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Endocrine and Women's Health > Diabetes Guideline Overview and Treatments > Flashcards

Diabetes Guideline Overview and Treatments Flashcards

1
Q

Two Guidelines

what are the two main diabetes guidelines?

A

Two Guidelines

  1. American Diabetes Association (ADA)-clinical practice Recommendations (updates annually (in january)

1.American Assocication of Clinical Endocrinologists (AACE)
updates periodically

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2
Q

What are the 2023 AACE guideline diabetes goals ?

A1C:
preprandial:
post prandial

A

2023 AACE guideliens

  1. A1C <6.5%
  2. pre prandial (FBG) < 110 mg/dL
  3. 2 hour post prandial: <140 mg/dL

If pt has any of these, less stringent a1c goal of 7-8% is recommended.
1.limited life expectancy
2. hx of severe hypoglycemia
3. hypoglycemia unawareness

  1. advanced renal disease
  2. pother severe comorbid conditions w. high risk for cvd event
  3. long t2d disease duration w. difficulty to attain an a1c goal
    prohibitive cognitive and or psychological status
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3
Q

Complications-Centric Algorithm for Glycemic control
2023 AACE guidelines

Purpose

A

Pts. w. T2DM are at an increased risk of ASCVD and experience significant morbitdity and mortality (leading cause of mortality) despite contemporary therapy w. lipid modifying, antiplatelet, and antihypertensie agents.

need for a paradigm shift from an exclusively glucose-centric approach to a complications centric approach.

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4
Q
A
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5
Q

What are the ADA guideline diabetes goals ?

(NEW 2023 GUIDELINES GOALS)
A1C:
Pre prandial (FBG)
Post prandial:

NEW METRICS
TIR:
TBR:
Time <54 mg/dL:

A

(NEW 2023 GUIDELINES GOALS)

A1C: <7% (<8% for individuals with limited life expectancy or greater risk of hypoglycemia)

Pre prandial (FBG):80-130mg/dL

Post prandial: <180 mg/dL

New Metrics

TIR: >70%
TBR: <4%
Time <54 mg/dL: <1%

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6
Q

in this class. when to use each guideline?

A

if patient is <65 years old and without clinical ASCVD:STRICT TARGETS
use AACE guidelines

If patient is >/= 65 years old OR <65 with clinical ASCVD: LOOSE TARGETS
use ADA guidelines

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7
Q

according to AACE and ADA, what are the T1DM treatment

A

Treatment of T1DM

ADA and AACE recommendations

Multiple-dose insulin (MDI) 3-4 injections per day, or continuous subcutaneous insulin infusion (insulin pump)

educate patient on how to match prandial insulin based on carb intake, pre-meal blood glucose and anticipated

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8
Q

Pivotal TRials

DCCT:

UKPDS:

ACCORD TRIAL:

ADVANCE TRIAL:

VADT:

A

Pivotal Trials

(DCCT):
for type 1 diabetics. microvascular complications were reduced remarkably with intensive insulin treatment and A1C lowering and CV (macrovascular) benefit won’t be realized until years down the line

UKPDS

for type 2 diabetics. shows microvascular outcomes benefits are improved with intensive therapy.

ACCORD trial
focued individualize goals.intensive glycemic treatment strategyy was associated wuth a higher risk of death in older people with preexisting conditions.

ADVANCE. saw decreased ;microvssc with lower blood glucose, but did not see increase risk in mortality like accord

VADT Trial: saw decreased ;microvssc with lower blood glucose, but did not see increase risk in mortality like accord

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9
Q

Sulfonylureas

examples:

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy:

Warning/ Precautions:

Drug Interactions :

Counseling Points:

Monitoring Parameters:

Class Specific Pearls:

A

Sulfonylureas

examples: Glyburide, Glipizide, Glimepiride

Class: Sulfonylureas

Indication: Adjunct to diet and exercise to improve glycemic control in adults with T2DM

Mechanism of Action: Stimulates insulin release from the pancreatic beta cells

Effects of mechanism of Action: increase in glucose uptake by cells, and decrease blood glucose

Adverse Effects: Hypoglycemia, N/V, weight gain, GI upset, rash, cholestatic jaundice, hemolytic anemia

Absolute Contraindications: hypersensitivity, DKA,T1DM, CrCL <50 (Glyburide only),

Pregnancy: CI in pregnancy near term (glyburide/glipizide only)

Warning/ Precautions: impaired renal and liver function, elderly, sulfonamide allergy (cross reactivity is low), thyroid dz, adrenal insufficiency, malnutrition, G6PD deficiency

Drug Interactions : Alcohol, displaced protein binding, decreased renal excretion with probenecid and allopurinol

Counseling Points:
1. Take first thing in the morning with breakfast or first main meal of the day
2. GlipiZIDE IR. take 30 min before breakfast
3. if it upsets your stomach, take it with food
avoid alcohol use.
4. ask about hypoglycemia and weight gain with every refill.

