Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Therapeutics II > Diabetes Kania Part 3 > Flashcards

Diabetes Kania Part 3 Flashcards

1
Q

Metformin mechanism of action

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Clinical applications of metformin

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Off-label uses of metformin

A

-Used in type 1 patients who are overweight and have a low risk of ketoacidosis
-PCOS – lowers androgen, increases ovulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How efficacious is metformin?

A

Metformin is very efficacious but does not beat insulin and shows no weight gain and oftentimes even weight loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How is metformin excreted?

A

Metformin is excreted through the kidneys so dose may have to be adjusted based on kidney function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Advantages of metformin

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Contraindications of metformin

A

-Renal dysfunction
-Unstable HF patients
-Alcoholics
-Patients at risk for lactic acidosis
-Post MI
-COPD
-Hepatic failure
-Shock
-Surgery/radiologic procedure with contrast dye

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Side effects of metformin

A

-GI effects: diarrhea, flatulence, nausea, vomiting
-Vitamin B12 malabsorption and/or deficiency
-Dementia risk? (studies are inconclusive)
-Rare cases of lactic acidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Starting dose of metformin

A

Initial dose is 500mg po BID or 850 mg po daily, with meals to decrease side effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Maximum dose of metformin

A

2 g/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How often should metformin be titrated?

A

Titrate dose weekly or bi-monthly and increase by 350-500 mg/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How to dose metformin in patients with an eGFR level of 60 or greater

A

-No renal contraindication to metformin
-Monitor SCr annually

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How to dose metformin in patients with an eGFR level between 45 and 60

A

-Safe to start therapy
-Continue use if already taking
-Monitor SCr every 3-6 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How to dose metformin in patients with an eGFR level between 30 and 45

A

-Starting metformin not recommended
-Reduce metformin dose by 50% if already taking
-Monitor SCr every 3 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How to dose metformin in patients with an eGFR level below 30

A

-Do not start metformin
-Stop metformin, if currently taking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

SGLT2 inhibitor mechanism of action

A

-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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Clinical application of SGLT2 inhibitors

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Efficacy of SGLT2 inhibitors

A

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 well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

How are SGLT2 inhibitors excreted?

A

Mostly in feces but 1/3 in urine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Adverse effects of SGLT2 inhibitors

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What SGLT2 inhibitors can you use if patient has an eGFR greater than 60?

A

-Canagliflozin 100mg daily
-Ertugliflozin 5 mg daily
-Dapagliflozin 5 mg daily
-Empagliflozin 10 mg daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What SGLT2 inhibitors can you use if patient has an eGFR less than 45?

A

-Dapagliflozin 5 mg daily
-Empagliflozin 10 mg daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

At what eGFR is empagliflozin 10mg daily effective

A

eGFR greater than 30

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What SGLT2 inhibitors can you use if patient has an eGFR between 30 and 60

A

Canagliflozin maximum of 100 mg daily if no albuminuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

At what eGFR can you not start Ertugliflozin?

A

At eGFR 45 do not start and if already on therapy then monitor. If eGFR is persistently low, may discontinue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What SGLT2 inhibitors can you use when the patient has an eGFR less than 30

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What SGLT2 inhibitors can you use when the patient has ESRD on HD

A

None

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is something to always tell a patient on an SGLT2 inhibitor?

A

They must know to always stay well hydrated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

GLP-1 agonist mechanism of action

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Clinical applications of GLP-1 agonists

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Efficacy of GLP-1 agonists

A

-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 well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

How are GLP-1 agonists excreted

A

Short-acting GLP-1s are eliminated by the kidneys and are contraindicated with severe renal disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Adverse effects of GLP-1 agonists

A

-Nausea, vomiting, diarrhea
-Acute pancreatitis
-Block box warning for thyroid c-cell tumors
-New warning for gall bladder disease
-Patients with gastroparesis
-Retinopathy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

How to dose dulaglutide

A

-Start at 0.75 mg once weekly
-Can go up to 4.5 mg once weekly
-Use with caution in ESRD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

How to dose semaglutide

A

-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

36
Q

How to dose liraglutide

A

-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

37
Q

Dulaglutide counseling information

A

-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

38
Q

Semaglutide counseling information

A

-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

39
Q

Liraglutide counseling information

A

-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

40
Q

Oral semaglutide dosing principles

A

-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)

41
Q

Mechanism of action of dual GLP-1 agonist and GIP receptor agonist

A

-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

42
Q

Efficacy of Mounjaro

A

Efficacy is very similar to metformin with an increased weight loss

43
Q

Adverse effects of Mounjaro

A

-Similar to GLP-1 agonists
-Nausea, vomiting, diarrhea
-Warnings for pancreatitis, thyroid tumors, and gallbladder disease
-Tachycardia

44
Q

How to dose Mounjaro

A

-2.5 mg SQ weekly
-Adjust once a month by 2.5 mg/week increments up to 15 mg SQ weekly

45
Q

Mechanism of action of DPP-4 inhibitors

A

-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

46
Q

Efficacy of DPP-4 inhibitors

A

Comparable to SGLT2 inhibitors in lowering A1C and is weight neutral

47
Q

How are DPP-4 inhibitors excreted?

