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Clin Med II Liza > Diabetes drugs > Flashcards

Diabetes drugs Flashcards

0
Q

TZDs

A

PioGlitazone (Actos) and RosiGlitazone (Avandia) / sensitizer: decreases insulin resistance and ins-sparing: decr ins requirements
- may worsen CHF!!!!!!!!! Don’t use in stage 3 or 4
- take 3-8 wks to see result, WGT GAIN, LIVER TOX (LFTs)
- Rosi: Black Box increased MI/angina and stroke?
- SE: LIVER TOXICITY (need freq LFT monitoring)
WGT GAIN

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1
Q

Metformin

A

(BiGuanides) / insuline sensitizer
DOC DM2 initial Tx for all types: under-over wgt and normal wgt
-reduces BS only (no effect on Insulin levels):
reduces hepatic glucose production and increases glucose uptake by cells
-NO HYPOglycemia, NO WGT GAIN
SE:
1) GI (bloat, gas) so TITRATE SLOWLY: start with 500mg before largest meal for 1 week, then increase to 500 BID for 1 wk, then to 1000 BID
2) LACTIC ACIDOSIS: cleared by kidney so avoid if cr >1.5 (men) cr > 1.4(women)
3) Iodine CONTRAST DYE: stop 2 days BF contrast and resume only after check cr and kidney fx is normal

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2
Q

SulfonuUreas

A

Ins Secretagogue

  • Blocks K channels on B cells -> increase Ins secretion
  • SE: HYPO and WGT GAIN (C/I: sulfa allergy)
  • Glipizide and Glimepiride are once daily
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3
Q

Meglitinides

A

Insulin secretagogues: increase ins secretion

  • RepaGlinide and NateGlinide
  • RAPID onset and 1/2 life: take 30 min BF meal
  • good for ppl with irratic eating schl, kinda like short-acting (“regular”) insulin
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4
Q

Which drug is not used in overwgt bc can cause wgt gain?

A

Sulfonylureas and TZD

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5
Q

Alpha-Glucosidase Inhibitors

A 
"carb blockers": delay absorption,
- helps with PostP hyperglycemia
- aCARBose, MigLitol
- SE: GAS, safe, work in all who can tolerate farting
(no wgt changes)
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6
Q

DM pathogenesis

A
  • increasing insulin resistance of liver, muscle receptors (type 2)
  • Decreasing insulin secretion by panctiatic B cells
  • excessive GLUCAGON section by alpha cells of pancreas
  • impaired INCRETIN hormones (incretin mimetics: boyetta, victoria, trucitia)
  • When DM appears, 80% of beta cells are gone
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7
Q

Incretin hormones

A

GLP-1 acts like insuline (looks like glucagon)
GIP: glucose-dependent Insulinotropic Polypeptide
- Both are stimulate insulin secretion in response to food consumption
- eat -> GIP and GLP1 secreted _> bind to b cells -> increase insulin section
(Resist GPP4 degradation)

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8
Q

Byetta/Exenatide

A

Incretin mimetic (synthetic version of GLP1)
GLP1 receptor Anogist -> binds to Beta cells -> increase insulin secreted
- MAY INCREASE BETA CELL # AND MASS!!!!!!!!!!!
- beta cell release insuline ONLY IF BS is high
decrease glucagon
- decreases hepatic glucose production (reducing insulin demand)
- increases SATIETY = eat less
- slows emptying - good for overwgt

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9
Q

When is Byetta/Exenatide indicate

A
  • in DM2, when failedt to respond to metformin, sulfonyreas or combo
  • SE: N/D, WGT LOSS (good!), hypoglycemia
  • BID subQ injection (has a once weekly injections Bydureion)
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10
Q

Necrotizing Pancreatitis is a SE of

A

Byetta/Edenatide

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11
Q

PrAMlintide

A

synthetic Amylin

  • in COMBO with insulin lowers BS
  • use in both type 1 and 2, control PP sugar
  • must inject separately before a meal
  • control PP sugar
  • less commonly used
  • comes in a pen
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12
Q

DPP4 inhibitors

A

“gliptins” (Sita, Saxa)

  • DPP4 degrades incretins
  • prevent GLP1 degradation by DPP4 -> GLP1 binds to b cell - > increase insulin secretion and glucose uptake by tissues, decreasing BS
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13
Q

SGLT2 inhibitors

A

Pee!out
CanAgliFLOzin 100-300 mg PO daily bf 1st meal!!!
dapagliFLOzin (farxiga) 5-10 mg PO qAM

  • MOA: inhibit Na-Glucose contrasporter (SGLT2) in kidney -> reduces glucose reabsorption from nephron -> pee out
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14
Q

Which med to use if you have pancreatic failure (decreased insulin production) - type 1

A 
Sulfonylueras
Incretin mimetic (byetta, victoria, trucilia)
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15
Q

Which med to use if you have glucose overproduction by liver (When would that happen except early AM?)

