Diabetes Treatment Flashcards
In general, what are our oral agents to treat diabetes?
Insulin secretagoguse, Alpha-glucoside inhibitors, Biguanides (metformin), Thiazolidinediones (TZD’s), and sitagliptin
What are the insulin secretagogues?
Sulfonylureas like glyburide
Stimulate pancreas to secrete insulin; or meglitinides (rapid acting stimulators)
How does Sulfonylureas work? Who are they indicated for?
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
How would we tell if Sulfonylureas is working?
Decrease HbA1c by 1-2%
What is the caution with Sulonylureas?
HYPOGLYCEMIA & hepatic problems. WEIGHT GAIN & interacts with alcohol
Which med is our meglitinides?
Rapaglinide (Prandin)
Meglitinides have a faster onset, how fast? What is it used for?
1 hr (short half-life); used before meals to control post prandial hyperglycemia
Are the meglitinides any better than the Sulonylureas’s?
Nope
What does metformin do?
Decreases hepatic glucose production; and decreases gluconeogenesis; reduces fasting & post prandial blood sugar
What are the benefits of metformin?
Does not cause hypoglycemia or weight gain
What is the first line therapy for DM?
metformin! Especially obese patients
What is the adjunct treatment with metformin?
Diet!
When we prescribe metformin, how much of a decrease do we expect in A1c?
1-2%
What does Metformin activate in its MOA?
Adenosine monophosphate-activated protein kinase (AMPK)
When can we not use metformin?
Contraindicated if creatinine >1.5 in males & >1.4 in females; alcoholism or CHF → can lead to lactic acidosis
How do we start dosing of Metformin?
titrate dose SLOWLY to max of 2000-2500/day
What are some side-effects of metformin?
GI upset, N/V/D
If we have a patient we need to get a CT or MRI with contrast, what must we always remember??
Hold their metformin the day of test & for 48 hours after!
What medication would we use to sensitize peripheral tissue to insulin, thus decrease peripheral insulin resistance?
TZD
What’s our most commonly used TZD?
Pioglitizone (Actos)
What must we always check prior to initiating a TZD?
LFT’s
What are the benefits of TZD’s?
No hypoglycemia & increase HDL and decrease trigs
What are the concerns with TZD’s?
Causes weight gain; fluid retention (so don’t use in HF patients)
What’s the black box warning with TZD’s?
Increase risk of acute heart failure
What medication inhibits the digestion of starch & sucrose? What enzyme does it inhibit?
Alpha-glucosidase enzyme Acarbose (precose)
What are the S/E of alpha glucosidase inhibitors?
Flatulence & Diarrhea
Who would we prescribe Acarbose (prescose) for?
“Mild DM”
What newer medication inhibits DPP-4 enzymes to decrease incretin hormones thus helping patients to control their glucose?
Sitagliptin
What is the effect of sitagliptin?
Potentiates insulin synthesis and release – decreases glucagon production
How much does Sitagliptin decrease HbA1c by? Is it well tolerated?
0.5-0.8%
Yes, very well tolerated
What newer medication can decrease A1c by about 1%, decrease weight by 5-10 pounds, and lowers BP?
SGLT2 inhibitors AKA Canaglifozin
What is an SGLT2?
Protein in proximal renal tubule that reabsorbs glucose in kidneys – thus increasing glucose excretion
What are the adverse effects of SGLT2 inhibitors?
yeast infections, hypoglycemia (if combined with insulin), hypotension, and impaired renal function (increase creatinine & decrease GFR).
What hormones are secreted from Beta cells?
Insulin & Amylin
When are insulin & amylin secreted?
Released in response to increased blood glucose
What does the alpha cell secrete?
Glucagon
What is the function of glucagon?
Maintains blood glucose between meals/fasting state
Glycogenolysis is…
Breakdown stored liver glycogen
Glyconeogenesis is…
glucose formation from amino acid
When else would glucagon levels increase?
In strenuous exercise
When Amylin is released from a beta cell, what does it do?
It inhibits gastric emptying & glucagon release
What does the delta cell release?
Somatostatin
What does somatostatin do?
Inhibits release of insulin
What hormone is derived from the ileum? What cell?
GLP-1 from the L cell
What medication increases GLP-1?
Sitagliptin [januvia]
What 2 meds are our incretin mimetics or GLP-1 agonists?
Exenatide [Byetta]
Liraglutide [Victoza]
What medication stimulates the release of Amylin? From what cell?
Pramlintide [Symlin]
Beta Cell
What 2 meds function at the KATP pump within the Beta cell of the pancreas?
Glipizide [glucotrol]
Repaglinide [Prandin]
What are our rapid acting insulins?
Lispro (Humalog) – ultra short
Regular insulin
What are the intermediate insulin?
NPH aka Humalin N
What are our long acting insulins?
Insulin glargine (lantus)
Which insulins do you give just before meals to control post-prandial?
Lispro (Humalog)
What must you correlate the dose of Lispro with?
Carbohydrate load
What can you combine with a Lispro to use 2-3 times daily?
Humulin N
What insulin do you give just before bed for 24 hours?
Insulin glargine (lantus)
What happens to glucose levels during 5-8AM?
Hyperglycemia
What medication can help with the early morning hyperglycemia?
Intermediates – Humulin N
What insulins can you mix together? When?
Intermediate + short In the morning & at night
What about Insulin Glargine (lantus) can it be mixed?
No, cannot mix with other insulins
For an insulin pump, what insulin is used? Is it based off of your BG levels?
Lispro Timed bolus delivery before meals or exercise – it’s programmable, therefore YOU must check BG levels and the catheter
Do we need insulin during exercise?
No, we need insulin immediately after exercise. Because glucose will go into the muscles during exercise.
What medication are the incretin mimetics?
GLP-1 Receptor Agonists – Exanatide
Can you use a GLP-1 while on insulin?
No this is an alternative to insulin
What do GLP-1 cause?
Promotes insulin release, suppress post-prandial glucagon, delay gastric emptying, promotes satiety
Do the GLP-1’s cause hypoglycemia & weight gain like sulfonurease?
Limited hypoglycemia, but it can cause weight gain
How much can the GLP-1’s lower A1c levels?
~1.2% (which is better than the DPP-4’s)
What are the “other” approaches to DM?
Pancreas transplant; islet cell transplant; or animal models
