Control of Blood Glucose and Drug Treatment of Diabetes

Question 1

TYPE OF INSULIN:
USE:
RAPID ACTING
Humalog, Amelog* (insulin lispro)

Answer 1

Bolus dosing(meals) and insulin
pumps (administration ranges 5-15
minutes before meals –see specific
product information

Question 2

TYPE OF INSULIN:
USE:
SHORT ACTING
Humulin R or Novolin R - Regular
insulin -

Answer 2

Bolus dosing(meals)
(administration ranges 15-30
minutes before meals –see specific
product information

Question 3

TYPE OF INSULIN:
USE:
INTERMEDIATE-ACTING
Humulin N or Novolin N - NPH ~

Answer 3

Basal-like (administration Q day
to BID)

Question 4

TYPE OF INSULIN:
USE:
ONG ACTING
Lantus, Basaglar* (insulin
glargine) – 100 units/mL
Toujeo (insulin glargine) – 300
unitls/mL
Levemir (insulin detemir) – dc
2024

Answer 4

Basal (administration Q day)

Question 5

TYPE OF INSULIN:
USE:
ULTRA LONG ACTING
Tresiba (insulin degludec)

Answer 5

Basal (administration Q day,
anytime of day

Question 6

— Glucose homeostasis:

Answer 6

balance between hepatic glucose
production and peripheral glucose uptake and utilization

Question 7

— Glucose –

Answer 7

source of energy

Question 8

— Insulin -

Answer 8

most important regulator of glucose/metabolic
equilibrium

Question 9

— Pancreatic Islet Hormones (endocrine)
◦ Maintains — balance
◦ 4 types of peptide-secreting cells:

Answer 9

glucose

– Beta (B) – secrete insulin
– Alpha (A) – secrete glucagon
– Delta (D) – secrete somatostatin
– PP (also known as gamma) – secrete pancreatic polypeptide

Question 10

Relationship between Glucose and Insulin

Answer 10

— Glucose is the main factor
controlling synthesis and
secretion of insulin

Question 11

Two ways insulin is released:

Answer 11

◦ Steady basal release of insulin
◦ Response to increased glucose

Question 12

About — of insulin stored in
the pancreas of an adult is
secreted daily

Answer 12

1/5

Question 13

Glucose stimulated insulin secretion

Answer 13

— Glucose transported by glucose
transporter into beta cell
— Metabolism alters ion channel
(Ca 2+) activity leading to insulin
secretion
— Incretin hormones: glucagon-like
peptide 1 (GLP1) and glucose -
dependent insulinotropic
polypeptide (GIP) released by
cells in the small intestines after
food ingestion, stimulate insulin
secretion when the blood
glucose is above the fasting level

Question 14

Diabetes Mellitus (DM)
— A group of complex chronic metabolic disorders
characterized by high blood glucose concentrations
(hyperglycemia)
(3)

Answer 14

◦ Insulin deficiency
◦ Often combined with insulin resistance
◦ Abnormalities in the metabolism of carbohydrates, proteins, fats
and insulin

Question 15

Hyperglycemia due to:
(3)

Answer 15

◦ Uncontrolled hepatic glucose output
◦ Reduced uptake of glucose by skeletal muscle
◦ Reduced glycogen synthesis

Question 16

Types of DM – Two Major Types
— Type 1 (T1DM)
(3)

Answer 16

◦ Absolute deficiency of insulin resulting from autoimmune destruction of pancreatic B
cells = insulin deficiency
◦ Commonly occurs in childhood and adolescence.
◦ Without insulin treatment patients will ultimately die of diabetic ketoacidosis

Question 17

ypes of DM – Two Major Types
— Type 2 (T2DM)

Answer 17

◦ Hyperglycemia due to insulin resistance (proceeds overt disease) + progressive loss of
insulin secretion
◦ May have normal, increased (hyperinsulinemia) or decreased insulin levels due to
abnormal beta cell function
◦ Most commonly presents in adulthood and in obese patients
◦ Managed with diet, oral/subcutaneous (SC) antidiabetic agents and insulin SC
◦ Accounts for ~ 95% of individuals with diabetes > 30 years
◦ Alarming increases T2DM in obese children and adolescents
◦ Can be delayed or prevented with lifestyle modifications – diet, physical activity and
weight control

Question 19

— Other forms

Answer 19

(e.g. gestational diabetes, medications - glucocorticoids)

Question 20

CLINICAL PRESENTATION
* Symptoms may include (5)

Answer 20

polydipsia,
polyphagia, polyuria, nocturia, blurred
vision. (More common on type 1/
occurs in varying degree in Type 2
DM).