A

metformin - DOC for type 2

DPP4 inhibitor -> increase incretin binding to Beta cells -> increase insulin section -> decrease BS

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16
Q

which drug to use for overeating (high PP glucose)

A

Byetta (exenatide) (INCRETIN mimetic)
aCARBose (migLitol) (alpha gluconodase inh)
DPP4 inhibitor (“glipins”) – why?
Why not metformin - no wgt changes in pharm and wgt loss Clin med

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17
Q

which drug to use in insulin resistance (type 2)

A

metformin

TZD (Pio, Rosi) - prophylactic

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18
Q

which to use in combo glucotherapy

A

when single drug not enough

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19
Q

Metformin is DOC for type 2

A

bc wgt loss and reduces insulin resistace (and good for heart: decrease MI, Strokes)

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20
Q

Tx of type 2

A
  • start with metformin (decreases insulin resistance)

- if taget HgA1c ( hunger -> wgt gain -> increase resistance

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21
Q

Insulin injection

A

Must give to DM1, may need in DM2

- normally don’t add oral agents in DM1

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22
Q

When to start insulin - A1C of

A

near 8% in spite of optimal oral therapy in DM2

in DM 2, earlier use of insulin may help with better glycemic control

23
Q

Goals of insulin therapy

A
  • achieve normal fasting glucose levels (which are 80-130) (act if >140 or < 7% (act if >8%)
24
Q

Rapid acting insulin

A 
Lispro(line), Aspart(ate), GluLisine
ONSET on action: 15 MIN!!!
Peak: 1 hr
Effective for : 2-4 hrs
- shouldn't take earlier than 5-15 min bf meal
- can induce hypoglycemia after eating
25
Q

Short acting insulin

A

REGULAR (humilin)
Onset: 30 min - 1 hr
Peak: 2-3 hr
Effective for: 3-6 hr

26
Q

intermediate acting insuline

A

NPH
Onset: 2-4 hr
Peak: 6-12 hr
Effective for: 10-16 hr

27
Q

Long acting insuline

A

Glargine (Lantus), Detemir
Onset: 1-2 hr
NO PEAK
Effective for: 20-24+ hrs

28
Q

When injecting rapid with intermediate or long insulin

A

injet 15 before meal

make sure insulins are compatibel

29
Q

Premixed insulins

Humilin 70/30

A

70% NPH (intermediate) and 30% Regular (short acting/not rapid)

30
Q

Humulin 50/50

A

50% NPH (int) and 50 Regular (short acting)

31
Q

Humalog 75/25

A

75 intermediate lispro and 25 RAPID lispro (not regular/short)

32
Q

1 ml insulin syringes are for

A

insulin doses up to 100 units

33
Q

1/2 ml syringes are for

A

insuline doses 50 units or less

34
Q

Start DM2 patients on injectable insulin when their A1C is what?

A

near 8%

Or if fail to achieve glycemic control with triple therapy

35
Q

Injectable insulin regimen for DM2

A
  • Add insulin after triple therapy fails, dc oral drugs except Metformin: -decrease dose by 50%?.. Or to 25% ????
  • BEST: Metformin + once daily long BASAL insulin (Glargine/Determir)
  • BASAL-BOLUS regimen: once daily long basal + 3 pre-meal rapid injections (lispro, aspart, glulisine)
  • Twice daily premixed insulin (70/30 intermediate and short)
  • Ins Pump
  • can d/c some or all oral agents but continuation of metformin or TZD may help minimize insulin RESISTANCE.
36
Q

When does intermediate insulin peak? (NPH)

A

6-12 hrs after admin
(onset is 2-4 hr)
lasts 10-16 hrs

37
Q

when does Regular insuline (short acting) peak?