Monitoring Parameters:

  1. Hypoglycemia
  2. Fasting Blood Glucose
  3. A1C
  4. weight gain
  5. allergic reactions
  6. sun sensitivity
  7. time to full effect: 4-6 weeks

Class Specific Pearls:

  1. Glyburide and Glimepiride is on the Beers List (identifies inappropriate medication use for older adults (>65)
  2. Glyburide. Do not use if CrCL <50 mL/min
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10
Q

Diabetes Drug Specific and Patient Specific Factors to
Consider for SU

General Pre or prandial target: 
Efficacy: 
Hypoglycemia: 
Weight change: 
CV effects 
a. ASCVD: 
b. CHF: 
Cost: 
Oral/SQ: 
Renal effects:
a. Dosing:
b. Progression of CKD.
A 
Diabetes Drug Specific and Patient Specific Factors to Consider
General Pre or Post prandial target: both 
Efficacy: (high) A1C lowering of 0.8-2%
Hypoglycemia: Yes
Weight change: Gain
CV effects: 
a. ASCVD: neutral
b. CHF: neutral
Cost: Low
Oral/SQ: Oral
Renal effects:
a. Dosing not recommended- Glyburide CrCl<50 mL/min.Glimerpiride (eGFR <15) and GlipiZIDE (eGFR <10)
b. Progression of CKD. none
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11
Q

examples of sulphonylureas

A

Glyburide
Glipizide
Glimepiride

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12
Q

Amy’c class psecific pearls for sulphonylureas

A

Class Specific Pearls:

  1. Glyburide and Glimepiride is on the Beers List (identifies inappropriate medication use for older adults (>65)
  2. Glyburide. Do not use if CrCL <50 mL/min
  3. Sun sensitivity
  4. Weight gain
  5. Hypoglycemia
  6. moa: stimulate beta cells to produce insulin
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13
Q

General dosing for sulphonylureas

A

PO daily first thing in the morning at breakfast or first meal of the day

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14
Q

Meglitinides

examples:

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy: –

Warning/ Precautions:

Drug Interactions :

Counseling Points:

Monitoring Parameters:

Class Specific Pearls:

A

Meglitinides

examples: Repaglinide (Prandin), Nateglinide (Starlix)

Class: Meglitinides

Indication: Adjunct to diet and exercise to improve glycemic control in adults with T2DM

Mechanism of Action: glucose dependent Stimulation of insulin release from the pancreatic beta cells. Short acting

Effects of mechanism of Action: increase in glucose uptake by cells, and decrease blood glucose

Adverse Effects: Hypoglycemia, GI disturbances, weight gain, headache,

Absolute Contraindications: hypersensitivity, DKA,T1DM,

Pregnancy: –

Warning/ Precautions: severe renal disease, impaired liver function, use with insulin

Drug Interactions :
Nateglinide: Mifepristone (anti progesterone drug). do not use within 14 days, Pazopanib (anti cancer)
Repaglinide: Mifepristone, GEMFIBROZIL, NPH INSULIN ( increase risk of MI)

Counseling Points:

  1. administer before meals. Repaglinide: 15-30 minutes before meals. Nateglinide: 1-30 min prior meals
  2. skip a meal, skip the dose
  3. short acting form of Sulfonylurea
  4. avoid alcohol use
  5. ask about hypoglycemia and weight gain with every refill

Monitoring Parameters:

  1. Post Prandial Glucose
  2. HYpoglycemia
  3. A1C
  4. Weight gain
  5. time to full effect: 4-6 weeks

Class Specific Pearls:

  1. Repaglinide DDI with Gemfibrozil (increases repaglinide levels) and NPH INSULIN (increased risk for MI)
  2. must eat before meal. if skip meal, skip dose.
  3. same MOA as SU, just shorter acting
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15
Q

examples of meglitinides

A

Repaglinide (prandin)

Nateglinide (Starlix)

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16
Q

repaglinide class and brand name

A

meglitinides

prandin

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17
Q

nateglinide class and brand name

A

meglitinides

starlix

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18
Q

amys clinical pearls for meglitinides

A

1.Repaglinide DDI with Gemfibrozil (increases repaglinide levels) and NPH INSULIN (increased risk for MI)
2. must eat before meal. if skip meal, skip dose
3. basically a short acting SU
Weight gain
Hypoglycemia

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19
Q

general meglitinide dosing

A

before meals. skip meal, skip dose

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20
Q

Diabetes Drug Specific and Patient Specific Factors to Consider for MEGLITINIDES

General Pre or prandial target: 
Efficacy: 
Hypoglycemia: 
Weight change: 
CV effects: 
a. ASCVD: 
b. CHF: 
Cost: 
Oral/SQ: 
Renal effects:
a. Dosing: 
b. Progression of CKD:
A 
Diabetes Drug Specific and Patient Specific Factors to Consider
General Pre or Post prandial target: Post prandial
Efficacy: low() A1C lowering of 0.6-1%
Hypoglycemia: Yes
Weight change: Gain
CV effects: 
a. ASCVD: neutral
b. CHF: neutral
Cost: intermediate
Oral/SQ: Oral
Renal effects:
a. Dosing: not required
b. Progression of CKD. neutral
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21
Q

Biguanides

examples:

Class:

Indication:

Mechanism of Action:

Effects of mechanism of Action:

Adverse Effects:

Absolute Contraindications:

Pregnancy: –

Warning/ Precautions:

Drug Interactions :

Counseling Points:

Monitoring Parameters:

Class Specific Pearls:

A

Biguanides

examples: Metformin

Class: Biguanides

Indication: Preferred initial pharmacologic agent for T2DM management when hyperglycemia cannot be managed with diet and exercise alone.