Question 21

• Type 1 DM often associated with
  (2)

Answer 21

weight loss, ketoacidosis (dehydration)

Question 22

• Majority of Type 2 patients are
  — and diagnosed by
  laboratory testing

Answer 22

asymptomatic

Question 23

Screening for T2DM and Prediabetes in Asymptomatic
Patients

Answer 23

— The ADA’s guidelines recommend screening for prediabetes and
T2DM through an informal assessment of risk factors or with a
validated assessment tool to help physicians determine whether
a diagnostic test is appropriate for a patient.
— The guidelines provide an example of an approved assessment
tool: ADA’s Risk Test.

Question 24

ADA’s Diabetes
Risk Test
Increasing aging
population and
numbers of
—
adolescents,
teenagers and
adults = rapid
increases in
prevalence

Answer 24

overweight

Question 25

A1C =

Answer 25

Hemoglobin A1c. Glucose binds hemoglobin. The A1C is a simple lab test that shows the average amount of glucose in a person’s blood over the last 3-4 months.

Question 26

Complications — Macrovascular (3) — Microvascular (4) — Strategic Risk Reduction Strategies

Answer 26

◦ Brain ◦ Heart ◦ Extremities (peripheral vascular disease) ◦ Eyes ◦ Kidney ◦ Nerves – Peripheral – Autonomic ◦ Periodontal disease

Question 27

Glycemic Goals

Question 28

Additional DM Goals – Risk Reduction Strategies — Reduce the risk of (2)(and other) complications through glycemic control and controlling co-morbid conditions to which DM contributes

Answer 28

macrovascular and microvascular

Question 29

Reduce cardiovascular risk factors (3)

Answer 29

– Control BP – Control lipids – Smoking Cessations

Question 30

◦ Reduce the risk of vaccine-preventable diseases (1)

Answer 30

– Immunizations – Examples: Flu, Tdap/Td, Pneumococcal, Hepatitis B (others)

Question 31

— Minimize periodontal complications due to diabetes mellitus, provide

Answer 31

safe and effective dental care and promote good oral health

Question 32

Non-pharmacologic therapy for DM — Medical Nutrition Therapy (4)

Answer 32

◦ Focus on carbohydrates for glycemic management – Typically stay between 3-4 carbohydrate choices or 45- 60 grams of carbohydrate per meal – Eat 3 meals or 5 smaller meals throughout day – If numeracy skills are low, may use plate method

Question 33

— Physical Activity (5)

Answer 33

◦ Helps body regulate glucose and decreases insulin resistance ◦ Lowers BP, cholesterol, stress, weight ◦ Amount – 150 min of moderate-intensity spread over at least 3 days and no more than 2 consecutive days without – Resistance training 2x per week

Question 34

Insulin — History of insulin in the treatment of diabetes = interesting ◦ Insulin destroyed in --- ◦ Before insulin therapy Type I DM = ◦ Breakthrough in 1920’s when insulin was isolated – Noble Prize = Banting and Best (University of Toronto) ◦ (2) sources – Bovine - discontinued in US in1978 – Porcine manufactured in US until 2005 ◦ Significant variability between batches ◦ Allergies – ---

Answer 34

GI tract death sentence (wasting and dying from ketoacidosis) Porcine or Bovine immune response to animal-based products

Question 35

Current Insulin therapy

Answer 35

— Recombinant human insulin (made by recombinant DNA-rDNA technology) — Avoid batch variability and allergies from animal sources — Modified amino acid sequences (insulin analogs) provide rapid/short acting and long acting/basal insulins ◦ Differences in timing to peak effect and duration ◦ Categorized by their onset or action

Question 36

Rapid-acting Insulin — (3)

Answer 36

Rx only — Appearance- clear/colorless — rDNA – human insulin analogs

Question 37

Short-acting (Regular) Insulin (3)

Answer 37

— Non-Rx – 100 units/ml (Humulin R U-500 - RX) — Appearance- clear/colorless — rDNA – human insulin analogs

Question 38

Inhaled Insulin - Afrezza (8)

Answer 38

— Rapid acting insulin – given with meals — Oral inhalation — Amount of insulin delivered to lungs depends on individual factors — Dosing conversion from injected insulin — Contraindicated in chronic lung disease (asthma/COPD) — Not recommended in smokers — Risk of bronchospasms and cough — EXPENSIVE!