A

2-3 hr after admin
onset is 30 min-1 hr
effective for 3-6 hrs

38
Q

when does rapid acting insulin peak? (lispro, aspart)

A

peaks 1 hr after admin
onset is 15 min after admin
lasts for 2-4 hr

39
Q

Mixed insulin regimen 2 injections:

A

give 2/3 of 70(intermediate)/30(rapid or regular) bf breakfast
give 1/3 of 70/30 or 50/50 15 min before evening meal

40
Q

Traditional 3 injection mixed insulin:

A

2/3 of daily 70(interm)/30(rapid or regular) BF breakfast
30% rapid or regular before supper
70% intermediate BEFORE BED
(+/- rapid or reg bf lunch if necessary)

41
Q

Best insulin regimen for both type 1 and 2

A

-“peakless” glargine (Lantus) as BASAL once a day
+ rapid acting BEFORE EACH meal:
- flexible meals, adjust rapid according to carbs
- avoids “stacking” of insulins (which increases hypoglycemia)
- need 3-4 injections but greater safety

42
Q

Bolus insulin is

A

prandial insulin: rapid insulin (lispro, aspart, lisine) injected before meals

43
Q

How much insulin for type 1?

A

Split Total Dialy Insulin (TDI) dose (precalculated) 50-50 between basal (garglin) and BOLUS (“prandial”):
Basal: give all 50% as one dose in am
or can give intermediate (NPH) BID as 1/2 dose
Bolus: divide 50% into 3 doses: before breakfast, lunch and dinner (if 50% of 30 units TDI is 15, then devide by 3 and give 5 units TID)

44
Q

Physiologic vs Nonphysiologiv Insulin regimen

A

Physiologic: mimics natural Beta cell secretions
typically replace “basal” and “prandial/bolus” insulin separately (what does this mean?)

Traditionally, intermediate was said to be a basal insuline and REgular was a prandial insulin but both have basal and prandial effects

45
Q

What is an example of nonphysiologic insulin

A

Gargine (Lantus) by itself

NPH (intermediate) by itself

46
Q

example of physiologic insulin regimen

A

GLargine plus Lispro or Aspart

Long/peakless plus rapid acting (to decrease postprandial hyperglycemia)

47
Q

When would you use a 3 injection regimen: 2/3 breakfast, 30% rapid Lispro at supper and 70 NPH intermediate at bed?

A

When pt has high pre-breakfast BS levels (“due to waning or insulin” or GH increasing insulin between 3 am and 7 am):
this way NPH intermediate will peak 6-12 hrs after admin - at the time of next breakfast, preventing high pre-breakfast BS

48
Q

How to start insulin in Type 2 DM?

A

Continue but reduce oral agents to

  • 50% of max dose if using NPH intermediate or pre-mixed insulins.
  • 25% if using glargine/detemir at bed

Begin: 0.1-0.2 units/kg (15 units max) in :
- NPH intermediate, Glargine or detemir at bed
- 70/30 mix given 30 min before dinner
- 75/25 mix (Humalog) before dinner
Monitor BS and adjust accordingly
Goal is morning glucose of 90-120 more than 50% of the time, WITHOUT HYPOglycemia

49
Q

what is the goal of insulin tx in DM2

A

AM glucose of 90-120 more than 50% of the time without HYPOglycemia

50
Q

Basal insulin

A

Supresses glucose production between meals and overnight

USE FOR 50% of daily needs

51
Q

Bolus insulin (prandial/mealtime)

A
  • limits hyperglycemia after meals
  • immediate rise and peaks 1-2 hrs after meal
  • 10-20% OF TOTAL DAILY INSULIN PER MEAL (ADDS UP TO 50% OF TOTAL)
52
Q

How many grams of carbs can be offset by how many units of Lispro rapid acting insulin?

A

1 unit of Lispro covers 15 gr of carbs (CHO)

53
Q

Diabetic follow-up

A

-ask ab sx of hypo or hyperglycemia
- get result of SMBG
- Sx of complications (infections, etc)
- Vital signs - wgt, BP
- fundoscopic, cardiovascular, skin, feet exam,
neuro exam: MONOFILAMENT (?), PINPRICK (?), vibraion, ankle DTRs
- Labs: A1C, LIPIDS, U/A (to check for albuminuria (UACR), urine glucose, ketones), BUN/Cr,

54
Q

Rx for diabetic Dyslepidemias (on boards)

A

STATINS!
75 with no risk factors: NO STATIN or moderate Statin for 75
40-75 with NO RISK: MODERATE STATIN
with CVD risk: HIGH STATIN
overt CVD: HIGH STATIN
CVD rist factors: LDL > 100, HBP (?), smoking, overwgt
Overt CVD: Hx of prev CV event or Acute Coronary Syndrome

55
Q

CVD rist factors:

A

LDL > 100, HBP (?), smoking, overwgt

Overt CVD: Hx of prev CV event or Acute Coronary Syndrome

Clin Med II Liza (6 decks)

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