Diabetes - Part 5 Flashcards
What are the SGLT2 inhibitors?
Dapagliflozin
Canagliflozin
Empagliflozin
What is the MOA of SGLT2 inhibitors?
SGLT2 us a high capacity transporter that is responsible for glucose reabsorption (90%) from the glomerular filtrate, & is over expressed in those with T2DM
These drugs inhibit SGLT2, thereby decreasing the reabsorption of glucose and increasing urinary glucose excretion
What is the efficacy of SGLT2 inhibitors?
Decrease A1C by 0.5-0.8% in clinical trials as add-on agent
Works on both FPG and PPG
Fast acting
Require functioning nephrons to work
What effect on weight do SGLT2 inhibitors have?
~2-3kg avg weight loss
Plateaus at 26 weeks; is sustained
What is the dosing for SGLT2 inhibitors?
Oral OD medications
Start at low dose
Results are not dose dependent
What is the renal dosing for SGLT2 inhibitors?
At eGFR ,45, no longer effective for BG (but beneficial for cardio renal protection)
What initially happens when starting a SGLT2 inhibitor?
Decrease in kidney function - about 5ml/min in eGFR
- will be reversed if drug is discontinued
What are the adverse effects of SGLT2 inhibitors?
Most common: increase urination, increase thirst, mycotic gentian infections
Less common/rare: UTIs, DKA
What are the precautions for SGLT2 inhibitors?
Dehydration potential: use cautiously in patients at risk for volume depletion effects
DKA risk: rare but sever if it occurs
What drug interactions do SGLT2 inhibitors have?
Use with diuretics may increase risk of hypovolemia and hypotension
Are SGLT2i cardioprotective?
Yes they are, they showed reduction in hospitalization for HF
Which SGLT2i is covered under the Sask formulary for treatment of class II and III HF?
Dapa
What are the premixed insulins for T2?
Premixed regular insulin - NPH (cloudy)
Premixed insulin analogues (cloudy)
What are the premixed regular insulins - NPH?
Humulin 30/70 and novolin ge 30/70 - 30% regular/70% NPH
Novolin ge 40/60 - regular/NPH
Novolin ge 50/50 - regular/NPH
What are the premixed insulin analogues?
Novomix 30 - 30% insulin aspart/70% insulin aspart protamine crystals
Humalog Mix25 - 25% insulin lispro/75% insulin lispro protamine
Humalog Mix50 - 50% insulin lispro/50% insulin lispro protamine
What long before each meal should each type of premixed insulin be administered?
Premix regular - 30-45 minutes before starting a meal
Premix analogues - up to 15 minutes before or after a meal
What are the barriers to insulin from patients?
More complexity
Sense of failure
Fear of hypo
Needle phobia
Fear/denial of disease progression
What are the barriers to insulin from HCPs?
More complexity
Fear of hypo
Patients cognitive ability to handle it
What are the insulin option for T2?
- Basal insulin + anti hyperglycemic medications
- usually initiated as 10U at bedtime - Basal and Bolus insulin
- Biphasic (premixed) insulin
Which insulin initiation option is preferred and why?
Basal only because:
- simplicity
- minimization of weight gain and hypo
- keeping oral meds on board helps with insulin sensitization
What are the options for if basal insulin/oral/sc pharmacotherapy is not working?
Evaluate / add other antihyperglycemics (DPP4i, GLP1RA, SGLT2i)
Basal insulin / GLP1RA combo products
Basal/Bolus
What is the traditional treatment strategy for T2?
Lifestyle -> Metformin -> other oral agents -> insulin
What are the A1C targets pre- and during pregnancy?
Pre-pregnancy: </=7.0% (ideally </= 6.5% if safe)
During pregnancy: </=6.5% (ideally </=6.1% if possible
What medications should be used in preconception for pregnancy?
Add folic acid 1mg/d
Discontinue ACEi / ARB and statin therapy
For T1: insulin
For T2: can continue Metformin, glyburide, or insulin
