1C lowering effect of SGLT2 inhibitors?
0.5 – 1%.
What are the renal dose adjustments for Canagliflozin (Invokana®)?
Do not initiate in patients with eGFR <30 mL/min, adjust dose based on eGFR.
What are some common side effects of SGLT2 inhibitors?
Genital mycotic infections, urinary tract infections, hypotension.
Which DPP-4 inhibitor does not require dose adjustment for renal function?
Linagliptin (Tradjenta®).
What are the common side effects of DPP-4 inhibitors?
Joint pain and pancreatitis.
Which DPP-4 inhibitors should be avoided in patients with heart failure?
Saxagliptin and Alogliptin due to increased risk of heart failure hospitalization.
Which DPP-4 inhibitor is weight neutral and has modest A1C lowering?
Sitagliptin.
What is the typical A1C lowering effect of DPP-4 inhibitors?
~0.7%.
Which drug combinations should be avoided in type 2 diabetes therapy?
DPP-4 inhibitors with GLP-1 receptor agonists, and Sulfonylureas with Meglitinides.
What are some common combination pills for type 2 diabetes?
Glipizide/metformin (Metaglip), Pioglitazone/metformin (Actoplus Met), Sitagliptin/metformin (Janumet).
Which drug classes are associated with weight loss in patients with type 2 diabetes?
GLP-1 receptor agonists and SGLT2 inhibitors.
Which drug classes are weight-neutral in type 2 diabetes?
Metformin and DPP-4 inhibitors.
Which drug classes are associated with weight gain in type 2 diabetes?
Sulfonylureas, Thiazolidinediones (TZDs), and Insulin.
What is the Rule of 15 for managing hypoglycemia?
Consume 15-20g of glucose, recheck in 15 minutes, and repeat if necessary.
Which carbohydrate options are used to treat hypoglycemia?
Glucose tablets, fruit juice, regular soda, or honey.
What is the maximum dose of Dulaglutide (Trulicity®)?
4.5 mg once weekly.
What is the titration schedule for Semaglutide (Ozempic®)?
Start with 0.25 mg once weekly, increase to 0.5 mg after 4 weeks, and titrate up to 1 mg or 2 mg.
Which patients should avoid GLP-1 receptor agonists?
Patients with a personal or family history of medullary thyroid carcinoma.
What are the contraindications for using GLP-1 receptor agonists?
History of pancreatitis or thyroid cancer.