Mechanism of Action: decrease glucose output from the liver ( hepatic glucose production). Increase peripheral muscle glucose sensitivity (glucose take and utilization)

Effects of mechanism of Action: lower blood glucose

Adverse Effects: GI: N/V, diarrhea, abdominal discomfort, anorexia, weightloss, Lactic acidosis (<0.1/1000 pts. per year)

Absolute Contraindications: hypersensitivity, renal disease/ dysfunction, metabolic acidosis, DKA, Lactic acidosis, iodinated contrast, impaired liver function, hypoxemia, dehydration, sepsis, surgery.

Pregnancy: –

Warning/ Precautions: Elderly, excessive alcohol use, CHF requiring drug therapy

Drug Interactions : Radiopaque contrast dyes, dofetilide, dalfampridine, cimetidine, trimethoprim, trospium, corticosteroids, danazol, luteinizing hormones, lamotrigine

Counseling Points:

  1. Take with food to decrease GI effects
  2. start low go slow (titration schedule listed below)
  3. avoid alcohol use
  4. GI upset/diarrhea should decrease over time. contact MD if it doesn’t
  5. ask about GI upset, weight loss, and signs and symptoms of lactic acidosis (SOB, muscle cramping, tachycardia)
  6. TIME TO PEAK EFFECT: 6-8 weeks

Monitoring Parameters:

  1. Renal function (eGFR)
  2. GI intolerance
  3. A1C
  4. B12 levels
  5. weightloss
  6. SS OF LACTIC ACIDOSIS: tachycardia, sob, MUSCLE CRAMPS
  7. FBG/PPG

Class Specific Pearls:
1.Dose must be titrates to MDD 2000 mg BID due to GI effects
example
Week 1: Metformin 500 mg with dinner
week 2: Metformin 500 mg with breakfast and 500 mg with Dinner
Week 3: Metformin 500 mg with breakfast and 1000 mg with Dinner
Week 4: Metformin 1000 mg with breakfast and 1000 mg with Dinner

  1. Has renal adjustments
    eGFR >45 mL/min: no adjustment
    eGFR 30-45 mL/min: half dose, up to 1000 mg a day
    eGFR =30 mL/min: discontinue
    ARF: Discontinue until reversed.
  2. potential for B12 defiicency
  3. DDI with contrast dye
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22
Q

metformin titration dosing

A

Week 1: Metformin 500 mg with dinner
week 2: Metformin 500 mg with breakfast and 500 mg with Dinner
Week 3: Metformin 500 mg with breakfast and 1000 mg with Dinner
Week 4: Metformin 1000 mg with breakfast and 1000 mg with Dinner

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23
Q

amys clinical pearls about MEtformin

A

1.Dose must be titrates to MDD 2000 mg BID due to GI effects
example
Week 1: Metformin 500 mg with dinner
week 2: Metformin 500 mg with breakfast and 500 mg with Dinner
Week 3: Metformin 500 mg with breakfast and 1000 mg with Dinner
Week 4: Metformin 1000 mg with breakfast and 1000 mg with Dinner

  1. Has renal adjustments
    eGFR >45 mL/min: no adjustment
    eGFR 30-45 mL/min: half dose, up to 1000 mg a day
    eGFR =30 mL/min: discontinue
    ARF: Discontinue until reversed.
  2. potential for B12 defiicency
  3. to minimize GI upset, take with food and titrate
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24
Q

Diabetes Drug Specific and Patient Specific Factors to Consider for METFORMIN

General fasting or prandial target: 
Efficacy: 
Hypoglycemia: 
Weight change: 
CV effects: 
a. ASCVD: 
b. CHF: 
Cost: 
Oral/SQ: 
Renal effects:
a. Dosing: 
b. Progression of CKD.
A

Diabetes Drug Specific and Patient Specific Factors to Consider
General fasting or prandial target: Fasting blood glucose
Efficacy: (High) A1C lowering of 1-2%
Hypoglycemia: No
Weight change: Neutral| modest loss
CV effects:
a. ASCVD: Potential benefit
b. CHF: neutral
Cost: low
Oral/SQ: Oral
Renal effects:
a. Dosing: eGFR >45 mL/min: no adjustment
eGFR 30-45 mL/min: half dose, up to 1000 mg a day
eGFR =30 mL/min: discontinue
ARF: Discontinue until reversed.
b. Progression of CKD. neutral

