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CDM 1 Exam 2 > Diabetes: Lecture 3 > Flashcards

Diabetes: Lecture 3 Flashcards

1
Q

Key factors to consider when selecting an agent for T2DM

A 
Efficacy in lowering A1c
Cost
Effect on weight
Side effects
Hypoglycemia risk
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2
Q

highest A1c efficacy?

A

GLP-1 RA (1-1.5% decrease)

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3
Q

A1c efficacy less than 1%?

A

SGLT2i and DPP-4 Inhib

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4
Q

Lowest cost T2DM drug?

A

Generally Sulfonylureas and Pioglitazone

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5
Q

Drugs causing Weight Change?

A 
Loss = SGLT2i, GLP1-RA (Most)
Gain = Sulfonylureas, Pioglitazone
Neutral = DPP4i
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6
Q

Drug with Hypoglycemia risk?

A

Sulfonylureas

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7
Q

Drugs to consider based on cost?

A

Sulfonylurea (Glipizide or Glyburide)

Pioglitazone (Actos)

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8
Q

Drugs to consider based on weight changes?

A

GLP1-RA (Most loss)

SGLT2i

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9
Q

Weight loss with GLP-1RA

A

Ozempic>Victoza>Trulicity> Byetta

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10
Q

Drugs in which you wanna minimize hypoglycemia?

A

Any meds except sulfonylureas.

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11
Q

Drugs that target Fasting BG levels?

A

Metformin
Basal Insulin
NPH insulin

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12
Q

Drugs that target post prandial BG levels?

A

DPP-4 Inhib
Exenatide (Byetta)
Regaglinide (Prandin)
Prandial insulin

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13
Q

Drugs that have mixed BG level targets

A 
Sulfonylureas
Long acting GLP1-RA
TZDs
SGLT2i
Mixed insulins
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14
Q

GLP1-RA Mechanism of Action

A

Increase glucose dependent insulin secretion
Suppresses post-prandial glucagon secretion
Decreases gastric emptying time
Increase satiety

** Increase Glucose dependent insulin secretion**

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15
Q

GLP1-RA are as effective as….

A

adding both prandial and basal insulin

similar BG effects, with less hypoglycemia, weight loss instead of gain, but more GI SE

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16
Q

Barriers to using GLP1-RA

A

Cost
injectable
can be too complicated for some

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17
Q

Typical place in therapy of GLP1-RA?

A

add on to lifestyle changes and when 1/2 agents +/- basal insulin are insufficient

considered preferred injection over basal insulin in most patients

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18
Q

Bydureon, Trulicity, Ozempic counseling

A

Once weekly, same day/time of the week. If miss dose inject when remember or within 3 days (5 for Ozempic)

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19
Q

Bydureon Titration

A

1 dose, no titration

2 mg SC once weekly

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20
Q

Trulicity Titration

A

0.75 mg 1st month

increase to 1.5 after 4 weeks, then 3mg, 4.5mg at 4 week interval

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21
Q

Ozempic Titration

A

0.25mg wkly for 4 weeks, after 4 week increase to 0.5mg, then after min 4 week can increase to 1mg

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22
Q

Victoza Titration

A

0.6mg/day week 1, 1.2mg/day week 2, 1.8mg/day week 3

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23
Q

Counseling for titrations

A

review each dose per week

GI SE usually light, go away..if not good then do extra week at the dose before increasing

