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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
Q

Oral Semaglutide (Rybelsus) Titration

A

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

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26
Q

Oral Semaglutide (Rybelsus) Patient education

A

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
Q

which injectable has separate pen needle?

A

Victoza/Ozempic

Victoza needs separate script, Ozempic doesn’t since they come in box

28
Q

Which injectables don’t need separate pen needles?

A

Trulicity

29
Q

Possible side effects GLP1-RA

A

Nausea
GI
Possible Pancreatitis (Don’t start if they have history of Gallstones)

30
Q

Bydureon ER side effects

A

small nodules/lumps where inject

Itchy at first, may be transient

31
Q

Ozempic Side effects

A

Risk of DM retinopathy complications

32
Q

When not to use GLP1-RA

A 
Thyroid C-cell tumors
Severely elevated TG
Gallbladder disease
Pancreatitis
Alcoholism
33
Q

DPP4 Inhibitors MOA

A

Same effects as GLP1-RA but less overall clinical GLP-1 effects

34
Q

Using DPP-4 Inhibitor and GLP1-RA together?

A

don’t use in combo

35
Q

Dose adjustment with Renal insufficiency DPP4?

A 
Sitaliptin = yes
Linagliptin = don't need
36
Q

DPP4 adverse effects?

A

well tolerated
Risk of pancreatitis = rare

** Saxagliptan associated with increase HF admissions, avoid in HF **

37
Q

DPP4 disadvantages

A

costly

less effective compared to other agents

38
Q

DPP4 are good to use in…

A

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
Q

SGLT2i Mechanism of Action

A

Blocks transporter of glucose in proximal tubule

** increase urinary glucose excretion **
Also has diuretic effect, slight BP drop/weight reduction

40
Q

SGLT2i will have risk of….

A

Mycotic genital infections and UTI

Women more prone, men too

41
Q

SGLT2i effect on reducing diabetes related chronic kidney disease?

A

All of them do it

also associated with reducing hospital admission rate due to HF.

Empagliflozin just got indication for HF

42
Q

Dosing in renal insufficiency

Empagliflozin (Jardiance)

A

eGFR < 30 avoid use

HF pts < 20 no defined

43
Q

Dosing in renal insufficiency

Dapagliflozin (Farxiga)

A

eGFR < 45 avoid use T2DM

All other indications eGFR < 25 avoid starting

44
Q

Dosing in renal insufficiency

Canagliflozin (Invokana)

A

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
Q

SGLT2i adverse effects

A 
Polyuria = bathroom al ot
Genital fungal infections
UTI
Monitor for volume depletion, hypotension
DKA
Amputations (Canagliflozin not others)
46
Q

Sulfonylurea agents vs Glinide agents?

A

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
Q

Adverse effects of Sulfonylurea and Glinides?

A

Hypoglycemia

Weight Gain

48
Q

Dosing Sulfonylurea

A

once daily

BID at higher dosing to try to minimize hypoglycemia

49
Q

Glinide Dosing (Repaglide)

A

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
Q

Can you still take Sulfonylurea agent if allergic to sulfa?

A

Generally yea, different moiety

51
Q

Secondary failure

A

Good response at first, and then over time your response to these meds decreases

Sulfonylureas + Glinides

52
Q

Who can benefit from Sulfonylureas + Glinides?

A

Thin body type
Newly diagnosed diabetes
Less significant Hyperglycemia

53
Q

Glypizide to Glyburide dose?

A

Glipizide generally 2 times Glyburide (Max daily dose)

54
Q

Glypizide vs Glyburide Metabolism?

A

Glyburide = metabolized in liver to active form, 50% renal elimination = longer hypoglycemia events

Glypizide = metabolized in liver to inactive form

55
Q

Most important cautions with Sulfonylureas?

A

Have to take with food, or BG will go too low

56
Q

Sulfonylurea and Meglitinide Agent counseling points?

A

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
Q

Thiazolidinediones Mechanism of Action

A

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
Q

How long can it take to see full effect of TZDs

A

can be seen in as little as 2-3weeks but can be up to 3-4 months

59
Q

Place in therapy for TZDs

A

generally used as add-on oral therapy when patient refuses injections and accepts the side effect profile risk

60
Q

Dosing Pioglitazone

A

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
Q

Pioglitazone side effects

A 
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
Q

Weird info Pioglitazone?

A

Possibility beneficial for NASH, animal models in liver cancer

induces ovulation = risk of getting preggers

63
Q

Liver issues with TZDs?

A

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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