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25
example of biguanides
MEtformin
26
what is the max daily dose of metformin
2000 mg qd. | 1000 mg BID
27
Thiazolidinediones (TZD's) examples: Class: Indication: Mechanism of Action: Effects of mechanism of Action: Adverse Effects: Absolute Contraindications: Warning/ Precautions: Drug Interactions: Counseling Points: Monitoring Parameters: Class Specific Pearls:
Thiazolidinediones examples: Pioglitazone (Actos), Rosiglitazone Class: Thiazolidinediones (TZDs) Indication: As an adjunct to diet and exercise, to improve glycemic control in adults with type 2 diabetes Mechanism of Action: increase peripheral glucose sensitivity (glucose uptake and utilization). decrease glucose output from the liver (hepatic glucose output (hepatic glucose output) Effects of mechanism of Action: lower blood glucose Adverse Effects: EDEMA (may worsen CHF), weight gain (especially with insulin or insulin secretagogues), hepatic toxicity , bladder cancer, fractures ``` Absolute Contraindications: hypersensitivity, T1DM, DKA,ALT >2.5X UNL, NYHA class III-IV CHF (symptomatic), ACS, active bladder cancer Pregnancy: -- ``` Warning/ Precautions: CHF NYHA Class I-II, edema, myocardial infarction, impaired liver function, insulin/SU use, bladder cancer history, females, fracture risk Drug Interactions: Pioglitazone: Oral contraceptives (pioglitazone inducrs ovulation, making oral contraceptives less effective), progestins, pazopanib Counseling Points: 1. Take once a day; same time each day 2. report weight gain and/or swelling of legs immediately avoid alcohol use 3. Do not use in NYHA Class III-IV CHF 4. ask about edema and weight gain at every refill 5. time to peak effect: 6-8 weeks Monitoring Parameters: 1. LFT's 2. edema 3. weight gain 4. cholesterol panel 5. FBG/PPG 6. A1C Class Specific Pearls: 1.Black Box warning: Can exacerbate both forms of Congestive Heart Failure. Monitor for symptoms (rapid weight gain, dyspnea, edema) Myocardial infarction (rosiglitazone) 2. contraindicated in CHF class III-IV and in hx of bladder cancer 3. take once a day, at same time each day Pioglitazone ddi with oral contraceptives
28
examples of TZDs
Pioglitazone (Actos) | Rosiglitozone
29
Pioglitazone class and brand name
TZDs | ACtos
30
Rosiglitazone class and brand name
TZDs | avandia
31
Pioglitazone dosing
PO daily
32
Amy's Class Specific Pearls for TZDs
Class Specific Pearls: 1.Black Box warning: Can exacerbate both forms of Congestive Heart Failure. Monitor for symptoms (rapid weight gain, dyspnea, edema) Myocardial infarction (rosiglitazone) 2. contraindicated in CHF class III-IV and in hx of bladder cancer. increase risk in fractures 3. take once a day, at same time each day 4. Pioglitazone interaction with oral contraceptives
33
Diabetes Drug Specific and Patient Specific Factors to Consider TZDS ``` General Pre or Post prandial target: Efficacy: Hypoglycemia: Weight change: CV effects: a. ASCVD: b. CHF: Cost: Oral/SQ: Renal effects: a. Dosing: b. Progression of CKD. ```
Diabetes Drug Specific and Patient Specific Factors to Consider General Pre or Post prandial target: fasting blood glucose Efficacy: (High) A1C lowering of approx. 1% Hypoglycemia: No Weight change: Gain CV effects: a. ASCVD: Potential benefit (pioglitazone) b. CHF: increased risk Cost: low Oral/SQ: Oral Renal effects: a. Dosing: no renal adjustment, but generally not recommended in renal impairment due to potential for fluid retention b. Progression of CKD. neutral
34
Alpha- gLucosidase inhibitors (AGI) examples: Class: Indication: Mechanism of Action: Effects of mechanism of Action: Adverse Effects: Absolute Contraindications: Warning/ Precautions: Drug Interactions: -- Counseling Points: Monitoring Parameters: Class Specific Pearls:
Alpha- gLucosidase inhibitors (AGI) examples: Acarbose (Precose) abd Miglitol (GLyset) Class: Alpha- gLucosidase inhibitors (AGI) Indication: As an adjunct to diet and exercise, to improve glycemic control in adults with type 2 diabetes Mechanism of Action: decrease breakdown of sucrose and complex carbs in brush border if the small intestine (GI) Effects of mechanism of Action: reduces rate of digestion of complex carbs and subsequent absorption of glucose Adverse Effects: Gastrointestinal: abdominal pain, Diarrhea, flatulance, bloating Absolute Contraindications: hypersensitivity, DKA, cirrhosis, Irritable bowel syndrome, churns disease, colonic ulceration, intestinal obstruction, Scr >2.0 Warning/ Precautions: impaired renal function Drug Interactions: -- Counseling Points: 1. start low, go slow, to manage GI side effects 2. take with he first bite of each meal. 3. skip a meal, skip a dose 4. call MD if severe diarrhea or vomiting occur 5. ask about GI upset and meal timing at every meal 6. Time to peak effect: 4-6 weeks Monitoring Parameters: 1. PPG 2. A1C 3. GI intolerance Class Specific Pearls: 1. tell pt to take at every meal. 2. only recommend if pt has a lot of complex carbs in diet 3. contraindicated in any GI diseases/issues(IBS, churns disease, colonic obstruction, intestinal obstruction)
35
examples of alpha glucosidase inhibitors
Acarbose (Precose) | Miglitol (GLyset)
36
acarbose class and brand name
alpha glucosidase inhibitor | Precose
37
