Diabetes Treatment

Question 1

In general, what are our oral agents to treat diabetes?

Answer 1

Insulin secretagoguse, Alpha-glucoside inhibitors, Biguanides (metformin), Thiazolidinediones (TZD’s), and sitagliptin

Question 2

What are the insulin secretagogues?

Answer 2

Sulfonylureas like glyburide

Stimulate pancreas to secrete insulin; or meglitinides (rapid acting stimulators)

Question 3

How does Sulfonylureas work? Who are they indicated for?

Answer 3

Bind to beta cell receptors to increase insulin release

For obese type 2 DM – goal to decrease insulin resistance

Non-obese type 2 DM – goal to improve early phase insulin release

*Must be used as adjunct therapy to Metformin

Question 4

How would we tell if Sulfonylureas is working?

Answer 4

Decrease HbA1c by 1-2%

Question 5

What is the caution with Sulonylureas?

Answer 5

HYPOGLYCEMIA & hepatic problems. WEIGHT GAIN & interacts with alcohol

Question 6

Which med is our meglitinides?

Answer 6

Rapaglinide (Prandin)

Question 7

Meglitinides have a faster onset, how fast? What is it used for?

Answer 7

1 hr (short half-life); used before meals to control post prandial hyperglycemia

Question 8

Are the meglitinides any better than the Sulonylureas’s?

Answer 8

Nope

Question 9

What does metformin do?

Answer 9

Decreases hepatic glucose production; and decreases gluconeogenesis; reduces fasting & post prandial blood sugar

Question 10

What are the benefits of metformin?

Answer 10

Does not cause hypoglycemia or weight gain

Question 11

What is the first line therapy for DM?

Answer 11

metformin! Especially obese patients

Question 12

What is the adjunct treatment with metformin?

Answer 12

Diet!

Question 13

When we prescribe metformin, how much of a decrease do we expect in A1c?

Answer 13

1-2%

Question 14

What does Metformin activate in its MOA?

Answer 14

Adenosine monophosphate-activated protein kinase (AMPK)

Question 15

When can we not use metformin?

Answer 15

Contraindicated if creatinine >1.5 in males & >1.4 in females; alcoholism or CHF → can lead to lactic acidosis

Question 16

How do we start dosing of Metformin?

Answer 16

titrate dose SLOWLY to max of 2000-2500/day

Question 17

What are some side-effects of metformin?

Answer 17

GI upset, N/V/D

Question 18

If we have a patient we need to get a CT or MRI with contrast, what must we always remember??

Answer 18

Hold their metformin the day of test & for 48 hours after!

Question 19

What medication would we use to sensitize peripheral tissue to insulin, thus decrease peripheral insulin resistance?

Answer 19

TZD

Question 20

What’s our most commonly used TZD?

Answer 20

Pioglitizone (Actos)

Question 21

What must we always check prior to initiating a TZD?

Answer 21

LFT’s

Question 22

What are the benefits of TZD’s?

Answer 22

No hypoglycemia & increase HDL and decrease trigs

Question 23

What are the concerns with TZD’s?

Answer 23

Causes weight gain; fluid retention (so don’t use in HF patients)

Question 24

What’s the black box warning with TZD’s?

Answer 24

Increase risk of acute heart failure

Question 25

What medication inhibits the digestion of starch & sucrose? What enzyme does it inhibit?

Answer 25

Alpha-glucosidase enzyme Acarbose (precose)

Question 26

What are the S/E of alpha glucosidase inhibitors?

Answer 26

Flatulence & Diarrhea

Question 27

Who would we prescribe Acarbose (prescose) for?

Answer 27

“Mild DM”

Question 28

What newer medication inhibits DPP-4 enzymes to decrease incretin hormones thus helping patients to control their glucose?

Answer 28

Sitagliptin

Question 29

What is the effect of sitagliptin?

Answer 29

Potentiates insulin synthesis and release – decreases glucagon production

Question 30

How much does Sitagliptin decrease HbA1c by? Is it well tolerated?

Answer 30

0.5-0.8% Yes, very well tolerated

Question 31

What newer medication can decrease A1c by about 1%, decrease weight by 5-10 pounds, and lowers BP?

