Diabetes / Endo Flashcards
Sulfonylureas MOA
bind to specific receptors on beta cells, causing adenosine triphosphate (ATP)–dependent potassium channels to close. The calcium channels subsequently open, leading to increased cytoplasmic calcium, which stimulates the release of insulin.
Sulfonylureas Indications:
DM for <5 yrs
No history of prior insulin therapy or Good glycemic control on less than 40 U/d
Close to normal body weight
FPG <180
Patients who are lean and insulinopenic or who have monogenic forms of DM
Sulfonylureas SE’s
Hypoglycemia (older adults, impaired renal function)
Hypoglycemia increases with alcohol abuse or overexertion
Caution in pregnancy (except Glyburide)
Declining efficacy over time
Sulfonylureas Patient Education
Signs and symptoms of hypoglycemia. Can cause weight gain 2-3 kg. Do not use it in sulfa allergies. Baseline renal and hepatic function tests. May cause photosensitivity.
Biguanides MOA
Inhibit hepatic glucose production and moderately improves peripheral sensitivity to insulin
Gluconeogenesis and glycogenolysis are inhibited in the liver
Biguanides Indications
For DMII or Pre-diabetes. Used with diet as first-line monotherapy or in combination with other diabetic drugs (including insulin)
No risk of hypoglycemia or hyperinsulinemia
No weight gain
OK in pregnancy
Biguanides Dosage
Metformin (Glucophage):
Immediate release (IR): Taken before meals in the morning and evening
Initial: 500-850 mg QD or BID
Increase: weekly by 500mg until desired blood glucose
Max: 2,550 mg/day
Peak: 2-2.5 H
Duration: 10-16 H
Steady State: 24-48 H
Extended Release (ER): Taken once a day with the evening meal or at bedtime
Initial: 500 mg QD
Max: 2,000 mg QD
Biguanides Contraindications
Severe renal impairment GFR <30
Chronic alcohol abuse
Hepatic disease
Heart failure
Children <10 yrs
Biguanides SE’s
GI upset (N/V/D/Bloating)
Anorexia
Metallic taste
Lactic acidosis if GI upset late in therapy (with advanced age and worsening renal function)
Vitamin B12 deficiency
Mitigation: start low and go slow
Biguanides Interactions
Combination with sulfonylureas, meglitinides, or insulin may cause hypoglycemia
Thiazolidinediones (TZD) MOA
Target specifically the TZD proliferated factor gamma in cells which plays a crucial role in regulating BG in cells.
Helps preserve some beta cell function.
Reduce hepatic glucose production lowering fasting BG levels.
Promote differentiation of preadipocytes into mature adipocytes which helps redistribute fat from muscle to subcutaneous tissue
Reduced r/o CVA and MI
Thiazolidiniones (TZD) Indications:
Recommended for DM II not controlled by other oral DM agents or when insulin is not preferred
Thiazolidinediones (TZD) Drug Types & Dose
Avandia:
Initial: 4 mg/d in single dose
Increase: If response is inadequate after 12 weeks. Increase to 8 mg/d in single dose
Pioglitazone (Actos)
Initial: 15-30 mg/d
Max: 45 mg/d as monotherapy and 30 mg/d as combined therapy
Pioglitazone (Actos) - TZD SE’s
Increased r/o bladder cancer with increased dose and duration of therapy
Decreased concentration of oral contraceptives
Not recommended for those in Class III or Class IV HF
Contraindicated in active liver disease
May stimulate weight gain (redistribution of fats into SQ compartments)
Thiazolidinediones (TZD) SE’s
Fluid retention, r/o Fx (particularly in women), liver injury/ liver enzyme elevation, macular edema
CXN in pregnancy
Contraindications in breastfeeding women and in children
Thiazolidinediones (TZD) SE’s
Strong CYP2C8 inhibitors
CXN when used with digoxin, fexofenadine, midazolam, nifedipine, and warfarin
Alpha-Glucosidase Inhibitors MOA
The enzyme alpha-glucosidase is found on the brush border of the intestine and is necessary for the absorption of starch and disaccharides. Slows the digestion and absorption of carbohydrates in the small intestine minimizing the postprandial rise in BG
Alpha-Glucosidase inhibitors Indications
DMII
Not for use in children
Not useful for patients with postprandial hyperglycemia
Does not lower A1c
Often used as adjunct, not monotherapy
Alpha Glucosidase Dosages and Drugs
Acarbose (Precose), Miglitol (Glyset)
Initial: 25 mg TID with the first bite of a meal
Increase: by 25 mg at 4-8 week intervals
Max: 300 mg
Take with the first bite of each meal
Peak: 2-3 hours
Maintain movement after meals to minimize buildup of GI gas
Alpha-Glucosidase Inhibitors Contraindications
IBD, Colonic ulceration, obstructive bowel d/o, chronic intestinal d/o of digestion or absorption
Acarbose: contraindicated in liver cirrhosis or SCr >2.0 or CrCl <25
CXN during pregnancy
Contraindicated in breastfeeding
Alpha-Glucosidase SE’s
GI (flatulence, diarrhea), less effective for fasting BG. dose dependent
Alpha-Glucosidase Interactions
May decrease levels of propranolol and ranitidine
Meglitinide Analogs MOA
Meglitinide analogs work by stimulating the release of insulin from the pancreatic beta cells in response to a meal. They primarily target the adenosine triphosphate-sensitive potassium (KATP) channels on these cells. When these channels are closed, it triggers the release of insulin, helping to lower blood sugar levels.
