Diabetes (pharm) Flashcards
Metformin MOA
-Activation of AMPK (major regulator for lipid and glucose production)
-Enhances insulin sensitivity in liver and peripheral tissues by activation of AMPK
-Decrease gluconeogenesis
-Increase glucose uptake
-Decrease fatty liver
Meformin key notes
-1-1.5% A1C lowering potential
-Low risk of hypoglycemia
-Helpful for MACE
-SADMAN (renal dosing)
-Neutral weight
-Low dose if GFT<60
-Do not initiate if GFR<30
-GI effects and risk of lactic acidosis
-May reduce B12 absorption
-Use with caution in patients with HF, renal/hepatic disease due to risk of lactic acidosis
SAD MAN medication list
-Medications to hold off when sick and dehydrated
Sulfonylureas
Ace inhibitors
Diuretics
Metformin
Angiotensin receptor blockers
NSAID
SLGLT2 inhibitors
Insulin secretagogue (sulfonylureas, meglitinides)
-Activate sulfonylurea receptor on B-cell to stimulate endogenous insulin secretion
-Sulfonylurea: Gliclazide, Glyburide
-Meglitinides
Sulfonylureas key notes
-0.6-1.2% A1C lowering potential
-Moderate risk of hypoglycaemia
-Glipizide (Increase MACE)
-Renal dosing SADMAN
-Increase weight 1-3 kg
-High risk of hypoglycaemia with Glyburide
-Gliclazide preferred over glyburide (by BEERS)
-1-2 weeks titration
-75% effect at 1/2 max dose
Meglitinides MOA
-Stimulate B-cell and enhances insulin release over short period of time
-Short acting
Meglitinides key notes
-0.7-1.1% A1C lowering potential
-helpful in postprandial hyperglycaemia
-Moderate risk of hypoglycaemia
-Limited benefit for MACE
-Renal dosing SADMAN
-TID dosing with each meal
-Weight gain 1.4-3.3
-TID dosing
-Not covered
-Lower risk of hypoglycaemia than sulfonylyreas in renal impairment
SGL2 inhibitor MOA
-Reduces glucose reabsorption by the kidneys leads to increased excretion of urinary glucose and lowering blood glucose
-At proximal tubule of nephrons
-Canagliglozin (Invokana)
-Dapagliflozin (Forxiga)
-Empagliflozin (Jardiance)
-Note SGL1inhibitor is responsible for small portion of renal glucose and reabsorption is what is remained after SGL2 in loop of Henle
SGL2 key notes
-0.5-0.7% A1C lowering potential
-Low risk of hypoglycemia
-Benefit for MACE and for CKD
-Renal dosing SADMAN
-Do not initiate if GFR<30
-Weight loss 2-3 kg
-S/E: decrease BP, increase urinary infections, mycotic infections
Incretin MOA (GLP1-RA and DPP-4 Inhibitor)
-Incretins are metabolic hormones that are produced when we eat, increase glucose dependent insulin release, slows gastric emptying and inhibits glucagon release and increases satiety, decrease glucose production by liver and increase glucose uptake therefore decreases blood glucose
-GLP1-RA: mimics GLP (an endogenous incretin), there are shorting acting and long acting such as ozempic, pharmacologic increase in GLP
-DPP-4 Inhibitor: DPP-4 is the enzyme that degrades GLP1 so inhibiting this enzyme increase availability of GLP-1 and GLP (incretin enhancer) examples: Linagliptin, saxagliptin, physiologic increase in GLP
GLP1-RA key notes
-0.6-1.4 A1C% lowering potential
-Low risk of hypoglycemia
-Decrease weight (more weight than DPP4)
-Benefit for MACE and mortality
-Decrease CKD
-Decrease HF hospitalization
-Caution: with family history of thyroid cancer or endocrine neoplasia, pancreatitis or ca, possible renal adverse events (risk of AKI)
-rare acute pancreatitis , N/V
DPP-4 key notes
-0.5-0.7 A1C% lowering potential
-neutral weight
-SADMAN renal dosing
-Linagliptin does not need renal dosing
-Don’t use with GLP1
-Rare arthralgia
-Increase risk of pancreatitis
Types of insulin
Prandial and bolus:
-Short duration fast acting (lispro)
-Short duration slower acting (regular)
Basal (long acting)
-Intermediate duration, slow acting (NPH)
-Long duration, slowest acting (Glargine)
-Avoid sulfonylureas
4 general regimens of insulin
-Intensive basal bolus (pre-meals rapid acting and long acting or intermediate, in DM1 and some DM2)
-Intensive continuous s/c infusion (rapid acting only)
-Basal insulin only (long or intermediate only, only in DM2)
-Basal-plus (rapid or short acting before the largest meal and intermediate or long acting daily, for patients that want less injections, only in DM2)