Miglitol class and brand name
alpha glucosidase inhibitor | Glyset
38
amy's class specific pearls for AGI
1. tell pt to take at every meal. 2. only recommend if pt has a lot of complex carbs in diet 3. contraindicated in any GI diseases/issues(IBS, churns disease, colonic obstruction, intestinal obstruction)
39
Diabetes Drug Specific and Patient Specific Factors to Consider for alpha glucosidase inhibitors ``` General Pre or Post prandial target: Efficacy: Hypoglycemia: Weight change: CV effects: a. ASCVD: b. CHF: Cost: Oral/SQ: Renal effects: a. Dosing: b. Progression of CKD. ```
Diabetes Drug Specific and Patient Specific Factors to Consider ``` General Pre or Post prandial target: Post prandial Efficacy: (High) A1C lowering of approx. 1% Hypoglycemia: No Weight change: Neutral CV effects: a. ASCVD: neutral b. CHF: neutral Cost: Intermediate Oral/SQ: Oral Renal effects: a. Dosing: no renal adjustment required b. Progression of CKD. neutral ```
40
DDP4-i examples: Class: Indication: Mechanism of Action: Effects of mechanism of Action: Adverse Effects: Absolute Contraindications: Warning/ Precautions: Drug Interactions: Counseling Points: Monitoring Parameters: Class Specific Pearls:
DDP4-i examples: the GLIPTINS Sitagliptin (Januvia), Linagliptin (Tradjenta), Saxagliptin (Onglyza), Alogliptin, (Nesina) Class: DDP4- inhibitors Indication: As an adjunct to diet and exercise, to improve glycemic control in adults with type 2 diabetes, as mono therapy or combination therapy Mechanism of Action:inhibits DDP4 (responsible for inactivating incretin hormones) enzyme resulting in prolonged active incretin levels. incretin hormones (ex. GLUCAGON LIKE PEPTIDE (GLP-1), and Glucose-dependent insulinotropic polypeptide (GIP))suppresses glucagon secretion, slows gastric emptying, reduces food intake, promotes Bets cell proliferation and insulin synthesis and secretion. Effects of mechanism of Action: lowers pre and post prandial glucose Adverse Effects: Nasopharyngitis, Upper respiratory infection, abdominal pain, diarrhea, N/V, edema, Pancreatitis, Heart Failure (saxagliptin and Aloglptin), hypoglycemia Absolute Contraindications: hypersensitivity, DKA, T1DM Warning/ Precautions: impaired renal and hepatic function, history of pancreatitis, HF (saxagliptin/ alogliptin), use with GLP1 receptor agonists Drug Interactions: Saxagliptin- conivaptan Linagliptin- carbamezapine, Efavirenz, phenytoins, rifampin, St. John's Wort Sitagliptin and Alogliptin: nothing Counseling Points: 1. Take once a day at same time each day 2. can be taken with our without food 3. avoid alcohol 4. ask about nasopharyngitis and URI at every refill 5. Time to peak effect: 6-8 weeks Monitoring Parameters: 1. FBG/PPG 2. A1C 3. GI intolerance Class Specific Pearls: 1. tell pt take once a day, same time each day, with or without food 2. All DDP-4 i need renal adjustment EXCEPT Linagliptin 3. Do not use with GLP-1 RA CHF: potential risk (saxagliptin and alogliptin
41
amy's class specific drug pearls for DDP-4i
1. tell pt take once a day, same time each day, with or without food 2. All DDP-4 i need renal adjustment EXCEPT Linagliptin 3. Do not use with GLP-1 RA 4. CHF: potential risk (saxagliptin and alogliptin
42
examples of DPP-4 i's
Sitagliptin (Januvia0 Linagliptin (TRadjenta) Saxagliptin (onglyza) Alogliptin (Nesina)
43
sitagliptin class and brand name
DDP4i | Januvia)
44
linaglitpin class and brand name
DDP4i | Tradjenta
45
saxagliptin class and brand name
ddp4 i's | Onglyza
46
Diabetes Drug Specific and Patient Specific Factors to Consider for DPP4-I ``` General Pre or Post prandial target: Efficacy: Hypoglycemia: Weight change: CV effects: a. ASCVD: b. CHF: Cost: Oral/SQ: Renal effects: a. Dosing: b. Progression of CKD. ```
Diabetes Drug Specific and Patient Specific Factors to Consider General Pre or Post prandial target: BOTH Efficacy: (Intermediate) A1C lowering of approx. 0.75% Hypoglycemia: No Weight change: Neutral CV effects: a. ASCVD: neutral b. CHF: potential risk (saxagliptin and alogliptin) Cost: high Oral/SQ: Oral Renal effects: a. Dosing: renal dosing required for all exceptionalities linagliptin b. Progression of CKD. neutral
47
SGLT-2 Inhibitor examples: Class: Indication: Mechanism of Action: Effects of mechanism of Action: Adverse Effects: Absolute Contraindications: Warning/ Precautions: Drug Interactions: Counseling Points: Monitoring Parameters: Class Specific Pearls:
SGLT-2 Inhibitor examples:the GLIFLOZINS Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro) Class: SGLT-2 inhibitors Indication: As an adjunct to diet and exercise, to improve glycemic control in adults with type 2 diabetes, as mono therapy or combination therapy Mechanism of Action: inhibitsSodium glucose cotransporter 2 (SGLT2) in the proximal tubules, which reduces reabsorption of filtered glucose form the tubular lumen and lowers the renal threshold for glucose. Effects of mechanism of Action: reduction of filtered glucose reabsorption resulting in increased urinary excretion of glucose, thereby reducing plasma glucose concentrations. Adverse Effects: Genetic mycotic infections (females>males), increased urination, UTI's, hypotension, weightloss, ketoacidosis- stay hydrated, Fournier's Gangrene, lower limb amputation an