These medications stimulate the pancreas to release insulin, but their action is shorter in duration compared to sulfonylureas. Meglitinides are particularly effective at controlling post-meal blood sugar spikes.
Meglitinide Analogs Indications
DMII
Rapid Onset of action - effective at controlling postprandial BG
Not for use in children
Monotherapy or in combination with other oral agents
Meglitinide Analog Dosages & Drugs
Repaglinide (Prandin):
Initial: 0.5 mg before two to four meals daily if patient has never received other tx for diabetes
If previous treatment: 1-2 mg with two to four meals daily
Max: double dose weekly to max of 16 mg/d
Peak: 1 hour
Nateglinide (Starlix)
Initial: 60-120 mg before each meal
Max: 360 mg/d
Peak: 1 hour
Take within 30 min before each meal
Add or skip if a meal is added or skipped
Meglitinide Analog Benefits
Rapid Onset of action
Lower r/o prolonged hypoglycemia
Less weight gain
Meglitinide analog SE’s
GI upset, URI’s, HA, Diarrhea/Constipation, arthralgias, back/chest pain
Less effective for fasting BG
May induce hypoglycemia
Short duration of action and frequent dosing
Meglitinide Analog Interactions
Use with BB or alcohol leads to increased r/o hypoglycemia
Meglitinide Analog Contraindications
DKA
Severe infection, surgery, trauma, severe stressors
Possible risk in pregnancy
Contraindicated in breastfeeding women and children
Dipeptidyl Peptidase-4 Inhibitors MOA
Inactivates GLP-1, therefore decreasing GLP-1 and glucoregulatory functions. Block the effect against GOP-1 and increase the amount of native circulating incretins
Dipeptidyl Peptidase-4 Inhibitors Indications
DM II
Not for use in children
Dipeptidyl Peptidase-4 Inhibitors: Sitagliptin (Januvia)
100 mg oral daily
50 mg PO QD CrCl 30-50 mL/min
25 mg PO QD CrCl <30 mL/min
Dipeptidyl Peptidase-4 Inhibitors: Saxagliptin (Onglyza)
5 mg QD
2.5 mg QD for CrCl <30 mL/min
Used in combo therapy with sulfonylureas and TZD’s, not insulin
Dipeptidyl Peptidase-4 Inhibitors: Alogliptin (Nesina)
6.25 mg, 12.5 mg, or 25 mg QD
12.5mg for CrCl 30-50 mL/min
6.25 mg for CrCl <30 mL/min
Dipeptidyl Peptidase-4 Inhibitors: Linagliptin (Tradjenta)
2.5 or 5 mg QD
No renal dosing is necessary
Dipeptidyl Peptidase-4 Inhibitors: (Vildagliptin (Galvus)
50 or 100 mg QD
Dipeptidyl Peptidase-4 Inhibitors: Contraindications
Hypersensitivity
CXN in pregnancy
Consider alternative for breastfeeding
Dipeptidyl Peptidase-4 Inhibitors: SE’s
URI
UTI
HA
Hypoglycemia when used in combination with sulfonylureas or insulin
Glucagon-Like Peptide Receptor Agonist (GLP1-RA) MOA
GLP-1 RAs work by binding to and activating the GLP-1 receptors on pancreatic beta cells, among other tissues. Their main actions include:
Stimulating Insulin Release: GLP-1 RAs enhance insulin secretion in a glucose-dependent manner, meaning they increase insulin production when blood sugar levels are elevated.
Inhibiting Glucagon Release: These medications reduce the release of glucagon, a hormone that raises blood sugar levels, from the pancreas.
