Diabetes Kania Part 3 Flashcards
Metformin mechanism of action
-Decreases hepatic production of glucose
-Increases intestinal glucose utilization and decreases glucose uptake into circulation
-Can increase GLP-1 secretion
-Modest effect on increasing tissue uptake and utilization of glucose by muscle
Clinical applications of metformin
-As an adjunct to diet in type 2 patients
-Used in combination with insulin and other non-insulin agents in type 2 patients
-Consider use in all type 2 patients if tolerated and not contraindicated
Off-label uses of metformin
-Used in type 1 patients who are overweight and have a low risk of ketoacidosis
-PCOS – lowers androgen, increases ovulation
How efficacious is metformin?
Metformin is very efficacious but does not beat insulin and shows no weight gain and oftentimes even weight loss
How is metformin excreted?
Metformin is excreted through the kidneys so dose may have to be adjusted based on kidney function
Advantages of metformin
-Less risk of hypoglycemia due to no insulin release
-Benefit on lipids: decrease in TG and LDL by 8-15%
-Weight loss or at least weight neutral
-Cost-effective
-Increase in fibrinolysis = CV protection
-Has been shown to decrease macrovascular complications and the risk of total mortality in clinical trials
-Decreased risk of stroke and all-cause mortality when compared to insulin and sulfonylureas
-Decrease in diabetes-related death and myocardial infarctions vs. conventional treatment in UKPDS trial
Contraindications of metformin
-Renal dysfunction
-Unstable HF patients
-Alcoholics
-Patients at risk for lactic acidosis
-Post MI
-COPD
-Hepatic failure
-Shock
-Surgery/radiologic procedure with contrast dye
Side effects of metformin
-GI effects: diarrhea, flatulence, nausea, vomiting
-Vitamin B12 malabsorption and/or deficiency
-Dementia risk? (studies are inconclusive)
-Rare cases of lactic acidosis
Starting dose of metformin
Initial dose is 500mg po BID or 850 mg po daily, with meals to decrease side effects
Maximum dose of metformin
2 g/day
How often should metformin be titrated?
Titrate dose weekly or bi-monthly and increase by 350-500 mg/day
How to dose metformin in patients with an eGFR level of 60 or greater
-No renal contraindication to metformin
-Monitor SCr annually
How to dose metformin in patients with an eGFR level between 45 and 60
-Safe to start therapy
-Continue use if already taking
-Monitor SCr every 3-6 months
How to dose metformin in patients with an eGFR level between 30 and 45
-Starting metformin not recommended
-Reduce metformin dose by 50% if already taking
-Monitor SCr every 3 months
How to dose metformin in patients with an eGFR level below 30
-Do not start metformin
-Stop metformin, if currently taking
SGLT2 inhibitor mechanism of action
-SGLT2 is the major transporter of renal glucose to assist in glucose reabsorption
-Inhibition of SGLT2 leads to renal glucose excretion (up to 60-90 gm/day)
Clinical application of SGLT2 inhibitors
-Adjunct to diet and exercise in T2DM patients
-Recommended with or without metformin as an appropriate INITIAL therapy for individuals with type 2 diabetes with or at high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease
Efficacy of SGLT2 inhibitors
Does not lower A1C as much as metformin but is good at lowering post-prandial glucose and can also lower weight and blood pressure
How are SGLT2 inhibitors excreted?
Mostly in feces but 1/3 in urine
Adverse effects of SGLT2 inhibitors
-Most common: UTIs, female/male genital fungal infections, increased urination
-Hypotension
-Hyperkalemia
-Increased cholesterol
-FDA warning for DKA
-Decreased bone mineral density in patients taking canagliflozin
-Acute kidney injury for canagliflozin and dapagliflozin
-Increased risk of leg and foot amputation with canagliflozin
-Serious genital infections
What SGLT2 inhibitors can you use if patient has an eGFR greater than 60?
-Canagliflozin 100mg daily
-Ertugliflozin 5 mg daily
-Dapagliflozin 5 mg daily
-Empagliflozin 10 mg daily
What SGLT2 inhibitors can you use if patient has an eGFR less than 45?
-Dapagliflozin 5 mg daily
-Empagliflozin 10 mg daily
At what eGFR is empagliflozin 10mg daily effective
eGFR greater than 30
What SGLT2 inhibitors can you use if patient has an eGFR between 30 and 60
Canagliflozin maximum of 100 mg daily if no albuminuria
At what eGFR can you not start Ertugliflozin?
At eGFR 45 do not start and if already on therapy then monitor. If eGFR is persistently low, may discontinue
What SGLT2 inhibitors can you use when the patient has an eGFR less than 30
-Canagliflozin: do not start, but if already taking, may use 100 mg daily if albuminuria is greater than 300 mg/d
-Dapagliflozin: eGFR less than 25: Do not start; if on therapy, may continue and monitor
-Empagliflozin: Do not start, if on therapy, may continue and monitor
What SGLT2 inhibitors can you use when the patient has ESRD on HD
None
What is something to always tell a patient on an SGLT2 inhibitor?
