Diabetes meds Flashcards
How does metformin work
inhibits gluconeogenesis= less hepatic glucose output
Increases insulin mediated glucose utilization in peripheral tissues
Yields 1-2% drop in A1c!
Weight neutral!
Side effects of Metformin are
GI s/e (diarrhea during titration)
Reduce intestine absorption of B12
IV contrast concerns; stop w/ IV contrast
CI if GFR <30
What are the Sulfonylureas
Glipizide
Glyburide
Glimepiride
How do Sulfonylureas work
stimulate insulin secretion from beta cells
yield 1-2% drop in A1c, but mildly less than metformin
Side effects of sulfonylureas are
high risk of hypoglycemia
weight gain
What are the GLP-1 agonists
TIDE's Exenatide Liraglutide Dulaglutide Albiglutide Lixisenatide Semaglutide
What is the “incretin effect”
oral glucose > IV glucose at stimulating insulin secretion 2/2 GI peptides (GLP) released in response to a meal
How do GLP agonists work
stimulate insulin release from beta cells slow gastric emptying inhibit post-meal glucagon secretion Yields 0.5-1% drop in A1c *Usu add on Tx*
Side effects of GLP agonists are
weight loss
N/V/D (warn pt)
Which GLP agonists yield improved cardiac outcomes
Liraglutide
Semaglutide
What are the DPP4 inhibitors
GLIPTAN's Sitagliptan Saxagliptin Linagliptin Alogliptin
How do DPP4 inhibitors work
DPP4 usually inactivates GLP-1 Block DPP4= allow GLP-1 to stimulate insulin, inhibit glucagon, and slow gastric emptying Yield 0.5-0.8% drop in A1c *Usu add on Tx* Weight neutral!
What are the SGLT2 inhibitors
FLOZIN’s
Empagliflozin
Canagliflozin
Dapagliflozin
How do SGLT2 inhibitors work
Sodium glucose cotransporters are in the proximal tubule and cause reabsorption of 90% of glucose
Inhibit transporters= increase glucose urine excretion= reduced blood glucose
Yield 0.5-0.7% drop in A1c
Usu add on Tx
Side effects of SGLT2 inhibitors are
Weight loss
reduced BP
+/- CV mortality
Vulvovaginal candidiasis, UTI
What are the Thiazolidinediones (TZD)
*Pioglitazone
Rosiglitazone
How do Thiazolidinediones work
Improve insulin action
increase insulin sensitivity in adipose, muscle, and liver
Yield 0.5-1.4% drop in A1c
Usu add on Tx
ADE of Thiazolidinediones are
fluid retention, HF weight gain bone fractures \+/- increase in MI w/ Rosiglitazone \+/- increase in bladder cancer w/ Pioglitazone
Thiazolidinediones are contraindicated in
Sx HF Class III-IV HF bladder cancer high fracture risk liver disease
What are the Meglitinides
Nateglinide
Repaglinide
How do Meglitinides work
Stimulate insulin secretion from beta cells
take WITH MEALS to reduce post-prandial hyperglycemia
Yield 0.5-1% drop in A1c
Usu add on Tx
Side effects of Meglitinides are
risk of hypoglycemia
weight gain
What are the alpha glucosidase inhibitors
Acarbose
Miglitol
How do alpha glucosidase inhibitors work
decrease absorption of glucose (take WITH meals)
Yield 0.5-0.8% drop in A1c
Usu add on Tx
Weight neutral!
What are the side effects of alpha glucosidase inhibitors
flatulence
diarrhea
What are the insulin therapy options
Basal therapy
Intensive insulin therapy
*Used when PO meds no longer work
Side effects of insulin therapy are
weight gain
hypoglycemia
What are the basal insulin therapy meds (long acting, 24 hr)
NPH
Glargine
Detemir
Degludec
what are the prandial insulin therapy meds
NPH short acting
Rapid acting: Lispro, aspart, glulisine
How do you decide what meds to give based on A1c
A1c <9%: Monotherapy (metformin + life management)
A1c >9%: dual therapy
A1c >10% and BG 300+: combo injectable therapy
When should you monitor/change monotherapy
Check A1c at 3 months.
If at target: monitor 1 3-6 months
If not target: assess meds and behavior, consider dual therapy
When should you monitor/change dual therapy
Check A1c at 3 months.
At target: monitor q 3-6 months
Not at target: assess meds and behavior, consider triple therapy
How do you choose a second agent in dual therapy
If w/ ASCVD: add agent that will reduce major adverse CV effects
If no ASCVD: add an agent considering drug specific events and pt factors
How do you monitor triple therapy
Check A1c at 3 months.
At target: monitor A1c q 3-6 months
Not at target: assess meds and behavior, consider injectable therapy
How do you start basal insulin therapy
at 10 units x day. increase by 1 unit daily and monitor FPG until target FPG is reached
If A1c is not controlled on Metformin + initial basal insulin therapy
- Add rapid acting insulin injection before largest meal
- Add GLP-1
- Change to premixed insulin BID before breakfast and dinner
An important consideration when choosing insulin therapy for a patient is
Cost!
insulin therapy is getting more expensive