d bone fracture (canagliflozin), bladder cancer (dapagliflozin), hyperkalemia (canagliflozin) Absolute Contraindications: Dialysis, eGFR<30 mL/min, ESRD Warning/ Precautions: Hypotension, genital mycotic infections, UTI, AKI, ketoacidosis (euglycemic, Hyperkalemia, bladder cancer, amputations Drug Interactions: UGT enzyme inducers, rifampin, ritonavir, phenytoin, phenobarbital. Hypotension (IF pt. is already using ACE-I, ARB, diuretics), may alter digoxin levels (monitor) ``` Counseling Points: 1. Take once a day at same time each day 2. hydraTION 3. hyperkalemia hx 4. bladder cancer 5. renal function status 6. discuss in women: yeast infections and UTI's. in men: circumcision status/UTIs/penile discharge ``` Monitoring Parameters: 1. FBG/ PPG 2. A1C 3. GI intolerance Class Specific Pearls: 1. all SGLT-2i contraindicated in eGFR<30 mL/min 2. can cause UTI, yeast infections, increased urination 3. additional considerations :DKA, amputations, gangrene, increased LDL, bladder cancer
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DDP4's general dosing
PO daily
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amys class specific pearls for SGLT-2 i
1. all SGLT-2i contraindicated in eGFR<30 mL/min 2. can cause UTI, yeast infections, increased urination 3. additional considerations :DKA, amputations, gangrene, increased LDL, bladder cancer
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Diabetes Drug Specific and Patient Specific Factors to Consider for SGLT2 ``` General Pre or Post prandial target: Efficacy: Hypoglycemia: Weight change: CV effects: a. ASCVD: b. CHF: Cost: Oral/SQ: Renal effects: a. Dosing: b. Progression of CKD: ```
Diabetes Drug Specific and Patient Specific Factors to Consider General Pre or Post prandial target: BOTH Efficacy: (High) A1C lowering of approx. 1-2% Hypoglycemia: No Weight change: Loss CV effects: a. ASCVD: benefit (canagliflozin, empagliflozin, dapagliflozin) b. CHF: benefit (canagliflozin, empagliflozin, dapagliflozin) Cost: high Oral/SQ: Oral Renal effects: a. Dosing: renal dosing required for all. ALL contraindicated with eGFR <30 mL/min b. Progression of CKD. benefit (canagliflozin, empagliflozin, dapagliflozin)
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Amy's Class Specific Pearls for Sglt2
Class Specific Pearls: 1. all SGLT-2i contraindicated in eGFR<30 mL/min 2. can cause UTI, yeast infections, increased urination 3. additoinal considerations :DKA, amputations, gangrene, increased LDL, hyperkalemia
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SGLT2-I examples
canagliflozin (Invokana) Dapagliflozin (Farxiga) Empagliflozin (Jardiance) Ertugliflozin (Steglatro)
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canagliflozin class, brand name, dose
SGLT-2i invokana 100-300 mg PO daily
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Dapagliflozin class, brand name, dose
SGLT2-i Farxiga 5-10 mg PO daily
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Empagliflozine class brand name dose
SGLT2-i Jardiance 10-25 mg PO daily
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Ertugliflozin class brand name dose
SGLT2-i steglatro 5-15 mg PO daily
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GLP-1 Receptor agonists examples: Class: Indication: Mechanism of Action: Effects of mechanism of Action: Adverse Effects: Absolute Contraindications: Pregnancy: Warning/ Precautions: Drug Interactions : Counseling Points: Monitoring Parameters: Class Specific Pearls:
GLP-1 Receptor agonists examples: the GLUTIDES (except exanitide and Lixisenitide) Semaglutide (Ozempic), oral semaglutide (Rybelsus), Liraglutide (Victoza) Exanitide IR (Byetta), Class: GLP-1 REceptor agonists Indication: Adjunct to diet and exercise to improve glycemic control in adults with T2DM Mechanism of Action:mimics the enhancement of glucose dependent insulin secretion and other antihyperglycemic actions of incretins. Effects of mechanism of Action: suppress glucagon secretion, increase insulin secretion, slows gastric emptying, promotes beta cell proliferation Adverse Effects: Hypoglycemia (not really), nausea/GERD/dyspepsia, vomiting, diarrhea, jitteriness, headache, URI/cough, injection site reaction, pancreatitis, cholelithiasis Absolute Contraindications: Thyroid C cell tumor (Black box warning), severe GI disease (colitis, chrons, obstruction, IBD, UC, gastroparesis, hypoglycemia, pancreatitis, renal impairment (ESRD or CrcL <30 mL/min (exanatide IR and ER only) Pregnancy:) Warning/ Precautions: impaired renal and liver function, elderly, sulfonamide allergy (cross reactivity is low), thyroid dz, adrenal insufficiency, malnutrition, G6PD deficiency Drug Interactions : cause hypoglycemia: androgens, insulins/SU, pegvisomant cause hyperglycemia: corticosteroids, Danazol, LHRH, somatropin, thiazide diuretics Counseling Points: 1. may cause upset stomach; should decrease over time (dont overeat and avoid large meals. eat smaller mroe frequent meals) 2. prior to initial use, store in the refrigerator 3. after initial use, may be stored at room temperature 4. Rybelsus only- take 30 min before eating first meal. NOT BEFORE the 30 min. decreases efficacy if you eat before the 30 min. must take with a little (4 oz of water 5. ask about GI upset and timing of doses at every regfill Monitoring Parameters: 1. renal function 2. FBG 3. PPG 4. GI symptoms 5. patient use of device Class Specific Pearls: 1. black box warning: CI in thyroid c cell tumor 2. CI in pancreatitis 3. rybelsus: only oral GLP-1. must take atleast 30 min before meal. no less. 4. renal dosing required for Exanatide and lixisenatide 5. SE: nausea/dysoeosia/gerd pranceatitis. GI symptoms should decrease over time. 6. before use, store in fridge. after may leave at room temp 7. ASCVD: benefit (liraglutide and dulaglutide, semaglutide SC) 8. RENAL benefit: liraglutide and dulaglutide