A

Excreted unchanged in the urine so adjust dose for renal function (except linagliptin)

48
Q

Adverse effects of DPP-4 inhibitors

A

-Nasopharyngitis
-Upper respiratory tract infections
-Headaches
-Some reports of acute pancreatitis
-FDA warning for joint pain
FDA warning for heart failure risk

49
Q

What dose of sitagliptin is recommended for a CrCl greater than 50 mL/min?

A

100 mg daily

50
Q

What dose of sitagliptin is recommended for a CrCl between 30 and 50

A

50 mg daily

51
Q

What dose of sitagliptin is recommended for a CrCl of less than 30 or ESRD on dialysis

A

25 mg daily

52
Q

What is a regular dose of saxagliptin?

A

2.5-5 mg once daily

53
Q

What dose of saxagliptin is recommended for a CrCl less than 50 mL/min?

A

2.5 mg daily

54
Q

What is a regular dose for linagliptin?

A

5 mg once daily

55
Q

What is a regular dose of Alogliptin?

A

25 mg daily

56
Q

What dose of alogliptin is recommended in patients with a CrCl between 30 and 60?

A

12.5 mg daily

57
Q

What dose of alogliptin is recommended in patients with a CrCl of less than 30 or with ESRD on dialysis?

A

6.25 mg daily

58
Q

Mechanism of action of sulfonylureas

A

-Stimulate insulin release from pancreatic beta cells
-May increase binding between insulin and receptors or increase number of receptors

59
Q

Clinical applications of sulfonylureas

A

-Adjunct to diet and exercise in type 2 patients
-Used in combination therapy with insulin and other non-insulin agents

60
Q

Efficacy of sulfonylureas

A

Efficacy is comparable to metformin

61
Q

How are sulfonylureas metabolized?

A

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

62
Q

When should glyburide and glipizide be taken?

A

They are most effective when taken 30 minutes before meals

63
Q

Adverse effects of sulfonylureas

A

-hypoglycemia
-Weight gain and GI upset
-Hematologic: leukopenia, thrombocytopenia, aplastic anemia
-Allergic skin reactions/photosensitivity

64
Q

How to dose sulfonylureas

A

-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

65
Q

Starting dose of glipizide (Glucotrol)

A

2.5-5 mg daily

66
Q

Max daily dose of glipizide (Glucotrol)

A

40 mg

67
Q

Starting dose of glipizide (Glucotrol XL)

A

2.5-5 mg daily

68
Q

Max daily dose of glipizide (Glucotrol XL)

A

20 mg

69
Q

Starting dose of glyburide (Micronase/Diabeta)

A

1.25-5 mg daily

70
Q

Max daily dose of glyburide (Micronase/Diabeta)

A

20 mg

71
Q

Starting dose of glyburide micronized (Glynase)

A

1.5-3 mg daily

72
Q

Max daily dose of glyburide micronized (Glynase)

A

12 mg

73
Q

What patients are at an increased risk of hypoglycemia when using sulfonylureas?

A

-Elderly or patients with renal/hepatic disease
-Irregular dietary intake
-Alcoholics
-Patients taking concomitant hypoglycemic agents

74
Q

Best candidates for sulfonylureas

A

-No type 1 patients
-Short duration of diabetes
-FBS less than 250 mg/dL
-High fasting C-peptide levels

75
Q

Thiazolidinediones mechanism of action

A

-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

76
Q

Benefits of TzDs

A

-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

77
Q

Efficacy of TzDs

A

Comparable to SGLT2 inhibitors

78
Q

Adverse effects of TzDs

A

-Hepatotoxicity
-Resumption of ovulation
-Exacerbations of HF
-Macular edema
-Increased fracture risk

79
Q

Initial dose of pioglitazone

A

15-30 mg daily

80
Q

Max dose of pioglitazone

A

30-45 mg daily

81
Q

How often should you titrate pioglitazone?

A

Titrate dose every 12 weeks

82
Q

What drug classes are recommended in patients with established/high risk of atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease?

A

SGLT2 inhibitors and GLP-1 agonists

83
Q

When should dual therapy be started for patients with T2DM?

A

When A1C is greater than 9%

84
Q

When should insulin therapy be started in patients with T2DM?

A

If A1C is greater than 10% or if blood glucose readings are greater than 300 mg/dL

85
Q

When should a basal-bolus regimen be considered for T2DM patients?

A

If the basal dose is ~0.5 units/kg/day

Therapeutics II (33 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions