Diabetes Medication Formulary Flashcards
Biguanides
Metformin (Glucophage, Glumetza, Fortamet)
Metformin brand names
Glucophage
Glumetza
Fortamet
Metformin Disadvantages
May cause Lactic Acidosis (3 cases per 100,00) (more adept to get it if have comorbidities)
Comorbidities:
-Post MI
-Hepatic failure
-SEVERE COPD
-Shock
Surgery/Radiologic procedure with contrast dye (hold metformin 1-2 days before and then ~2 days after depending upon patient status)
Metformin cautions and contraindications
Renal dysfunction
Acute decompensated hospitalized HF patients, unstable HF patients, or HF coupled with severe renal/hepatic disease - avoid
Alcoholics
GI effects (30-50% BIG)
Vitamin B12 malabsorption and or deficiency (~15%)
Dementia risk - debated
Metformin dosing - initial dosing
Initial dose is 500 mg po BID or 850 mg po daily, with meals to decrease SE; titrate dose weekly or bi-monthly and increase by 250-500mg/day
Metformin max clinical dose
2 mg/day
Metformin dosing in renal insufficiency
eGFR level:
≥60
-No renal contraindication to metformin
-Monitor SCr annually
eGFR level
<60 and ≥45
-Safe to start therapy
-Continue use if already taking
-monitor SCr every 3-6 months
eGFR level:
<45 and ≥30
-Starting metformin not recommended
-Reduce metformin dose by 50% if already taking
-Monitor SCr every 3 months
eGFR level
< 30
-DO NOT start metformin
-Stop metformin if currently taking
Metformin important points
Mostly helpful with insulin sensitivity - helps the insulin you have work better
ADA recommended for type 2 if not contraindicated
Off label: Being used in T1DM who are overweight with low risk of ketoacidosis
Off label: PCOS - stimulates ovulation
Efficacy:
-Drops A1C 1.5-2%
CV protection
DPP-4 inhibitors
Alogliptin (Nesina)
Sitagliptin (Januvia)
Alogliptin brand name
Nesina
Sitagliptin brand name
Januvia
DPP 4 inhibitors MOA
Increases the activity of endogenous incretin hormones (GLP-1 and GIP - enhance insulin secretion in response to food)
DPP 4 inhibitors AE
Nasopharyngitis (23 vs 12%)
Upper RTI (11% vs 6%)
Headache (9% vs 7%)
Some reports of acute pancreatitis - counsel patients about signs and symptoms, and avoid use in patients with history of chronic pancreatitis
DPP 4 inhibitors FDA warnings
FDA warning for joint pain
-33 cases over 7 years; 10 needing hospitalization
-Symptoms usually resolved w/in one month of drug D/C
FDA warning for heart fialure risk
-SAVOR-TIMI 53 study with saxagliptin
EXAMINE study with alogliptin
TECOS study with sitagliptin
Sitagliptin dosing
100 mg daily for CrCl > 50 mL/min
50 mg daily for CrCl 30-50 mL/min
25 mg daily for CrCl < 30 mL/min or with ESRD on dialysis
Saxagliptin dosing
2.5-5.0 mg once daily
2.5 mg daily for CrCl < 50 mL
Linagliptin dosing
5 mg once daily
Alogliptin dosing
25 mg daily
12,5 mg CrCl 30-60
6.25 mg CrCl <30 or with ESRD on dialysis
GLP-1 agonists
Dulaglutide (Trulicity)
Liraglutide (Victoza, Saxenda)
Semaglutide (Wegovy, Ozempic, Rybelsus)
GLP-1 agonists MOA
GLP-1 agonists/analogs - Decrease BP
GLP-1 potentiates glucose-dependent insulin secretion by stimulating B-cell growth -> slow down absorption of sugar from gut
Inhibit B cell death
Inhibits glucagon secretion, delays gastric emptying, and decrease 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 -> only does this in a glucose dependent manner if glucose starts rising - will release insulin; if glucose is falling - shuts down -> less risk of hypoglycemia
GLP-1 Agonist AE
Nausea - dose titration decreases symptoms, which also improve after first 4-8 weeks
Acute pancreatitis
Black box warning for thyroid C-cell tumors
GLP-1 Agonist New warnings
Gall Bladder diseases
- More common w/high dose for weight loss and in long-term use
Gallstones
Abdominal pain, particularly in the right upper quadrant, nausea, vomiting, and fever should prompt immediate medical evaluation
Preventative measures: low fat diet, good hydration, and physical activity
Gastroparesis
Retinopathy
Caution for use in patients with severe non-proliferative disease and avoid in patients with proliferative diabetic retinopathy -> PERLIFERATIVE DO NOT USE
GLP-1 agonist dosing: Trulicity
Dulaglutide
-Once weekly
-0.75 mg up to 4.5 mg