Slowing Gastric Emptying: GLP-1 RAs slow down the emptying of the stomach, leading to a more gradual release of glucose into the bloodstream after meals.
Promoting Satiety: They induce a feeling of fullness and can reduce food intake, leading to potential weight loss.
Glucagon-Like Peptide Receptor Agonist (GLP1-RA) Indications
GLP-1 RAs are known for their glucose-lowering effects, weight management benefits, and cardiovascular benefits.
Indicated for DMII in adults
DM II in adolescents over the age of 10 (Liraglutide)
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): Exenatide (Byetta, Bydureon)
Only available as an injectable
Monotherapy or conjunction with oral agents, metformin, sulfonylureas, TZD’s, and insulin
Initiate: 5 mcg administered 60 min before morning and evening meals or prior to the largest meals of the day
Space doses 6 hours apart
Dose can be increased to 10 mcg BID within 1 month of initiation
Bydureon = ER. Dosed once weekly without regard to meals
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): Liraglutide (Victoza)
Once daily at any time
Initial: 0.6 mg/day not effective for glycemic control, start low to reduce GI symptoms
Effective Dose: 1.2 mg daily
Max: 1.8 mg/day for glucose control
Approved for adolescents over the age of 10
Shown to reduce r/o CV mortality and reduce MI and CVA
Reduction in new or worsening albuminuria in addition to reduction in new onset nephropathy
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): Dulaglutide (Trulicity)
Dose once weekly at any time of the day
0.75 or 1.5 mg dose injector pen
Shown to reduce r/o CV mortality and reduce MI and CVA
Reduction in new or worsening albuminuria in addition to reduction in new onset nephropathy
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): Semaglutide (Ozempic)
Dose once a week injectable or oral tab (Rybelsus) once daily in the morning
0.5-1 mg dose
Initiate: 0.25 mg and advance to 0.5 mg after 2-4 weeks
Max: 1 mg after 4 weeks of therapy
Reduce the r/o CV death
Reduction in new or worsening albuminuria in addition to reduction in new onset nephropathy
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): Benefits
Effective Glucose Control: GLP-1 RAs help lower blood sugar levels by stimulating insulin secretion and inhibiting glucagon release.
Weight Loss: Many patients experience weight loss while taking GLP-1 RAs due to reduced appetite and delayed gastric emptying.
Cardiovascular Benefits: Some GLP-1 RAs have been associated with cardiovascular benefits, including a reduced risk of major adverse cardiovascular events (MACE) in high-risk individuals.
Low Risk of Hypoglycemia: GLP-1 RAs have a low risk of causing hypoglycemia when used as monotherapy. However, when combined with other antidiabetic medications, the risk may increase.
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): SE’s
Gastrointestinal Side Effects: Common side effects include nausea, vomiting, diarrhea, and abdominal discomfort, especially when starting the medication. These side effects often improve with time.
Injection: GLP-1 RAs are administered via subcutaneous injection, which may be a drawback for some patients.
Pancreatitis: There have been rare reports of pancreatitis (inflammation of the pancreas) associated with GLP-1 RAs.
Thyroid C-Cell Tumors: Long-term use of certain GLP-1 RAs has been associated with an increased risk of thyroid C-cell tumors in animal studies, although the significance of this risk in humans is still being studied.
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): Interactions
Do not administer close to drugs that have a therapeutic window
CXN with patients taking warfarin
Glucagon-Like Peptide Receptor Agonist (GLP1-RA): Contraindications
Ketoacidosis, allergy, severe GI d/o including gastroparesis and acute gallbladder disease
CXN: not studied in pregnancy
Contraindicated in breastfeeding
Increased r/o Thyroid C-Cell tumors
Individuals with h/o medullary thyroid carcinoma
Association with acute pancreatitis
Dopamine Receptor Agonists MOA
Not fully understood
Bromocriptine’s action on dopamine receptors in the brain’s hypothalamus is thought to help regulate glucose metabolism. It may also influence circadian rhythms, which can impact insulin sensitivity.
Dopamine Receptor Agonists: Bromocriptine Mesylate Dosing
0.8 mg within 2H after waking with the first meal of the day
Titration: Increased by 0.8 mg weekly
Max: 1.6-4.8 mg
Dopamine Receptor Agonists: Indications
DMII to improve postprandial BG
Does not significantly increase plasma insulin concentrations
Used when other treatments have not achieved glycemic control
Monotherapy, or in combination with other antidiabetic meds
Dopamine Receptor Agonists: SE’s
nausea, vomiting, fatigue, and dizziness, orthostatic hypotension, headache