They must know to always stay well hydrated
GLP-1 agonist mechanism of action
-GLP-1 potentiates glucose-dependent insulin secretion by stimulating beta-cell growth and differentiation and insulin gene expression
-Has been shown to inhibit beta-cell death
-Inhibits glucagon secretion, delays gastric emptying, and decreases appetite
-GLP-1 agonist medications are resistant to dipeptidyl peptidase IV, the enzyme that rapidly inactivates natural GLP-1
-Increases in both first and second-phase insulin secretion after meals occur
-Leads to insulin release only in presence of elevated blood sugar
Clinical applications of GLP-1 agonists
-Recommended with or without metformin as an appropriate INITIAL therapy for individuals with type 2 diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease
-In T2DM, a GLP-1 RA is preferred to insulin when possible
-If insulin is used, combination therapy with a GLP-1 RA is recommended for greater efficacy and durability of treatment effect
Efficacy of GLP-1 agonists
-A little better at lowering A1C than SGLT2 inhibitors but still not as good as metformin
-Short-acting GLP-1s have more effect on PPg vs. long-acting GLP-1s, which control FBG more
-Can show a major decrease in weight
How are GLP-1 agonists excreted
Short-acting GLP-1s are eliminated by the kidneys and are contraindicated with severe renal disease
Adverse effects of GLP-1 agonists
-Nausea, vomiting, diarrhea
-Acute pancreatitis
-Block box warning for thyroid c-cell tumors
-New warning for gall bladder disease
-Patients with gastroparesis
-Retinopathy
How to dose dulaglutide
-Start at 0.75 mg once weekly
-Can go up to 4.5 mg once weekly
-Use with caution in ESRD
How to dose semaglutide
-Start at 0.25 mg once weekly for 4 weeks
-Then increase to 0.5 mg once weekly for 4 weeks
-Can go up to 2 mg once weekly
How to dose liraglutide
-Start at 0.6 mg daily for 7 days
-Then increase to 1.2 mg daily for 7 days
-Can go up to 1.8 mg daily
Dulaglutide counseling information
-May be given at any time of the day, independent of meals
-May be administered in thigh, abdomen or arm
-May be administered cold
-Available in single dose pens
-Remove gray cap and place pen firmly against the skin
-Unlock the top of the pen and then press green button to administer medication
-At second click, medication has been administered; you can remove pen
-Use with caution in ESRD
-Storage similar to insulin
Semaglutide counseling information
-May be administered in thigh, abdomen, or arm
-Prior to use, store semaglutide in the fridge
-After first use, the pen can be stored for 56 days at room temperature or in the fridge
-Check the flow with each new pen (prime it)
-During injection, push the button until the dose counter goes back to zero, then count to 6 before removing the pen
Liraglutide counseling information
-May be given at any time of the day, independent of meals
-May be administered in thigh, abdomen, or arm
-Available in pre-filled pens with 18 mg per pen
-Pens should be stored in the fridge when not opened
-In-use pen may be kept at room-temperature
-Discard unused medication after 30 days
-Only prime prior to first injection
-Limited experience in ESRD
Oral semaglutide dosing principles
-3 mg po daily for 30 days, then increase to 7 mg daily
-Can increase to 14 mg daily if needed for glucose control
-If on semaglutide 0.5 mg SQ weekly, can change to 7 mg po daily
-Take 30 minutes before first food, beverage, or other oral medications with no more than 4 oz of plain water (food decreases absorption of drug)
Mechanism of action of dual GLP-1 agonist and GIP receptor agonist
-Enhances first and second-phase insulin secretion
-Reduces glucagon levels, in a glucose-dependent manner
-Delays gastric emptying
-Increase satiety
-CV outcomes expected in 2025
-Being marketed especially for weight loss
Efficacy of Mounjaro
Efficacy is very similar to metformin with an increased weight loss
Adverse effects of Mounjaro
-Similar to GLP-1 agonists
-Nausea, vomiting, diarrhea
-Warnings for pancreatitis, thyroid tumors, and gallbladder disease
-Tachycardia
How to dose Mounjaro
-2.5 mg SQ weekly
-Adjust once a month by 2.5 mg/week increments up to 15 mg SQ weekly
Mechanism of action of DPP-4 inhibitors
-Inhibits the enzyme dipeptidyl peptidase-4 inhibitors
-Increases the activity of endogenous incretin hormones
-GLP-1 is degraded by the DPP-4 enzyme; therefore DPP-4 inhibitors prevent the breakdown of endogenous GLP-1
Efficacy of DPP-4 inhibitors
Comparable to SGLT2 inhibitors in lowering A1C and is weight neutral
How are DPP-4 inhibitors excreted?
