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Therapeutics > Diabetes Medication Formulary > Flashcards

Diabetes Medication Formulary Flashcards

1
Q

Biguanides

A

Metformin (Glucophage, Glumetza, Fortamet)

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2
Q

Metformin brand names

A

Glucophage
Glumetza
Fortamet

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3
Q

Metformin Disadvantages

A

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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4
Q

Metformin cautions and contraindications

A

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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5
Q

Metformin dosing - initial dosing

A

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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6
Q

Metformin max clinical dose

A

2 mg/day

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7
Q

Metformin dosing in renal insufficiency

A

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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8
Q

Metformin important points

A

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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9
Q

DPP-4 inhibitors

A

Alogliptin (Nesina)
Sitagliptin (Januvia)

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10
Q

Alogliptin brand name

A

Nesina

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11
Q

Sitagliptin brand name

A

Januvia

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12
Q

DPP 4 inhibitors MOA

A

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

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13
Q

DPP 4 inhibitors AE

A

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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14
Q

DPP 4 inhibitors FDA warnings

A

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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15
Q

Sitagliptin dosing

A

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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16
Q

Saxagliptin dosing

A

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

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17
Q

Linagliptin dosing

A

5 mg once daily

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18
Q

Alogliptin dosing

A

25 mg daily

12,5 mg CrCl 30-60

6.25 mg CrCl <30 or with ESRD on dialysis

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19
Q

GLP-1 agonists

A

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

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20
Q

GLP-1 agonists MOA

A

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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21
Q

GLP-1 Agonist AE

A

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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22
Q

GLP-1 Agonist New warnings

A

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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23
Q

GLP-1 agonist dosing: Trulicity

A

Dulaglutide
-Once weekly
-0.75 mg up to 4.5 mg
-Use cation in ESRD
-Needles included (attached)

24
Q

GLP-1 agonist dosing: Ozempic

A

Semaglutide
Once weekly
0.25 mg * 4 weeks, then 0.5 mg up to 2 mg
Needles included in carton

25
Q

GLP-1 agonist dosing: Victoza

A

Liraglutide
-Daily dosing
-0.6 mg * 7 days, then 1.2 mg up to 1.8 mg
-Needles not included

26
Q

GLP-1 agonist dosing: Byetta

A

Exenatide
-BID dosing
-5 mcg * one month, then 10 mcg
-Avoid CrCl <30
-Needles not included

27
Q

Adylyxin dosing

A

Lixisenatide
-Daily
10 mcg * 14 days, then 20 mcg; avoid eGFR <15
Needles not included

28
Q

Diraglutide brand name

A

Trulicity

29
Q

Liraglutide brand names

A

Victoza
Saxenda

30
Q

Semaglutide brand names

A

Wegovy
Ozempic
Rybelsus (oral)

31
Q

SGLT-2 Inhibitors

A

Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
Ertugliflozin (Steglatro)

32
Q

Dapagliflozin brand name

A

Farxiga

33
Q

Empagliflozin brand name

A

Jardiance

34
Q

Ertugliflozin brand name

A

Steglatro

35
Q

SGLT2 Clinical application

A

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

36
Q

SGLT2 inhibitors AE

A

Most common: UTIs, female/male myotic infections, increased urination

Hypotension

Hyperkalemia

Raised cholesterol

37
Q

SGLT2 inhibitors FDA warnings

A

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

38
Q

Canagliflozin dosing

A

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

39
Q

Dapagliflozin Dosing

A

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

40
Q

Empagliflozin dosing

A

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

41
Q

Ertugliflozin

A

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

42
Q

Insulins

A

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)

43
Q

Aspart dosing

A

Dosage forms: Pen, vial, cartridge
Onset: 10-20 minutes
Peak 30-90 minutes
Duration 3-5 hours
Compatible when mixed with: NPH

44
Q
A
45
Q

Glargine dosing

A

Dosage forms: Pen, vial, cartridge
Onset: 2-4 hours
Peak: no peak
Duration: 20-24 hours
Compatible with: None

46
Q

Lispro dosing

A

Dosage forms:
Pen, cartridge, vial
Onset:
10-20 minutes
Peak:
30-90 minutes
Duration 3-5 hours
Compatible NPH

47
Q

Sulfonylureas

A

Glipizide (Glucotrol)

48
Q

Sulfonylureas AE

A

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

49
Q

Glipizide dosing

A

Starting dose: 2.5-5 mg
Max daily dose: 40 mg

50
Q

Sulfonylureas use caution in patients:

A

Increased risk of hypoglycemia
-Elderly patients or patients with renal/hepatic disease
-Irregular dietary intake
-Alcoholics
-Pts taking concomitant hypoglycemic agents

51
Q

Glipizide brand name

A

Glucotrol

52
Q

TZD

A

Pioglitazone (Actos)

53
Q

Pioglitazone brand name

A

Actos

54
Q

TZDs adverse effects

A

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

55
Q

Pioglitazone dosing

A

Initial dose: 15-30 mg daily
Max dose: 30-45 mg daily
Titrate dose every _ weeks

56
Q

Combination products

A

Insulin degludec + Liraglutide (Xultrophy)

Sitagliptin + Metformin (Janumet)

Empagliflozin + Metformin (Synjardy)

Therapeutics (61 decks)

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