Diabetes Pharm Part 1 Flashcards

1
Q

What are the three main categories of Diabetes medications?

A

Oral Glucose lowering

Non-insulin injectables

Insulin

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2
Q

Biguanides

  • drug name
  • major SE
  • how to dose
  • MOA
  • other SE
  • CI
A
  • Metformin
  • Diarrhea (where will you be when it hits??)
  • Dose: start low and titrate up.
  • MOA: inhibits hepatic glucose production (gluconeogensis and glycogenolysis) and improves insulin sensitivity.
  • SE: n/v, flatulence, sx tend to decrease over time. ***can rarely cause lactic acidosis, this is increased risk if on glucocorticoids or with ETOH.
  • CI: alcoholics (lactic acidosis)
  • -renal dysfunction
  • -if recieveing iodinated contrast (decreased perfusion to kidneys, may progress to shock, sepsis, CV failure, lactic acidosis)
  • -Serum creatinine greater than 1.5M and 1.4F
  • abnormal creatinine clearance from any cause
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3
Q

WHat are 6 reasons Metformin is first line therapy in DM?

A
  • Glycemic efficacy
  • no weight gain (may lose weight)
  • no hypoglycemia
  • may help improve lipids
  • well tolderated
  • favorable cost
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4
Q

Metformin BBW

A
  • lactic acidosis, the risk in increased with acute congestive heart failure, dehydration, excessive alcohol intake, hepatic or renal impairment.
    sx: abd distress, malaise, myalgia, resp. distress, solmnolence.
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5
Q

Sulfonylureas

  • drug names
  • major SE, who is most at risk of this?
  • MOA
  • when is this drug most effective
  • how to dose
  • other SE
  • CI
  • Ideal patient for this drug
A
  • Glipizide (Glucotrol), Glyburide (Diabeta), or Glimepiride (Amaryl)
  • major SE: Hypoglycemia, Elderly, ETOH, poor nutrition, and renal insufficiency are most at risk.
  • MOA: bind to beta cell receptors and cause ATP-dependent potassium channels to close, the calcium channels then open leading to increased insulin release from pancreas. (stimulates insulin release from the pancreas)
  • only effective in the first 5 years of disease, if disease has already progressed and you dont have any beta cells left its not going to increase insulin secretion.
  • How to dose: start low and titrate up
  • SE: weight gain from increased levels of insulin.

CI: sulfa allergy, high risk of hypoglycemia, ketoacidosis

Ideal pt:

  • duration of disease less than 5years*
  • close to normal body weight* (likely they have less insulin resistance)
  • no sulfa allergy
  • no hx of prior insulin therapy
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6
Q

Sulfonylureas

-what are the notable differences between each of the drugs?

A
  • Glipizide (“slide down a short slide”) 14-16hr duration
  • Glyburide: 20-24+ hrs
  • Glimepiride: (goin on a ride, for awhile) 24+hrs
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7
Q

Thiazolidinediones aka TZD

  • drug names
  • major SE
  • MOA
  • utility of TZD
  • does this cause hypoglycemia?
A

Drugs: Rosiglitazone (Avandia)
Pioglitazone (Actos)

-Major SE: cankles, causes a lot of water retention. peripheral edema, weight gain, hepatotoxicity

  • MOA: increase insulin sensitivity in skeletal muscle and fat by bind to PPAR-gamma receptor thereby decreasing peripheral resistance. At higher doses may decrease hepatic glucose production.
  • Can have positive effect on lipid profile*
  • Utility: used as add-on therapy down the line
  • Does not cause hypglycemia b/c its not increasing insulin production, just insulin sensitivity.
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8
Q

TZD BBW

A

-CONGESTIVE HEART FAILURE, these drugs cause or exacerbation of CHF.

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9
Q

TZD: Rosiglitazone BBW

A

-MYOCARDIAL INFARCTION

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10
Q

Alpha-glucosidase inhibitors

  • drugs
  • Major SE
  • MOA
  • most useful in which patients
  • CI
  • how to dose
A
  • Acarbose (Precose)
  • Miglitol (Glyset)
  • major SE: gas, abd bloating, distention, diarrhea
  • MOA: slows the absorption of carbs (decrease glucose?)
  • Most useful in patietns with postprandial hyperglycemia and high A1C levels
  • CI: patients with GI motility disorders**, cirrhosis, and disease of the bowel.
  • Dose: dose with first bite of meal(TID), start at lowest dose and titrate up every 1-2mo as needed, monitor LFTs 1st year of therapy
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11
Q

Meglitinides

  • drug names
  • major side effects
  • MOA
  • uses
A
  • Nateglinide (Starlix)
  • Repaglinide (Prandin)

-Major SE: hypoglycemia

  • MOA: increase insulin secretion from pancreas, similar to sulfonylureas.
  • lowers post prandial glucose but does not change fasting plasma glucose.
  • uses: generally not very effective, alternative for patients who are candidates for SU’s but have sulfa allergy
  • good for pt with erratic eating schedule (take with meals, only take if they eat)
  • for pts with acceptable fasting plasma glucose and elevated post prandial levels
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12
Q

Meglitinides

-drug interactions?