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Amy's Class Specific Pearls: glp1 RA
Class Specific Pearls: 1. black box warning: CI in thyroid c cell tumor 2. CI in pancreatitis 3. rybelsus: only oral GLP-1. must take atleast 30 min before meal. no less. 4. renal dosing required for Exanatide and lixisenatide 5. SE: nausea/dysoeosia/gerd pranceatitis. GI symptoms should decrease over time. 6. before use, store in fridge. after may leave at room temp 7. ASCVD: benefit (liraglutide and dulaglutide, semaglutide SC) 8. RENAL benefit: liraglutide and dulaglutide
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GLP-1 daily dosing drugs
Exenatide IR (Byetta) Liraglutide (Victoza) Lixisenatide (Adylxin) SEmaglutide oral (Rybelsus)
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GLP-1 weekly dosing drugs
Exanatide ER (Bydureon) Exenatide ER auto injector (Bydureon, BCise) Dulaglutide (TRulicity) Semaglutide (Ozempic)
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which GLP-1s do not have any CV benefit
Semaglutide PO. (Rybelsus) Exenatide ER( Bydureon,BCIise) and IR(Byetta, Bydureon) Lixasenatide (Adylixin)
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which GLP-1s havE CV benefit
Liraglutide (Victoza) dulaglutide (Trulicity) semaglutide (ozempic)
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Diabetes Drug Specific and Patient Specific Factors to Consider for GLP-1s ``` General Pre or Post prandial target: Efficacy: Hypoglycemia: Weight change: CV effects: a. ASCVD: b. CHF: Cost: Oral/SQ: Renal effects: a. Dosing - b. Progression of CKD. ```
iabetes Drug Specific and Patient Specific Factors to Consider General Pre or Post prandial target: BOTH Efficacy: (high) A1C lowering of 1-2% Hypoglycemia: No Weight change: Loss CV effects: a. ASCVD: benefit (liraglutide and dulaglutide, semaglutide SC) b. CHF: neutral Cost: Low Oral/SQ: SQ: Oral (rybelsus) Renal effects: a. Dosing - renal dosing required for exaNATIDE and lixisenatide b. Progression of CKD. improved renal outcomes(liraglutide and dulaglutide
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exenatide IR class, brand name, frequency of dosing
GLP-1 RA byetta DAILY DOSING
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exenatide ER class, brand name, frequency of dosing, pearl
GLP-1 RA (bydureon) weekly dosing must be reconstituted
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Exenatide ER auto injector class brand name dosing
GLP1-RA bydureon BCISE weekly dosing
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lixisenatide class, brand name, frequency of dosing
GLP1-RA Adlyxin daily dosing
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Liraglutide class, brand name, frequency of dosing
GLP-1RA Victoza daily dosing
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Dulaglutide class, brand name, frequency of dosing
GLP-1RA Trulicity weekly dosing
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Semaglutide class, brand name, frequency of dosing
GLP-1 RA Ozempic weekly dosing
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Insulins TYpes of Insulins: Class: Indication: Mechanism of Action: Effects of mechanism of Action: Adverse Effects: Absolute Contraindications: -- Pregnancy: Warning/ Precautions: -- Drug Interactions : Counseling Points:-- Monitoring Parameters:
Insulins TYpes of Insulins: ``` Ultra rapid: Aspart (Fiasp), Lispro-aabc (Lyumjev) Rapid: Aspart, Lispro, Glulisine Regular NPH Long acting: Glargine, detemir, degludec ``` Basal: NPH, Glargine, Detemir, Degludec Bolus (Rapid acting): REgular, Aspart, Glulisine, Lispro Bolus: ultra rapid: Aspart, Lispro-aabc Inhaled inisulin: Afrezza Class: insulins Indication: used for the treatment of T1DM and T2DM Mechanism of Action: acts via specific membrane bound receptors on target tissues to regulate metabolism of carbs, protein, and fats. Effects of mechanism of Action: stimulate hepatic glycogen synthesis, hepatic synthesis of fatty acids, increase protein synthesis and increase glycogen synthesis,, stimulate hydrolysis of of TGD to FFA and storage into adipocytes, stimulate cellular uptake of aminoacids and increase cellulaer permeability to several ions, including k+, mg, phosphate. also promotes intracellular movement of potassium Adverse Effects: Hypoglycemia, allery (rare), injection site reaction, lipohypertrophy, cough (Afrezza only) Absolute Contraindications: -- Pregnancy: first line in pregnancy Warning/ Precautions: -- Drug Interactions : TZDS, ACE-I, MAOI, Hormones (estrogens/NDROGENS/THYROID), BETA BLOCKERS, ALPHA- GLUCOSIDASE INHIBITORS Counseling Points:-- Monitoring Parameters: 1. FBG/PPG 2. hypoglycemia 3. weight gain 4. injection site reactions (tell them to rotate injection sites 5. cough (afrezza only) variable time to peak Class Specific Pearls: ``` Diabetes Drug Specific and Patient Specific Factors to Consider General Pre or Post prandial target: BOTH Efficacy: (high) A1C lowering unlimited Hypoglycemia: yes Weight change: gain CV effects: a. ASCVD: neutral b. CHF: neutral Cost: Human: low |analogs: high Oral/SQ: SQ, inhaled (afrezza) Renal effects: a. Dosing: none, but lower doses may be required b. Progression of CKD. neutral ```