-Use cation in ESRD
-Needles included (attached)
GLP-1 agonist dosing: Ozempic
Semaglutide
Once weekly
0.25 mg * 4 weeks, then 0.5 mg up to 2 mg
Needles included in carton
GLP-1 agonist dosing: Victoza
Liraglutide
-Daily dosing
-0.6 mg * 7 days, then 1.2 mg up to 1.8 mg
-Needles not included
GLP-1 agonist dosing: Byetta
Exenatide
-BID dosing
-5 mcg * one month, then 10 mcg
-Avoid CrCl <30
-Needles not included
Adylyxin dosing
Lixisenatide
-Daily
10 mcg * 14 days, then 20 mcg; avoid eGFR <15
Needles not included
Diraglutide brand name
Trulicity
Liraglutide brand names
Victoza
Saxenda
Semaglutide brand names
Wegovy
Ozempic
Rybelsus (oral)
SGLT-2 Inhibitors
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
Ertugliflozin (Steglatro)
Dapagliflozin brand name
Farxiga
Empagliflozin brand name
Jardiance
Ertugliflozin brand name
Steglatro
SGLT2 Clinical application
Adjunct diet and exercise in T2DM - First line
-Recommended with or without metformin as an appropriate INITIAL therapy for individuals with T2DM and:
-Those with ASCVD (e.g. MI, CVA, or revascularization procedure)
-Those at high risk for atherosclerotic CVD (≥55 y/o + 2 risk factors [HTN, HLD, obesity, smoking or albuminuria])
-Those with Heart failure
-Those with CKD
SGLT2 inhibitors AE
Most common: UTIs, female/male myotic infections, increased urination
Hypotension
Hyperkalemia
Raised cholesterol
SGLT2 inhibitors FDA warnings
Fournier’s gangrene
DKA
Elevated blood sugar
Hold SGLT2 three days before surgery (four if on ertugliflozin)
-May restart therapy once oral intake is back to baseline and other risk factors for ketoacidosis have resolved
FDA warning for bone fractures and decreased BMD in patients taking Canagliflozin
FDA warning for AKI for canagliflozin and dapagliflozin
FDA warning increased risk of leg and foot amputations with canagliflozin
Canagliflozin dosing
eGFR > 60: 100mg daily; MAX 300 mg daily
eGFR 30-60: Max: 100 mg daily if no albuminuria
eGFR: < 30: do not start, but if already taking may use;
100 mg daily if albuminuria > 300mg/d
ESRD on HD: Do not use
Dapagliflozin Dosing
eGFR > 45: 5 mg daily; Max: 10 mg daily
eGFR < 25: Do not start; if on therapy, may continue and monitor
ESRD on HD: Do not use
Empagliflozin dosing
eGFR > 30: 10 mg daily
Max: 25 mg daily
eGFR < 30: Do not start; if on therapy, may continue and monitor
ESRD on HD: Do not use
Ertugliflozin
eGFR > 60: 5 mg daily
Max: 15 mg daily
eGFR < 45: Do not start; if on therapy, monitor; if eGFR persistently low, may D/C
ESRD and on HD - do not use
Insulins
Aspart (Novolog U-100, Fiasp U-100)
Glargine (Lantus U-100, Basaglar U-100, Semglee U-100, Toujeo U-300, Toujeo max U-300)
Insulin Lispro (Humalog U-100, Humalog U-200)
Aspart dosing
Dosage forms: Pen, vial, cartridge
Onset: 10-20 minutes
Peak 30-90 minutes
Duration 3-5 hours
Compatible when mixed with: NPH
Glargine dosing
Dosage forms: Pen, vial, cartridge
Onset: 2-4 hours
Peak: no peak
Duration: 20-24 hours
Compatible with: None
Lispro dosing
Dosage forms:
Pen, cartridge, vial
Onset:
10-20 minutes
Peak:
30-90 minutes
Duration 3-5 hours
Compatible NPH
Sulfonylureas
Glipizide (Glucotrol)
Sulfonylureas AE
Hypoglycemia:
-Renal/hepatic insufficiency in patients
-Elderly or malnourished patients
-Concurrent hypoglycemic drugs
Weight gain (up to 3 kg)
Hematologic: leukopenia, thrombocytopenia, aplastic anemia
Allergic skin reactions/photosensitivity
Glipizide dosing
Starting dose: 2.5-5 mg
Max daily dose: 40 mg
Sulfonylureas use caution in patients:
Increased risk of hypoglycemia
-Elderly patients or patients with renal/hepatic disease
-Irregular dietary intake
-Alcoholics
-Pts taking concomitant hypoglycemic agents
Glipizide brand name
Glucotrol
TZD
Pioglitazone (Actos)
Pioglitazone brand name
Actos
TZDs adverse effects
Hepatoxicity
Resumption of ovulation - used in women with PCOS
Exacerbations of HF
Macular Edema
25% increased fracture risk
-Women have higher risk
-Commonly wrists, forearms, ankles, or feet
Pioglitazone dosing
Initial dose: 15-30 mg daily
Max dose: 30-45 mg daily
Titrate dose every _ weeks
Combination products
Insulin degludec + Liraglutide (Xultrophy)
Sitagliptin + Metformin (Janumet)
Empagliflozin + Metformin (Synjardy)