A

-drug interacctions with drugs metabolized through the CYP450 3A4 pathway

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13
Q

Dipeptidyl Peptidase-4 inhibitors

  • drugs
  • Major SE
  • moa
  • drug interactions
  • other SE
A

Drugs: Sitagliptin(Januvia)
Saxtagliptin (Onglyza)
Linagliptin (Tradjenta)
Alogliptin (Nesina)

  • Major SE: HA
  • MOA: inhibit enzyme that breaks down GLP-1 therby increased amounts of GLP-1 leading to decreased hepatic glucose production.
  • Drug interactions: Saxtagliptin is a potent CYP3A4/5 inhibitor avoid with ketoconazole, diltiazem, and erythromycin.
  • Other SE: URI, UTI, hypoglycemis w/ SU, hypersensitivity rxn, elevated liver enzymes, pancreatitis
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14
Q

SGLT2 Inhibitor (Sodium glucose transporter)

  • drugs
  • Major Se
  • MOA
  • benefits
  • other SE
A

Drugs: Canagliflozin (Invokana)
Dapaglifloxin (Farxiga)
Empagliflozin (Jardiance)

-SE: GU infections, candida infections

  • MOA: block SGLT2 sites in the renal tubule which decreases glucose reabsorption in the kidney therefore causing glucosuria. GFR needs to be at least 45ml/min
  • basically, to counteract your hyperglycemia you pee out the excess glucose.
  • benefits: no hypoglycemia, promotes weight loss, effective in all stages of DM, targest the kidney so minimal risk for off target adverse effects.
  • SE: polyuria, dehydration, low BP, increased LDL
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15
Q

GLP-1 Receptor Agonists

  • drugs
  • Main SE
  • MOA
  • which one of these medications is not yet approved for use with insulin?
A

Drugs: Exenatide (byetta)
Liraglutide (Victoza)
Albiglutide (Tanzeum)
Dulaglutide (Trulicity)

Main SE: GI upset*, N/V, diarrhea

MOA: they slow transit through the gut. Glucose dependent effects on insulin and therefore no hypoglycemia.

-Exanitide (Byetta) is not approved for use with insulin.

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16
Q

Amylinomimetic

  • drugs
  • used in which type of diabetes?
  • MOA
  • SE
A

Drugs: Pramlintide Acetate (Symlin)

-used in type 1 and 2 Diabetes

  • MOA: synthetic anaolog of human amylin cosecreted with insulin by pancreatic beta cells.
  • reduces postprandial glucose increases via the following mechanisms:
    1. ) prolongation of gastric emptying
    2. ) reduction of postprandial glucagon secretion
    3. ) reduction of caloric intake through centrally-mediate appetite suppression.

-SE: n/v, hypoglycemia,

  • CI:
  • gastroparesis
  • hypoglycemia unawareness
  • poor compliance
  • A1C greater than 9
  • dont use with alpha-glucosidase inhibitors
17
Q

What diabetes medications are most cost effective?

A
  • metformin (biguanide)
  • Gulfonylurease (glyburide, glipizide, glimepiride)
  • TZD’s (Rosiglitazone, Pioglitazone)

they all are $20 or under

18
Q
Step-wise approach to therapy: 
- for each new class of noninsulin agent added to initial therapy expect A1C lowering of \_\_\_%.
A

-0.9-1.1%

19
Q

Glycemic Targets:

  • preprandial
  • postprandial
  • tigher targets for younger and healthier
  • looser targets for older, comorbidities
A

Pre-prandial Plasma Glucose less than 130

Post-prandial plasma glucose less than 180

Tighter: 6.0-6.5% A1C
Looser: 7.5-8.0% A1C

20
Q

Anti-hyperglycemic therapy in T2D (Tx)

A

EVERY diabetic patient should be striving for healthier eating, weight control, increased physical activity & diabetes education.

  • Start with monotherapy (Metformin) …..if HbA1C not achieved after 3 mo proceed to a 2 drug combo
  • Metformin and sulfonylurea(Cheapest)…if HbA1C not achieved after 3 mo of dual therapy proceed to 3 drug combo
  • Metformin, SU, and SGLT-2…. if HbA1C not achieved in 3mo proceed to combination injectable therapy.
  • Basal insulin + Mealtime Insulin or GLP-1 Receptor Agonist
21
Q

If A1C at 10% will metformin alone get you to goal?

What if A1C starts in the teens? What medication therapy would you start with?

A

No. Anything greater than 9% youre not going to get to goal with just one therapy, you need to use dual or triple therapy.

-Start at Combo injectable therapy.

22
Q

If trying to avoid hypoglycemia which classes of drugs would you get rid of and which would you keep?

A
  • Get rid of sulfonylureas, insulin (& Meglitinides but not on her chart)
  • Keep TZD, DPP-4inhib, SGLT2inhib, GLP-1 RA
23
Q

If trying to avoid weight gain which classes of drugs would you avoid? which would you keep?

A
  • avoid sulfonylureas, insulin, TZD, and GLP-1

- Keep DPP-4inhib,SGLT2inhib & GLP-1RA (only as dual therapy)

24
Q

What is the go to drug for T2D?

A

Metformin