Diabetes Deck 2 Flashcards
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - Agents
liraglutide (Victoza™), dulaglutide (Trulicity™), exenatide (Byetta™), semaglutide
(Ozempic™, Rybelsus™ - oral)
○ The “-glutides”
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) Moa
: increase insulin release in the presence of elevated glucose,
decreases glucagon secretion, and delays gastric emptying (reducing the rate at which
postprandial glucose appears in circulation); decreased appetite
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - Efficacy
○ Nausea, decreased appetite, vomiting, indigestion, diarrhea
○ Headache
○ Injection site reactions
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - SE
○ Pancreatitis
○ Gallstones/Cholecystitis
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - Serious SE
○ A1C, Blood glucose
○ Weight
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) Contraindications
○ History of medullary thyroid carcinoma
○ History of multiple endocrine neoplasia syndrome type II
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - place in therapy
○ Common agent used after metformin
○ Benefit in patients with ASCVD
○ Beneficial for weight loss
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - Administration
Technique varies across agents
■ Injection technique for Victoza and Ozempic are similar to insulin pens
■ Trulicity is a self contained system
■ Bydureon pen is being discontinued; Kit is hard to use
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - Pearls
Lower dose is started and titrated to higher dose to reduce GI issues. Starting doses are generally
not sufficient for BG control/management
○ Generally one of these agents is covered by insurance, but varies
○ Trulicity and Ozempic are once weekly
○ Rybelsus is oral but not well covered yet
○ Bydureon kit is hard to set up – if only agent covered can be helpful to train a family
member/Home Health to assist with administration
Glucagon-Like peptide-1 agonist (GLP-1
Agonists) - Monitoring
○ A1C, Blood glucose
○ Weight
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) - Agents
canagliflozin (Invokana™), empagliflozin (Jardiance™), dapagliflozin (Farxiga™)
○ The “-flozins”
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) - MOA
Inhibits glucose reabsorption in the kidneys through inhibition of
sodium-glucose cotransporter 2; Decreases serum glucose concentrations
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) Efficacy
○ Additional benefit in chronic kidney disease
○ Additional benefit in cardiovascular disease: empagliflozin, canagliflozin (ASCVD); empagliflozin,
canagliflozin, and dapagliflozin (HF)
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) - SE
○ Genitourinary infections (UTIs, Yeast Infections)
○ Increased urination
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) - Serious SE
○ Kidney Injury ○ Hypovolemia ○ Limb/Foot amputations ○ Bone fractures (canagliflozin) ○ DKA risk
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) Monitoring
○ Blood Pressure
○ A1C, Blood glucose
○ Volume status
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) Contraindications
○ Dialysis
○ Acute Kidney Injury
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) - Place in therapy
○ Common agent used after metformin
○ Benefit in patients with ASCVD and/or HF or CKD
○ Benefit for weight loss
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) - Administration
○ Take before the first meal of the day
Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT2-inhibitors) Pearls
○ Generally avoided in older patients due to infection risk
○ Can be expensive if not covered by insurance but benefits with ASCVD/HF/CKD pushing for more
coverage
Insulin General fact
Replaces the insulin the body produces to help with blood glucose uptake in the tissues
● Many, many different products
● Human and synthetic insulin products
● Differ based on molecular structure which determines duration, onset, and peak of these
agents
Insulin Dosing regimens
○ Long + Rapid Acting/Short acting
○ Intermediate BID
Insulin - Available In
pens, vials, and IV
○ Generally stored in the refrigerator but can be stored at rooom temp when in use
○ Beyond use dates vary when removed from refrigeration
Insulin - Administered
subcutaneously in the thighs, arms, buttocks, or abdomen (most common)
Insulin - Adminsitration schedule
e depends on the product
Insulin Monitoring
○ A1C
○ Blood sugars
○ Hypoglycemia
Insulin - Adverse Effects
○ Hypoglycemia
○ Injection site reactions
○ Weight gain
Insulin - Dosing
○ Generally guided by blood glucose
○ High fasting - Adjust basal
○ High 2 hour PP - Adjust mealtime
Insulin - Short Acting - Agents
○ Insulin glulisine (Apidra™)
○ Insulin Lispro (Humalog™)
○ Insulin Aspart (Novolog™)
Insulin - Short Acting generally administered
10-15 minutes
before a meal or immediately after
Gluisine Onset Peak Duration
Onset ~10 - 20 minutes Peak 0.5- 1.5 hours Duration ~5 hours
Humalog Onset Peak Duration
Onset 15-30 min Peak 0.5-2.5 hours Duration 3-6.5 hours
Insulin - Long Acting Agents
Agents:
○ Insulin detemir (Levemir™)
○ Insulin glargine (Lantus™/Basaglar™)
○ Insulin glargine (Toujeo™) 300 units/mL
○ Insulin degludec (Tresiba™) – Ultra-long acting
Insulin - Long Acting Gneral dosing
Generally once daily, but will sometimes see BID dosing
Levemier onset peak duration
Onset 1-2 hours
Peak 6-8 hours
Duration 7.6 - 24+
Lantus onset peak duration
Onset 1 to 1.5 hours
Peak None
Duration 24 hours
(11-24+ hours)
Toujeo Onset peak duration
O - 5 hours
P - None
D - >24 hours
Tresiba onset peak duration
O - 30 to 90 min
P - None
D - At least 42 hours
Insulin - Ultra Rapid Acting - Agents
○ Fiasp™ (insulin aspart)
○ Lyumjev™ (insulin lispro-aabc)
Lyumjev - Formulated
with
niacinamide for faster absorption
○ Inject within 20 minutes after the
start of the meal
Fiasp - Inject at the
start of the meal or
within 20 min after the start of the
meal
Insulin - Short Acting Regular - Agents
○ Humulin R™
○ Novolin R™
Insulin - Short Acting Regular - can be used
in insulin pumps
Humulin R - One to three
times daily
30 minutes before a meal
Novolin R - One to three t
times daily
30 minutes before a meal
Insulin - Short Acting Regular - used in conjunction with
h basal/long
acting insulin
Insulin - Intermediate Acting (NPH) - Agents
○ Novolin N™
○ Humulin N™
Human insulin (rDNA origin) in
isophane suspension
Insulin - Intermediate Acting (NPH) generaly
Generally administered twice daily but can be further divided
● Generally fewer injections
● NPH = neutral protamine Hagedorn
● Appears cloudy
Insulin - Premixed Insulins
○ Novolog 70/30 (aspart protamine + aspart)
○ Humalog 75/25 (lispro protamine + lispro)
○ Humalog 50/50 (lispro protamine + lispro)
○ Novolin 70/30 (NPH + regular insulin)
○ Humulin 70/30 (NPH + regular insulin)
Insulin - Premixed Insulins - Fast facts
Generally administered twice daily
● Less flexibility to dose based on meals eaten as with other regimens
● Fewer injections each day
● Appear cloudy
