Diabetes - Oral

Question 1

Diabetes Diagnosis

Answer 1

Diabetes
-FPG: => 126
-RG (sx): => 200
-A1C: => 6.5%
-2 hr PG OGTT: => 200

PRE Diabetes
-FPG: => 100-125
-A1C: => 5.7-6.4%
-2 hr PG OGTT: => 140-199

Question 2

ADA Guidelines for Glycemic Control

Answer 2

-A1C: < 7
-Pre glucose: 80-130
-Post glucose: <180

6-6.5 if low risks, 7.5-8 if higher risks

Question 3

For T2D, first line therapy of =

Answer 3

Metformin, MNT, Physical Activity

Question 4

Medical Nutrition Therapy

Answer 4

-Whole grains, veggies/fruits, high fiber (almonds/walnut/pistachio)

• < 30% fat, cholesterol < 200 mg, sat fat < 7, (2+ fish servings a week)

-Na: < 2.3 grams/day

-2 cups of coffee/day

-No protein restrictions unless nephropathy requirements (0.8 g/kg/day)

Question 5

Metformin, AE CI DDI

Answer 5

-Biguanide, First Line
-MOA: decrease hepatic glucose production
-Favorable lipid profile
-↓ A1C 1.5-2%, FPG 50-70

AE
-GI: NVD, anorexia, metallic taste
-Lactic acidosis (weak, myalgia, malaise, abd)

CI
-RENAL, GFR =< 30 (30-45 don’t initiate)
-Hepatic, CHF, acidosis, alcohol abuse, MI, resp. disease
-Hold for iodinated contrast studies
CHARRMAA

DDI
-Cimetidine (increase metformin conc)
-Iondinated contrast

Question 6

GLIFLOZINS, SGLT2 Inhibitors

Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
Ertugliflozin (Steglatro)
Bexagliflozin (Brenzavvy)

Answer 6

MOA: inhibit reabs. of glucose

AE:
-Female genital mycotic infections and UTIs
-Hypotension, depletion, dehydration, dizzy, fainting, high K
-Gangrene, ketoacidosis
GLUKK

Precautions
-Yeast infections, UTIs, urinary frequency
-AKI (NO IF GFR < 20)

Contra/DDI
-Cana: Digoxin, Rifampin, pheny, phenobarbital, ritonovir (DPPRR)
-Cana/Bexa: bone fractures, osteoporosis
-Cana/Ertu/Bexa: lower limb amputation

CONTRA: ESRD, dialysis, blood or urine ketones

Question 7

SGLT-2 Inhibitors and DKA Risk

Answer 7

-Stop SGLT2I 24 hours before surgery or stressful physical activity (immediately for emergency)
-Avoid excess alcohol, ketogenic diets, stopping insulin

Question 8

Dual SLGT1/2 inhibitor (oral):
Sotagliflozin (Inpefa)

Answer 8

Suggest reserving for T2D with HF

-similar AE, slightly more GI

200 mg once day, 1 hr max before first meal

Question 9

ORAL GLP1- Receptor Agonist
Oral Semaglutide (Rybelsus)

Answer 9

AE:
-GI, pancreatitis, retinopathy, hypoglycemia, AKI, gallbladder disease - GGG RAP

-CI in pregnancy/BF (d/c 2 mo before planned preg)

Dosing:
-3 mg once daily for 1 month, then 7 mg daily, not at goal - then 14 mg

Convert
-14 mg oral = 0.5 mg inject
-0.5 mg inject = 7 or 14 mg oral (start 7 days after last injection)

Question 10

GLP-1 RAs BBW (glutides)

Answer 10

Thyroid cancer risk

CI in pts with MTC hx or MEN2

Question 11

DPP-4 Inhibitors (Gliptins)

• Sitagliptin (Januvia®)
• Saxagliptin (Onglyza®)
• Linagliptin (Tradjenta®)
• Alogliptin (Nesina®)

Answer 11

AE
-ALL: HA, URTI, nasopharyngitis, UTI, nausea, joint pain, J HUUNN
-Lina: urticaria, derma, bronchospasm, hypoglycemia H DUB

CI
-ALL CI in pregnancy
-Saxa and Allo: CI IN CHF
-Sita/Saxa/Alo: dose adj for RENAL
-Alo: hepatic CI
SAC, SASR, AH

DDI
-Lina: Rifampin
-Saxa: Ketoconazole (reduce saxa dose)

Question 12

Sulfonylureas (SU)
-Glipizide, Glyburide, Glimepiride

Answer 12

AE
-Hypoglycemia with glyburide
-Weight gain
-Rash, sun sensitivity

DDI
-Cautin with antacids, fluconazole, gemfibrozil, salicylates, FAGS
-Glip: cyclosporin

Take GLIP 30 min before food (XL ok with food)

Question 13

Thiazolidinediones (TZDs, glitazones)

Answer 13

PIO: bladder cancer concern

AE:
-Weight gain, edema, anemia
-Increased ovulation
-Osteoporosis
AE WOO

BBW
-Do not use in NYHA Class III or IV HF (worsen CHF)
-Increased risk of pregnancy
-Avoid in acute liver disease and osteoporosis
-Caution in edema/anemia pts

DDI
-Induces CYP3A4 (pio)

Question 14

Alpha-glucosidase Inhibitors (AGIs)
* Acarbose (Precose®)
* Miglitol (Glyset®)

Answer 14

AE: GI: flatulence, diarrhea, cramps, abd. distention

Avoid Acarbose if SCr > 2

Sep other meds by 1-2 hrs