Excreted unchanged in the urine so adjust dose for renal function (except linagliptin)
Adverse effects of DPP-4 inhibitors
-Nasopharyngitis
-Upper respiratory tract infections
-Headaches
-Some reports of acute pancreatitis
-FDA warning for joint pain
FDA warning for heart failure risk
What dose of sitagliptin is recommended for a CrCl greater than 50 mL/min?
100 mg daily
What dose of sitagliptin is recommended for a CrCl between 30 and 50
50 mg daily
What dose of sitagliptin is recommended for a CrCl of less than 30 or ESRD on dialysis
25 mg daily
What is a regular dose of saxagliptin?
2.5-5 mg once daily
What dose of saxagliptin is recommended for a CrCl less than 50 mL/min?
2.5 mg daily
What is a regular dose for linagliptin?
5 mg once daily
What is a regular dose of Alogliptin?
25 mg daily
What dose of alogliptin is recommended in patients with a CrCl between 30 and 60?
12.5 mg daily
What dose of alogliptin is recommended in patients with a CrCl of less than 30 or with ESRD on dialysis?
6.25 mg daily
Mechanism of action of sulfonylureas
-Stimulate insulin release from pancreatic beta cells
-May increase binding between insulin and receptors or increase number of receptors
Clinical applications of sulfonylureas
-Adjunct to diet and exercise in type 2 patients
-Used in combination therapy with insulin and other non-insulin agents
Efficacy of sulfonylureas
Efficacy is comparable to metformin
How are sulfonylureas metabolized?
They are metabolized by the liver and some are excreted in the urine. Glipizide is metabolized without the formation of active metabolites so it is preferred in renal disease
When should glyburide and glipizide be taken?
They are most effective when taken 30 minutes before meals
Adverse effects of sulfonylureas
-hypoglycemia
-Weight gain and GI upset
-Hematologic: leukopenia, thrombocytopenia, aplastic anemia
-Allergic skin reactions/photosensitivity
How to dose sulfonylureas
-Start at the low end of the dosing range, especially in the elderly
-Increase dose every 1-2 weeks until maximum dosage
-Exceeding the maximum dosage increases side effects, but does not decrease blood glucose
-Current maximum doses now being questioned
Starting dose of glipizide (Glucotrol)
2.5-5 mg daily
Max daily dose of glipizide (Glucotrol)
40 mg
Starting dose of glipizide (Glucotrol XL)
2.5-5 mg daily
Max daily dose of glipizide (Glucotrol XL)
20 mg
Starting dose of glyburide (Micronase/Diabeta)
1.25-5 mg daily
Max daily dose of glyburide (Micronase/Diabeta)
20 mg
Starting dose of glyburide micronized (Glynase)
1.5-3 mg daily
Max daily dose of glyburide micronized (Glynase)
12 mg
What patients are at an increased risk of hypoglycemia when using sulfonylureas?
-Elderly or patients with renal/hepatic disease
-Irregular dietary intake
-Alcoholics
-Patients taking concomitant hypoglycemic agents
Best candidates for sulfonylureas
-No type 1 patients
-Short duration of diabetes
-FBS less than 250 mg/dL
-High fasting C-peptide levels
Thiazolidinediones mechanism of action
-Binds to peroxisome proliferator activator receptor-gamma (PPAR-gamma) on fat cells and vascular cells
-Improves cellular response to insulin without increase pancreatic insulin secretion
-Decreases insulin resistance
-Decreases hepatic glucose production
Benefits of TzDs
-Pioglitazone can decrease triglyceride levels by 10-20%
-LDL remains unchanged on pioglitazone
-Both meds convert small atherogenic LDL particles to large fluffy ones
-Both medications increase HDL by 3-9 mg/dL
-Endothelial function has improved and blood pressure may decrease slightly
Efficacy of TzDs
Comparable to SGLT2 inhibitors
Adverse effects of TzDs
-Hepatotoxicity
-Resumption of ovulation
-Exacerbations of HF
-Macular edema
-Increased fracture risk
Initial dose of pioglitazone
15-30 mg daily
Max dose of pioglitazone
30-45 mg daily
How often should you titrate pioglitazone?
Titrate dose every 12 weeks
What drug classes are recommended in patients with established/high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease?
SGLT2 inhibitors and GLP-1 agonists
When should dual therapy be started for patients with T2DM?
When A1C is greater than 9%
When should insulin therapy be started in patients with T2DM?
If A1C is greater than 10% or if blood glucose readings are greater than 300 mg/dL
When should a basal-bolus regimen be considered for T2DM patients?
If the basal dose is ~0.5 units/kg/day