Answer 31

SGLT2 inhibitors AKA Canaglifozin

Question 32

What is an SGLT2?

Answer 32

Protein in proximal renal tubule that reabsorbs glucose in kidneys – thus increasing glucose excretion

Question 33

What are the adverse effects of SGLT2 inhibitors?

Answer 33

yeast infections, hypoglycemia (if combined with insulin), hypotension, and impaired renal function (increase creatinine & decrease GFR).

Question 34

What hormones are secreted from Beta cells?

Answer 34

Insulin & Amylin

Question 35

When are insulin & amylin secreted?

Answer 35

Released in response to increased blood glucose

Question 36

What does the alpha cell secrete?

Answer 36

Glucagon

Question 37

What is the function of glucagon?

Answer 37

Maintains blood glucose between meals/fasting state

Question 38

Glycogenolysis is...

Answer 38

Breakdown stored liver glycogen

Question 39

Glyconeogenesis is...

Answer 39

glucose formation from amino acid

Question 40

When else would glucagon levels increase?

Answer 40

In strenuous exercise

Question 41

When Amylin is released from a beta cell, what does it do?

Answer 41

It inhibits gastric emptying & glucagon release

Question 42

What does the delta cell release?

Answer 42

Somatostatin

Question 43

What does somatostatin do?

Answer 43

Inhibits release of insulin

Question 44

What hormone is derived from the ileum? What cell?

Answer 44

GLP-1 from the L cell

Question 45

What medication increases GLP-1?

Answer 45

Sitagliptin [januvia]

Question 46

What 2 meds are our incretin mimetics or GLP-1 agonists?

Answer 46

Exenatide [Byetta] | Liraglutide [Victoza]

Question 47

What medication stimulates the release of Amylin? From what cell?

Answer 47

Pramlintide [Symlin] Beta Cell

Question 48

What 2 meds function at the KATP pump within the Beta cell of the pancreas?

Answer 48

Glipizide [glucotrol] Repaglinide [Prandin]

Question 49

What are our rapid acting insulins?

Answer 49

Lispro (Humalog) – ultra short | Regular insulin

Question 50

What are the intermediate insulin?

Answer 50

NPH aka Humalin N

Question 51

What are our long acting insulins?

Answer 51

Insulin glargine (lantus)

Question 52

Which insulins do you give just before meals to control post-prandial?

Answer 52

Lispro (Humalog)

Question 53

What must you correlate the dose of Lispro with?

Answer 53

Carbohydrate load

Question 54

What can you combine with a Lispro to use 2-3 times daily?

Answer 54

Humulin N

Question 55

What insulin do you give just before bed for 24 hours?

Answer 55

Insulin glargine (lantus)

Question 56

What happens to glucose levels during 5-8AM?

Answer 56

Hyperglycemia

Question 57

What medication can help with the early morning hyperglycemia?

Answer 57

Intermediates – Humulin N

Question 58

What insulins can you mix together? When?

Answer 58

Intermediate + short In the morning & at night

Question 59

What about Insulin Glargine (lantus) can it be mixed?

Answer 59

No, cannot mix with other insulins

Question 60

For an insulin pump, what insulin is used? Is it based off of your BG levels?

Answer 60

Lispro Timed bolus delivery before meals or exercise – it’s programmable, therefore YOU must check BG levels and the catheter

Question 61

Do we need insulin during exercise?

Answer 61

No, we need insulin immediately after exercise. Because glucose will go into the muscles during exercise.

Question 62

What medication are the incretin mimetics?

Answer 62

GLP-1 Receptor Agonists – Exanatide

Question 63

Can you use a GLP-1 while on insulin?

Answer 63

No this is an alternative to insulin

Question 64

What do GLP-1 cause?

Answer 64

Promotes insulin release, suppress post-prandial glucagon, delay gastric emptying, promotes satiety

Question 65

Do the GLP-1’s cause hypoglycemia & weight gain like sulfonurease?

Answer 65

Limited hypoglycemia, but it can cause weight gain

Question 66

How much can the GLP-1’s lower A1c levels?

Answer 66

~1.2% (which is better than the DPP-4’s)

Question 67

What are the “other” approaches to DM?

Answer 67

Pancreas transplant; islet cell transplant; or animal models