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Amy's Class Specific Pearls for insulin ``` Diabetes Drug Specific and Patient Specific Factors to Consider General Pre or Post prandial target: Efficacy: Hypoglycemia: Weight change: CV effects: a. ASCVD: b. CHF: Cost: Oral/SQ: ) Renal effects: a. Dosing: b. Progression of CKD. ```
Class Specific Pearls: ``` Diabetes Drug Specific and Patient Specific Factors to Consider General Pre or Post prandial target: BOTH Efficacy: (high) A1C lowering unlimited Hypoglycemia: yes Weight change: gain CV effects: a. ASCVD: neutral b. CHF: neutral Cost: Human: low |analogs: high Oral/SQ: SQ, inhaled (afrezza) Renal effects: a. Dosing: none, but lower doses may be required b. Progression of CKD. neutral ```
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Basal Insulins
NPH glargine detemir degludac
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bolus (rapid acting insulins)
regular aspart glulisine Lispro
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Bolus (ultra rapid acting)
aspart | Lispro-aabc
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insulin aspart ultra rapid brand name
Fiasp
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insulin lispro aabc ultra rapid brand name
Lyumjev
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insulin lispro rapid acting brand name
humalog
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insulin aspart rapid acting brand name
novolog
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insulin glulisine brand name
apidra
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clinical pearls with ultra rapid insulins
can be used in SC pumps but cannot be administered IV. onset. about 15 min peak about 2 hours durstion: 5-7 hours
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clinical pearls about rapid acting insulin
onset : about 30 min peak: about an hour duration: 5-7 hours
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Regular insulin brand names
short acting Humalin-R Novalin-R Afrezza (inhaled) dry powder
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clinical pearls abput regular insulin
can be given IV (DKA treatment and TPN), and can be used in SC pumps onset: 30-150 min Peak 30-150 min duration: 5-8 hours
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NPH insulin brand names
intermediate acting Humalin-NPH Novalin-NPH
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clinicalpearls of NPH insulin
``` intermediate acting made with zinc and protamine its cloudy because it is a suspension, but if it is frosty, it lost its potency onset: 2-4 hours peak: 4-10 hours duration of action: 10-16 hours ```
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insuline glargine brand name
lantus toujeo basaglar semglee
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insulin detemir brand name
Levemir
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insulin degludac brand name
tresiba
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long acting insulin pearls
do not dilute and do not mix onset: 1-9 hours peak: NONE curation of action: 20-48 hours
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insulin glargine mOA
acifidc ph , . so when injected, forms precipitates. they dissociate into hexamers , dimers, and finally monomers
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insulin detemir MOA
injected at same ph of body. binds to albumin. albumin takes it to target tissue
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insulin degludec MOA
mix of both glargine and detemir. | has acidic ph forming hexamers. also binds to albumin to be transported to tissues
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Afrezza BBW
acute bronchospasm
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AACE guidelines for dosing of basal insulin
if A1C< 8. 0.1-0.2 U/kg if A1C >8 0.2-.03 U /kg
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AACE guidelines for adding prandial insulin
1. make sure pt is on GLP-1. if cant be on a glp-1 then can use sglt2, then ddp4 2. for pt already on insulin. give 10% of basal insulin for insulin naive that need basal bolus: 0.3-0.5% u/kg. 50% to basal and 50% to bolus (divided by 3). start at largest meal and then do stepwise to cover all 3 meals
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ADA guidelines for dosing basal insulin
if above target A1C, 0.1-0.2 u/kg
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ADA guidelines for dosing prandial insulin
10% of basal insulin dose. stepwise approach to cover each meal

Endocrine and Women's Health (14 decks)

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