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Pharm- DM and Thyroid > Diabetes Lecture 3 > Flashcards

Diabetes Lecture 3 Flashcards

1
Q

Oral Agents

A 
Biguanides
Sulfonylureas
Meglitinides
TZD’s
Alpha glucosidase inhibitors
Incretin Mimetics
DPP-IV inhibitors
GLP-1 agonists
Amylin mimetics
Sodium glucose co-transporters
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2
Q

Biguanides MOA

A

Inhibits hepatic glucose production and increases insulin sensitivity to peripheral tissues

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3
Q

Biguanides Drugs

A

Glucophage, Riomet, Glucophage XL, Glumetza (Metformin)

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4
Q

Biguanides Place in Therapy and Dose

A 
1st line (monotherapy or with other agents or insulin) especially for type 2
1000mg BID (titrate the dose)
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5
Q

Biguanides A1C

A

1.5-2%

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6
Q

Biguanides Side Effects

A

GI (diarrhea)…take with meals
Lactic acidosis (rare)
Vitamin B12 deficiency (very frequent)
Weight loss

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7
Q

Biguanides Absolute CI

A

Cr ≥ 1.4 (women) or Cr ≥ 1.5 (men)

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8
Q

Biguanides Precaution

A

> 80 years old
Liver disease and excessive alcohol intake (more than 2 drinks per day)
Acute CHF, infection, surgery

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9
Q

Sulfonylureas Drugs

A

1st Generation: Rarely used due to increased side effects, NOT USED ANYMORE

2nd Generation
Amaryl (glimepiride)
Glucotrol, Glucotrol XL (glipizide)
Micronase (glyburide)

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10
Q

Sulfonylureas MOA

A

Increases insulin production from the beta cells in the pancreas

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11
Q

Sulfonylureas Places in Therapy

A

Monotherapy or conjunction with basal insulin or other oral agents

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12
Q

Sulfonylureas A1C and Dose

A

A1C= 1-2%

Typically dosed once or twice daily
Skip dose is patient is not going to be eating a meal
If renal insufficiency is noted use Glipizide

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13
Q

Sulfonylureas Side Effects and Precautions

A

Hypoglycemia
Weight gain- using more insulin

Precautions= Sulfa Allergy

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14
Q

Meglitinides Drugs

A

Starlix (nateglinide)

Prandin (repaglinide)

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15
Q

Meglitinides MOA

A

Increases insulin production from the beta cells in the pancreas (binds to a different receptor than the sulfonylureas)

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16
Q

Meglitinides Place in Therapy

A

Monotherapy or conjunction with other oral agents

Note: After 3-5 years there is a reduction in the benefit seen due to loss of beta cell function

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17
Q

Meglitinides A1C and dose

A

A1C Reduction: 0.5-2%

Dose:
Shorter half lives than sulfonylureas
Take right before a meal (3 times a day)

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18
Q

Meglitinides Side Effects

A

Less hypoglycemia than sulfonylureas

Less weight gain than sulfonylureas

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19
Q

TZD’s Drugs

A

Avandia (rosiglitizone)

Actos (pioglitizone)

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20
Q

TZD’s MOA

A

Increases insulin-dependent glucose disposal and decreases hepatic glucose output by decreasing insulin resistance in the periphery and in the liver

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21
Q

TZD’s Place in Therapy

A

Monotherapy or conjunction with other oral agents or insulin

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22
Q

TZD’s Side Effects

A

Weight gain
Edema
Increase ovulation in women(metformin can do this too)
Hepatic dysfunction
Avandia: Increases likelihood of an MI and has negative lipid effects NO LONGER IN US
Actos: Positive effects on lipids but increased risk of bladder cancer

23
Q

TZD’s A1C and Dose

A

A1C Reduction: 0.5-1 %
Dose:
Takes several weeks to see an effect (up to 8 weeks)

24
Q

TZD’s CI

A

Stage 3 or 4 heart failure

25
Q

TZD’s Precaution

A

Do not initiate in patients with active liver disease or ALT > 2.5x normal
Monitor LFTs in all patients at baseline, every 2 months for 12 months, and then periodically; d/c drug if ALT > 3x ULN

26
Q

Alpha Glucosidase Inhibitors Drugs

A

Glyset (miglitol)

Precose (acarbose)

27
Q

Alpha Glucosidase Inhibitors MOA

A

inhibits enzyme that hydrolyzes complex starches and sugars into readily absorbable molecules, delaying absorption of glucose

28
Q

Alpha Glucosidase Inhibitors Place in Therapy

A

Monotherapy or conjunction with other oral agents…especially high post-prandial glucose values

29
Q

Alpha Glucosidase Inhibitors A1C and Dose

A

A1C- 0.5- 1%

Typically dosed with food (3 times a day)
Titrate the dose to allow for adjustment to GI effects

30
Q

Alpha Glucosidase Inhibitors Side Effects

A

GI!!! Flatulence, diarrhea

If hypoglycemia occurs…must take simple sugars (glucose)

