Diabetes Medication Formulary Flashcards by Jenna Tapper

Biguanides

Metformin (Glucophage, Glumetza, Fortamet)

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Metformin brand names

Glucophage
Glumetza
Fortamet

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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)

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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

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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

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Metformin max clinical dose

2 mg/day

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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

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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

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DPP-4 inhibitors

Alogliptin (Nesina)
Sitagliptin (Januvia)

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Alogliptin brand name

Nesina

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Sitagliptin brand name

Januvia

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DPP 4 inhibitors MOA

Increases the activity of endogenous incretin hormones (GLP-1 and GIP - enhance insulin secretion in response to food)

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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

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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

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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

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Saxagliptin dosing

2.5-5.0 mg once daily
2.5 mg daily for CrCl < 50 mL

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Linagliptin dosing

5 mg once daily

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Alogliptin dosing

25 mg daily

12,5 mg CrCl 30-60

6.25 mg CrCl <30 or with ESRD on dialysis

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GLP-1 agonists

Dulaglutide (Trulicity)
Liraglutide (Victoza, Saxenda)
Semaglutide (Wegovy, Ozempic, Rybelsus)

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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

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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

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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

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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)