Question 39

Intermediate-acting (NPH)Insulin (4)

Answer 39

— NPH - Neutral Protamine Hagedorn — Non-Rx — Appearance - cloudy — rDNA – human isophane insulin suspension

Question 40

Long-acting Insulin —(4)

Answer 40

Rx only — Appearance – clear, colorless — rDNA – human insulin analogs

Question 41

Ultra Long-acting Insulin (3)

Answer 41

— Rx only — Appearance – clear, colorless — rDNA – human insulin analogs

Question 42

— NPH/Regular

Answer 42

◦ 70%/30% ◦ 50%/50%

Question 43

— Insulin aspart protamine suspension/ insulin aspart solution

Answer 43

— 70%/30%

Question 44

— Insulin degludec and insulin aspart injection

Answer 44

— Ryzodeg 70/30 ®

Question 45

— Insulin lispro protamine/insulin lispro

Answer 45

◦ 75%/25%

Question 46

— Insulin lispro protamine/insulin lispro

Answer 46

◦ 50%/50%

Question 47

— Actions of immediate/short and longer acting insulin combined — Typically given pre-breakfast and pre-supper or pre-breakfast, lunch and supper. — Disadvantages in dosing and individualizing therapy – more risk of ---

Answer 47

hypoglycemia

Question 48

* Reusable insulin pen– * Disposable insulin pens -

Answer 48

must load with insulin cartridges - sold separately come filled with insulin and are thrown away when empty

Question 49

Examples of Pens used in DM

Answer 49

— Apidra® SoloStar®, Humalog® KwikPen™, Humulin® Pen, Lantus® Solostar®, Levemir® FlexPen®, NovoLog® Mix FlexPen®, NovoPen Junior®, AutoPen®

Question 50

Common Insulin Regimens (2)

Answer 50

— Basal-bolus regimen (4 injections total/day) ◦ Mimic physiologic insulin release

Question 51

Rapid-acting/NPH (2)

Answer 51

— 2 injections/day ◦ Rapid or regular insulin mix with NPH

Question 52

Continuous Insulin Infusion Pumps

Answer 52

— Growing use - primarily in T1DM — Deliver exogenous insulin that more closely approximates the normal biologic function and performance of the pancreas ◦ devices only use short- or rapid-acting acting insulin as basal insulin with continuous delivery with bolus administration as needed — Programed external pump - worn continuously ◦ Delivers insulin through a cannula inserted just beneath the surface of the skin ◦ One injection site for 72 hrs — Many pumps have Continuous Glucose Monitoring (CGM) system integrated within the pump or they can be used separately

Question 53

Continuous Insulin Infusion Pumps — Advantages (3)

Answer 53

◦ Improved glycemic control ◦ Decreased A1c ◦ Decreased risk of hypoglycemia

Question 54

Continuous Insulin Infusion Pumps ¾ Adverse Effects:

Answer 54

* Pump failures – hyperglycemia or hypoglycemia * Mechanical failures * Blockages within the infusion set * Infusion site complications * Instability of the insulin stored within the pump * User error – usually the most common * Rates declining as technology improves * Importance of patient education * Infections at injection site, lipomas * More expensive than multiple daily injections ¾ Dental: Either Hypo- or Hyperglycemia may occur! * If pt confused/unresponsive, always push “suspend” button immediately. * Then check display to assess last glucose trend.

Question 55

Glucose Monitors and Continuous Glucose Monitoring (CGM) — Purpose:

Answer 55

to monitor blood glucose levels in patients with diabetes — Safety and efficacy of insulin and other diabetic drugs

Question 56

— Blood Glucose Meters (many brands)

Answer 56

◦ Finger sticks – moment in time ◦ Self-monitoring of Blood Glucose (SMBG) – Frequency of monitoring varies depending on type of diabetes and medications – Occasional to Morning fasting, before meals, before exercise, etc.

