Diabetes lecture 2

Question 1

Biguanide

Answer 1

Metformin

Question 2

SGLT2 inhibitors

Answer 2

Canagliflozin
Dapagliflozin
Empagliflozin

Question 3

GLP-1 receptor agonist

Answer 3

Exenatide
Liraglutide
Dulaglutide
Semaglutide (Ozempic (Sc) and Rybelsus (PO)

Question 4

Sulfonylureas

Answer 4

Glyburide

Glipizide

Question 5

Non-SU secretagogues

Answer 5

Repaglinide

Question 6

DPP4 inhibitors

Answer 6

Sitagliptin
Saxagliptan
Linagliptin

Question 7

TZDs

Answer 7

Pioglitazone

Question 8

Metformin MOA

Answer 8

decreases hepatic glucose output, lowing fasting BG levels

enhances insulin sensitivity of both hepatic and muscle tissue

Question 9

Metformin efficacy

Answer 9

lowers A1C 1-1.5%

weight loss

does not cause hypoglycemia

Question 10

Metformin ADE

Answer 10

GI –> diarrhea, cramping, bloating
ER formulation –> less GI effects

Vitamin B 12 deficiency

Lactic acidosis -rare

Question 11

Metformin (when to not use)

Answer 11

known hypersensitivity

surgical procedures

alcohol abuse

liver dysfunction

Significant renal disease

iodinated contrast media (GFR < 60)

Question 12

Metformin and renal insufficiency

Answer 12

GFR > 60 –> ok
GFR 45-59 –> ok
GFR 30-44 –> metformin shouldn’t be started but can be continued
GFR < 30 –> do not use

Question 13

Metformin dosing

Answer 13

usual dose is 1000 mg BID

500 or 850 mg po daily (with largest meal)
500mg po BID (with two largest meals)

if no GI effects, increase every 1-2 wks to max dose of 2000-25500mg/day

Question 14

Metformin ER

Answer 14

given once daily
500, 750, 1000 ER tabs

titrate to 2000mg/daily

if taking 750 tab, max dose is 1500mg/day

Question 15

Metformin monitoring

Answer 15

Counsel on adherence
A1c, renal function, vit B12
SMBG readings
take with meals

Question 16

Advantages of metformin

Answer 16

 Shown to reduce macrovascular 
complications in obese pts
 Other oral agents are not more 
effective in reducing HbA1c 
 Does not cause hypoglycemia when 
used as monotherapy
 Does not cause weight gain (may be 
a/w weight loss of about 6 lb)
Helps minimize weight gain with other 
agents
 Inexpensive
 Should see effects on BG within a week
 Comes in combination pills with many 
other oral agents

Question 17

Disadvantages of metformin

Answer 17

 GI adverse effects 
 It is a large pill to swallow
 Metformin generally given BID 
 Metformin ER given QD, but require 
multiple pills at the same time
 Risk of lactic acidosis  - RARE
 Monitor for renal insufficiency
 Monitor for vit B12 deficiency

Question 18

If A1c target is not achieved in about 3

months with metformin monotherapy,

Answer 18

add a second agent while: 
 Re-emphasizing lifestyle measures 
 Assessing adherence / access to 
medications
 Arranging routine follow-up

Question 19

Second line therapy:

ASCVD

Answer 19

GLP and/or SGLT2 i

Question 20

Second line therapy:

HF

Answer 20

SGLT2i

Question 21

Second line therapy:
CKD
elevated UACR

Answer 21

SGLT2i preferred or GLP

Question 22

Second line therapy:
CKD
no elevated UACR

Answer 22

GLP and/or SGLT2i

Question 23

Agents to avoid in HF

Answer 23

Pioglitazone

Saxagliptan

Question 24

Highest A1C efficacy

Answer 24

GLP-1 receptor

Question 25

Weight loss

Answer 25

SGLT2 i

GLP-1

Question 26

only one with risk of hypoglycemia

Answer 26

Sulfonylureas

Question 27

Drugs that target fasting blood glucose

Answer 27

metformin
basal insulin
NPH insulin

Question 28

Drugs that target post prandial BG levels

Answer 28

DPP-4 inhibitors
Exenatide
Regalinide
Prandial insulin

Question 29

Drugs that have mixed BG level targets

Answer 29

Sulfonylureas 
long acting GLP-1 RA
TDZ
SGLT2i
mixed insulins