31
Q

Alpha Glucosidase Inhibitors CI

A

GI disorders

Conditions that would risk bowel perforation

32
Q

DPP-IV Inhibitors Drugs

A

Januvia (sitagliptin)
Onglyza (saxagliptin)
Tradjenta (linagliptin)
Nesina (alogliptin)

33
Q

DPP-IV Inhibitors Place in Therapy

A

Type 2 DM and used in addition with other oral agents

34
Q

DPP-IV Inhibitors A1C and Dose

A 
A1C- 0.4-0.85%
Dose:
All gliptin’s are dosed once daily orally
Sitagliptin, saxagliptin and alogliptin
Require renal dose adjustments
35
Q

DPP-IV Inhibitors Side Effects and Precautions

A

Side Effects:
Headache
URI
Weight loss/weight neutral

Precautions:
Pancreatitis has been reported

36
Q

GLP-1 Analogs Drugs

A

Byetta (exenatide)
Bydureon (XR exenatide)
Victoza (liraglutide)

37
Q

GLP-1 Analogs Place in Therapy

A

Adjunctive therapy in patients with type 2 diabetes who are taking metformin, a sulfonylurea, TZD or a combination of the above but have not achieved adequate glycemic control

38
Q

GLP-1 Analogs A1C and Dose

A

A1C= 1-1.5%

Dose:
Inject in abdomen, thigh, or upper arm
Exenatide
Twice daily injection (1 hour before meals and no closer than 6 hours from next dose)
Need to dose adjust for renal impairment.
XR Exenatide
Once weekly injection.
Liraglutide
Once daily injection. Do not need to time with meals

39
Q

GLP-1 Analogs Side Effects and Precautions

A

Side Effects:
GI upset
Some hypoglycemia (if combined with sulfonylurea)
Some weight reduction

Precaution:
Take antibiotics and birth control pills at least 1 hour prior to injecting

40
Q

GLP-1 Analogs Storage and Black Box Warning

A

Storage:
Keep refrigerated, keep away from light, discard after 30 days

Black Box Warning:
Liraglutide: Thyroid carcinoma (found in rats)

41
Q

Amylin Analog Drug

A

Symlin (pramlintide)

42
Q

Amylin Analog Place in Therapy

A

Adjunct therapy in type 1 or type 2

43
Q

Amylin Analog Dose

A 
Dose:
Inject in abdomen, thigh, or upper arm 
Immediately prior to major meals (3 times a day)
Type 1:
Initial, 15 mcg SQ
Maintenance, titrate at 15 mcg increments to 30 and then to 60 mcg SQ as tolerated…if 30mcg is not tolerated D/C
Type 2:
Initial, 60 mcg SQ
Maintenance, 120 mcg SQ as tolerated
44
Q

Amylin Analog A1C

A

0.3-0.6%

45
Q

Amylin Analog Side Effects

A

GI (nausea, vomiting, anorexia)
Headache
Some weight loss (at least weight neutral)
Risk of hypoglycemia when administered with insulin
Slows gastric emptying thus avoid other agents that do the same
Take other medications either 1 hour before or 2 hours after injection

46
Q

Patients that should be excluded from Amylin Analog

A

Poor compliance with current insulin regimen
Poor compliance with monitoring blood glucose
A1C > 9%
Recurrent severe hypoglycemia in the past 6 months
Hypoglycemia unawareness
Confirmed gastroparesis diagnosis
Use of drugs that stimulate gastric motility
Pediatric patients

47
Q

Sodium Glucose Co-Transporters Inhibitors (SGLT-2)

A

SGLT-1 and SGLT-2 receptors in kidneys
SGLT-2: Responsible for glucose reabsorption
DM pts have more SGLT-2 receptors
Leads to 200-300 k/cal per day lost by inhibiting SGLT-2

48
Q

Random Facts about SGLT-2

A

Mainly dosed once daily and does require renal dose adjustment.
Reduction in A1C (~1% reduction compared to placebo)
Reduction in FPG
Reduction in weight by about 4-7 pounds
Slightly increase LDL
Modestly lower BP
ADE: Polyuria, thirst, nasopharengitis, UTI’s, genital infections

49
Q

What medicines work on the brain

A

dopamine agonists

pramlintide

50
Q

What medicines work on the liver

A

Metformin

TZD’s

51
Q

What medicines work on the GI

A

GLP-1 agonists
alpha glucosidase inhibitors
pramlintide

52
Q

What medicines work on the muscle/fat

A

Metformin

TZD’s

53
Q

What medicines work on the kidney

A

SGLT2 inhibitors

54
Q

What medicines work on the pancreas

A 
insulin,
GLP-1 agonists,
DPP-4 inhibitors, 
sulfonylureas, 
pramlintide (alpha cells only)
meglitinides

Pharm- DM and Thyroid (4 decks)

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