Question 57

— Continuous Glucose Monitoring (CGM) – stand alone

Answer 57

◦ Compact medical systems that continuously monitor glucose in almost real time – Readings generally at 5-minute intervals – Small sensor with with a cannula is inserted into arm or abdomen – replaces every 10-14 days (secured with adhesive) – Reusable transmitter sends readings wirelessly, usually to phone, computer or other monitoring device – Alerts can be sent to notify of low or high glucose (or customized) and can share device data with providers, parents, etc. – Used by patients with either T1DM or T2 DM – Insurance coverage varies with T2DM

Question 58

Use of insulin in DM — Type 1 (3)

Answer 58

◦ Life-long insulin required along with diet management ◦ Multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion. ◦ Often require lower doses of insulin than Type 2 because less issue with insulin resistance

Question 59

Use of insulin in DM — Type 2 (5)

Answer 59

◦ Other treatment options usually implemented first unless severe hyperglycemia – Diet management – Oral anti-diabetic agents ◦ Approximately 1/3 patients (more?) benefit from insulin – Eventually every patient with type 2 DM requires insulin – beta cell failure ◦ Often require higher doses than Type 1 because of insulin resistance ◦ Often start with basal/long-acting insulin and continue certain oral anti-diabetic agents ◦ May add bolus to basal if glycemic goals not met

Question 60

Insulin Dosing — Type 1 (1)

Answer 60

◦ Generally, the starting insulin dose is based on weight, with doses ranging from 0.4 to 1.0 units/kg/day of total insulin with higher amounts required during puberty

Question 61

Insulin dosing — Type 2 (4)

Answer 61

◦ Basal insulin alone is the most convenient initial insulin regimen, beginning at 10 units per day or 0.1–0.2 units/kg/day, depending on the degree of hyperglycemia. ◦ Many individuals with type 2 diabetes may require mealtime bolus insulin dosing in addition to basal insulin ◦ The recommended starting dose of mealtime insulin is 4 units, 0.1 units/kg, or 10% of the basal dose ◦ After titration to goals and advancing disease, patients with Type 2 often require higher doses (unit/kg) than Type 1 because of insulin resistance

Question 62

Adverse Effects of Insulin — HYPOGLYCEMIA! (7)

Answer 62

◦ Highest risk of any diabetes medication ◦ Tighter control (of glucose) = é risk of hypoglycemia ◦ Symptoms: shaky/tremors, confusion, nervous, sweating, clamminess, light headed/dizziness, fatigue, sleepiness, agitation, anxiety, hunger, nausea tingling or numbness (especially of lips and tongue), vision changes, headache, anger/stubbornness, sadness, tachycardia ◦ Severe hypoglycemia may result in seizures or loss of consciousness ◦ Manage patient as if hypoglycemic, until proven otherwise ◦ Check blood glucose with monitor ◦ Implications for Dental Practice: Patients skipping a meal for a dental procedure or even a visit should not take their short/rapid acting insulin dose. Patients who eat normally should take all of their insulin prior to a visit.

Question 63

Definitions for Hypoglycemia ◦ Serious, clinically significant: < -- mg/dL ◦ Glucose Alert Value: < -- mg/dL

Answer 63

◦ Not all patients will experience hypoglycemia – Certain antidiabetic drugs and patient risk factors increase risk 54 70

Question 64

Management of Hypoglycemia — Rule of 15s — Treat if < -- mg/dl

Answer 64

70 * 15-20 gms fast acting carbs = 3-4 glucose tablets, 4 oz juice or regular soda, 5 lifesavers, 3 peppermints * Glucose gel also available – follow directions on tube * If next meal is more than 1 hr away consider a small snack to prevent recurrence or eat meal * Observe patient 30-60 mins after recovery. Confirm normal glucose level before patient allowed to leave office * Consider referring patient to physician for follow up

Question 65

Management of Hypoglycemia — Unconscious patient or unable to swallow (6)

Answer 65

◦ Call 911 (have someone call or if alone call after administering 1st dose of glucagon) ◦ Stimulates gluconeogenesis - release of stored glucose ( glycogen) from the liver. ◦ 1mg glucagon intravenously or intramuscularly in buttock, arm or thigh (may give IM at almost any body site if necessary). Repeat at 15 minutes if no response ◦ 0.5 mg for pediatrics < 44 lbs – Patient needs glucose after injection ◦ OR, give 50ml of 50% dextrose IV — Turn on side to prevent aspiration

Question 66

Therapy for Type 2 DM (6)

Answer 66

— Diet Management — Oral antidiabetic agents ◦ Possess varying amounts of hypoglycemic risk — Insulin therapy — Other injectable therapy (GLP1 inhibitors) — Be able to identify the magnitude of risk for hypoglycemic for various antidiabetic agents — Many classes and lots endings and abbreviations for drug classes to keep up with

Question 67

Biguanides — Metformin (Glucophage) only available drug in class — MOA (4)