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24
Q

Dose adjustment with Renal function and GLP1-RA

A

Caution w/ Bydureon…should not be used in <30ml/min

No dose adjustments in others

No hepatic adjustments for any

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25
Oral Semaglutide (Rybelsus) Titration
Start 3mg/day for 30 days increase to 7mg/day for 30 days increase to 14mg/day if need more BG lowering No renal or hepatic adjustments
26
Oral Semaglutide (Rybelsus) Patient education
take 30min prior to 1st food/drink/other meds Taken with sip of water <4oz swallow whole schedule meds with similar dosing around this time
27
which injectable has separate pen needle?
Victoza/Ozempic Victoza needs separate script, Ozempic doesn't since they come in box
28
Which injectables don't need separate pen needles?
Trulicity
29
Possible side effects GLP1-RA
Nausea GI Possible Pancreatitis (Don't start if they have history of Gallstones)
30
Bydureon ER side effects
small nodules/lumps where inject | Itchy at first, may be transient
31
Ozempic Side effects
Risk of DM retinopathy complications
32
When not to use GLP1-RA
``` Thyroid C-cell tumors Severely elevated TG Gallbladder disease Pancreatitis Alcoholism ```
33
DPP4 Inhibitors MOA
Same effects as GLP1-RA but less overall clinical GLP-1 effects
34
Using DPP-4 Inhibitor and GLP1-RA together?
don't use in combo
35
Dose adjustment with Renal insufficiency DPP4?
``` Sitaliptin = yes Linagliptin = don't need ```
36
DPP4 adverse effects?
well tolerated Risk of pancreatitis = rare ** Saxagliptan associated with increase HF admissions, avoid in HF **
37
DPP4 disadvantages
costly | less effective compared to other agents
38
DPP4 are good to use in...
Frail or elderly persons that may not need significant A1c reduction or who have concern about Hypo risk, AE of other agents or unable to use injectable
39
SGLT2i Mechanism of Action
Blocks transporter of glucose in proximal tubule ** increase urinary glucose excretion ** Also has diuretic effect, slight BP drop/weight reduction
40
SGLT2i will have risk of....
Mycotic genital infections and UTI Women more prone, men too
41
SGLT2i effect on reducing diabetes related chronic kidney disease?
All of them do it also associated with reducing hospital admission rate due to HF. Empagliflozin just got indication for HF
42
Dosing in renal insufficiency | Empagliflozin (Jardiance)
eGFR < 30 avoid use | HF pts < 20 no defined
43
Dosing in renal insufficiency | Dapagliflozin (Farxiga)
eGFR < 45 avoid use T2DM | All other indications eGFR < 25 avoid starting
44
Dosing in renal insufficiency | Canagliflozin (Invokana)
eGFR 30-59: lower dose to 100mg/day eGFR < 30 avoid use if already taking, eGFR <30 and UACR > 300 can continue 100mg/day
45
SGLT2i adverse effects
``` Polyuria = bathroom al ot Genital fungal infections UTI Monitor for volume depletion, hypotension DKA Amputations (Canagliflozin not others) ```
46
Sulfonylurea agents vs Glinide agents?
Sulfonylurea = longer acting, target other fasting and post prandial BG lvls Glinide agents = primaire target post prandial BG levels, shorter acting they target Beta cells
47
Adverse effects of Sulfonylurea and Glinides?
Hypoglycemia | Weight Gain
48
Dosing Sulfonylurea
once daily | BID at higher dosing to try to minimize hypoglycemia
49
Glinide Dosing (Repaglide)
start 0.5-1mg po TID 15min before each meal, skip med if skip meal Increase dose every week as needed to max daily dose of 16mg
50
Can you still take Sulfonylurea agent if allergic to sulfa?
Generally yea, different moiety
51
Secondary failure
Good response at first, and then over time your response to these meds decreases Sulfonylureas + Glinides
52
Who can benefit from Sulfonylureas + Glinides?
Thin body type Newly diagnosed diabetes Less significant Hyperglycemia
53
Glypizide to Glyburide dose?
Glipizide generally 2 times Glyburide (Max daily dose)
54
Glypizide vs Glyburide Metabolism?
Glyburide = metabolized in liver to active form, 50% renal elimination = longer hypoglycemia events Glypizide = metabolized in liver to inactive form
55
Most important cautions with Sulfonylureas?
Have to take with food, or BG will go too low
56
Sulfonylurea and Meglitinide Agent counseling points?
Ensure you take with food Getting Hypoglycemia episodes? ** If people fast, dose adjustment likely needs to happen...1/2 dose or skip dose depending on A1c**
57
Thiazolidinediones Mechanism of Action
Act on muscle level, improve insulin resistance and increase uptake into muscle Use PPR-g Takes 2-3 weeks for BG to start working due to protein turnover
58
How long can it take to see full effect of TZDs
can be seen in as little as 2-3weeks but can be up to 3-4 months
59
Place in therapy for TZDs
generally used as add-on oral therapy when patient refuses injections and accepts the side effect profile risk
60
Dosing Pioglitazone
start 15-30mg daily increase dose every 3-4 weeks to a max of 45mg daily no dose adjustment needed for renal insufficiency (not recommended due to fluid retention) and hepatic impairment
61
Pioglitazone side effects
``` Fluid retention and edema Weight gain Fracture risk Macular edema ** Black Box Warning for HF ** ** Contraindicated in Class 3/4 HF** caution in pt with Class 1/2 HF ```
62
Weird info Pioglitazone?
Possibility beneficial for NASH, animal models in liver cancer induces ovulation = risk of getting preggers
63
Liver issues with TZDs?
should not be used in patients with active liver disease monitor LFTs at baseline and periodically after

CDM 1 Exam 2 (16 decks)

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