Answer 67

◦ Keeps the liver from releasing too much glucose ◦ ̄ Hepatic glucose production (gluconeogenesis – markedly increased in Type 2) – PRIMARY MECHANISM ◦ Decreases insulin resistance (increases insulin sensitivity)- glucose utilization in muscle and adipose tissues ◦ Inhibits intestinal absorption of glucose

Question 68

Metformin

Answer 68

— Often a drug of choice in Type 2 (especially in obese patients and because of lower costs) ◦ Lower cost ◦ Effective A1C lowering for oral agent — Use in pre-diabetes (decreases risk of progression to DM) — Weight neutral/ameliorates insulin-associated weight gain — Low risk of hypoglycemia with monotherapy — Notable GI adverse drug effects (ADEs) such as diarrhea/loose stools, flatulence, dyspepsia, abdominal distension/pain, nausea/vomiting ◦ Titrating the dose up slowly can help patients tolerate and taking with food can help minimize ◦ Some patients can’t tolerate and must discontinue therapy – XL formulation may cause less GI side effects — Risk of B12 deficiency (should be checked annually) — Rare risk of causing lactic acidosis ◦ watch with dehydration ◦ contraindicated in chronic kidney disease (GFR < 30 ml/min), caution with GFR between 30-45 ml/min)

Question 69

Glucagon Like Peptide-1 Receptor Agonists (GLP 1-RA, “incretin mimetics” - Glutides) emptying

Answer 69

— Albiglutide, Dulaglutide, Exenatide, Liraglutide, Lixisenatide, Semaglutide — Most options available as injections (sc) only — Semaglutide available sc and po — Dosing frequency varies – BID, daily and weekly depending on medication and formulation — MOA: stimulates GLP-1 receptors in the pancreas to increases insulin secretion in response to elevated glucose. In addition, stimulation of GLP-1 receptors in the GI tract and CNS decrease glucagon secretion and slow gastric

Question 70

GLP 1- Receptor Agonists

Answer 70

— Benefits ◦ Weight loss ◦ Higher dosages approved for weight loss – semaglutide (Wegovy) - injection – liraglutide (Saxenda) - injection ◦ CV benefits (except lixisenatide and immediate-release exenatide) – Atherosclerotic Cardiovascular Disease (ASCVD) ◦ Kidney benefits – Chronic Kidney Disease (CKD) (liraglutide, semaglutide) – but SGLT2 preferred — ADEs – nausea, diarrhea, injection site reactions, pancreatitis (rare), gallbladder disease, risk of Thyroid-C cell tumors — Hypoglycemia: low risk with monotherapy (may increase risk in combination therapy with sulfonylureas/others that cause hypoglycemia)

Question 71

Glucose-dependent insulinotropic polypeptide (GIP) agonist + Glucagon-like, peptide-1 (GLP-1) agonist (“twincretin”) — Tirzepatide (Mounjaro) – FDA approved 2022 for the treatment of adults with type 2 diabetes ◦ Weight management indication ◦ MOA:

Answer 71

increases insulin secretion in response to elevated glucose, decreases glucagon secretion, slows gastric emptying

Question 72

GIP/GLP-1 Receptor Co-agonist (“twincretin”) — ADEs: (5) — Additional Information: (5)

Answer 72

◦ GI (e.g., diarrhea, nausea, vomiting) ◦ Pancreatitis (rare) ◦ Gallbladder disease (rare) ◦ Low risk of hypoglycemia when used as monotherapy. ◦ Linked to medullary thyroid cancer in rats ◦ More weight loss than GLP-1 agonists ◦ More A1c reduction than most GLP-1 agonists. ◦ No CV or kidney outcomes data yet! ◦ Monitor for retinopathy progression ◦ May delay oral contraceptive absorption

Question 73

Sodium glucose cotransporter-2 (SGLT2) inhibitors - MOA

Answer 73

— Located in the S1 segment of the proximal renal tubule — SGLT2 -responsible for 90% of glucose reabsorption — MOA - Blocks glucose reabsorption in the kidney, increases urinary excretion of glucose ◦ Block sodium reabsorption — Results in increased urinary excretion of glucose

Question 74

SGLT2 Inhibitors (Flozins) — Bexagliflozin, canagliflozin, dapagliflozin, empagliflozin, ertugliflozin — ADEs

Answer 74

◦ Genital mycotic (fungal/yeast) infections ◦ UTIs ◦ Increased urination may lead to volume depletion, hypotension, syncope, falls, and acute kidney injury ◦ Hyperkalemia (canagliflozin) ◦ Fractures (rare) ◦ Increased risk of amputations (rare) ◦ Ketoacidosis (rare) ◦ Acute pancreatitis (rare) ◦ Fournier’s gangrene - infection in the scrotum (which includes the testicles), penis, or perineum (rare) ◦ Hypoglycemia: – Low risk as monotherapy – with insulin or secretagogueus

Question 75

SGLT2 Inhibitors (Flozins) — Benefits (3) — Other information (3)

Answer 75

◦ CV benefits – Atherosclerotic Cardiovascular Disease (ASCVD) – Heart Failure ◦ Renal benefits (Chronic Kidney Disease - CKD) ◦ Weight loss (less than GLP1 agonists) ◦ Dosage modification needed with renal impairment – Do not use ertugliflozin with GFR < 60 mL/min – Do not use other SGLT2s with GFR < 45 mL/min

Question 76

Sulfonylureas (SU)

Answer 76

— Glimepiride, glyburide and glipizide (2 nd generation) — MOA (Secretagogues) ◦ Help the pancreas release more insulin which lowers glucose ◦ Stimulate beta cells causing insulin secretion — Lower fasting and post-prandial glucose

Question 77

Meglitinides

Answer 77

— Nateglinide, repaglinide — Similar to sulfonylureas but shorter acting – taken with meals ◦ hold dose if skipping meals — MOA (Secretagogues) ◦ Increase insulin release in response to food, keeping blood glucose from rising too high after meals — Lower post-prandial glucose

Question 78

Adverse Drug Effects (ADEs)/Disadvantages of Secretagogues — Insulin secretors/secretagogues (SU’s and meglitinides) (4)

Answer 78

— HYPOGLYCEMIA! — Caution using with other drugs the cause hypoglycemia (usually discontinue with use of insulin) — Weight gain — “Durability” declines over time - relatively short-lived efficacy

Question 79

Thia-zolidine-diones (glitazones, TZDs)

Answer 79

— Pioglitazone and rosiglitazone — MOA ◦ Increase glucose uptake into muscles by enhancing the effectiveness of endogenous insulin ◦ bind to nuclear receptor – peroxisome proliferator-activated receptor γ(gamma) - (PPARγ) in adipose, muscle and liver ◦ Reduce glucose output — Low risk of hypoglycemia when used as monotherapy

Question 80

TZDs Adverse Effects and Additional Information — ADEs (4) — Additional information (1)

Answer 80

◦ Edema ◦ Weight Gain ◦ Heart Failure (avoid in patients with symptomatic heart failure) ◦ Increased risk of fractures ◦ Glycemic control better sustained over diabetes course

Question 81

Dipeptidyl-Peptidase-4 Inhibitors (DPP-4 inhibitors, “gliptins”)

Answer 81

— Alogliptin, Linagliptin, Saxagliptin Sitagliptin — MOA ◦ Inhibit glucagon release which results in insulin secretion, decreased gastric emptying and decreased blood glucose levels — Hypoglycemia with monotherapy – low risk

Question 82

DPP-4 inhibitors Adverse Effects and Additional Information — ADEs (3) — Additional information (4)

Answer 82

◦ May be associated with pancreatitis (rare) ◦ New or worsening heart failure (alogliptin and saxagliptin) ◦ May cause severe joint pain (rare) ◦ Dosage modification needed with renal impairment (alogliptin, saxagliptin, sitagliptin) ◦ CYP3A4 drug interaction (linagliptin, saxagliptin) ◦ Weight neutral ◦ Generally well tolerated

Question 83

Less Commonly Used Medications (4)

Answer 83

— Alpha-glucosidase inhibitors — Bile acid sequestrant — Dopaminergic agents — Amylin analog

Question 84

Take Home Points:

Answer 84

— Diabetes mellitus (DM) is a group of chronic metabolic disorders characterized by high blood glucose concentrations ◦ Insulin deficiency ◦ Often combined with insulin resistance ◦ Risks for microvascular and macrovascular complications ◦ Uncontrolled diabetes leads to devastating consequences — T1DM = insulin therapy + diet management — T2DM = diet management with oral and/or insulin/GLP1RA therapy — The mechanisms of action of the drug therapy involved with treating DM involves either providing/increase insulin and/or lowering glucose by various means — Hypoglycemia is the most dangerous adverse event of some diabetic medications ◦ Knowing which ones and how to manage is important for dental practice